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Use of extraoral periapical radiography in Indian

population: Technique and case reports
DATASET FEBRUARY 2013

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183

2 AUTHORS:
Rahul Kumar

Neha Khambete

MGM University of Health Sciences

Chatrapati Shahu Maharaj Shikshan Sanstha

49 PUBLICATIONS 38 CITATIONS

36 PUBLICATIONS 43 CITATIONS

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Available from: Rahul Kumar

Retrieved on: 23 February 2016

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Short Communication
Use of extraoral periapical radiography in Indian
population:Technique and case reports
Rahul Kumar, Neha Khambete1
Department of Conservative
Dentistry and Endodontics,
MGM Dental College and
Hospital, Navi Mumbai,
1
Department of Oral Medicine
and Radiology, CSMSS
Dental College and Hospital,
Aurangabad, India

ABSTRACT

Received
: 220211
Review completed : 18-05-12
Accepted
: 070213

Performing intraoral radiography in certain patients is difficult as these patients are unable to
tolerate intraoral film placement. To assist such patients a new technique has been innovated
using extraoral film placement. Use of this technique has been documented in Caucasian and
Taiwanese populations. In this paper we report use of this technique for Indian population.
We have done about 40cases using this technique and have found the average angulation for
maxillary(25+/5 degrees) and mandibular(15+/5 degrees) teeth for Indian population. We
recommend use of this technique in the personal dental clinics where panoramic radiographic
machines are not readily available. Here we report the technique and cases where diagnostic
imaging was performed in patients using the extraoral periapical technique.
Key words: Extraoral radiography, intraoral films/sensors, periapical radiographs

The need for intraoral periapical radiographs is well

established in all branches of dentistry. However, a large
group of patients are unable to tolerate the intraoral film/
sensor placement. To overcome this, Michael Newmann
and Seymour Friedman in 2003 developed an alternative
technique for treating a wide spectrum of patients which
included developmentally disabled patients, patients with
exaggerated gag reflex, pediatric dental patients, anxious
dental patients, patients with trauma and patients with
limited mouth opening.[1,2] ChiaHuiChen etal., in 2007
developed a sensor beam alignment aiming device for
performing radiographs using this technique.[3] Both of these
reports document use of extraoral periapical technique in
Caucasian and Taiwanese population, respectively.

TECHNIQUE
For maxillary teeth

The patient sits upright, with his/her mouth was opened

Address for correspondence:
Dr.Rahul Kumar
Email:dr.rahul1982@gmail.com
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DOI:
10.4103/0970-9290.116689

271

as wide as possible, to allow the Xray beam to pass to the

sensor unobstructed from the opposite side of the mouth.
The sensor was placed on the external surface of the cheek,
directly buccal to the tooth. A cotton roll was placed
between the sensor and the cheek to parallel the sensor
with the buccal surface of the tooth. The Xray cone was
angled approximately25+/5 degrees from the horizontal
plane (for Indian population). Additionally, the Xray
beam was aligned perpendicular to the sensor to provide
an accurate image[Figure1a and b].

For mandibular teeth

The patient sits upright with raised chin. The sensor was
placed on the external surface of the cheek, directly buccal to
the tooth. The Xray cone was angled approximately15+/5
degrees from the horizontal plane(for Indian population).
The Xray beam was aligned perpendicular to the sensor to
provide an accurate image[Figure2a and b]. The images
were obtained using SOPRO digital imaging system(Acteon
Group, Marseills, France) and a 30 40 mm standard
intraoral sensor SOPIX(Acteon Group, Marseills, France).
An intraoral Xray machine (Biomedicare, Thane, India)
was used to take the radiographs set at 65kVp, 10 mA,
0.450.55seconds.

CASE SERIES
Application in patients with trismus

A 24yearold male patient reported to us with chief

complaint of extraoral swelling and dull, throbbing pain in
maxillary left posterior region. The patient was a diagnosed
case of oral submucous fibrosis and the interincisal distance
Indian Journal of Dental Research, 24(2), 2013

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Extraoral periapical radiography

Kumar and Khambete

was 15mm. Thus, it was not possible to placethe Xrayfilm

intraorally. Thus, it was decided to use the extraoral
technique for radiograph, which provideduswith essential
diagnostic information[Figure3].

Application in patients with severe gag reflex

Patients with severe gag reflex are unable to tolerate

intraoral film placement. Hence, radiographs were taken for
such patients with extraoral film placement which provided
us with necessary diagnostic information[Figure4ac].

Application in patients with rubber dam

Taking intraoral radiographs in patients with placement

of rubber dam is time consuming and uncomfortable for
patients. Hence, using the extraoral technique in such
patients results in increased patient compliance and
also requires lesser time providing essential diagnostic
information[Figure5a and b].

Application in pediatric patients

Pediatric patients are generally apprehensive and reluctant

to intraoral film placement. We used the extraoral technique
to obtain radiographs of such apprehensive patients.
The radiographs provide us with essential diagnostic
details[Figure6]. Also, patients found this technique less
traumatic and it was easier to obtain patient cooperation.

DISCUSSION
In 1974, Fisher proposed an extraoral radiographic technique
for obtaining images of third molars using occlusal films, but

Figure 2 (a and b): Patient positioning for taking extraoral radiographs

of mandibular teeth

Figure 1 (a and b): Patient positioning for taking extraoral radiographs

of maxillary teeth
a

c
Figure 4 (a-c): Extraoral periapical radiograph of patients with severe
gag reflex

Figure 3: Extraoral periapical radiograph of patient with trismus

Figure 5 (a and b): Extraoral periapical radiographs of dental patients

with rubber dam
Indian Journal of Dental Research, 24(2), 2013

Figure 6: Extraoral periapical radiograph of pediatric dental patient

272

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Extraoral periapical radiography

the requisite high kVP(as high as 90 kVP) had limited its

daily clinical application.[4] We found that, using a digital
imaging system 65 kVP was sufficient to produce image
with adequate diagnostic quality comparable with the
conventional intraoral periapical radiographs.
The extraoral radiographic technique is a useful alternative
technique and has proved to be effective for the patients
who are unable to tolerate the conventional technique.
Appropriate images having been successfully acquired
which provide us with adequate details and diagnostic
quality. However, the disadvantages of this technique are
the procedure being technique sensitive, slightly lower
resolution of images and inability to obtain radiographs of
anterior teeth.
With recent advances in dental radiology, various
techniques like panoramic radiography are available to
manage such patients. However, we recommend use of this
technique in the personal dental clinics where panoramic

273

Kumar and Khambete

radiographic machines are not readily available. Also, this

technique can be used where active treatment is being
carried out.
To conclude, this technique is not meant for replacing
conventional intraoral radiography. However, it can be
used where intraoral film placement is difficult to achieve.

REFERENCES
1.
2.
3.
4.

NewmanME, FriedmanS. Extraoral radiographic technique: An

alternative approach. JEndod 2003;29:41921.
IngleJI, BaklandLK, BaumgartnerJC. Ingles Endodontics. 6th ed. USA:
PMPH Publisher; 2008. p.554600.
ChenCH, LinSH, ChiuHL, LinYJ, ChenYK, LinLM. An aiming device
for an extraoral radiographic technique. JEndod 2007;33:75860.
FisherD. Extraoral radiographic technique of third molars. Aust DentJ
1974;19:3067.

How to cite this article: Kumar R, Khambete N. Use of extraoral periapical

radiography in Indian population: Technique and case reports. Indian J Dent
Res 2013;24:271-3.
Source of Support: Nil, Conflict of Interest: None declared.

Indian Journal of Dental Research, 24(2), 2013