Extraoral Radiographic Technique, An Alternative Approach

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Extraoral Radiographic Technique: An Alternative Approach

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

The inability of certain patient populations to ac-

cept intraoral films and/or sensors can cause com-

plications in the performance of endodontic ther-

apy. An alternative technique (extraoral film

placement) can be used to obtain clinically diag-

nostic radiographs. This article describes the al-

ternative 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 radiogra-

phy. 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. Developmentally disabled patients

2. Patients with exaggerated gag reflex

3. Pediatric patients

4. Dental phobic patients

5. Trauma/trismus patients

FIG 1. Extraoral radiographic technique for the maxillary arch. FIG 2. Extraoral radiographic technique for the mandibular arch.

JOURNAL OF ENDODONTICS Printed in U.S.A.

Copyright © 2003 by The American Association of Endodontists VOL. 29, NO. 6, JUNE 2003

419



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 per-

pendicular to the sensor to provide an accurate image.

5. Increasing the exposure time may be necessary when conven-

tional 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):

1. The patient is sitting upright.

2. The patient’s 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 thehorizontal. Additionally, the X-ray cone must be aligned per-

pendicular to the sensor to provide an accurate image.

5. Increasing the exposure time may be necessary as described

above.

Case 1

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. Thepatient was well behaved but was unable to tolerate the sensor in

FIG 3. Extraoral technique for a working radiograph of tooth #3 with

the rubber dam in place.

FIG 4. Maxillary working length.

FIG 5. Extraoral techniquefor a postoperative radiograph of tooth #3.

FIG 6. Maxillary postoperative.

420 Newman and Friedman Journal of Endodontics



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

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 end-

odontic 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 resolu-

tion 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 theDirector of Endodontics, State University of New York at Stony Brook, StonyBrook, NY. Address requests for reprints to Scott Whitney, DDS, School ofDental Medicine, 140 Rockland Hall, State University of New York at StonyBrook, Stony Brook, NY 11794.

References

1. Glickman NG. Preparation for treatment. Principles of endodontic ra-diography. 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 J1974;19:306–7.

3. Poyton HG, Fireman SM Poyton HG, Fireman SM. The oblique lateralradiographic projection in dental practice. J Can Dent Assoc 1974;40:727–31.

FIG 8. Mandibular preoperative.

FIG 9. Mandibular postoperative.

FIG 7. Extraoral technique for pre- and postoperative radiographs of

tooth #19.

Vol. 29, No. 6, June 2003 Extraoral Radiographic Technique 421

Extraoral Radiographic Technique, An Alternative Approach

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