Panoramic Radiography

Maxillo-Facial Radiology &

Diagnostic Sciences
Maxillo-Facial Radiology
3rd Acadenic Year
 Objectives:
* Describe the fundamentals of panoramic
radiography.
* Describe the equipment used in panoramic
radiography.
* Describe the patient preparations, equipment
preparations, and patient positioning procedures
needed before exposing a panoramic film.
Objectives:
* Identify the patient preparation and positioning
errors seen on panoramic radiographs, and the
necessary measures needed to correct such errors.
* Discuss advantages and disadvantages of
panoramic radiography.
* Describe the purpose and uses of panoramic
radiography in dentistry as general, and as a
diagnostic tool in pre-prosthetic management,
specifically.
 Panoramic Radiography
Is an unobstructed view in every direction
In case of a
lesion bigger
than the
periapical film
size how can
we make a
radiographic
examination?
 Panoramic radiography is an extra-oral
radiographic procedure that produce a single
image of the facial structures, including the
maxillary and mandibular arches and their
supporting structures.
 Purpose & Use
•Evaluate impacted tooth.
•Evaluate eruption pattern.
•Detect diseases, lesions, and conditions of the jaw.
•Examine the extent of large lesions
•Evaluate trauma.
•Evaluation of Generalized disease
• Inability to tolerate intraoral films
• Assessment for surgical procedures
 Panoramic X-ray is introduced in 1959,
and is produced by applying the principle
of scanography & tomography on curved
structure.
 Scanography:

 Is the process by which an X-ray source

and the dental film rotate around a fixed
object (patient head) during exposure,
where both of them moves in opposite
direction.
 Tomography:

 It is a form of radiography where it is

possible to radiograph only a section or
layer within an object by focusing on this
layer while images of above and below
structures are made invisible by blurring.
NB: The name “Tome” is Greek and
means a “section or cut”.
There are 2 types of tomography:
• Linear
• Curved

 Panoramic radiography used the curved

tomography.
 Rotation center:

It is the pivot point around which the

cassette carrier and X-ray head rotate.
There are 3 basic rotation center used
in panoramic x-ray machine:
• Double center
• Triple center
• Moving center
In all cases moving of the rotation center
allow the image layer to conform to the
elliptical shape of the arch.

The location and number of rotation center

influence the size and shape of the focal
trough.
 FocalTrough:

The focal trough can be defined as a three-

dimensional curved zone in which structures are
clearly demonstrated on a panoramic radiograph.
The structures located within the focal trough
appear in focus and very sharp on the resultant
radiograph, while other structures will appear
blurred or out of focus.
The size and shape of the focal trough
vary with the manufacturer of the panoramic
X-ray unit, and this depends on………..
Each manufacturer provides specific
instruction about patient positioning to
ensure that the teeth are positioned within
the focal trough.
 Equipment:

•Panoramic X-ray unit

•Screen film
•Cassette
 Panoramic X-ray unit

The main components of the Panoramic X-

ray unit include:
• X-ray tube head
• Head positioner
• Exposure control
 Panoramic X-ray unit:
X-ray tube head
The main difference between the panoramic
unit head and the intraoral head is the collimator.
The collimator in the intraoral unit is?
That’s for panoramic unit is formed of lead plate
with an opening in the shape of a narrow vertical
slit.
The film also moves inside the cassette carrier
which is made of lead except for a slit which is
left opened
 Panoramic X-ray unit:
Head positioner
The head positioner used to align the patient’s
teeth as accurately as possible in the focal trough.
It consist of:
• Chin rest
• Bite-block
• Forehead rest
• Lateral head support
 Panoramic X-ray unit:
Exposure control
The milliampirage and Killovoltage setting are
adjustable.
In the new machines the time also can be changed.
 Screen film:
 It is sensitive to light emitted from intensifying
screen.
There is two types of screen:
1. Conventional screen: emit blue light e.g.
crystalline calcium tungestate.
2. Rare-earth screen: emit green light e.g.
gadolinium and lanthanum
Cassettes:
The cassette may be rigid or flexible, curved or
straight, this depends on the panoramic X-ray unit.
The cassette must be marked to orient the
finished radiograph by a metal mark L or R.
Special labels may be attached or adhered to
the radiograph.
 Step By Step Procedures:

Equipment preparation:
•Load the panoramic cassette.
•Cover the bite-block with a disposable
plastic cover slip
•Set the exposure factor ( kilovolt,
milliampirage & time)
 Patient preparation:

•Explain the procedure to the patient.

•Remove all objects that may interfere with film
exposure.
•Place a lead apron.
Patient positioning:

•Patient must be as straight as possible

•The patient’s neck should be extended
•Anterior teeth should be in the notch on the bite-
stick (edge to edge position)
•Adjust the mid-sagittal plane
•Instruct the patient to put his tongue on the palate
•Then told the patient to remain still
 Errors due to positioning:

The mid-sagittal plane is not adjusted (Head turned to

the right) moving the teeth closer to the film on that side.
The teeth on the left side, being farther from the film,
will be magnified more and appear larger.
 Teeth too anterior

If the incisors are positioned anterior to the notch

in the bite-stick, they will end up closer to the film
and, since they are now slightly outside the focal
trough, the images of the teeth will be blurred.
 Teeth too posterior

If the incisors are positioned posterior to the

notch in the bite-stick, they will end up farther
from the film and, since they are now slightly
outside the focal trough, the images of the teeth
will be blurred.
 Head tipped down

If the head is tipped down too much, so that

the Frankfort Plane is angled downward, the
resulting film will show a V-shaped mandible
and shortening of the mandibular incisors.
 Head tipped up

If the head is tipped up too much, so that the

Frankfort Plane is angled upward, the resulting film
will show a squared-off mandible and the hard
palate will be superimposed over the roots of the
maxillary teeth. A “reverse smile” may be seen.
 Vertebral (spinal) shadow

White area in the center of the film represents the

shadow of the vertebral column due to patient
slouching. Although faint, you will usually be able
to see outlines of the teeth and bone in the area.
 Lead Apron shadow

The lead apron should be placed so that it does not block

off the x-ray beam. (A thyroid collar is never used for
panoramic films). If the apron blocks the beam, a
completely radiopaque shadow is produced on the film
overlying a portion of the mandible; no evidence of teeth or
bone is seen in this area.
 Ghost Images

As the x-ray beam passes around the patient, objects such as
jewelry will produce a real image on the side where the object
is located and a “ghost” image on the opposite side. This ghost
image will have the same shape and orientation as the real
image, but it will be larger and projected higher on the film and
will be very blurred.
Ghost images of earrings. The ghost image has the same
shape and orientation, but is higher, larger and on the
opposite side when compared to the image of the actual
object .
 Palatoglossal Air Space

Right before exposing the film, the patient is asked to keep

the tongue against the palate during the entire exposure. This
will help to eliminate the palatoglossal air space (see red
arrows above). If this radiolucent band appears on the film, it
may mask periapical radiolucencies that might be present .
 Advantages

•Broad anatomical coverage

•Well-tolerated by patients
•Minimal time to expose when compared to
intraoral radiographs
•Relatively low patient dose
•Useful for patient education (although never
exposed only for that purpose!)
• 10 times less radiation than a complete
intraoral survey using long, round PID &
E+ film
• 4 time less radiation than a bitewing
survey using long, round PID and E+
film
 Disadvantages:

•Resolution is not as good as intraoral films due to

the intensifying screen. This results in decreased
detail
•Only objects in focal trough are seen clearly
•Distortion of image
– Overlapped teeth
– Magnification
– Minification
•Equipment cost
1. Mandibular condyle. 2. Articular eminence. 3. Coronoid process of mandible
superimposed on zygomatic arch. 4. Posterior wall of maxillary sinus. 5. Posterior
wall of zygomatic process of maxilla. 6. Hard palate. 7. Nasal septum. 8. Tip of
nose. 9. Dorsum of the tongue 10. Hyoid superimposed over inferior border of
mandible. 11. Inferior border of maxillary sinus. 12. Image of cervical spine. 13.
Medial bolder of maxillary sinus. 14. infraorbital canal. 15. Infraorbital rim. 16.
Pterygomaxillary fissure. 17. Anterior border of the pterygoid plates, 18. Lateral
pterygoid plate superimposed over soft palate coronoid process of the mandible 19.
Ear lobe, 20. Inferior border of mandibular canal. 21. Mental foramen. 22. Posterior
wall of nasopharynx. 23. Inferior border of mandible superimposed from opposite
side, 24. Soft palate over mandibular foramen of mandible.
 Maxilla:
1 = Middle concha
2 = Nasal septum
3 = Ethmoid plate
4 = Inferior orbital rim
5 = Infraorbital foramen
6 = Pterygo-maxillary 2
Identify
fissure the
following
7 = Anterior of the lateral
pterygoid plate
radiographi
8 = Zygomatic process of
c
thefeatures
temporal bone
9 = Posterior border of the
labeled
maxillary sinus 1-
15: process of
10 = Zygomatic
the maxilla
(“innominate” line
11 = Soft tissue shadow of
the pinna
12 = Inferior alveolar 1
(mandibular) canal
13 = Anterior nasal spine
14 = Lower border of the
mandible
15 = Hyoid bone
 Posterior
Mandible:
1 = Anterior nasal spine
2 = “Ghost” image of the
contralateral hard palate
3 = Orbit
4 = Hard palate
Identify the 2
5 = Inferior border of the
following
maxillary sinus
radiographi
6 = Soft palate shadow
7 = Oropharyngeal air space
c features
8 = Dorsum of tongue
labeled
9 = “Ghost” image of 1-
the
13:
contralateral lower border
of the mandible
10 = Mental foramen
11 = Shadow of the spine
12 = Submandibular gland
fossa / inferior alveolar 1
canal
13 = Articular tubercle
 Posterior
Mandible:
1 = Middle concha
2 = Medial wall of the maxillary sinus
3 = Zygomatic process of the maxilla
(“innominate” line)
4 = Posterior border of the maxillary
Identify the
sinus 2
5 = Zygomatic process of the temporal
bonefollowing
radiographi
6 = Hard palate
7 = Inferior border of the maxillary
c features
sinus
labeled 1-
8 = Tuberosity
9 = Coronoid15:process
10 = Posterior wall of nasopharynx
11 = Soft palate
12 = Dorsum of tongue
13 = Styloid ligament calcification
(stylomandibular) 1
14 = Soft tissue shadow of the pinna
15 = “Ghost” shadow of the
contralateral lower border of the
mandible
• Oral Radiology Principles And Interpretation

Stuart C. White
Michael J. Pharoah
6th Edition