**Outline** * Principles of Radiography * Positioning Devices * Radiographic Interpretation * Tube Shift Techniques * **Endodontic “Working” Radiography** * Specific Techniques for Each Tooth # **Principles of Radiography** > [!info] Lecture Focus > ==This lecture revisits key radiographic principles, particularly as they apply to endodontics. The primary focus is on # **Positioning Devices** > [!info] > ==Standard positioning devices, such as Rinn or Neoss holders, are essential for diagnostic and follow-up radiography when a rubber dam is not in place. However, during endodontic treatment, several factors make these devices impractical:== > 1. ==**Rubber Dam:** The dam obstructs normal placement.== > 2. ==**Rubber Dam Clamp:** The clamp prevents the patient from biting down on a holder.== > 3. ==**Endodontic Instruments:** Files or filling materials protrude from the tooth, preventing the patient from closing their mouth on a holder.== > [!tip] > ==Alternative methods for holding the film or sensor are therefore required for working radiography.== **Endodontic "Working"** **Radiography** Figure showing a patient with a dental dam and an image of endodontic files in a tooth. # **Endodontic “Working” Radiography** **Endodontic “Working”** **Radiography** A slide showing an endodontic procedure with rubber dam application and close-up views of the tooth being treated, with instruments and gutta-percha points. **Outline** 🔹 Principles of Radiography 🔹 Positioning Devices 🔹 Radiographic Interpretation 🔹 **Tube Shift Techniques** 🔹 Endodontic “Working” Radiography 🔹 Specific Techniques for Each Tooth # **Tube Shift Techniques** > [!info] > ==Tube shift techniques are essential in endodontics for separating superimposed anatomical structures, such as multiple canals within a single root, and providing a pseudo-three-dimensional view.== **Tube Shift Techniques** - Vertical Shift - **Horizontal shift** ## **Vertical Shift** > [!note] > ==Vertical tube shifts have limited diagnostic value, with one important exception.== # **Tube Shift Techniques** * Vertical Shift * Increased angle * Decreased angle * **Horizontal shift** * **Mesial** * **Distal** - Mesial - Distal ## **Tube Shift Techniques** - Vertical Shift - Increased angle - Decreased angle Diagram illustrating the effect of increased and decreased vertical angle on radiographic image shift for both multi-rooted and single-rooted teeth. - Increased angle - Decreased angle ### **Decreased Angle** > [!warning] > ==A decreased vertical angle is **not recommended** as it causes image distortion, specifically elongation of the tooth, which compromises diagnostic accuracy.== **Tube Shift Techniques** - **Vertical Shift** - **Increased angle** - **Decreased angle** Diagram illustrating the concept of vertical tube shift showing image formation with increased and decreased vertical angles. **Tube Shift Techniques** Vertical Shift * **Decreased angle** $\rightarrow$ **elongates the image** * **NO diagnostic value** * **NO practical value** - → elongates the image - NO diagnostic value - NO practical value ### **Increased Angle** > [!success] Modified Parallel Technique > ==An increased vertical angle of approximately **15 degrees** is a core component of the **modified parallel technique**. This technique should be used for all intraoral radiographs (endodontic, restorative, periodontal) to produce the most geometrically accurate images with minimal distortion.== Dental X-rays with magenta lines indicating angles between adjacent teeth **Tube Shift Techniques** Vertical shifts * **Increased angle** * $\to$ 15º vertical shift * Modified parallel technique * Provides more apical detail and definition - → 15º vertical shift - Modified parallel technique - Provides more apical detail and definition **Tube Shift Techniques** Vertical shifts - **Increased angle** → 15º vertical shift - Modified parallel technique - Provides more apical detail and definition → Occlusal views - Esp. useful for trauma diagnosis > **Root Fractures & Lateral Luxation** - → Occlusal views - Esp. useful for trauma diagnosis > **Root Fractures & Lateral Luxation** ## **Horizontal shift** **Tube Shift Techniques** **Horizontal shifts** - **Mesial** - **Distal** <img src="Tube Shift Techniques illustration" width="300"/> **Tube Shift Techniques** ⠀⠀⠀⠀⠀**Horizontal shifts** ⠀⠀⠀⠀⠀⠀**Mesial** ⠀⠀⠀⠀⠀⠀**Distal** * **Used to separate objects that are otherwise superimposed over each other** * **Can help to indicate the “3rd dimension”** A diagram illustrating tube shift directions (Distal, Straight, Mesial) and a second image showing a dental x-ray. - Used to separate objects that are otherwise superimposed over each other - Can help to indicate the “3rd dimension” **Straight View** Film Bu Li Li Bu CR **Mesial** Film Li Bu M Li Bu CR **Distal** Bu Li Film M Li Bu CR **SLOB rule: Same Lingual Opposite Buccal** ### **SLOB Rule** - **SLOB rule: Same Lingual Opposite Buccal** > [!info] Explanation > ==This means that the object (e.g., canal) that is on the **lingual** (or palatal) side will appear to move in the **same** direction as the x-ray tube head. The object on the **buccal** (or labial) side will appear to move in the **opposite** direction. The key takeaway is to remember ** #### **Views** - **Straight View** - ==Canals are often superimposed. In an upper molar, the palatal root typically appears between the two buccal roots.== - Film - Bu - Li - Li - Bu - CR - **Mesial** - ==The x-ray beam is directed from a more mesial angle.== - ==The lingual/palatal canal or root will appear more **mesial** on the radiograph.== - ==The buccal/labial canal or root will appear more **distal** on the radiograph.== - > [!tip] Clinical Clue > ==For a posterior radiograph, the canine may become visible on the image.== - Film - Li - Bu - M - Li - Bu - CR - **Distal** - ==The x-ray beam is directed from a more distal angle.== - ==The lingual/palatal canal or root will appear more **distal** on the radiograph.== - ==The buccal/labial canal or root will appear more **mesial** on the radiograph.== - > [!tip] Clinical Clue > ==For a posterior radiograph, the most distal molar will be more fully visible, and the canine will likely be absent from the image.== - Bu Li - Film - M - Li - Bu - CR **Straight View** **Mesial** **Distal** Diagram showing different views of teeth including straight, mesial, and distal views. **Straight View** **Mesial** **Distal** <img src="crop_2.jpg"/> <img src="crop_3.jpg"/> <img src="crop_4.jpg"/> Radiographs showing Mesial and Distal views. **Mesial** **Distal** Radiographs showing Mesial and Distal views. **Mesial** **Distal** **Endodontic "Working"** **Radiography** Four images showing different stages of endodontic treatment, including placement of a rubber dam, instrumentation with files, and a tooth with a master cone inserted. **Nygaard-Östby Frame** A collage of images showing the Nygaard-Östby Frame, its incorrect and correct uses in a dental setting, and a separate patient with a dental dam in place. - Nygaard-Östby Frame Nygaard-Östby dental dam frame and its clinical application **Endodontic “Working” Radiography** **Lower Posterior Teeth** **Image only with labels or sparse text:** Three images showing techniques for taking radiographs during endodontic procedures, with the top and bottom left images depicting proper methods and the bottom right image showing an improper technique (marked with a red X). ## **General Techniques** > [!info] > ==Successful working radiography depends on managing access and stabilizing the film/sensor.== ### **Importance of the Rubber Dam Frame** > [!tip] Recommended Frame > - ==A plastic, full-circumference frame like the **Nygaard-Ostby frame** is ideal.== > - ==It should be placed *underneath* the rubber dam sheet.== > - ==This setup allows a corner of the frame and dam to be easily lifted for sensor placement without the entire assembly collapsing.== > [!warning] Not Recommended > - ==Placing the frame on the *outside* of the dam severely restricts access.== > - ==Three-sided or metal frames are problematic. Metal frames must be removed to prevent superimposition on the image, and three-sided frames tend to collapse when a corner is released.== ### **Film/Sensor Holding Methods** ### **Lower Posterior Teeth** > [!example] Technique > - ==**Device:** A pair of straight artery forceps is used to grip the film/sensor. (If using a sensor, protect it with a cardboard sleeve from the forceps' grip).== > - ==**Patient Positioning:** The patient is instructed to create a Three images showing techniques for taking radiographs during endodontic procedures, with the top and bottom left images depicting proper methods and the bottom right image showing an improper technique (marked with a red X). **Endodontic "Working"** **Radiography** Radiographs showing working length determination with and without rubber dam, indicating the correct procedure. **Endodontic "Working" Radiography** **Upper Posterior** **Teeth** Image of a patient with a dental dam in place, showing the procedure for taking a working radiograph for upper posterior teeth. ### **Upper Posterior Teeth** > [!example] Technique > - ==The patient holds the film/sensor in place with their **index finger**.== > - ==The rubber dam clamp can help to position the film and keep it relatively parallel to the tooth.== > - ==The patient applies light pressure against the clamp and the palate.== **Endodontic “Working”** **Radiography** Upper Anterior Teeth A patient undergoing a dental radiography procedure, likely for an endodontic working length confirmation, with a rubber dam and lead apron in place. ### **Upper Anterior Teeth** > [!example] Technique > - ==The lower part of the rubber dam frame is lifted.== > - ==The patient holds the film/sensor with their **index finger**.== > - ==Using the index finger is preferable to the thumb, as the thumb can apply excessive pressure, potentially bending the film or dislodging the rubber dam clamp.== **Endodontic “Working”** **Radiography** **Lower Anterior** **Teeth** <br> <br> An image showing a patient undergoing a dental procedure, likely endodontic treatment, with a dental dam in place and an X-ray apparatus being used for working radiography on the lower anterior teeth. ### **Lower Anterior Teeth** > [!example] Technique > - ==The upper part of the rubber dam frame is lifted.== > - ==The patient holds the film/sensor in place with their **index finger**.== ## **Specific Techniques for Each Tooth** > [!info] Guiding Principle > ==For all teeth, the starting point is the **modified parallel technique**, incorporating a **+15 degree vertical angulation**. The primary variable is the horizontal angle.== ### **Upper Incisors + Canines** - ==**Standard View:** A **straight-on** horizontal view is usually sufficient, as these teeth typically have one canal.== **Rinn XCP Endodontic Film Holder** An image showing an endodontic film holder and a close-up of a tooth during an endodontic procedure with instruments in place. - Rinn XCP Endodontic Film Holder **EndoRay® II Film holder** A dental film holder used for endodontic radiography is shown, along with examples of its application with a patient and a dental model. - EndoRay® II Film holder # **Radiographic Interpretation** > [!info] > ==Accurate interpretation is crucial, especially when using tube shift techniques to visualize complex anatomy. The lecture emphasizes understanding how different angles project three-dimensional structures onto a two-dimensional image.== **Outline** **u** Principles of Radiography **u** Positioning Devices **u** Radiographic Interpretation **u** Tube Shift Techniques **u** Endodontic "Working" Radiography **u** Specific Techniques for Each Tooth **Endodontic “Working” Radiography** **Upper Incisors + Canines** - **Vertical:** 15° **increase** - **i.e. Modified parallel technique** - **Vertical:** 15° **increase** - i.e. Modified parallel technique **Endodontic "Working" Radiography** **Upper Incisors + Canines** ♦ **Vertical**: $15^{\circ}$ **increase** - **i.e. Modified parallel technique** ♦ **Horizontal**: **only if a problem is suspected** - **e.g. perforation, extra canal** → Central incisors - $\underline{Mesial}$ **shift** → Lateral incisors and canines - $\underline{Distal}$ **shift** - **Horizontal**: **only if a problem is suspected** - e.g. perforation, extra canal - → Central incisors - `Mesial` **shift** - → Lateral incisors and canines - `Distal` **shift** > [!info] > ==This is due to the curvature of the arch, which makes positioning for a mesial shift difficult and can lead to image distortion.== **Endodontic "Working" Radiography** Four radiographic images showing files in root canals **Endodontic "Working" Radiography** **Lower Incisors + Canines** - **Vertical: 15° increase** * **i.e. Modified parallel technique** ### **Lower Incisors + Canines** > [!note] Anatomy & Technique > - ==**Anatomy:** These teeth have a high probability (50-60%) of having two canals (labial and lingual). Always assume two canals exist until proven otherwise.== > - ==**Standard View:** A **horizontal tube shift is mandatory** to separate the potential labial and lingual canals.== > - ==**Interpretation:** Apply the SLOB rule to identify the lingual and labial canals and assess the working length for each.== - **Vertical: 15° increase** - i.e. Modified parallel technique **Endodontic "Working" Radiography** **Lower Incisors + Canines** - **Vertical: 15° increase** * i.e. **Modified parallel technique** - **Horizontal:** * **Central incisors** - **Mesial shift** * **Lateral incisors and canines** - **Distal shift** - **Horizontal:** - **Central incisors** - **Mesial shift** - **Lateral incisors and canines** - **Distal shift** ==due to the arch curvature.== **Endodontic “Working” Radiography** **Distal** **Mesial** **Distal** Endodontic working length radiographs showing different views (Distal, Mesial, Distal). **Distal** **Mesial** **Distal** **Endodontic "Working" Radiography** **Upper & Lower Premolars** - **Vertical**: $\text{15° increase}$ - $\text{i.e. Modified parallel technique}$ ### **Upper & Lower Premolars** - **Vertical**: 15° increase - i.e. Modified parallel technique **Endodontic "Working" Radiography** **Upper & Lower Premolars** * **Vertical**: $\underline{15^{\circ}\text{ increase}}$ * i.e. $\underline{\text{Modified parallel technique}}$ * **Horizontal**: * $\underline{\text{Mesial shift}}$ - **Horizontal**: - Mesial shift **Endodontic "Working" Radiography** Radiographs showing working length determination with endodontic files in the root canals. **Endodontic "Working" Radiography** Radiographs showing working length determination and final obturation in endodontic treatment. **Endodontic “Working” Radiography** **Lower Molars** * **Vertical:** **15° increase** * **i.e. Modified parallel technique** ### **Lower Molars** - **Vertical:** **15° increase** - i.e. Modified parallel technique **Endodontic "Working" Radiography** **Lower Molars** * **Vertical**: $\underline{15^{\circ}\text{ increase}}$ * i.e. **Modified parallel technique** * **Horizontal**: * $\underline{Mesial\ shift}$ - usually * Can do distal shift if necessary - **Horizontal**: - Mesial shift > [!info] Rationale & Interpretation > ==A distal shift is often difficult, especially for first premolars, because the curvature of the palate (upper) or mandible (lower) prevents proper anterior placement of the sensor.== > > **Interpretation (Upper Premolars):** ==You can use two methods to confirm which root is which:== > 1. ==**Horizontal SLOB Rule:** The palatal root will appear mesial on a mesial shift.== > 2. ==**Vertical Angulation Effect:** With a modified parallel technique, the palatal root will always appear longer on the radiograph than the buccal root.== - usually > [!info] Rationale > ==A distal shift can create distortion due to the flaring angle of the posterior mandible. A straight-on view is often non-diagnostic, as it superimposes the mesiobuccal and mesiolingual canals and can be misleading about the length of the file in the distal canal.== - Can do distal shift if necessary > [!example] Interpretation > - ==A mesial shift effectively separates the two mesial canals. Using the SLOB rule, the **mesiolingual** canal will be the one that appears more **mesial** on the image.== > - ==If two files in a root remain superimposed after a tube shift, it often indicates they are in a single, large, oval-shaped canal.== > [!warning] Pitfall > ==Be careful not to mistake the outline of the periodontal ligament (PDL) for a missed canal. A tube shift can make the PDL space on both the buccal and lingual aspects of the root visible as two separate dark lines. Attempting to instrument towards one of these lines can lead to a perforation.== **Endodontic "Working" Radiography** <img Endodontic working radiographs with straight and mesial angulation. />**Straight** **Mesial** **Straight** **Mesial** Endodontic working radiographs showing intraoperative views with files inside root canals, labeled "Mesial". **Endodontic "Working" Radiography** # **Upper Molars** * **Vertical**: **15° increase** * i.e. **Modified parallel technique** * **Sometimes also vary vertical angle for Pal. root** ### **Upper Molars** > [!note] Complexity > ==These are the most challenging teeth to radiograph due to:== > - ==Three roots (mesiobuccal, distobuccal, palatal) with different axial inclinations.== > - ==High frequency of a second canal in the mesiobuccal root (MB2).== > - ==Superimposition of the zygomatic bone.== - **Vertical**: **15° increase** - i.e. Modified parallel technique - Sometimes also vary vertical angle for Pal. root **Endodontic “Working” Radiography** <p style="text-align: center;">**Upper Molars**</p> - **Vertical**: $\underline{15^\circ \text{ increase}}$ - i.e. Modified parallel technique - Sometimes also vary vertical angle for Pal. root - **Horizontal**: - Distal shift - usually (for MB root) - Sometimes also need mesial shift (for DB root) - **Horizontal**: - Distal shift - usually (for MB root) - Sometimes also need mesial shift (for DB root) > [!example] Standard Views & Strategy > ==Often, **two or even three radiographs are necessary** to visualize all root apices clearly.== > 1. ==**Distal Shift (First Choice):** This is the primary view taken because it is best for separating the **MB2 canal** from the MB1 canal in the mesiobuccal root.== > - > [!failure] Problem > > ==The distobuccal root is often superimposed over the palatal root in this view.== > 2. ==**Mesial Shift (Second View):** This view is taken to visualize the **distobuccal root**, which will be projected distally and away from the other roots.== > - > [!failure] Problem > > ==The mesiobuccal root is often superimposed over the palatal root in this view.== > [!tip] Interpretation > - ==Use the SLOB rule to identify the roots in each view.== > - ==A **distal shift** moves the palatal root distally.== > - ==A **mesial shift** moves the palatal root mesially.== > - ==The presence of a periapical radiolucency can sometimes make the root apex easier to see by reducing the amount of overlying bone.== > - ==By combining information from multiple angled radiographs, a complete picture of the working length in all canals can be established.== **Endodontic “Working” Radiography** A drawing showing the cross section of a tooth with B and P labels and an outline drawing of a tooth with root canal lines superimposed on it. **Endodontic “Working” Radiography** **Straight** **Distal** **Mesial** Three radiographic images showing endodontic working length and labeled Straight, Distal, and Mesial **Straight** **Distal** **Mesial** # **Specific Techniques for Each Tooth** **Endodontic “Working” Radiography** Radiographic comparison of working length radiograph with mesial and distal + vertical angulation. # **Endodontic “Working” Radiography** > [!info] > ==This section details the practical techniques for taking radiographs during treatment while a rubber dam is in place.== **Outline** - Principles of Radiography - Positioning Devices - Radiographic Interpretation - Tube Shift Techniques - Endodontic “Working” Radiography - Specific Techniques for Each Tooth ## **Outline** - Principles of Radiography - Positioning Devices - Radiographic Interpretation - Tube Shift Techniques - Endodontic “Working” Radiography - Specific Techniques for Each Tooth No discernible text is visible in the image. 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