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Accurad™-200Headholder for Transcranial Radiography

of the Temporomandibular Joint Region

Instruction Manual

Acknowledgements

It has been a gratifying experience to develop the Accurad™-200 headholder. This innovative instrument brings a new, broader dimension to transcranial TMJ radiography in order to meet the practitioner's ever-increasing professional requirements.

We wish to acknowledge the great contribution made by Dr. Bernard Williams to the development of the Accurad™-200 headholder. The "Twin Axis Adjustment Wheel" greatly expands the diagnostic capabilities of transcranial radiography by allowing doctors to adjust the angulation of the central X-ray beam to suit their individual needs and preferences for viewing each patient’s TMJ. It also allows precise quantification of patient head positioning and changes in the TMJ.

Thanks also go to Drs. Terry Tanaka and Carl Rieder. Their experience and foresight were invaluable in taking the concept of the wheel and designing it for this instrument.

We also wish to thank Dr. Harold Gelb for helping to bring transcranial TMJ radiography to the attention of dentistry. His efforts in educating the profession have helped many to understand the importance of this diagnostic modality.

The evolution of the Accurad™-200 headholder also incorporates the invaluable suggestions made during the development stages by doctors including Al Crawford, Peter Dawson, Alvin Fillastre, Jack Haden, Yasuo Hatano, Charles Holt, Errol Lader, Hiroshi Muraoka, Gerald Murphy, Brendan Stack, Yoshitane Tanaka, George Tateno, Skip Truitt and John Witzig.

We are very grateful for the suggestions and encouragement we have received while developing the Accurad™-200 headholder. This product embodies the technical sophistication needed to better serve modern dentistry.

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The Accurad™-2001. Horizontal Adjustment Scale

2. Support Strap

3. Anterior-Posterior Adjustment Scale

4. Beaded Support Chain

5. Film Transport Window with "Slide-Bar" to indicate Left and Right Sides

6. Fixed Ear Rod*

7. Nasion Piece*

8. Vertical Adjustment Scale

9. Film Cassette Transport

10. Film (to be purchased separately)

11. Patient Film Envelope

12. Film Cassette with Intensifying Screens

13. Allen Wrench

14. 12" and 16" Lead Aperture

15. Ruler

16. Adjustable Ear Rod*

17. Modified Twin Axis Adjustment Wheel

18. Universal Adapter Adjustment Knobs

19. Universal Adapter with Lead Aperture

20. Wall Chart (not shown)

* Non-sterile. Disinfect before each use.

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Actual Transcranial Radiograph

Maximum Open Rest Centric Occlusion

Maximum Open Rest Centric Occlusion

Landmarks to look for on the transcranial radiograph: Articular Eminence (A.E.) Mandibular Condyle (C.) External Auditory Meatus (E.A.M.) Glenoid Fossae (G.F.) Petrous Portion of Temporal Bone (P.T.B.) Petro-Tympanic Fissure (P.T.F.)

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Table of Contents I Features and Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

II Attaching the Accurad™-200 Headholder to the X-Ray Machine . . . . . . . . . . . . . . . . 8

A. First -Time Attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8B. Selecting the Correct Lead Aperture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9C. Attaching Support Strap to Tubehead. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

III Procedure for Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

A. Loading the Cassette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11B. Test Film Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11C. Test Film Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11D. Patient Set-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12E. Adjusting the Nasion Aligner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13F. Recording Patient Positioning on the Film Envelope . . . . . . . . . . . . . . . . . . . . . . . . . 14G. Exposing the Film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14F. Radiographing the Temporomandibular Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

IV Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

A. Clinical Specifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17B. Film Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17C. Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19D. Procedure Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20E. Anatomical Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25F. Accurate Head Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25G. Manufacturer’s Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

V Exposure Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1. Philips Oralix-65 Exposure Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272. Lanex Rare Earth Intensifying Screens/OG Film . . . . . . . . . . . . . . . . . . . . . . . . . . . 283. Conversion Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

VI Warranty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

VII Care and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

VIII Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

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I. Features and BenefitsWith the increased emphasis on the treatment of occlusal and TMJ problems, there arose a need in the dental profession for a simple clini-cal instrument to obtain radiographs of the TMJ region. The Accurad™-200 headholder, incorpo-rating the following features, meets and exceeds that basic need:

• Attacheseasilyandsecurelytostandardden-tal X-ray machines.

• Usedwith thepatient’shead in theuprightposition (norma lateralis) and with no head rest. This unstrained, natural vertical posi-tion avoids gravitational and unusual muscle influences induced by extreme postural posi-tions of the head.

• Accuraterepeatabilityofpatientpositioningmade possible by specially designed nasion aligner, ear rods for the external auditory meatus and fixed attachment to the X-ray machine.

• The modified twin axis adjustment wheelallows for individualized transcranial TMJ radiographs. Adjustments on the modified wheel enable the horizontal and vertical angles of the beam to be changed allowing different views of the TMJ anatomy to appear on the radiograph for diagnosis and treatment.

• Leadletterspermanentlyaffixedto"slidebar"over film transport window identify patient’s left and right TMJ directly on the film to aid in diagnosis and eliminate confusion.

• Allows interchangeability between X-raymachines.

• Sixradiographscanbetakenonone5"x7"film to provide a convenient means to evalu-ate TMJ relationships (mandible in maximum intercuspation, rest and maximum open posi-tions).

• Unitaccommodatesmostpatientheadsizes.Lightweight plastic film cassette is easy to handle and store.

• Color-codedindicatoronfilmcassettemini-mizes confusion by identifying if the cassette is loaded/unloaded or if the film is exposed/unexposed.

• Spongelayerinsidecassetteensuresoptimalfilm/screen contact.

• Procedurecaneasilybedelegatedtoauxil-iary personnel.

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II. Attaching the Accurad™-200 Headholder to the X-Ray Machine

The Accurad™-200 headholder was designed to be used in conjunction with any standard dental X-ray machine. This instrument complies with applicable Department of Health, Education and Welfare standards under the Radiation Control for Health and Safety Act. In using this acces-sory instrument, be certain you proceed in accordance with the X-ray instructions pro-vided by the manufacturer of your X-ray equipment.NOTE: Prior to installation and testing, all darkroom criteria must be met per instructions outlined in Appendix B.

A. First-Time Attachment1. Turn the four adjustment knobs of the cone

adapter (Figure 1) to retract clamp plates to their maximum open position.

Figure 12. Measure the outer diameter of the X-ray cone

with the millimeter scale (longer scale) of the supplied ruler (Figure 2).

NOTE: Both height and width dimensions are required for rectangular cones.

Figure 23. First, adjust the clamp plates with red knobs.

Position the ruler onto the adapter so the top right of the adapter frame seats into the square cut-out of the ruler with the shorter millime-ter scale projecting towards the center of the round adapter opening (Figure 3). Center the ruler over the clamp plate to be adjusted. Turn the knob until the inner surface of the clamp plate aligns with the scale mark which corre-sponds to the cone dimension. Tighten until it is flush with cone adapter. This will allow you to quickly realign clamp plates should they become loose.

Figure 3

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4. To secure the X-ray cone, insert the cone into the adapter until it mates flush with the base of the lead cup and rests against the two pre-set clamp plates. While maintaining these contacts, turn the black knobs until the cone is securely held by the clamps (Figure 4).

Figure 4Additional Notes1. A second method for first-time attachment is

outlined in Appendix C, VI. Image Geom-etry, C. Not centered within apparatus.

2. Retracting the clamp plates with black knobs will allow removal of the cone.

3. The cone will quickly realign into the adapt-er if the clamp plates with red knobs are not disturbed. These should remain in place for fast set-up.

B. Selecting the Correct Lead Aperture

The lead aperture installed in your Accurad™-200 headholder is designed to satisfactorily collimate the primary beam of all X-ray tube-heads utilizing the standard 8" technique. Two additional apertures have been included and are indicated for either 12" or 16" techniques and are so labeled. (To determine cone tech-nique, measure from the focal point to the end of the X-ray cone.) When necessary, remove the two screws securing the lead aperture (lead disc with the square cut-out) (Figure 5) and install the correct aperture. Refer to Appendix

G for comments regarding individual X-ray machines.

Figure 5

C. Attaching Support Strap to Tubehead

1. With the Accurad™-200 headholder attached to the cone, rest the cassette holder on a support (counter top, chair arm rest, etc.) so that the back plane of the cassette holder is vertical.

2. Open the metal clasp of the beaded chain and attach the chain around the tubehead yoke where it connects with the X-ray arm (Figure 6).

Figure 63. Lengthen the long support strap by sliding

it through the plastic clasp. Engage the two plastic clasps (Figure 7). Adjust the long sup-port strap to eliminate slack by pulling the free strap end through the clasp.

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Figure 74. With the Accurad™-200 headholder attached

to the X-ray tubehead and supported by the support strap, the back plane of the cassette holder should be vertical and the upper rods of the Accurad™-200 headholder should be horizontal. Readjust the support strap if nec-essary.

Note: Confirm that the cone is flush with the base of the lead cup (Figure 4).

5. When not in use, the Accurad™-200 head-holder may be removed and stored. Rest the cassette holder on a suitable support, disengage the two plastic clasps and leave the support chain and short strap around the tubehead yoke for simple reattachment of the unit. Retract the two black cone adapter knobs to remove the X-ray cone.

6. When the Accurad™-200 headholder is attached, the X-ray tubehead assembly may drift down prior to positioning on the patient. The X-ray arm may be counterbalanced, but it is not recommended. During the patient positioning procedure, the cassette holder is always supported by the patient regardless of drift. Patient support of the cassette holder reduces patient anxiety and increases control of the procedure.

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III. Procedure for Use

A. Loading the Cassette(Must be done in complete darkness or under the required filter.)

1. Remove the protective paper from the film cassette.

2. Open the cassette by releasing the 2 metal clasps (Figure 8).

Figure 83. Insert the film into the cassette, close and

latch.4. Lanex Rare Earth screened cassettes: Film should not be stored in the cassette.

The intensifying screens are coated with a protective layer which will wear away after prolonged cleaning. Only load the cassette prior to the radiographic procedure.

5. Use the color-coded indicator on the front of the cassette (Figure 9) to identify if your cassette is loaded or unloaded. (For example, the green dot may indicate that the cassette is unloaded, red loaded.) This indicator may also be used to identify if the film in the cas-sette is exposed or unexposed. To eliminate confusion, establish a procedure in your office for routine use of this indicator.

Figure 9

B. Test Film ProcedureFollowing the initial installation procedure, but prior to positioning the patient into the Accu-rad-200 headholder, confirm proper installation with a test film as follows:

1. Rest the cassette holder on a support (coun-ter tip, chair arm rest, etc.) so the top of the cassette holder is horizontal, confirm that the cone is flush with the base of the lead cup.

2. Insert the loaded cassette into the cassette holder with the edge of the cassette flush with the edge of the cassette holder track.

3. Set the exposure timer at approximately 1⁄2

the suggested time for an adult male and make an exposure.

4. Process per instructions in Appendix B.5. The resulting image should be approximately

13⁄4" – 2" with a 1⁄4" to 1⁄2" gray perimeter. The balance of the film should be window-pane clear.

NOTE: If additional adjustment is required to center the cone, use the red and black knobs on the side of the cone adapter.

C. Test Film Troubleshooting Procedure

1. Problem: Balance of film not window-pane

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clear. Solution: Film has been exposed to improper safelight illumination and/or white light leakage. Refer to Appendix B.

2. Problem: Image smaller than 13⁄4" square. Solution: Recheck tubehead specifications for 12" or 16" technique and install correct aperture. Refer to Appendix E.

3. Problem: Image 21 ⁄4" square resulting in image overlap. Solution: Recheck the tube-head specifications for 8" or 12" technique and install correct aperture. Refer to Appen-dix E.

When you are satisfied with a proper test film as outlined above, proceed to patient set-up.

D. Patient Set-UpProtect the Patient from scatter or stray radiation with a lead apron.

1. To minimize slouching, seat the patient upright on a stool or in the dental chair with the head rest removed (Figure 10).

Figure 102. When radiographing the right TMJ:a. Standard settings: The lead letter "R" must

appear in the window. The modified twin axis wheel must be set at 0 degrees. A setting of 0 mm on the sliding scale will align the ear rods. If set between 7 and 12 mm, the patient will be angled slightly towards the cassette which may be more advantageous for radio-graphing the condyle.

b. Set the ear plug on the modified twin axis adjustment wheel as recommended above and the pointer at 0 degrees. To move the ear plug, turn it one half turn to loosen, slide it to the desired position and tighten. To move the pointer, loosen the black knob, move it to the desired setting and tighten (Figure 11). Refer to Appendix D for procedure variations.

Figure 11c. Have the patient position their right hand on

their right shoulder, palm up. Have them take hold of the cassette holder (Figure 12).

Figure 12d. As you guide the instrument into position,

have the patient place the fixed ear rod pro-jecting from the cassette holder into their right ear hole. (The fixed ear rod should be in the most posterior position on the cassette holder, with the "R" appearing over the window.)

e. Guide the adjustable ear rod into the patient’s left ear hole (Figure 13). Important: Instruct

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the patient to carefully insert the ear rod into the ear hole to its maximum position to obtain an optimal object-to-film relationship with minimal magnification and distortion. Appendix F contains more in-depth informa-tion on accurate head stabilization.

f. Be sure the wheel remains horizontal. Secure in this position by tightening the silver knob (Figure 13). If the patient cannot close into maximum intercuspation at this point, back out the ear rod only to the point where they can comfortably achieve maximum intercus-pation.

Figure 13g. Confirm that the patient’s mid-sagittal plane

is vertical and the patient is sitting erect. Cor-rect as necessary and recheck adjustments.

E. Adjusting the Nasion Aligner1. Loosen the two black thumbscrews in the car-

riage on the horizontal rods (Figure 14a & b).

Figure 14a

Figure 14b2. Center the carriage over the patient’s head.

Slide the nasion support rod through the car-riage toward the patient (Figure 15).

Figure 153. The nasion piece must be brought into contact

with the bridge of the nose (Figure 16) and support the head with the mandibular occlusal planeangledslightlydown(5 -̊7˚)(Figure17)when the teeth are in maximum intercuspa-tion.

Figure 16

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Figure 174. Tighten the two carriage thumbscrews and

the thumbscrew which secures the nasion height.

F. Recording Patient Position-ing on the Film Envelope

1. On the patient film envelope (Figure 18), record the settings of the modified twin axis wheel. (See Appendix E for further instruc-tions on ear rod placement.)

Figure 182. Record the three cranial alignments: (a)

Horizontal – read scale from film transport to X-ray attachment (Figure 19), (b) Anterior-Posterior – read mid-sagittal scale from back to front of patient’s head (Figure 20), and (c) Vertical – read scale at nasion (Figure 21).

Figure 19

Figure 20

Figure 213. The radiographic position of the condyle is

also recorded, as determined by the position of the mandible during the sequence of expo-sures (see Section III-G-3).

4. The developed film should be inserted into the patient’s film envelope and retained in the patient’s file after the radiographic procedure has been completed. The recorded data pro-vides the necessary information to exactly duplicate the radiographic position for com-parative viewing at a later time.

1. Frankfort Plane external auditory meatus and lower rim of orbit or

2. Mandibular occlusal plane 5˚-7˚

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G. Exposing the Film1. Your Accurad™-200 cassette contains Lanex

Rare Earth intensifying screens. A compat-ible X-ray film such as Kodak® OG or T-mat G film should be used.

2. Although the enclosed suggested exposure guidelines are based on standards, it may be necessary to slightly alter them for your particular X-ray unit. Once these guidelines have been established and recorded on your exposure chart (refer to Section V) under "Selected Techniques," use becomes routine. For this reason, it is strongly recommended that a single "Scout" exposure be taken of one TMJ for the first few procedures prior to a full series to ensure proper patient position-ing and darkroom technique. If the "Scout" film is acceptable, proceed with the rest of the series. If the film is unacceptable, refer to the troubleshooting schedule in Appendix C.

3. Three exposures may be taken on each side, with the mandible in varying positions. It is recommended that a preferred sequence of exposures be established so that your procedures are consistent and become standardized. The following is an example of this procedure:

Exposure 1: Mandible in maximum intercu-pation (closed/clenched)

Exposure 2: Mandible in rest position Exposure 3: Mandible opened to the maxi-

mum position Other exposures may be taken depending on

patient treatment.

H. Radiographing the Temporomandibular Joint

1. Facing the patient, insert the cassette into the track of the cassette holder (Figure 22). The cassette should always be loaded from the front (the side by the patient’s face). The cas-sette label indicates cassette positioning for the appropriate side.

Figure 222. The first exposure is taken with the film cas-

sette aligned flush to the edge of the cassette transport track in front of the patient (Figure 23).

Figure 233. For the second exposure, slide the film cas-

sette in and align it between the two vertical edges of the cassette transport (in the middle of the transport) (Figure 24).

Figure 24

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4. For the third exposure, slide the cassette in until it is even with the far edge of the cas-sette transport track behind the patient’s ear (Figure 25).

Figure 255. After completing these three exposures of

the TMJ, remove the film cassette. Loosen the carriage screws and slide the nasion away from the patient. Loosen the silver screw on the adjustable ear rod and retract it from the patient’s ear.

6. Lift the headholder away from the patient. Do not detach the Accurad™-200 from the cone.

NOTE: Confirm that the cone is still flush with the base of the lead cup.

7. Change the settings to radiograph the left TMJ. (See page 12, D. Patient Positioning, 2. a.)a. Fixed Ear Rod: Turn the ear plug counter-

clockwise to loosen, slide it across the win-dow so the "L" appears over the window, and tighten.

b. Adjustable Ear Rod: Loosen the black knob and move the pointer to the 180 degrees setting on the wheel and tighten.

8. Rotate the X-ray arm for exposure of the left TMJ.

9. Remove the nasion aligner and reinsert it into the opposite side.

10. Repeat parts D, E, F and G of Section III and steps 1-5 of Section H. (Be sure to invert the cassette before inserting it into the cassette holder so that the unexposed film is now in place behind the transport window and the cassette label indicates positioning for the left side.)

11. If necessary, readjust the nasion to support the head with the mandibular occlusal plane angledslightlydown(5 -̊7˚).

12. To remove the Accurad™-200 headholder form the X-ray tubehead, rest the cassette holder on a suitable support, disengage the two plastic clasps, loosen the two black clamp adjustment knobs (do not touch the red knobs) and remove.

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IV. Appendices

The following clinical specifications were deter-mined by the research and clinical studies per-formed over a ten-year period by Dr. William Buhner* and several of his colleagues.

• The25-degreeangulationofthecentralX-ray beam of the Accurad™-200 was selected as an average for measuring, at the midpoint, the superior wall or roof of the glenoid fossa in relation to the Frankfort plane. This 25-degree angulation is oriented to the roof of the glenoid fossa – not to the condylar head. The movable condylar head relates to the fixed glenoid fossa.

• Thecorrectangulationandexposure,bothvertical and horizontal, will show a well defined line of bone density completely around the glenoid fossa from the articular tubercle to the petrotympanic fissure. The articular disk establishes the space between

the condylar head and the roof of the glenoid fossa.

• Differences in anatomical structures andtheir relationships may require a change of angulation in the vertical and/or horizontal planes to obtain the best view of the TMJ. This can be accomplished by adjusting the dial on the twin axis adjustment wheel per the instructions in Appendix D. Adherence to the standard technique (ear rod set at 0 or 180 degrees) should give satisfactory results in most instances. Refer to Appendix D for optional and corrected views.

• Manyfindreferencetothemandibularocclu-salplaneangleof anegative5˚-7˚ affordsthem more consistent results than reference to the Frankfort plane due to misinterpreta-tions of the Frankfort plane.

* See Section VIII – Bibliography

Appendix A – Clinical Specifications

Extra-Oral Film ProcessingThe quality of the radiograph will be affected by various light factors. The suggestions below are provided to help identify and correct these potential problems.

The FilmThe film used in conjunction with your Accurad™-200 is blue or green sensitive and is far more light sensitive than conventional intra-oral film. Screen film exposed to radiation is approximately eight times more sensitive to safelight illumination than unexposed film. Con-sequently, screen-exposed film should be pro-cessed promptly and the following criteria met.

The DarkroomLight-tight – Apply self-adhesive weatherstrip-ping around all door, window or light fixtures which emit white light.

Safelight – Filter must be a Type GBX with a 15 watt frosted light bulb. 6B, ML-1 or ML-2 filters with a 7 1/2 or 15 watt light bulb are unaccept-able and will fog (darken) green-sensitive extra-oral film. A GBX fluorescent dental safelight is recommended. All safelights must be mounted a minimum of 4 feet from the working surface.

Manual ProcessingUse Kodak® GBX Developer and Fixer with an accurate darkroom thermometer immersed in the developer section. Do not agitate film dur-ing development. Process as indicated on the chart at the top of page 18.

When scheduling solution changes, bear in mind that one 5" x 7" film contains more emulsion than 16 intra-orals and consequently will short-en the life of the solution. Maximum life is two weeks. Replenish 1 1/2 ounces of developer and fixer per film. Clean tanks with hot water. Do not use detergent.

Appendix B – Film Considerations

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Temperature Development Final Wash in of Solution Time Rinse Fix Running Water

60˚F(15.5˚C) 81/2minutes 30seconds 4minutes 20minutes 65˚F(18.5˚C) 6minutes 30seconds 4minutes 20minutes 68˚F(20.0˚C) 5minutes 30seconds 4minutes 20minutes 70˚F(21.0˚C) 41/2minutes 30seconds 4minutes 20minutes

Automatic ProcessingA 5-minute dry to dry cycle is recommended. Confirm manufacturer’s recommended devel-oper temperature with accurate thermometer. For optimum results, use Kodak® Readymatic premixed solution #102-8869.

Film/Screen CombinationsWith Lanex Rare Earth Intensifying Screens use only Kodak® 5" x 7" OG green-sensitive film.

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The following schedule has been prepared to help you achieve the highest quality radiographic results possible. When evaluating your processed films, check the appropriate boxes to highlight the appar-ent problems seen on your films and identify their probable causes.

I. Insufficient development (due to improper solutions, time/temperature imbalance, etc.) A. Excessive hypo (results in excessive

matte finish, wavy patterns along film edge – visible by reflecting overhead light off film surface).

B. Graininess.

II. Fog A. Light fog (due to white light leaks,

improper safelight). B. Chemical fog (due to wrong/aged/

contaminated solutions).

III. Adjustable ear rod not inserted into its maximum. Results in: A. Fossae appear high within image.

Should be centered approximately. B. Fossae outline acceptable. Condyle out-

line in centric occlusion and rest posi-tions unacceptable.

C. Excessive discrepancy between nasion aligner settings. (Should be identical if patient positions the adjustable ear rod into its maximum.)

IV. Blurred image. Suspect one or more of the following: A. Fog B. Adjustable ear rod not inserted into its

maximum C. Adjustable ear rod not horizontal in

respective position. D. Insufficient development. E. Insufficient rinse. F. Insufficient exposure time. G. Excessive exposure time. H. Angle of patient’s mandibular occlusal

plane incorrect (should be positioned down 5 to 7 degrees).

Angled too far down Angled too far up I. Patient characteristics

V. Artifacts A. Scratches attributed to transport rollers

or handling. B. Fingerprints. C. Fingernail indents. D. Ear ring image. E. Fixer stains. F. Smears (debris on transport rollers). G. Other:

VI. Image geometry A. Too large (results in unnecessary scatter

and patient radiation, further sensitizes unexposed film area). Use next smaller lead aperture.

B. Too small (insufficient to record required anatomy). Use next larger lead aperture.

C. Cone not centered within adapter. To adjust, remove cone from the X-ray machine. Back out the red and black screws on the Accurad-200 cone adapt-er. Insert the X-ray cone into the adapter until the cone abuts uniformly against the lead cup. Tighten both the red and black screws (lightly to moderately) and center the X-ray cone within the adapter. Secure the red screws with lock nuts. Remove the X-ray cone and install onto the tubehead. Attach the Accurad-200 by inserting the cone into the adapter until it mates flush with the base of the lead cup and rests against the two preset clamp plates. While maintaining these contacts, turn the black knobs until the cone is securely held by the clamps. Visually confirm that the X-ray cone is centered. Readjust if necessary. Uniform tightening will reduce alignment error.

D. Not symmetrical (See "C" above). E. Lead letters not positioned in primary

image. Move ear positioner slide until the lead letter is positioned in the win-dow.

VII. Rare Earth Intensifying Screens Lanex Film type Other A. Quantum Mottle Excessive Acceptable Similar to grain in appearance but a

product of film processing.

Appendix C – Accurad™-200 Headholder Troubleshooting Schedule

20

When you have determined other view(s) you would like to see on your radiographs and what angulation you will need to achieve these views, follow this procedure:

I. Determine the inter-ear distance of the patient by reading the calibrated scale on the long rod on the wheel.

II. Use the following charts as guidelines to enable you to set the horizontal and vertical angles of the wheel. These charts are for 90 mm, 120 mm, 150 mm and 180 mm inter-ear distance. Use the chart which is closest to the patient’s measurement.

III. Three variations can be achieved:a. Standard. This procedure is described on

pages 12 & 13 under D. Patient Set-Up. It is based upon using the 0 degree horizon-tal and 25 degree vertical standard settings which are the same on all charts.

b. Modified. Using the appropriate chart, select the horizontal angle desired and move down that column until you reach the row for your desired vertical angle. The top number in each box (measured in degrees) corresponds to the setting of the pointer on the wheel. Example: To radio-

graph the left condyle on a patient with 90 mm inter-ear distance at 15 degree hori-zontal and 20 degree vertical angles, you would set the pointer at 143 degrees and the ear plug at 26 mm.

c. Corrected Transcranial (using the sub-mental vertex radiograph). Using the appropriate chart, use the horizontal angle derived from the submental vertex radio-graph and move down the column until you reach the row for your desired vertical angle. Example: To radiograph the left condyle on a patient with 120 mm inter-ear distance at a 25 degree horizontal and the standard 25 degree vertical angles, you would set the pointer at 180 degrees and the ear plug at 51 mm. Following this procedure, you will achieve a corrected transcranial on the Accurad-200.

d. Make a series of exposures as outlined on pages 14-16.

By using the settings on the modified twin axis adjustment wheel as described on the charts, your radiographs will provide repeatable, quan-tifiable data for use in progressive treatment.

Appendix D – Procedure Variations

Sample

Left Condyle90mm

Horizontal Angle Desired (From Submental Vertex)

0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 51˚ 72˚ 100˚ 123˚ 138˚ 148˚ 154˚33mm 29mm 29mm 31mm 36mm 42mm 48mm

20˚ 32˚ 58˚ 110˚ 143˚ 157˚ 163˚ 166˚28mm 22mm 21mm 26mm 32mm 39mm 46mm

25˚ 180˚ 180˚ 180˚ 180˚ 180˚ 180˚ 180˚Standard 0mm 8mm 16mm 23mm 31mm 38mm 45mm

30˚ 328˚ 302˚ 250˚ 217˚ 203˚ 197˚ 194˚28mm 22mm 21mm 26mm 32mm 39mm 46mm

35˚ 309˚ 288˚ 260˚ 237˚ 222˚ 212˚ 206˚33mm 29mm 29mm 31mm 36mm 42mm 48mm

Vert

ical

Ang

le D

esir

ed

Pointer reading form twin axis wheel

Reading from sliding ear plug on twin axis wheel

Intercondylar distance

21

Left Condyle 90mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 51˚ 72˚ 100˚ 123˚ 138˚ 148˚ 154˚ 33mm 29mm 29mm 31mm 36mm 42mm 48mm

20˚ 32˚ 58˚ 110˚ 143˚ 157˚ 163˚ 166˚ 28mm 22mm 21mm 26mm 32mm 39mm 46mm

25˚ 180˚ 180˚ 180˚ 180˚ 180˚ 180˚ 180˚ Standard 0mm 8mm 16mm 23mm 31mm 38mm 45mm

30˚ 328˚ 302˚ 250˚ 217˚ 203˚ 197˚ 194˚ 28mm 22mm 21mm 26mm 32mm 39mm 46mm

35˚ 309˚ 288˚ 260˚ 237˚ 222˚ 212˚ 206˚ 33mm 29mm 29mm 31mm 36mm 42mm 48mm

Vert

ical

Ang

le D

esir

ed

Right Condyle 90mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 129˚ 108˚ 80˚ 57˚ 42˚ 32˚ 26˚ 33mm 29mm 29mm 31mm 36mm 42mm 48mm

20˚ 148˚ 122˚ 70˚ 37˚ 23˚ 17˚ 14˚ 28mm 22mm 21mm 26mm 32mm 39mm 46mm


30˚ 212˚ 238˚ 290˚ 323˚ 337˚ 343˚ 346˚ 28mm 22mm 21mm 26mm 32mm 39mm 46mm

35˚ 231˚ 252˚ 280˚ 303˚ 318˚ 328˚ 334˚ 33mm 29mm 29mm 31mm 36mm 42mm 48mm

Vert

ical

Ang

le D

esir

ed

22

Left Condyle 120mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 59˚ 83˚ 111˚ 131˚ 143˚ 151˚ 156˚ 37mm 34mm 35mm 40mm 47mm 55mm 64mm

20˚ 40˚ 78˚ 128˚ 150˚ 160˚ 165˚ 167˚ 29mm 23mm 26mm 34mm 43mm 52mm 61mm


30˚ 320˚ 282˚ 232˚ 210˚ 200˚ 195˚ 193˚ 29mm 23mm 26mm 34mm 43mm 52mm 61mm

35˚ 309˚ 288˚ 260˚ 237˚ 222˚ 212˚ 206˚ 37mm 34mm 35mm 40mm 47mm 55mm 64mm

Vert

ical

Ang

le D

esir

ed

Right Condyle 120mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 121˚ 97˚ 69˚ 49˚ 37˚ 29˚ 24˚ 37mm 34mm 35mm 40mm 47mm 55mm 64mm

20˚ 140˚ 102˚ 52˚ 30˚ 20˚ 15˚ 13˚ 29mm 23mm 26mm 34mm 43mm 52mm 61mm


30˚ 220˚ 258˚ 308˚ 330˚ 340˚ 345˚ 347˚ 29mm 23mm 26mm 34mm 43mm 52mm 61mm

35˚ 239˚ 263˚ 291˚ 311˚ 323˚ 311˚ 356˚ 37mm 34mm 35mm 40mm 47mm 55mm 64mm

Vert

ical

Ang

le D

esir

ed

23

Left Condyle 150mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 64˚ 90˚ 117˚ 134˚ 146˚ 152˚ 157˚ 42mm 39mm 42mm 49mm 59mm 69mm 79mm

20˚ 46˚ 91˚ 135˚ 153˚ 161˚ 166˚ 168˚ 31mm 26mm 31mm 42mm 53mm 65mm 76mm


30˚ 314˚ 269˚ 225˚ 207˚ 199˚ 194˚ 192˚ 31mm 26mm 31mm 42mm 53mm 65mm 76mm

35˚ 296˚ 270˚ 243˚ 226˚ 214˚ 208˚ 203˚ 42mm 39mm 42mm 49mm 59mm 69mm 79mm

Vert

ical

Ang

le D

esir

ed

Right Condyle 150mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 116˚ 90˚ 63˚ 46˚ 34˚ 28˚ 23˚ 42mm 39mm 42mm 49mm 59mm 69mm 79mm

20˚ 134˚ 89˚ 45˚ 27˚ 19˚ 14˚ 12˚ 31mm 26mm 31mm 42mm 53mm 65mm 76mm


30˚ 226˚ 271˚ 315˚ 333˚ 341˚ 346˚ 348˚ 31mm 26mm 31mm 42mm 53mm 65mm 76mm

35˚ 244˚ 270˚ 297˚ 314˚ 326˚ 332˚ 337˚ 42mm 39mm 42mm 49mm 59mm 69mm 79mm

Vert

ical

Ang

le D

esir

ed

Left Condyle 180mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 68˚ 95˚ 120˚ 137˚ 147˚ 153˚ 158˚ 47mm 44mm 49mm 58mm 70mm 82mm 95mm

20˚ 51˚ 101˚ 140˚ 155˚ 162˚ 166˚ 169˚ 33mm 29mm 37mm 50mm 64mm 78mm 91mm


30˚ 309˚ 259˚ 220˚ 205˚ 198˚ 194˚ 191˚ 33mm 29mm 37mm 50mm 64mm 78mm 91mm

35˚ 292˚ 265˚ 240˚ 223˚ 213˚ 207˚ 202˚ 47mm 44mm 49mm 58mm 70mm 82mm 95mm

Vert

ical

Ang

le D

esir

ed

Right Condyle 180mm


0˚ 5˚ 10˚ 15˚ 20˚ 25˚ 30˚

15˚ 112˚ 85˚ 60˚ 43˚ 33˚ 27˚ 22˚ 47mm 44mm 49mm 58mm 70mm 82mm 95mm

20˚ 129˚ 79˚ 40˚ 25˚ 18˚ 14˚ 11˚ 33mm 29mm 37mm 50mm 64mm 78mm 91mm


30˚ 231˚ 281˚ 320˚ 335˚ 342˚ 346˚ 349˚ 33mm 29mm 37mm 50mm 64mm 78mm 91mm

35˚ 248˚ 275˚ 300˚ 317˚ 327˚ 333˚ 338˚ 47mm 44mm 49mm 58mm 70mm 82mm 95mm

Vert

ical

Ang

le D

esir

ed

25

Appendix E – Anatomical InfluencesIndividual anatomical anomalies and variations (such as a large and prominent sella turcica, an extreme roof angle of the glenoid fossa, and the depth and direction of the external auditory meatus or ear canal in relation to the external auditory meatus on the cranium) are some fac-tors that adversely affect film definition, the actual relationship of the condyle to the glenoid fossa and the accurate orientation of the ear rods to the auriculor point.

The decision to use a technique other than what was previously outlined under Section III, parts A to G must be made on the premise that film resolution is satisfactory, but either another view is desired to verify or refute a question-able anomaly, a repositioning of the TMJ is desired to reduce scatter from adjacent anatomi-cal structures or the standard series taken war-rants a "corrected" view(s). Film resolution is a property of proper exposure and processing. Repositioning of the TMJ will not increase film resolution.

When utilizing one of the following techniques, it is recommended that one "Scout" exposure be

taken of the TMJ in question to assure the proper technique prior to proceeding with a six-expo-sure series.

Optional Adjustments1. Placing the adjustable ear rod into the ear

canal to its maximum position orients the head towards the film and in most instances directs the central ray posterior to the sella turcica and zygomatic arch. Relocating the adjustable plastic ear plug on the adjustable ear rod from its 0 mm position to a more posterior point along the 20 mm scale and reinserting it to its maximum position as before will direct the central ray further anterior and superimposi-tion of the sella turcica and/or zygomatic arch should be reduced.

2. For the patient with a significant bilateral auricular discrepancy, the dial on the twin axis adjustment wheel can be adjusted from its normal position of 0 or 180 degrees to a more comfortable position. When adjusting, it is important to maintain mid-sagittal plane symmetry and have the adjustable ear rod inserted to its maximum position.

Appendix F – Accurate Head StabilizationIt is imperative that a tight object-to-film rela-tionship is maintained. Reducing this distance will result in less distortion, less magnification and a sharper image of the condylar head. Failure to maintain this relationship will generally result in an acceptable image of the glenoid fossae, but will result in a blurred, magnified and distant appearance of the condylar head. The reason for this is that the condylar head is anatomically fur-ther away from the film cassette than the glenoid fossae and the patient’s failure to hold his head tightly against the cassette holder will exagger-ate the effect.

In order to ensure an optimum object-to-film relationship, the patient must be instructed to insert the adjustable ear rod to its maximum extension. This can be done most effectively by the patient. The patient must be instructed as follows:

1. When radiographing the right side, instruct the patient to place the right hand on the right shoulder with palm up.

2. Grasp the cassette holder and place the fixed ear piece in the right ear canal.

3. The operator brings the adjustable ear rod into the left ear hole.

4. The patient brings the left hand up to the left ear to grasp the wheel. He inserts the ear rod into the ear hole to its maximum position.

5. With the ear plug in its innermost position, hold slight pressure on the end of the adjust-able ear rod shaft as the operator tightens the lock nut.

6. If the patient cannot close into maximum intercuspation at this point, back out the ear rod only until the point where they can com-fortably achieve maximum intercuspation.

26

7. Adjust the nasion support to support the patient with the Frankfort Plane parallel to the floor.

8. If the patient properly inserts the adjustable ear rod into its maximum extension, the nasi-on settings should be identical left and right. There may be a 1 - 2 mm discrepancy on the horizontal scale, which is acceptable. If the

discrepancy is significant by 5 or more, it indicates either a severe auricular discrepancy or improper insertion of the adjustable ear rod into the ear hole.

If the anatomical detail continues to be unac-ceptable and the instructions have been followed, review the suggested darkroom procedures in Appendix B.

Appendix G – Manufacturer’s NotesX-ray open-end cones are designated 8", 12" and 16" for the techniques they allow. For exam-ple, the "8-inch cone" is typically 5-6 inches in length. The cathode tube is recessed in the tube-head the remaining 2-3 inches.

S.S. White Company Units1. The "Long Beam" tubehead utilizes a recessed

cathode tube for a 16" technique in a standard size tubehead. The 16" "Long Beam" can be identified by either a label on the external oil cap and/or by the absence of an aluminum filter (2 3/4" disc) where the cone attaches to the tubehead.

2. The "Intrex," like the "Long Beam," also uti-lizes a 16" technique. As the "Intrex" is of the capacitor discharge type, the suggested expo-sure time for a 70 KVP 10 Ma may overex-pose the film. Select a proper exposure tech-nique following the "Scout" film procedure.

Philips "Oralix-65" X-Ray Unit1. Due to the offset yoke utilized, the strap and

chain support assembly of the Accurad-200 assembly is non-functional. The Accurad-200 tubehead assembly must either be supported by the patient or the strap/chain assembly must be custom adapted to attach to the top plate of the X-ray arm.

2. Due to the "Oralix-65" exposure time system, a suggested technique has been computed. Select the proper exposure technique for your unit by following the "Scout" film procedure and using the formula shown in Section V – Exposure Charts.

Siemens Heliodent 70 Unit1. Due to the offset yoke utilized, the strap and chain support assembly of the Accurad-200 assembly is non-functional. The Accurad-200 tubehead assembly must either be supported by the patient or the strap/chain assembly must be custom adapted to attach to the top plate of the X-ray arm.

27

V. Exposure Charts

A. Philips Oralix-65 Exposure Chart

Lanex Rare Earth Intensifying Screens/OG Film Patient Type Film Type Mas Adult Male (Large Head) 1.34 2.2 3.4 Adult Male (Average Head) 1.34 2.2 2.6 Adult Female 1.34 3.2 1.5 Child (Large Head) 1 1.5 1.5 Child (Small Head) 1 1 1.5

Exposure Time (seconds) = (Film Type x Patient Type x Mas) ÷ 7.5

This chart is intended to be used only as a general guide to radiographic exposure times, bone structure, size, and weight of the patient should be taken into consideration and exposure times varied accordingly. All film results are based on good darkroom procedures and fresh solutions. Note: For lighter pictures, reduce exposure time, for darker pictures, increase exposure time.

28

B. D

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50 5

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0 80

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29

20

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29

D. Conversion Chart for Time Intervals in Seconds for Dental X-Ray Machines

The following chart simplifies the change from frac-tions to decimals to impulse intervals. These compu-tations are listed for a single-phase, half-wave recti-fied, 60-hertz generator.

Fractions Decimals Impulses1/60. . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . . .11/30. . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . . .21/20. . . . . . . . . . . . . 0.05 . . . . . . . . . . . . . . . . .31/15. . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . . .41/12. . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . . .51/10. . . . . . . . . . . . . 0.10 . . . . . . . . . . . . . . . . .61/82/15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83/20. . . . . . . . . . . . . 0.15 . . . . . . . . . . . . . . . . .91/6. . . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . .101/5. . . . . . . . . . . . . . 0.20 . . . . . . . . . . . . . . . .121/4. . . . . . . . . . . . . . 0.25 . . . . . . . . . . . . . . . .154/153/10. . . . . . . . . . . . . 0.30 . . . . . . . . . . . . . . . .181/3. . . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . .207/20. . . . . . . . . . . . . 0.35 . . . . . . . . . . . . . . . .213/82/5. . . . . . . . . . . . . . 0.40 . . . . . . . . . . . . . . . .245/129/20. . . . . . . . . . . . . 0.45 . . . . . . . . . . . . . . . .277/151/2. . . . . . . . . . . . . . 0.50 . . . . . . . . . . . . . . . .308/1511/20. . . . . . . . . . . . 0.55 . . . . . . . . . . . . . . . .337/123/5. . . . . . . . . . . . . . 0.60 . . . . . . . . . . . . . . . .365/813/20. . . . . . . . . . . . 0.65 . . . . . . . . . . . . . . . .392/3. . . . . . . . . . . . . . 0.00 . . . . . . . . . . . . . . . .407/10. . . . . . . . . . . . . 0.70 . . . . . . . . . . . . . . . .4211/153/4. . . . . . . . . . . . . . 0.75 . . . . . . . . . . . . . . . .454/5. . . . . . . . . . . . . . 0.80 . . . . . . . . . . . . . . . .4817/20. . . . . . . . . . . . 0.85 . . . . . . . . . . . . . . . .5113/157/89/10. . . . . . . . . . . . . 0.90 . . . . . . . . . . . . . . . .5411/1214/1519/20. . . . . . . . . . . . 0.95 . . . . . . . . . . . . . . . .571 . . . . . . . . . . . . . . . 1.00 . . . . . . . . . . . . . . . .601-1/4 . . . . . . . . . . . . 1.25 . . . . . . . . . . . . . . . .751-1/2 . . . . . . . . . . . . 1.50 . . . . . . . . . . . . . . . .90

VI. WarrantyWhip Mix Corporation warrants the Accurad-200 to be free from defects in material and/or work-manship for a period of one year. In the event of a defect, please notify the factory in writing of the defect prior to returning the instrument. Whip Mix Corporation will, at its option, either repair, replace or issue credit for such defects.Because Whip Mix Corporation is continu-ally advancing the design of its products and manufacturing methods, it reserves the right to improve, modify or discontinue products at any time, or to change specifications or prices with-out notice and without incurring obligations.

VII. Care and MaintenanceThe Accurad™-200 headholder is a sturdy instrument that should provide long and depend-able use. Rubbing alcohol may be used to clean all parts of the instrument, including the plastic window. Care should be taken not to jar or bend the upper horizontal rods of the instrument. If the Accurad™-200 headholder is dropped it needs to be returned to the factory for repair.When not in use, the Accurad™-200 headholder should be stored in a clean, dry atmosphere free of plaster and carborundum dust. Storage must not be near acids, alkalies, or medicaments since their fumes may be of a corrosive nature to the instrument.Your cassette is also a precision instrument and should be treated properly. To make sure you get the longest possible use from your cassette, always follow these simple rules:1. Don’t place it where it can be knocked to the

floor, or where heavy objects can fall on it. It is durable but not unbreakable.

2. Promptly remove processing solutions with a soft, dry cloth. The cassette should always be kept dry.

3. The inside of the cassette should always be kept clean. Intensifying screens should be cleaned in accordance with manufacturer’s recommendations.

Nasion and Fixed/Adjustable Ear Rod – Non-sterile. Disinfect before each use.

30

VIII. Bibliography1. "A Headholder for Oriented Temporoman-dibular Joint Radiographs," William A. Buhner, DDS, Journal of Prosthetic Dentistry, Vol. 29, No. 1, pp 113-117, January, 1972

2. "Statistical Study of the Angle Formed by the Lateral Part of the Mandibular Condyle and the Horizontal Plane," G. Preti, MD, DDS, Journal of Prosthetic Dentistry, Vol. 50, No. 4, pp 571-575, October 1983.

3. "Transcranial Radiography: Contours of the Condyle and Fossa of the TMJ," Stacy V. Cole, DDS, Journal of Craniomandibular Practice, Vol. 1, Number 4, pp 33-36, September 1983 - November 1983.

4. "Transcranial Radiography: Correlation Between Actual and Radiographic Joint Spac-es," Stacy V. Cole, DDS, Journal of Cranioman-dibular Practice, Vol. 2, Number 2, pp 153-158, March 1984 – May 1984.

Whip Mix Corporation - West 1730 East Prospect Rd., Suite 101 Fort Collins, CO 80525 Toll-Free: 800-201-7286 Fax: 970-472-1793 www.whipmix.com

EU Representative Whip Mix Europe GmbH Raudestraße 2 D-44141 Dortmund Germany Phone: 49 231 567 70 8-0 Fax: 49 231 567 70 8-50

©2008 Whip Mix Corporation

Whip Mix®, Denar®, and logos are registered trademarks and Accurad is a trademark of Whip Mix Corporation. Kodak® is a registered trademark of Eastman Kodak Company.

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