ISSN 0975-8437 INTERNATIONAL J OURNAL OF DENTAL CLINICS 2011:3(4):47-49

INTERNATIONAL J OURNAL OF DENTAL CLI NICS VOLUME 3ISSUE 4 2011 47

Panoramic radiograph a valuable diagnostic tool in dental practice-Report of three cases
Mathew Jose, Jomy Varghese
Abstract
Many pathologic conditions remain asymptomatic and observed only when they cause soft or hard
tissue expansion or is secondarily infected. Routine panoramic views very often reveal hidden lesions other than
those related to the patients chief complaint. The present case series reports three cases wherein pathologic
conditions remain undetected due to lack of appropriate radiographic evaluation even after multiple dental
procedures.
Key Words: Panoramic Radiographs; Dental; Diagnostic Yield
Introduction
Routine panoramic views very often
reveal hidden lesions other than those related to the
patients chief complaint. There have been sporadic
case reports of such incidental discovery of
lesions.(1-3) Many pathologic conditions remain
asymptomatic and observed only when they cause
soft or hard tissue expansion or is secondarily
infected. This delay in detection increases
morbidity and mortality associated with the disease
and treatment. It is prudent to evaluate indicated
cases with radiographs prior to dental treatment
which might reveal incidental pathologies/findings
helping to achieve early diagnosis and treatment.
The present manuscript reports three cases where
pathologic conditions remain undetected even after
multiple dental visits along with a discussion on
the versatility of panoramic radiograph in
screening and early detection of many clinical
problems.
Case 1
A 44 year old female patient reported to
our center with a complaint of dull aching
continuous pain in the left side of face for last two
years. She had two decayed teeth in the left side of
maxilla and underwent root canal treatment in a
dental clinic. As the pain persisted she was referred
to a maxillofacial surgeon for the management of
temporomandibular joint pain. TMJ being found to
be clinically normal she was referred to a
periodontist who ruled out any periodontal
involvement.

Clinical examination revealed fractured
25, 26 and mild obliteration of the upper buccal
vestibule on the left side. Panoramic radiograph
was advised which revealed endodontically treated
25, 26. Well circumscribed lesion with mixed
radio opacity and radiolucency was observed apical
to 25 and 26 pushing the maxillary sinus
superiorly. Horizontally Impacted 18 was also
observed deep to the alveolar crest. Lesion was
enucleated under General anesthesia and
submerged 18 was also removed. Histopathology
examination of the lesion revealed a complex
odontoma.
Case 2
A 33 year old female patient was
presented with pain and swelling on the right side
of maxilla. She noticed the swelling one month
back and took antibiotics as per her dentists
advice. She had one of her lower tooth extracted 4
years back, oral prophylaxis was done two years
back and amalgam filling on two teeth a year back.

Panoramic radiograph of the patient
revealed impacted right maxillary third molar in
the right maxillary sinus close to medial wall with
well circumscribed radiolucency surrounding the
crown of the impacted tooth. Lesion was
enucleated along with removal of the tooth and
histopathology report confirmed it as dentigerous
cyst.
Case 3
A 31 year female patient presented with
abnormal mobility of two lower teeth (36 and 37)
on left side which was restored five years back and
had no history of extraction. Her left third molar
was missing clinically.

CASE REPORT
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INTERNATIONAL J OURNAL OF DENTAL CLI NICS VOLUME 3ISSUE 4 2011 48
Panoramic radiograph was advised which
revealed a very extensive multilocular radiolucent
lesion extending from second premolar till condyle.
Root resorption was noted on 35, 36 and 37. The
38 was found close to the coronoid process.
Incisional biopsy revealed an ameloblastoma of
follicular type.
Discussion
Panoramic images are useful clinically for
those patients requiring broad coverage of the jaws,
such as evaluation of trauma, extensive dental or
osseous disease, known or suspected large lesions,
location of third molars, evaluation of missing
teeth, teeth development and eruption status,
retained tooth and root tips in edentulous patients,
maxillary sinus and temporomandibular joint
afflictions and developmental anomalies like
prognathism and retrognathism. Panoramic
imaging is often used as the initial evaluation
image that can provide the required insight and
assist in determining need for other projections.
One of the strengths of the panoramic
image is the demonstration of the complete
dentition and allows diagnosing gross
abnormalities in number, position and anatomy of
the teeth. Panoramic radiographs reveal the
proximity of impacted teeth with vital structures
like inferior alveolar canal, floor and posterior wall
of maxillary sinus, maxillary tuberosity and
adjacent teeth. Above all patients readily
understand the image and are useful visual aid in
patient education.
In all three cases patients have visited
dental clinics for various dental problems and taken
routine dental treatments like oral prophylaxis,
restorations, root canal treatments and extractions.
Number of visits ranged from three to more than
ten. None of the cases was evaluated with
panoramic radiographs even in those patients with
missing wisdom teeth and over retained deciduous
teeth.
Panoramic radiographs cover a broad area
of facial bones and teeth with low radiation
dose.(4) Relative exposures dose from panoramic
radiography has been estimated at 6.7 microSv and
26microSv carrying an associated risk of inducing
fatal cancer of 0.21 and 1.9 cases per million
examinations respectively.(5)
The main disadvantage of panoramic
radiology is that the images does not display the
fine anatomic details and so it cannot replace
periapical radiograph or bite wing radiography in
detecting small carious lesions or early periodontal
and periapical lesions. Other problems include
unequal magnification and geometric distortion
across the image. The presence of cervical spine
can obscure the image particularly in the incisor
region.(6) Rushton et al suggested the following
clinical factors as being the best predictors of a
diagnostic yield of significance to treatment.
Clinical suspicion of teeth with periapical
pathology, presence of partially erupted teeth,
clinically evident caries lesions swelling and
clinically suspected unerupted teeth.(7) Asaumi et
al observed lesions in 12.8% among 1092 patients
in a retrospective study in pediatric population and
among this 47.1 % had different lesions from those
underlying the chief complaint.(1) Panoramic
radiographs are a valuable tool in early
identification of problems in dental development
during the mixed dentition stage. This gives
information regarding dental maturity, leeway
space, the eruption of permanent teeth, anomalies
and developmental disturbances.(8)
Panoramic radiographs are used in
assessment of root length and tooth axis prior to
orthodontic treatment. It has been observed that the
mean length measured were higher than the actual
length by 22% for maxillary teeth and 1% by
mandibular teeth.(9) There is a chance of
overlooking significant dental abnormalities in the
premaxillary area in a panoramic radiograph even
though the chance is 43%.(10) Panoramic
radiographs are used in forensic age estimation of
unaccompanied minors, but this should be
combined with hand and collar bone radiographs
for better accuracy.(11) Mucosal thickening and
mucosal antral cysts in the maxillary sinus are very
frequent incidental finding in panoramic
radiographs, dental infections are highly correlated
with antral mucosal thickening.(12) Panoramic
radiographs reveal calcified carotid artery
atheromatous lesions in diabetic patients and help
the dentist for appropriate referral for diabetic
care.(13) Alteration of mandibular inferior cortical
width and shape in panoramic radiographs in post-
menopausal women is an accepted predictor of
spinal osteoporosis.(14) A reliable diagnostic
accuracy in panoramic radiographs is observed in
preoperative evaluation of the relationship between
third molars and the inferior alveolar canal.(15)
Careful observation of panoramic radiographs
could reveal temporomandibular joint pathologies
like aneurismal bone cyst, traumatic bone cyst, and
synovial chondramatosis and TMJ arthrosis.(16)
Conclusion
Panoramic radiographs are indeed a
valuable tool in early detection of lesions in the
maxillofacial area. Considering the radiation dose
involved in the panoramic radiograph, and its
diagnostic yield, routine examination by panoramic
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INTERNATIONAL J OURNAL OF DENTAL CLI NICS VOLUME 3ISSUE 4 2011 49
radiograph on the initial clinical visit may be useful
in early detection of various pathologic conditions.
Authors Affiliations: 1. Dr. Mathew J ose, Professor and
Head, 2. Dr. J omy Varghese, Senior Lecturer, Dept. of
OMFS, Sree Mookambika Institute of Dental Sciences,
Kulasekharam, Kanyakumari Dist, Kerala, India.
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Address for Correspondence
Dr. Mathew J ose, MDS,
Professor and Head,
Dept .of OMFS,
Sree Mookambika Institute of Dental Sciences,
Kulasekharam,
Kanyakumari Dist.
Email: matjosein@yahoo.co.uk

Source of Support: Nil, Conflict of Interest: None Declared