PANORAMIC IMAGING
CDS IV
PANORAMIC IMAGING
Pantomography
A technique for producing a single tomographic image
of the facial structures that includes both the maxillary
and mandibular dental arches and their supporting
structures.
Tomography = a specialized technique for producing
radiographs showing only a section or slice of a patient.
Each tomograph shows the tissues within that section
sharply defined and in focus focal plane / focal trough
( a three-dimensional curved zone or image layer in which
structures are reasonably well defined )
Structures outside the section are blurred and out of focus.
By taking multiple slices, three-dimensional information
about the whole patient can be obtained.
PRINCIPLES OF PANORAMIC IMAGE FORMATION
Theory of dental panoramic tomography:
Linear tomography using a wide or broad X-ray beam
Linear tomography using a narrow or slit X-ray beam
Rotational tomography using a slit X-ray beam.
Broad-beam linear tomography
Narrow-beam linear tomography
Narrow-beam rotational tomography
SELECTION CRITERIA
Orthodontic assessment the state of the dentition
and the presence/absence of teeth
To assess bony lesions / an unerupted tooth that are too
large to be demonstrated on intraoral films
Prior to dental surgery under general anaesthesia
Assessment of periodontal bone support where there is
pocketing greater than 5 mm
Assessment of third molars wether they should be
removed or not.
REAL AND GHOST IMAGE
The normal anatomical shadows that are evident on panoramic
radiographs vary from one machine to another, but in general they can
be subdivided into:
1. Real or actual shadows of structures in, or close to, the focal trough.
2. Ghost or artefactual shadows created by the tomographic movement
and cast by structures on the opposite side or a long way from the
focal trough.
Real / Actual Shadows
Important hard tissue shadows
• Teeth
• Mandible
• Maxilla, including the floor, medial and posterior walls
of the antra
• Hard palate
• Zygomatic arches
• Styloid processes
• Hyoid bone
• Nasal septum and conchae
• Orbital rim
• Base of skull.
Fig. 15.17 A dental panoramic tomograph showing the main real hard tissue shadows,
including the plastic head support, drawn in on one side of the radiograph, NS — nasal
septum, MIT — middle and inferior turbinates, O — orbital margin, HP — hard palate, A
— floor of antrum, Z — zygomatic arch, EAM — external auditory meatus, MP —
mastoid process, SP — styloid process, H — hyoid, P — plastic head support.
Air shadows :
• Mouth/oral opening
• Oropharynx.
Important soft tissue shadows :
• Ear lobes
• Nasal cartilages
• Soft palate
• Dorsum of tongue
• Lips and cheeks
• Nasolabial folds.
Fig. 15.18 A dental panoramic tomograph showing the main real soft tissue and air
shadows drawn in on one side of the radiograph, NC — nasal cartilages, EL — ear lobe, SP
— soft palate, DT — dorsum of tongue, Or — oropharnyx, NF — naso-labial fold, M —
mouth.
Ghost Shadows
Ghost or artefactual shadows :
• Cervical vertebrae
• Body, angle and ramus of the contralateral side
of the mandible
• Palate.
Fig. 15.19 A dental panoramic tomograph showing the main anatomical ghost or
artefactual shadows drawn in on one side of the radiograph, PI — palate, Md —
mandible, CV — cervical vertebrae.
PANORAMIC MACHINES
Although varying in design, all panoramic machines
consist of three main components :
• An X-ray tube head : producing a narrow fan-shaped X-
ray beam, angled upwards at approximately 8° to the
horizontal
• A cassette and cassette carriage assembly
• Patient-positioning apparatus including light beam
markers.
PATIENT POSITIONING & HEAD ALIGNMENT
1. Patients should be asked to remove any earrings,
jewellery, hair pins, spectacles, dentures or orthodontic
appliances.
The procedure and equipment movements should be
explained, to reassure patients.
2. The anteroposterior position radiograph of the patient
is typically achieved by having patients place the incisal edges
of their maxillary and mandibular incisors into a notched
positioning device (the bite block).
Be sure patients do not shift their mandible to either side when
making this protrusive movement.
The midsagittal plane must be centered within the image layer
of the particular x-ray unit.
3. The occlusal plane is aligned so that it is lower anteriorly,
angled 20 to 30 ° below the horizontal plane.
A general guide for chin positioning is to place the patient
so that a line from the tragus of the ear to the outer
canthus of the eye is parallel with the floor.
4. Patients are positioned with their backs and spines as
erect as possible and their necks extended.
5. Proper neck extension is best accomplished by using a gentle
upward force on the mastoid eminences when positioning
the head in a manner similar to applying cervical traction.
straighten the spine, minimizing the artifact produced by a
shadow of the spine.
6. Instruct the patient to swallow and hold the tongue on
the roof of the mouth. This raises the dorsum of the
tongue to the hard palate, eliminating the air space
and providing optimal visualization of the apices of
the maxillary teeth.
IMAGE RESEPTOR
Intensifying screens : used in panoramic radiography to
reduce the amount of radiation required for properly
exposing a radiograph.
Fast films combined with high speed (rare earth)
screens are indicated for most examinations.
In most cases, the manufacturer provides panoramic
machines with intensifying screens.
PANORAMIC FILM DARK ROOM TECHNIQUES
Panoramic films are far more light sensitive than
intraoral films, especially after they have been exposed.
A reduction in darkroom lighting from that used for
conventional intraoral film is necessary.
IMAGE DISTORTION
Failure to position the midsagittal plane in the rotational midline
of the machine results in a radiograph showing right and left sides
that are unequally magnified in the horizontal dimension
Poor midline positioning causing horizontal distortion in the
posterior regions and, on occasion, non diagnostic, clinically
unacceptable images.
A simple method for evaluating the degree of horizontal
distortion of the image is to compare the apparent width of the
mandibular first molars bilaterally. The smaller side is too close to
the receptor, and the larger side is too close to the x-ray source.
INTERPRETING PANORAMIC IMAGES
I. THE MANDIBLE (MANDIBULA)
Condylar process and temporomandibular joint
Coronoid process
Ramus
Body and angle
Anterior sextant
Teeth and supporting structures
II. THE MIDFACIAL REGION
Cortical boundary of the maxilla (posterior border, alveolar
ridge)
Pterygomaxillary fissure
Maxillary sinuses
Zygomatic complex (including inferior and lateral)
Orbital rims, zygomatic process of maxilla, & anterior
portion of zygomatic arch
Nasal cavity and conchae
Temporomandibular joint
Maxillary dentition and supporting alveolus
III. DENTITION
Identification of all erupted and developing teeth
Examined for gross abnormalities of number, position,
and anatomy
Existing dentistry : endodontic obturations, crowns, and
other fixed restorations
Examine impacted third molars closely
- orientation
- the numbers and configurations of the roots
- the relationships of the tooth components to critical
anatomic structures (mandibular canal, the floor and
posterior wall of the maxillary sinus, the maxillary
tuberosity, and adjacent teeth
- abnormalities in the pericoronal and/or periradicular
bone
REFERENSI :
1. White, S.C., Pharoah, M.J., 2004, Oral Radiology, 5th ed.,
Mosby, Canada
2. White, S.C., Pharoah, M.J., 2000, Oral Radiology, 4th ed.,
Mosby, Canada
3. Whaites, E., 2002, Essentials of Dental Radiography and
Radiology, 3rd ed., Churchill Livingstone, London
IV. SOFT TISSUE
Palate (roughly from the region of the right angle of the
mandible to the left angle)
Lip markings (in the middle of the film),
Soft palate extending posteriorly from the hard palate over
each ramus,
Posterior wall of the oral and nasal pharynx, the nasal
septum, ear lobes, nose, and nasolabial folds.
The epiglottis and thyroid cartilage
