Al-Mustansiriya University

College of Dentistry
Endodontics lectures

Endodontic Radiography Lec.18

Prof. Dr. Iman Mohammed

 Endodontic Radiography

Radiographs are essential to all phases of endodontic therapy. They

inform the diagnosis and the various treatment phases and help
evaluate the success or failure of treatment. Because root canal
treatment relies on accurate radiographs, it’s necessary to master
radiographic techniques to achieve films of maximum diagnostic
quality.

Importance of radiography in endodontics

1. DIAGNOSIS
a- Identifying the Pathosis : The radiographs help in identifying the
lesion whether it is Pulpal, Periapical, Periodontal, Bony lesions.
b-Determining the Root and Pulpal anatomy : The number of roots/
root canals, Unusual root morphologies, Root curvatures, Canal
locations with respect to the pulp chamber, Bifurcations/ trifurcations,
Calcifications.
c-Characterizing Normal Structures: Helps in differentiating the
normal from abnormal structures.

2- TREATMENT
a- Determining Working Length.
b-Moving superimposed structures: Certain normal anatomic
structures may superimpose on the apices of the teeth. Changing the
angulations help in separating them.
c- Locating canals : Extra canals, Missed canals.
d-Evaluating the Obturation: The radiographs help us to assess the
quality of obturation by helping us to evaluate the:
- Length - if the working length has been maintained ( overfilling –
underfilling).
- Density - the radiopacity of the material.
- Taper of the preparation of the configuration.

3- RECALL / FOLLOW UP
Most of the times the patient does not know the status of the root
canal treatment. In most cases the patient may be asymptomatic. In
such cases only radiographs help in diagnosing the endodontic
failures. There may be evidence of development of new lesions:
Periapical, Periodontal, Nonendodontic or evaluation of the healing /
progress of the treatment.

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 Endodontic Radiography

Requirements:
1-Radiograph should depict the tooth in the center of the films. Because
the center of the films contains the least amount of distortion.
2-At least 3mm of bone must be visible beyond
the apex of the tooth. Failure to capture this
bony area may result in misdiagnosis or
incorrect determination of file lengths for canal
cleaning and shaping.
3-The image on the film must be as
anatomically correct as possible, (no elongation
or shortening).

Film placement and cone angulation:

Paralleling technique:
For endodontic purposes, the paralleling technique produces the
most accurate periradicular radiograph. Also known as the long cone or
right-angle technique.
The film is placed parallel to the long
axis of the teeth, and the central beam is
directed at right angles to the film and
aligned through the root apex. To achieve
this parallel orientation it’s often necessary
to position the film away from the tooth,
toward the middle of the oral cavity,
especially when the rubber dam clamp is in
position.
The long-cone aiming device is used in the paralleling technique to
increase the focal spot-to-object distance. This has the effect of directing
only the most central and parallel rays of the beam to the film and teeth,
reducing size distortion. This technique permits:
1-More accurate reproduction of the tooth’s dimensions, thus enhancing a
determination of the tooth’s length and relationship to surrounding
anatomic structure.
2-Reduce the possibility of superimposing the zygomatic processes over
the apices of maxillary molars, which often occurs with more angulated
films, such as those produced by means of the bisecting-angle technique.
3-It will provide the clinician with films with least distortion, minimal
superimposition, and utmost clarity.

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Prof, Dr. Iman M.
 Endodontic Radiography

Bisecting-angle technique:
The bisecting-angle technique is not preferred for endodontic
radiography, however, when a modified paralleling technique can not be
used, there may be no choice because of difficult anatomic configurations
or patient management problems.
The basis of this technique is to place the film directly against teeth
without deforming the film. The structure
of the teeth, however, is such that with the
film in this position there is an obvious
angle between the plane of the film and the
long axis of the teeth. This causes
distortion, because the tooth is not parallel
to the film. If the x-ray beam will be
shorter than the actual tooth. If the beam is
directed perpendicularly to the long axis of
the teeth, the image will be much longer
than the tooth. Thus by directing the central beam perpendicular to an
imaginary line that bisects the angle between tooth and film, the length of
the tooth’s image on the film should be the same as the actual length of
the tooth.
Although the projected length of the tooth is correct, the image will
show distortion because the film and object are not parallel and the x-ray
beam is not directed at right angles to both. This distortion increases
along the image toward its apical extent. The technique produces
additional error potential, because the clinician must imagine the line
bisecting the angle. In addition to producing more frequent
superimposition of the zygomatic arch over apices of maxillary molars,
the bisecting angle technique causes greater image distortion than the
paralleling technique and makes it difficult for the operator to reproduce
radiographs at similar angulations to asses healing after root canal
treatment.

Film holder and aiming devices:

Film holder and aiming devices are required for the parallel
technique because:
1-They reduce geometric distortion caused by misorientation of the film,
central beam and tooth.
2-They also minimize cone cutting.
3-Improve diagnostic quality.

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 Endodontic Radiography

4-Allow similarly angulated radiographs to be taken during treatment and

at recall.
5-Eliminating the patient’s finger from the x-ray field and thus the
potential for displacing the film.
6-Help to minimize retakes and make it easier for the patient and clinician
to properly position the film.

Types of film holder devices:

1-Hemostat: one of the most versatile film-holding devices, the operator
positions a hemostat
held film, and the
handle is used to
align the cone
vertically and
horizontally. The
patient then holds the
hemostat in the same
position and the cone is positioned at a 90-degree angle to the film.

2-Green stabe: it’s ideal for taking preoperative and postoperative films.
It’s disposable film holder.
3-Dunvale Snapex system.
4-XCP: extension cone paralleling.
5-Endo Ray endodontic film holder.
6-Uni-Bite film holder.
7-Snap-A-Ray film holder.
8-Snap Ex system film holder.
9-Crawford film holder.

Generally these holders all have an x-ray beam-guiding device (for

proper beam to film relationship) and a modified bite block and film
holder, for proper positioning over or around the rubber dam clamp.

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Prof, Dr. Iman M.
 Endodontic Radiography

Buccal-object rule (cone shift):

In endodontic therapy, it’s imperative that the clinician know the
spatial or buccolingual relation of an object within the tooth or alveolus.
The technique used to identify the spatial relation of an object is called
the cone or tube shift technique; other names for this procedure are the
buccal-object rule, Clark’s rule, and the SLOB (Same Lingual, Opposite
Buccal) rule.
Proper application of the technique allows the dentist to locate:
1- Additional canals or roots.
2- Distinguish between objects that have been superimposed.
3- Distinguish between various types of resorption.
4- Determine the buccal-lingual position of fractures and
perforative defects.
5- Locate foreign bodies.
6- Locate anatomic landmarks in relation to
the root apex.
The principle states that the object closest to
the buccal surface appears to move in the direction
opposite the movement of the cone or tube head,
when compared with a second film. Objects closest
to the lingual surface appear to? Thus “same lingual,
opposite buccal” rule.

Digital radiography:
As dentistry parallels photography, in the move from silver halide
film to digital photography and computer processing, the profession will
undergo continued growth toward digital radiographic systems. The
number of practitioners using digital radiography is increasing. Film has
always been the benchmark of image quality and is obviously cheaper.
There is, however, a continuous supply of chemicals to be bought and
disposed of responsibly. Digital radiography, on the other hand, requires a
significant capital investment, but has so many advantages over film. The
image quality is continuously improving. Radiographs can be read
instantly and are a great communication tool. There is nothing better than
showing the pre-op and post-op together or the pre-op and review image
that shows healing to convince your patient that endodontic treatment is
worth the investment. Archiving is easy, and provided you back up, you
will never lose a “film.” Radiation exposure is reduced from 50% to 90%
compared with conventional film-based radiography.

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Prof, Dr. Iman M.
 Endodontic Radiography

For endodontics, the power of digital radiography is in the ability

to read the image instantly while the holder is still in the mouth and make
changes accordingly (Obtained immediately).

Digital radiography used in dentistry is

available in three variations:
1-Direct digital system: use 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: use a photo-stimulable phosphor plate that

stores the latent image in the phosphor for subsequent readout by an
extra-oral laser scanner.

3-Indirect digital system: use a scanning device connected to a computer

for digitizing traditional silver halide dental films.

Direct digital systems have three components:

1-Radio component: consists of a high resolution sensor with an active

area that is similar in size to conventional film.
The sensor is protected from x-ray degradation
by a fiber-optic shield, and it can be cold
sterilized. For infection control, disposable
plastic sheaths are used to cover the sensor
when it’s in use.

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Prof, Dr. Iman M.
 Endodontic Radiography

2-Visio component: consists of a video

monitor and display-processing unit. As the
image is transmitted to the processing unit, it’s
digitized and stored by the computer.

3-Graphy component: high resolution video printer that provides a

hard copy of the screen image, using the same video signal.

Nothing is impossible because imposible itself says that

I M POSSIBLE

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Prof, Dr. Iman M.
Endodontic Radiography

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Prof, Dr. Iman M.