Nerve injury associated with root canal treatment is relatively rare, but can lead to significant morbidity. The role of 2D and 3D radiography in case assessment is explored and a new three-tier grading system is proposed to aid in risk assessment and clinical decision-making. This grading system would assist dentists to fully appraise patients, gain appropriate informed consent and guide treatment of endodontic cases where there is an increased risk of nerve injury. CPD/Clinical Relevance: A new three-tier grading system to assist in the pre-operative assessment and risk management of endodontic cases where there is an increased risk of nerve injury is proposed.