JOURNAL OF ENDODONTICS
Copyright © 2003 by The American Association of Endodontists
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-
FIG 1. Extraoral radiographic technique for the maxillary arch.
419
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VOL. 29, NO. 6, JUNE 2003
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 2. Extraoral radiographic technique for the mandibular arch.
420 Newman and Friedman Journal of Endodontics

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 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 as described
above.

Case 1

A 16-yr-old male was referred for endodontic treatment of tooth

FIG 3. Extraoral technique for a working radiograph of tooth #3 with
#3. The patient had an exaggerated gag reflex and was unable to
the rubber dam in place.
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). FIG 5. Extraoral technique for a postoperative radiograph of tooth #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): FIG 6. Maxillary postoperative.
Vol. 29, No. 6, June 2003
FIG 7. Extraoral technique for pre- and postoperative radiographs of
tooth #19.
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
Extraoral Radiographic Technique 421
FIG 9. Mandibular postoperative.
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 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.
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 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;40:727–31.