U N IV ERS IT Y O F M O S U L

CO LLEG E O F D EN T IS T RY

Interpretation 2020-2021

Of Endodontic Radiograph

5 th YEARs

Department of
Conservative
By :Dr Ali Moayid Dentistry
 UNIVERSITY OF MOSUL

COLLEGE OF DENTISTRY

Imaging and imaging interpretation are essential to the

.contemporary practice of endodontics for:

Diagnosis During Treatment outcome assessment

Or Recall

the clinician must have knowledge of the normal imaging

appearance of anatomy and morphology of maxillofacial
structures such as teeth, jaws, articulation, and sinuses, as well
as of common pathologic conditions affecting these structures.
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COLLEGE OF DENTISTRY

2020-2021
Commonly used imaging modalities used in endodontic
practice have included intraoral dental radiographs ,
panoramic radiography, and more recently cone-beam
computed tomography (CBCT).

One of the most important advantages of any of the aforementioned

imaging techniques is that it provides the clinician with visualization
of hard tissue anatomy, or pathology, not normally visible by clinical
examination alone.
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COLLEGE OF DENTISTRY

Basic radiographic concepts

1- X-rays are similar to light rays in that both travel in a straight line
until deflected or absorbed. Deflected rays reduce image clarity.
2- The radiograph is a shadow image representing differences in a
density of objects in the x-rays path. Therefore, the radiograph is a
two dimensional image of a three dimensional structure.
3.The size, shape and contrast of the shadow image are subjected
to many distortions since they are dependant on the physical
properties of: a) The object through which the x-ray passes. b) The
radiation source. c) The film on which the image is recorded

Various states of pulpal pathosis are indistinguishable in an X-ray

shadow.
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COLLEGE OF DENTISTRY

Sometimes a teeth may become symptomatic but show no radiographic changes; thus,
the lack of radiolucency should not be interpreted as an absence of a bone resorbing
process .
Neither healthy nor necrotic pulps cast an unusual image .
Furthermore, periapical soft tissue lesions cannot be accurately diagnosed by
radiographs; they require histologic verification. Chronic inflammatory tissue cannot be
differentiated from healed, fibrous, “scar ”tissue, nor can a differential diagnosis of
periapical radiolucencies.

In fact, investigators have demonstrated that lesions of the medullary bone often go
undetected unless there is marked resorption or until the resorption has eroded a
portion of the cortical plate
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COLLEGE OF DENTISTRY

There was more disagreement than agreement among the

different examiners. 2020-2021

Information obtained from proper interpretation of the radiograph

is not always absolute and must be always integrated with
information gathered from a detailed medical and dental history,
clinical examination, and pulp testing procedures .
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COLLEGE OF DENTISTRY

Suggestions for good endodontic radiography

1- For periapical exposures the edge of the film is positioned parallel to and near the
incisal or occlusal surface of the teeth so that the tooth apices are near the center of
the film. On the other words ,it is preferable to align the cone so the beam strikes
the film at a right angle. This alignment ensures a fairly accurate vertical image.
Elongation of an image, however, may be corrected by increasing the vertical angle
of the central ray. Conversely, foreshortening is corrected by decreasing the vertical
angle of the central ray.
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COLLEGE OF DENTISTRY

2- The plastic film holder facilitates standardization of a

radiographic technique by aiding in film positioning and
preventing movement of the film during exposure.

3- Because of the angle of the hard palate the films that

are held by the finger usually show maxillary molars
with short buccal roots and very long palatal root.
Frequently, an impinging palatal vault prevents parallel
alignment of the film and the teeth. However, if the film
angle is no greater than 20° in relation to the long axis
of the teeth, and the beam is directed at a right angle to
the film.
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COLLEGE OF DENTISTRY
Horizontal Angulation
Walton introduced an important refinement method in dental
radiography. By this method overlying canals may be separated,
and by applying Clark’s rule, the separate canals may then be
identified. Clark’s rule states that “the most distant object from
the cone (lingual/palatal) moves toward the direction of the
cone.”
in another way, Clark’s rule has been referred to as the Same
Lingual, Opposite Buccal (SLOB) rule: the object that moves in
the Same direction as the cone is located toward the Lingual.
The object that moves in the Opposite direction from the cone is
located toward the Buccal. The SLOB rule, simply stated, is “The
lingual object follows the tube head.”

Ingle’s rule is MBD : If “shot” from the Mesial, the Buccal root
will be to the Distal
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COLLEGE OF DENTISTRY

2020-2021
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COLLEGE OF DENTISTRY
Horizontal Cone Angulations
For working and/or diagnostic radiographs, the
following cone angles are preferred:
.1Maxillary anterior teeth (straight facial).
.2Maxillary premolars and molars (mesial angle)
3. Mandibular incisor teeth (distal angle).
4. Mandibular canines (mesial angle).
5. Mandibular premolars (mesial).
6. Mandibular molars (distal)..
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Mandibular Molars COLLEGE OF DENTISTRY

Through the Walton projection (SLOB) , however, the roots will “open up. 2020-2021
”
Mandibular Molars
”This is done by directing the central beam 20° to 30 °from either the distal or the mesial (Figure 9A-11A .(
By applying Ingle’s rule (MBD: project the central beam from the mesial ), the buccal canals are toward the
distal , the lingual canals toward the mesial .
Another point concerns a frequent mistake in “reading ”periapical radiographs.
Roots containing two canals are often hourglass shaped. When an X-ray beam passes
directly through this structure (center image), the buccal and lingual portions of the
root are in the same path (arrows). These will change with distal and mesial projection.
Because a double thickness of tooth structure is penetrated by the X-rays, it is seen in
the film as a radiopaque root outline in close contact with the lamina dura .
By aiming the cone 20 °from the mesial, however, the central beam passes through the hourglass-shaped root
at an angle (Figure 9A-14 .(In this case, the two thicknesses of the root are projected separately onto the film.
Because less tooth structure is penetrated by the X-ray, the image on the film is less dense. A radiolucent line is
clearly seen (open arrow). This radiolucent line can be erroneously interpreted as a canal. By following up the
length of the line, instead of entering the pulp chamber, the line can be traced to the gingival surface of the root;
this is the PDL space. This simple interpretive error can easily lead to gross mistakes.
Mandibular Premolars
The importance of varying the horizontal angulation for mandibular premolars is demonstrated in Figure 9A-
15A. The central beam is directed at a right angle to the film. What appears to be a single straight canal is
discernible in each premolar (Figure 9A-15B) .
Mandibular Premolars
There is an indication, however, in the image of the first premolar that the canal might bifurcate at the
point of the abrupt change (“fast break.(worra) ytisned ni (” Directing the central ray 20° from the mesial
in the first premolar (Figure 9A-16A) causes the bifurcation to separate into two canals (Figure 9A-16B).
The tapering outline of the tooth, seen in both projections, would indicate, on the other hand, that the
two canals undoubtedly rejoin to form a common canal at the apex. In both the right-angle and 20°
variance projections, the second premolar appears as a single canal.
Maxillary Molars
Maxillary molars are consistently the most difficult to radiograph because of
(1) their more complicated root and pulp anatomy ,
(2) the frequent superimposition of portions of the roots on each other) ,
(3) the superimposition of bony structures (sinus floor, zygomatic process) on root structures, and
(4) the shape and depth of the palate.
Each of these, singly or in combination, can be a major impediment.
Maxillary Molars
the complex root anatomy and superimpositions may be dealt with by varying the horizontal angulations.
Film placement must be parallel to the median raphe, not to the posterior maxillary arch. The standard
right-angle projection for a maxillary first molar, illustrated in Figure 9A-17A, produces the image seen in
Figure 9A-17B, where in the zygomatic process is superimposed on the apex of the palatal root (arrow) and
the distobuccal root appears to overlie the palatal root. The sinus floor is also superimposed on the apices
of both the first and second molars.
When the horizontal angulation is varied by °20to the mesial (Figure 9A-18A), the zygomatic process is
“moved ”to the distal of the first molar and the distobuccal root is cleared of the palatal root (Figure 9A-
18B, arrows). The mesial projection also better “opens ”the mesiobuccal root to demonstrate both canals.
The opposite projection can also be used to isolate the mesiobuccal root of the first molar, that is, the
central ray may be projected from 20° distal to the right angle 9 erugiF)A-19A). Although this projection
distorts the shape of the mesiobuccal root, it also isolates it (Figure 9A-19B), so that the canal is readily
discernible (arrow). In addition, the zygomatic process is moved completely away from any root
structure, including the second molar. The same technique illustrated here for the maxillary first molar
can be applied to the second or third molars .
Maxillary Premolars
Variance in the horizontal projection has great value in maxillary premolar radiography, particularly for the
first premolar, that generally has two roots and canals, but sometimes three. The clinical efficacy of the
Walton (SLOB) technique is well illustrated in Figure 9A-20 The right-angle horizontal projection produces
the single canal image seen in Figure9A-20A. By varying the angulation by 20 ,°however, the
two canals are separated (Figure 9A-20B), giving an unobstructed view of the obturation quality in both
canals.
Mandibular Anterior Teeth
Aberrations in canal anatomy in the mandibular anterior teeth are not uncommon. Variance of the horizontal
X-ray projections in this region will bring out the differences. Figure 9A-21A illustrates the standard X-ray
projection bisecting the film held parallel to the arch. The incisor teeth appear to have single canals.
However, a deep single canal is seen in the distorted canine image (Figure 9A-21B).
By varying the film placement and projecting directly through the canine, as seen in Figure 9A-22A (about 30°
variance for the incisors), separate canals appear in the incisors (Figure 9A-22B, arrow); the canals join at the
apex. This would be expected. However, when viewing the tapered incisor roots seen in both horizontal
projections, the roots are far too narrow to support two separate canals and foramina. Once again, the abrupt
change in canal radiodensity in the premolars (arrow) indicates a canal bifurcation.
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Maxillary Anterior Teeth

COLLEGE OF DENTISTRY

Although canal or root aberrations appear less

frequently in the maxillary anterior teeth, root
curvature in the maxillary lateral incisors is a
particularly vexing problem .Also for example, how
difficult it is to determine when foramina exit to the
labial or lingual. Their radiographs of extracted teeth
matched with photographs of instrument perforation
short of the apex are a warning to all (Figure 9A-23).
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COLLEGE OF DENTISTRY

Panoramic radiography also represents a 2-D image of 3-D anatomy

that again has some limitations It also contains artifacts and unique
distortions that can further complicate panoramic interpretation.
Digital radiography UNIVERSITY OF MOSUL

COLLEGE OF DENTISTRY
Digital radiography used in dentistry is available in three variations:
1) Direct digital system: It uses a solid-state sensor such as a charge coupled device (CCD). These systems
have a cable that connects the sensor to the computer and in turn to screen monitor.
2) Storage phosphor system: It uses a photo stimulable phosphor plate that stores the image in the phosphor
for subsequent readout by an extra oral laser scanner.
3) Indirect digital system: It uses a scanning device connected to a computer for digitizing traditional silver
halide dental films.

Advantage of digital radiography: 1) Image enhancement, contrast stretching and reversing. 2) Storage for
further use and evaluation. 3) Retrieval immediately. 4) Transmission of images to remote sites in a digital
format. 5) Radiation exposure is reduced from 50% to 90% compared with conventional filmbased
radiography.

Disadvantages: 1) High initial cost. 2) Reduction

in image quality when compared with
conventional radiography.
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COLLEGE OF DENTISTRY

THE ADVENT OF CBCT AND THE THIRD PLANE OF VISUALIZATON

CBCT has been optimized for dental applications. Smaller fields of view and higher resolution scans
appear to be ideal for endodontic use and may impact the nature of endodotic practice and
radiographic decision-making in the near Future. One of the disadvantages of CBCT use is cost and
access to the technology. However, with time, costs should continue to decrease and access to
increase
 UNIVERSITY OF MOSUL

COLLEGE OF DENTISTRY

2020-2021

A major advantage of CBCT is the visualization of anatomic

structures in three planes, generally referred to as coronal,
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euqilbo dna cimaronap rof swolla osla ygolonhcet
cfiiceps-cimotana ot notiidda ni snoticurtsnocer
)JMT( tnioj ralubidnamoropmet sa hcus gnttiamrofer
eht devorpmi sensitivity and specificity of accurately
detecting lesions or conditions affecting the jaws
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COLLEGE OF DENTISTRY

Currently, CBCT imaging is generally recommended for endodontic cases in 2020-2021

which conventional dental radiographs may not yield adequate information
UNIVERSITY OF MOSUL

COLLEGE OF DENTISTRY

2020-2021
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COLLEGE OF DENTISTRY

Information gained from the radiograph

1- The crown and pulp anatomy
2- Hard tissue alterations in the tooth (sclerosis or resorption)
3- Number, size, location and direction of the roots
4- Estimation of the working length
5- Related anatomical structures as mental foramen, maxillary
sinus etc…
6- Confirm position of master cone
7- Evaluation of success of obturation 8- Instrument separations or
perforations.
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COLLEGE OF DENTISTRY

They are obviously essential, but are frequently overused and/ or

misinterpreted .
For these reasons, it is important not to exclude the possibility of pulpal pathosis in
situations in which there are no radiographic changes
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THE END COLLEGE OF DENTISTRY

Hope to you life without apical pathosis