Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2012; 57:(1 Suppl): 4045

doi: 10.1111/j.1834-7819.2011.01655.x

Interpretation of panoramic radiographs

S Perschbacher*
*Department of Radiology, Faculty of Dentistry, The University of Toronto, Ontario, Canada.

ABSTRACT
Panoramic radiography has become a commonly used imaging modality in dental practice and can be a valuable diagnostic
tool in the dentists armamentarium. However, the panoramic image is a complex projection of the jaws with multiple
superimpositions and distortions which may be exacerbated by technical errors in image acquisition. Furthermore, the
panoramic radiograph depicts numerous anatomic structures outside of the jaws which may create additional interpretation
challenges. Successful interpretation of panoramic radiographs begins with an understanding of the normal anatomy of the
head and neck and how it is depicted in this image type. This article will describe how osseous structures, soft tissues, air spaces
and ghost shadows contribute to the final panoramic image. A systematic and repeated approach to examining panoramic
radiographs, which is recommended to ensure that critical findings are not overlooked, is also outlined. Examples of
challenging interpretations, including variations of anatomy, artefacts and disease, are presented to illustrate these concepts.
Keywords: Dental radiology, orthopantomograph.

INTRODUCTION
Panoramic radiography has become a commonly used
imaging modality in dental practice and can be a
valuable diagnostic tool in the dentists armamentarium. However, the panoramic image is a complex
projection of the jaws with multiple superimpositions
and distortions which may be exacerbated by technical
errors in image acquisition. Furthermore, the panoramic radiograph depicts numerous anatomic structures
outside of the jaws which may create additional
interpretation challenges. Successful interpretation of
panoramic radiographs begins with an understanding
of the normal anatomy of the head and neck and how it
is depicted in this image type. This article will describe
how osseous structures, soft tissues, air spaces and
ghost shadows contribute to the final panoramic image.
A systematic and repeated approach to examining
panoramic radiographs, which is recommended to
ensure that critical findings are not overlooked, is also
outlined. Examples of challenging interpretations,
including variations of anatomy, artefacts and disease,
are presented to illustrate these concepts.

may be less clear how the other structures of the head

and neck become captured on the image. It is often
these superimposing hard and soft tissues and airways
that create confusing shadows which cause challenges
in interpretation.
The panoramic perspective
The first step in understanding panoramic anatomy is to
appreciate the perspective from which each part of the
image is presented. Because the image is captured by an
X-ray tube which rotates around the patients head,
rather than from a stationary source, this perspective
changes from the posterior regions of the jaws to the
anterior area. The right and left posterior parts of the
image represent lateral views, looking at the patient
from the side; the anterior part of the image represents
an anterior-posterior view, looking at the patient from
the front (Fig. 1). The entire panoramic image is
analogous to a composite of portions of two lateral
and one anterior-posterior skull views, except without
as many superimpositions.
Osseous anatomy

Anatomy of a panoramic radiograph

Although it is obvious that a panoramic radiograph
depicts the teeth and jaws in a single convenient view, it
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With the panoramic perspective in mind, the osseous

structures of the maxillofacial region can be reviewed.
The structures around the posterior maxilla, which
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Interpretation of panoramic radiographs

Fig 1. Top composite photograph depicting the osseous anatomy of the maxilla and surrounding bones from the panoramic perspective. The
anterior region is viewed from the front while the posterior regions are viewed from the side. Bottom a panoramic radiograph divided to match the
regions represented by the photograph above. a and black dotted outline = pterygoid plate; b = pterygomaxillary ssure; c = zygomatic process
of maxilla; d = zygomatic arch; e = temporal component of temporomandibular joint; f = mastoid process of temporal bone (not imaged in
panoramic radiograph); g = lateral and inferior orbital rim; h = infraorbital canal; i and white dotted outline = inferior concha turbinate;
j = hyoid bone.

include the sphenoid, zygomatic and temporal bones,

are likely the least familiar for many dental practitioners but contribute an important part of the panoramic
image. The pterygoid plates of the sphenoid bone
articulate with the posterior wall of the maxilla and,
together, form the pterygomaxillary fissures (Fig. 1a
and b). The zygomatic processes of the maxilla are
thick buttresses of bone extending laterally from the
maxilla bilaterally and are seen as J-shaped shadows
superimposed over the maxillary sinuses (Fig. 1c). They
articulate with the zygomatic bones which, in turn,
articulate with the zygomatic processes of the temporal
bones to form the zygomatic arches (Fig. 1d). The
zygomatic arches can be followed posteriorly to where
the temporal bones form the superior components of
the temporomandibular joints (Fig. 1e). Sometimes the
mastoid processes of the temporal bones, containing
multiple radiolucent air cells, are imaged posterior and
inferior to the temporomandibular joints (Fig. 1f).
Occasionally, the mastoid air cells may extend anteriorly and pneumatize the roof of the temporomandibular joint (Fig. 2). This is a normal anatomic variation
but may seem to mimic pathology due to the multilocular appearance produced. The lateral and inferior
orbital rims of the orbits are seen as thick, curved,
linear radiopaque structures superior to the maxillary
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Fig 2. Mastoid air cells are seen bilaterally where they have pneumatized the articular processes of the temporal bones creating
rounded, radiolucent loculations (black arrows). This is a variation of
normal anatomy.

sinuses (Fig. 1g). Each infraorbital canal may be seen as

thin parallel cortices, extending inferiorly and medially
from the floor of the orbit (Fig. 1h). The inferior
turbinates of the nasal fossa create surprisingly large
shadows across a large portion of the maxillary sinuses
(as seen from the lateral perspective). They are also seen
in the middle part of the image on either side of the
nasal septum (seen from the anterior perspective)
(Fig. 1i). The hyoid bone, which is normally seen
inferior to the mandible, may create confusion when it
becomes superimposed over the inferior border because
of patient positioning (Fig. 1j).
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S Perschbacher
Soft tissues and air spaces
The osseous structures of the maxillofacial region are
surrounded by the soft tissues of the face, neck and oral
cavity. These soft tissues create indistinct radiopaque
shadows which superimpose over the osseous and
dental structures. The external nose may be seen over
the apices of the maxillary incisors with the ala curving
laterally from the midline (Fig. 3a). The soft tissues of
the external ear are often seen superimposed over the
mandibular condyle with the earlobe forming a
rounded radiopacity posterior to the ramus (Fig. 3b).
The largest intraoral shadow is created by the tongue,
whose dome-shaped image occupies a large proportion
of the panoramic radiograph (Fig. 3c). In the posterior
parts of the radiograph, the posterior region of the
tongue may have a more irregular surface due to the
lingual tonsils (Fig. 3d). The epiglottis can often be seen
as a thin finger-like projection extending from the
posterior tongue, below the angles of the mandible
(Fig. 3e). The soft palate is seen from a lateral
perspective on both sides of the panoramic image as
an oval or inverted tear-drop shape extending off the
hard palate (Fig. 3f). Its inferior surface is superior and
approximately parallel to the tongue.
The upper airway includes the nasal fossa, oral cavity
and pharynx, all of which are imaged on the panoramic
radiograph as radiolucent passages. These radiolucencies may be confused for bone destroying pathology or
fractures (Fig. 4). The nasal fossa is seen in the midline,
superiorly, and extends bilaterally across the region of
the maxillary sinuses (Fig. 3,1). Posteriorly, it opens
into the nasopharynx. The nasopharynx is seen posterior to the maxilla and superior to the soft palate
(Fig. 3,2). It is continuous with the oropharynx inferiorly, which occupies the region anterior to the cervical
spine and posterior to the tongue (Fig. 3,3). The oral
cavity may be seen as a variably-sized radiolucent strip
between the superior surface of the tongue and the
palate (Fig. 3,4). The increased radiolucency of the oral
cavity may obscure the roots of the anterior teeth due to
overexposure. This effect may be minimized by having
the patient place his or her tongue flat against the palate
during imaging. The oral orifice, or space created
between the upper and lower lips, may be seen as a
kiss-shaped radiolucency over the crowns of the
maxillary and mandibular incisors (Fig. 3,5). Having
the patient close his or her lips around the bite-stick can
prevent overexposure of this area.
Ghost shadows
Ghost shadows are shadows of structures imaged when
they are not within the focal trough. Because these
structures are outside the plane of focus, they appear
increasingly magnified and blurry. For example, when
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Fig 3. Panoramic radiograph with major soft tissue structures (af)

and airways (15) traced. a = external nose; b = external ear;
c = tongue; d = lingual tonsils on posterior tongue; e = epiglottis;
f = soft palate; 1 = nasal fossa; 2 = nasopharynx; 3 = oropharynx;
4 = oral cavity; 5 = oral orice.

Fig 4. The air shadow of the oral cavity may create a thin radiolucent
line superimposed over the mandibular ramus, which may be mistaken
for a fracture if not properly identied (open black arrows). Careful
examination of the periphery of the radiograph is done to avoid
missing ndings in the tissues surrounding the jaws. An elongated
styloid process (black arrow) and submandibular calcication (white
arrow), most likely representing a submandibular gland sialolith, are
detected in this patient.

the left side of the mandible is being imaged, the film or

sensor is positioned close to this side. However, the Xray source is positioned on the right side of the patient
and the beam must pass through the right mandible in
order to image the left side. Because the right side is at a
greater distance from the film, its image is enlarged and
indistinct. Hence there is a ghost shadow of the right
mandible seen superimposed, in a slightly superior
position and a reversed orientation, over the left
mandible. Of course, the same is true for the contralateral side (Fig. 5a). The cervical spine may be seen in
focus on a panoramic radiograph on the most posterior
parts of the image. However, a ghost shadow of the
cervical spine is formed when the anterior teeth are
imaged because the X-ray beam originates from behind
the patients head. This shadow may obscure a clear
view of the anterior region of the jaws (Fig. 5b). Having
a patient stand as tall as possible with his or her cervical
spine extended maximally helps minimize this superimposition. Foreign objects, such as earrings or facial
jewellery, may also create ghost shadows which can
obstruct visualization of the underlying anatomy if they
are not removed (Fig. 6).
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Interpretation of panoramic radiographs

Fig 5. The ghost shadows produced by the contralateral mandible (a)

and cervical spine (b) are traced on this panoramic radiograph. The
shadows of these structures are indistinct because they are so far
outside the focal trough when imaged.

Fig 6. Earrings worn by this patient during image acquisition have

created ghost shadows. The right earring is seen superimposed over the
left maxillary sinus (white arrow) and the left earring is projected over
the right zygomatic arch (black arrow).

An approach to reading panoramic radiographs

The interpretation of a panoramic image follows the
same principles as with any other image or image
series. A systematic and repeated process is used to
ensure that all significant findings are identified. An
observer cannot count on abnormalities to present
themselves. Rather, one must be vigilant in assessing
all anatomic structures to ensure they are present
and normal. In the systematic approach recommended here the osseous structures and surrounding
soft tissues are assessed first. Second, the alveolar
processes are examined. Finally, the teeth are
evaluated.

appearing bilaterally are generally anatomic. Comparing the left and right sides may also allow detection of
any asymmetries that may be indicative of disease or a
developmental condition.
The following steps are an example of an approach to
analysing the complex projection of the anatomic
structures on a panoramic radiograph:
1. Assess the periphery and corners of the image
Start here to avoid zoning in on the teeth and
neglecting important findings in the tissues
surrounding the jaws (Fig. 4).
Structures that may be seen in this area include
the:
orbits
articular processes of the temporal bones (at the
temporomandibular joints)
cervical spine
styloid processes
pharynx
hyoid bone.
2. Examine the outer cortices of the mandible
Trace the periphery of the bone starting at one
spot and completing a circuit which includes:
anterior and posterior rami
coronoid processes
condyles and condylar necks
inferior border.
Look for continuity and evenness of the cortices
(Fig. 7).
3. Examine the cortices of the maxilla
This includes the posterior and medial walls and
floor of each maxillary sinus.
While examining the posterior wall of the sinus,
also look at the:
zygomatic process of the maxilla
pterygomaxillary fissure

Osseous structures and surrounding soft tissues

Compared to intraoral radiographs, the panoramic
image depicts a much larger area of anatomic structures
of the oral and maxillofacial region. More time will
therefore be required to assess these structures, though
once a routine is established a practitioner will find that
this becomes a quick and natural process. It is critical to
have a good understanding of the normal anatomy in
order to identify the presence of any abnormalities. It is
useful to compare the left and right sides of the image
when deciding if a finding is normal, since structures
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Fig 7. Careful examination of this panoramic radiograph reveals that

the inferior cortex of the mandible is not seen clearly on the left side,
compared to the right. Assessment of the bone pattern also reveals
increased trabecular bone density in the posterior left mandible. This
has caused the mandibular nerve canal to appear relatively more
prominent. The path of the nerve canal is also altered in a superior
direction. These ndings are consistent with brous dysplasia. This
image cannot portray the buccal-lingual expansion that is characteristic of this condition.
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S Perschbacher
Alveolar processes and teeth

Fig 8. Examination of the cortical lines in the posterior maxillary

regions of this image would allow the observer to detect that the
posterior wall of the left maxillary sinus is absent (open black arrows
indicate where the cortex should be seen). This destruction was caused
by a malignancy within the sinus. The white lines formed by the
zygomatic process of the maxilla and posterior boundary of the
pterygomaxillary ssure, which should be assessed at the same time as
the posterior wall of the maxilla, are still visible.

- The thin radiopaque lines produced by these

structures run roughly parallel to the posterior wall of
the maxillary sinus, and may be confused with it.
Destructive disease affecting the maxillary sinus may
erode the posterior wall, which can be easily missed if
all three lines are not identified (Fig. 8).
4. Examine the zygomatic bones and arches
Follow where they extend posteriorly from the
zygomatic processes of the maxilla to the
temporal bones.
5. Assess the internal density of the maxillary sinuses
Compare left and right sides.
Opacification is most commonly a sign of
inflammatory disease but could be a sign of
more serious pathology.
6. Assess the structures of the nasal cavity and the
palates
Examine the nasal floor hard palate and conchae extending horizontally along both sides
of the image.
Examine the nasal septum in the midline.
Note the soft palate seen bilaterally extending
from the posterior aspect of the hard palate
and into the oropharynx.
7. Examine bone the pattern of the maxilla and
mandible
Assess the density and pattern of the trabeculae
for abnormalities (Fig. 7).
Keep in mind that some metabolic conditions
may present with a generalized alteration in
bone pattern and therefore comparing left
and right sides may not be helpful.
In the mandible examine the size, position,
cortication and symmetry of the:
inferior alveolar nerve canals
mandibular foramina
mental foramina.
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The spatial resolution of a panoramic image is much

lower than intraoral radiographs, making detailed
assessment of the alveolar processes and teeth more
difficult. Nonetheless, full evaluation is required to
avoid missing disease. These structures should be
viewed in a systematic manner. A sequence from the
posterior of the first quadrant to the posterior of the
fourth quadrant in a clockwise direction, repeated for
each finding to be evaluated, is recommended.
The following steps are suggested as an approach to
this part of the interpretation: (1) assess the crestal bone
position of the alveolar processes to identify any
periodontal bone loss; (2) examine the periodontal
ligament spaces and lamina duras around each tooth
for signs of inflammatory disease; (3) dont forget to
examine the follicles and papillae of developing teeth
for anything affecting their size, position or cortical
boundaries. These changes could be indicative of
developing pathology; (4) evaluate the teeth for presence absence eruptive or positional abnormalities, caries, inadequate restorations, calculus, developmental or
acquired abnormalities.
Interpretation of pathology on panoramic
radiographs
The panoramic radiograph is especially useful when
examining regions of the jaws which cannot be imaged
with intraoral radiographs, such as the temporomandibular joints and third molar regions. Due to distortion and a limited two-dimensional view, the temporomandibular joint cannot be assessed in detail, however,
a general overview is provided which allows major
abnormalities to be ruled out. When a lesion in the jaws
needs to be studied, it is important to be able to
examine its entire boundary, which may be best
achieved on a panoramic image. Usually the location,
periphery and shape, internal density and effects on the
surrounding structures of lesions in the jaws can be
appreciated on panoramic images. However, this
modality is limited by the numerous superimpositions
projected on the image, especially in the maxillary sinus
and palate regions, and by its inability to demonstrate
medial-lateral changes (Fig. 7). Advanced imaging,
such as computerized tomography, cone beam computerized tomography or magnetic resonance imaging may
be required to provide multidimensional views to
supplement the information obtained from a panoramic
radiograph.
CONCLUSIONS
Panoramic radiographs have many useful applications
in dentistry but require diligence on the part of the
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Interpretation of panoramic radiographs

observer to examine the image thoroughly. For this
reason, a systematic approach is recommended for the
interpretation of this image type. Understanding the
perspective of the anatomy on a panoramic radiograph
as well as the many superimpositions and distortions
produced will help the practitioner to be more successful at this task.

2012 Australian Dental Association

Address for correspondence:

Dr Susanne Perschbacher
Department of Radiology
Faculty of Dentistry
124 Edward Street
Toronto
Ontario M5G 1G6
Canada
Email: s.perschbacher@dentistry.utoronto.ca

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