JOURNAL OF ENDODONTICS Copyright 2003 by The American Association of Endodontists

Printed in U.S.A. VOL. 29, NO. 6, JUNE 2003

Extraoral Radiographic Technique: An Alternative Approach

Michael E. Newman, DDS, and Seymour Friedman, DDS

The inability of certain patient populations to accept intraoral films and/or sensors can cause complications in the performance of endodontic therapy. An alternative technique (extraoral film placement) can be used to obtain clinically diagnostic radiographs. This article describes the alternative technique.

The need for radiographs in all phases of endodontic therapy has been well established. The clinician has a variety of aids to facil-

itate a diagnostic radiograph. Most of these aids (i.e. Rinn XCP holders, snap-a-ray, etc.) rely on conventional intraoral radiography. In this technique, the film is placed lingual to the tooth. The X-ray cone is placed directly buccal to the tooth causing the X-ray beam to pass through the tissues, exposing the film (1). Some patients are unable to tolerate the conventional intraoral technique. This group has increased in size with the advent of digital radiography. The digital sensor is larger and more rigid than a standard X-ray film. The authors have found certain patients have difficulty with the added bulk of the sensor. An alternative procedure may be utilized while performing endodontic therapy for these patients. Possible indications for this alternative technique include: 1. 2. 3. 4. 5. Developmentally disabled patients Patients with exaggerated gag reflex Pediatric patients Dental phobic patients Trauma/trismus patients

FIG 1. Extraoral radiographic technique for the maxillary arch. 419

FIG 2. Extraoral radiographic technique for the mandibular arch.

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1. The patient is sitting upright. 2. The patients chin is raised, which allows the X-ray beam to pass to the sensor unobstructed, thus avoiding superimposition of the contralateral tissues on the image. 3. The sensor is placed on the external surface of the cheek, directly buccal to tooth. A cotton roll is placed between the sensor and the cheek to parallel the sensor with the buccal surface of the tooth. 4. The X-ray cone is angled approximately 35 degrees from the horizontal. Additionally, the X-ray cone must be aligned perpendicular to the sensor to provide an accurate image. 5. Increasing the exposure time may be necessary as described above. Case 1
FIG 3. Extraoral technique for a working radiograph of tooth #3 with the rubber dam in place.

A 16-yr-old male was referred for endodontic treatment of tooth #3. The patient had an exaggerated gag reflex and was unable to tolerate the sensor against the palate. The extraoral technique was utilized for both working lengths (Figs. 3 and 4) and preoperative and postoperative radiographs (Figs. 5 and 6). Case 2 An 8-yr-old female was referred for treatment of tooth #19. The patient was well behaved but was unable to tolerate the sensor in

FIG 4. Maxillary working length.

Technique The extraoral technique can be utilized for both maxillary and mandibular teeth. It can be used both with and without the rubber dam in place (2, 3). Maxilla (Fig. 1): 1. The patient is sitting upright. 2. His/her mouth is open as wide as possible. This allows the X-ray beam to pass to the sensor unobstructed from the opposite side of the mouth. Consequently, superimposition of the contralateral tissues on the image is avoided. 3. The sensor is placed on the external surface of the cheek, directly buccal to tooth. A cotton roll is placed between the sensor and the cheek to parallel the sensor with the buccal surface of the tooth. 4. The X-ray cone is angled approximately 55 degrees from the horizontal. Additionally, the X-ray cone must be aligned perpendicular to the sensor to provide an accurate image. 5. Increasing the exposure time may be necessary when conventional radiographs are used. Digital radiography may not require an increase in exposure time because the image can be adjusted digitally within radiographic software programs. Mandible (Fig. 2):
FIG 6. Maxillary postoperative.

FIG 5. Extraoral technique for a postoperative radiograph of tooth #3.

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Extraoral Radiographic Technique

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FIG 9. Mandibular postoperative. FIG 7. Extraoral technique for pre- and postoperative radiographs of tooth #19.

image for patients who are unable to tolerate the placement of intraoral films or sensors. The technique may be utilized with the rubber dam in place, making it applicable for all phases of endodontic therapy. Patients tolerate the procedure well, preferring it to conventional intraoral radiography. The most important advantage may be that the technique permits appropriate endodontic films for patients who previously could or would not tolerate intraoral films. The possible disadvantage of an increase in radiation to the patient is generally negated by the reduction in the number of unacceptable films taken intraorally. A slight decrease in resolution may be noted; however, this does not affect the diagnostic quality of the images. This technique is not meant to replace conventional intraoral radiography. It is a useful supplement to add to our clinical practice.
Dr. Newman is a former second year resident and Dr. Friedman is the Director of Endodontics, State University of New York at Stony Brook, Stony Brook, NY. Address requests for reprints to Scott Whitney, DDS, School of Dental Medicine, 140 Rockland Hall, State University of New York at Stony Brook, Stony Brook, NY 11794.

FIG 8. Mandibular preoperative.

the floor of the mouth. She became agitated and upset when a conventional periapical radiograph was attempted. A decision was made to utilize the extraoral technique (Figs. 7, 8, and 9), and the patient tolerated the procedure well as a result. DISCUSSION Extraoral radiography is an efficient technique for achieving diagnostic films in a select population of patients. The technique is a simple method that allows the clinician to capture an appropriate

References 1. Glickman NG. Preparation for treatment. Principles of endodontic radiography. In: Cohen S, Burns RC, eds. Pathways of the pulp. 7th ed. St. Louis: CV Mosby, 1998:89 102. 2. Fisher D. Extraoral radiographic technique of third molars. Aust Dent J 1974;19:306 7. 3. Poyton HG, Fireman SM Poyton HG, Fireman SM. The oblique lateral radiographic projection in dental practice. J Can Dent Assoc 1974;40:72731.