17

American Journal
Medical Science
www.arnaca.com

of

Advances

in

Vol-1: No-1: 2013

Original Research Article

Endodontic applications of extra

oral periapical radiography

.
*1

Suman Yadav, 2Harish Yadav,

1
3
Monika
Varshney,
Atul
Kaushik
1

Department
of
Conservative
Dentistry and Endodontics, SGT
Dental College and Hospital,
Gurgaon, Haryana, India.
2
Department of Prosthodontics,
SGT Dental College and Hospital,
Gurgaon, Haryana, India.
3
Department of Oral Medicine and
Radiology, SGT Dental College
and Hospital, Gurgaon, Haryana,
India.
drmonikakaushik@gmail.com
+91 - 9540606555

Key Words: Extra oral radiographic

technique, beam aiming device, periapical
radiography, endodontics

Abstract
Intra-oral periapical (IOPA) radiographs
form an integral part of endodontic
treatment for management of various dental
pathologies. However to assist certain
patient populations who are unable to
tolerate intraoral films and/or sensors, an
alternative technique (extraoral film
placement) has been introduced by Newman
and Friedman in 2003 and later improvised
by few authors. In the present study, we
validate
and
reintroduce
extra-oral
periapical (EOPA) radiography as an
effective approach in endodontics for a wide
spectrum of patients where conventional
IOPA radiography is not feasible

Vol-1: No-1: 2013

18

Figure-1A

Figure-1B

rubber
dam
during
intraoral
radiography[3,4]. EOPA technique can be
effectively utilized in such patients as the
film is placed extra-orally and the technique
is patient-friendly [5].
Endodontic therapy can be required in the
above mentioned patient population group
where IOPA radiography may prove to be
very difficult. Hence, the present study was
carried out to validate, implement and reintroduce EOPA radiography technique
during various endodontic procedures.
2.0 Materials and Methods
This study was carried out in the
Department of Conservative Dentistry and
Endodontics using EXPLOR-70 dental xray unit (Confident Dental Equipments,
India,70
KVp,8mA,2mm
aluminium
filtration) and Kodak E-speed films number2 for adult patients (Eastman Kodak Co,
France, 31x41 mm). The technique was
initially tried on dry skulls with full
complement of upper and lower teeth. Once
the exposure parameters were standardized,
the technique was adapted on patients.
Approval from the ethical committee was
obtained.

Figure-2A

Figure- 1A: Placement of EOPA film holder for radiographing maxillary premolars and
molars.
Figure- 1B: Placement of EOPA film holder for radiographing mandibular premolars and
molars.
Figure- 2A: Preoperative diagnostic EOPA radiograph for 24, 24, 25 and partially 26.
The procedure was explained to the patients
and informed consent was taken. Initially,
Newman and Friedman used cotton rolls

between cheek and film/sensor to parallel

the film with the buccal surface of the tooth.
In 2007 Chia-Hui Chen et al devised a

Original Research Article

1.0 Introduction
IOPA radiographs are the main aid for
diagnosis and follow up of various
dentofacial pathologies such as periapical
infections, periodontal status, tooth and
dentoalveolar fractures, assess the presence
and position of unerupted teeth, assessment
of root morphology during endodontic
procedures, preoperative assessment and
postoperative appraisal of apical surgery
and evaluation of implants postoperatively
[1]. But there are some patient populations
who are
unable to tolerate intraoral
films/sensors due to various reasons. To
assist such patients, an alternative technique
of EOPA radiography was introduced by
Newman and Friedman in 2003 [2]. Possible
indications for this alternative technique are
exaggerated gag reflex, developmental
anomalies like shallow palate and floor of
the mouth, macroglossia, large maxillary
and mandibular tori, painful mucosal
conditions like ulcers, large painful intraoral
swelling, pediatric patients, patients with
dental phobia, differently abled patients who
are unable to follow the clinicians
instructions, trismus and trauma patients,
impacted third mandibular molar and use of

Vol-1: No-1: 2013

19

film/sensor beam aiming device for the

EOPA radiographic technique to align the
X-ray beam directly at the film/sensor under
the guidance of the locator ring to avoid the
cone cuts.6 In the present study, the
film/sensor holder was assembled using the
technique suggested by Sujatha S Reddy et
al3 and radiographs for maxillary and
mandibular posterior teeth were made.

Figure-2B

(Figure-1A and 1B) For trismus patients

with reduced mouth opening, the patients
chin was raised and the beam indicating
device was placed at -35 degree to the
vertical which allows the X-ray beam to
pass to the film/sensor unobstructed, thus
avoiding
superimposition
of
the
contralateral tissues on the image.

Figure-3A

Figure-3B

Figure-2B: Preoperative diagnostic EOPA radiograph for 43, 44, 45 and partially 46.
Figure-3A: Working length determination EOPA radiograph for 15. 16, 17 and 18 are also
visible.
Figure -3B: Working length determination EOPA radiograph for 25. 24, 26, 27 and 28 are
also visible.
maxillary and mandibular posterior teeth
were successfully obtained using EOPA
radiographic technique in patients having
possible indications of this technique.
3.0 Results and discussion
IOPA radiography forms the most common
form of periapical radiography in clinical
practice. In certain conditions, placement of
the film / sensor intra orally in the ideal
positions may not always be possible.

Figure-4A
Figure-4B
Figure-4A: Intra operative EOPA radiograph showing rubber dam clamp and root canal
treatment in relation to 46. 44, 45 and 47 are also visible.

Original Research Article

Exposure time was set at 0.6 seconds for

films. The exposure time was increased to
compensate for the increased distance
between the X-ray source and the
film/sensor.Radiographs required during
various stages of endodontic therapy like
preoperative radiographs (Figure 2A and
2B),
working
length
determination
radiographs (Figure 3A and 3B) and post
operative radiographs (Figure 4A and 4B) of

Vol-1: No-1: 2013

20

Figure-4B: Post operative EOPA radiograph showing post and core treated 17. 16 is also
visible.
In such situations, EOPA radiography can be used effectively. In the current study, EOPA
radiographic technique is introduced in endodontic practice to obtain preoperative, operative and
post operative radiographs of maxillary and mandibular posterior teeth in situations where IOPA
radiography is not feasible.
The extraoral radiographic technique suggested by Newman and Friedman is not intended as a
substitute for conventional intraoral radiography.2 Nonetheless, it is a useful alternative
technique which can prove to be an effective approach for those patients who are unable to
tolerate the conventional radiographic technique.
From the results of the current and previous studies, it can be accomplished that the EOPA
radiographic technique is patient friendly, easy to perform, no risk of cross infection as salivary
contamination is prevented, an increase in the radiation dose is generally negated by the
reduction in the number of unacceptable films required intra orally in compromised situations,
the radiation dose and cost factor are much lesser in comparison to the conventional panoramic
radiographs and the film/sensor aiming device is inexpensive and available at most of the dental
clinics. Possible disadvantages of this technique in comparison to conventional IOPA
radiography are minimally increased radiation dosage, slightly reduced resolution and contrast,
it can not be used for anterior maxillary and mandibular teeth due to curvature of the arch and
difficulty in positioning of the x- ray cone
4.0 Conclusion
EOPA radiography is an effective approach for obtaining periapical radiographs in those patients
where IOPA radiography is not possible. It is simple and inexpensive technique. Although this
technique is not meant to replace IOPA radiography, it can be a useful supplement to add to our
clinical practice. It should be implemented and improved for various endodontic procedures on a
larger sample size.

1. Eric Whaites. Periapical radiography. In: Michael Parkinson editor. Essentials of Dental
Radiography and Radiology. 3rd ed. Churchill Livingstone, An imprint of Elsevier
Science Limited 2002: 161-176.
2. Newman ME, Friedman S. Extra oral radiographic technique: an alternative approach. J
Endod. 2003;29:419 421.
3. Sujatha SR, Atul K, SriRekha R, Kunal A. Extraoral PeriapicalRadiography : A
Technique Unveiled. J Ind Acad Oral Med Radiol. 2011;23(3);336-339.
4. Fisher D. Extra oral radiographic technique of third molars. Aus Den.t J 1974;19:306307.
5. Chai-Hui C,Shui-Hui L,Hui-Lin C,Yu-Ju L,Yuk-Kwan C. An aiming device for an
extraoral radiographic technique. J Endod. 2007;33(6);758-760.

Original Research Article

References