Panoramic innominate line and related

roentgen anatomy of the facial bones

A uew radiographic line has been identified in a study of the facial bones as seen in
panoramic radiographs made with the Panex.

P anoramic radiography is primarily used for the examination of dental

structures; however, the films include a part of the facial bones, such as maxilla,
zygomatic arch, palatine bones, etc. In order to use panoramic radiography for
the diagnosis of abnormalities of the facial bones, a study of roentgen anatomy
is essential.
In a review of the literature, articles on panoramic roentgen anatomy are
quite limited in number.‘, L’ Recently, Domar& reported on the panoramic
roentgen anatomy of the midfacial bones. In our series of studies, the maxillary
region was investigated with special attention, and preferable projections were
pointed out for each anatomic structure of the facial bones.

METHOD OF INVESTIGATION
Radiopaque markers were attached to certain anatomic landmarks of a
human dry skull and radiographed with Panex Ellipsopantomography (manu-
factured by Morita Company of Japan) at 65 KVP, 3 to 11 Ma., 25 seconds,
focal-skin distance of 74 cm., and 4 mm. aluminum filter. The film used was
30 by 20 cm. in size, manufactured by Fuji Company. The cassette was provided
with a Kyokko MS type of intensifying screen.
The skull was held on the chin rest of the Panex unit with radiolucent poly-
styrene foam, setting the chin of the skull at the zero point of tomographic scale
of the unit. The central ra?- of the x-ray beam was projected at 7 degrees
cranially, which is standard in this machine. The skull was radiographed in six
different positions, varying the anthropological plane as shown in Fig. 1. Posi-
tions of the skull were divided into three major groups, such as chin-up, neutral,

*Radiology Department, Faculty of Medicine, Kyushu University, Fukuoka, Japan.

““Dental Radiology Department, Kyushu Dental College, Kitakyushu, Japan.

131
132 Kafnya,rna, Oh& rind Ogawn

Pig. 1. Six diflerent projections with regard to a meatal infraorbital anthropologic plane.
Chin-up positions include +30”, +20”, and +lO”; chin-down positions include -10” and -20”.

Table I. Evaluation of the delineation of anatomic landmarks with regard to the

various positions

Orbital margin n a a a n 0
Superior aspect of zygomatic arch 0 0 X
Inferior aspect of zygomatie arch 0 0 2 ii ii X
Posteromedial wall of maxilla 0 0 0 a n X
Lateral wall of maxilla x X X X X
Lateral pterygoid plate it X X
Medial pterygoid plate z : :: A X X
Posterior margin of palatine bone x X X x X X
Lateral wall of nasal cavity x X X x
Lateral wall of orbit X X X z z x
Floor of nasal cavity 0 0 0 n n X
Floor of orbit x X X
Optic foramen x X X i i 2
Foramen rotundum x X X x X x
o = Good. a = Fair. x = Poor.
*Angle to anthropologic plane.

and chin-down positions. The anatomic structures investigated were as follows :

(1) superior and inferior aspects of the zygoma, (2) posteromedial wall of the
maxilla, (3) anteromedial wall of the maxilla, (4) medial and lateral plates of
the pterygoid process, (5) posterior margin of the palatine bones, (6) lateral
wall of the nasal cavity, (‘7) floor of the nasal cavity, (8) foramen rotundurn
and optic foramen, and (9) posterior surfaces of the zyygomatic process of the
maxilla and the frontal process of the zygoma. Panoramic radiographs of the
human dry skull were independently interpreted by two radiologists and results
were combined later.
RESULTS
In general, the chin-down position made an analysis of the anatomy of the
facial bones easy. This was especially true for the maxillary antra.
The zygomatic arch was well outlined in chin-down positions, and the POS-
terior aspect of the arch was likely to be obscured by dense petrous bones. The
posterior wall of the maxillary sinus was in part projected on the outermost
lateral image on the panoramic radiograph. The lateral wall of the maxillary
Volume 37 Panoramic in7bomi7late line and related anatomy 133
Number 1

Fig. .‘Z. A dry skull with attached radiopaque markers and Pantomogram of the dry skull.
Line 2 indicates the posteromedial part of the maxilla, and line I indicates the posterior
surface of the zygomatic process of the maxilla and the frontal process of the zygoma
(panoramic innominate line).

sinus did not cast any identifiable image on a panoramic radiograph. The
pterygoid process was projected just lateral to the maxillary sinus and was in
part superimposed on adjacent bony structures, such as the coronoid process of
the mandible.
The posterior margin of the palatine bones was not well shown because of
superimpositions, and the lateral wall of the nasal cavity was not delineated. The
134 Katayama, Ohba, and Ogawa Oral Surg.
January, 1974

Pig. 3. A Pantomogram in neutral projection (anthropologic plane) and its diagrammatic

illustration of the facial hones. Number in diagram indicates each anatomic landmark as shown
below.
1, Optic foramen. 10, Frontal sinus.
8, Pituitary fossa. 11, Orbit.
3, Panoramic innominate line. 13, Sphenoidal sinus.
4, Anteromedial wall of the maxillary sinus. 13, Eminentia articularis.
5, Coronoid process. 14, Head of the mandible.
6, Posteromedial wall of the maxillary sinus. 15, Inferior margin of the zygoma.
7, Floor of the nasal cavity. 16, Lateral ptergoid plate.
8, Floor of the maxillary sinus. 17, Mandibular canal.
9, Mental foramen.
Volume 37 Panoramic iwnomi~~ate line and related alzatomy 135
Number 1

minus 20’

Fig. 4. Pantomogram made in the chin-down position (-20” to anthropologic plane)

and its diagrammatic illustration. Number in diagram indicates the same anatomic landmark
as shown in Fig. 3.

floor of the nasal cavity was shown as a horizontal line across the inferior part of
the maxillary sinus. The foramen rotundum and the optic foramen were not well
defined. A line running vertically in the projection of the outer third of the
maxillary sinus was not made by a single bony structure but by the posterior
surfaces of the zygomatic process of the maxilla and the frontal process of the
zygoma (Fig. 2).
The results of the visualization of each anatomic landmark of the facial bones
by projection are shown in Table I.
136 Katnyama, Ohba, trod Ogtrwa Oral Burg.
.Tanuary, 1974

Fig. 3 shows a radiograph made in a neutral projection with a representative

schematic roentgen anatomy. Fig. 4 shows t,he results of a projection made at
minus 20 degrees.

DISCUSSION
As Cardini and Vecchi4 pointed out, the panoramic radiography was very
useful for a diagnosis of facial abnormalities with such etiologic factors as
trauma, inflammatory processes, neoplastic lesions, and others. The reasons for
this may be ease of technique and low exposure dose. Langland and Sippy”
reported that a special transverse projection of the maxillary sinus was possible
with the orthopantomograph if the patient,‘s head was moved forward approxi-
mately 25 mm. However, the use of panoramic radiography for studying the
facial bony structures has not been widespread.
In order to diagnose a facial abnormality, it, is very important to know the
normal rocntgrn anatomy. In t,his series of studies the central x-ray beam was
directed 7 degrees craniad, which was standard in use of the I’anex, and the
skull was intentionally positioned at different angles with regard to the selected
anthropologic plane. This was, we presumed, a more practical approach to view-
ing the facial struet,urcs.
A vertical lint, running across the outer third of the maxillary sinus, was
made not by only one bony structure but by a cross section of the posterior
surfaces of the zygomatic process of the maxilla and the frontal process of the
zygoma. This line was quite similar in appearance to the innominate line seen
in the Caldwell projection of the skull, but it is actually quite different in origin.
The innominate line, which is best shown in the Cal&e11 projection, crosses the
outer third of the orbit, in an oblique vertical direction and corresponds to a
cross section of the squamozygomat,ic surface of the sphenoid bone.F
We propose to name the line seen vertically crossing the outer third of the
maxillary sinus in the panoramic view as the ~~~wwrn~ic i?t?to?tti?trrfe he (Figs.
2, d and B, 3, .1 and B, and 4, A and B). To repeat, the panoramic innominate
line and the innominate line were quite similar in appearance but quite different
in origin. The panoramic innominate line should not be confused with the
posterior wall or the lateral wall of the maxillary sinus.
A part of the posterior wall of the marillary sinus was clearly visualized as
the outermost lint of the maxillary sinus seen on the panoramic radiographs.
It might be hard to understand why the posterior wall of the maxillary sinus,
a structure of considerable depth, cast a shadow on the panoramic radiograph,
in spite: of t,he tomographic effect. of the panoramic radiography of the dental
arch. We thought these were certainly effects of zonography and short-distance
radiography. Schrameck and Rappaport’ suggested the use of a panoramic x-ray
unit as a screening device for maxillary sinus pathoses. Hirose and Tokoshimag
found panoramic racliographv useful in the diagnosis of odontogenic sinusitis
and maxillary tumors. Greenbaum and associate9 reported that the panoramic
x-ray examination was better than routine radiography for visualizing the extent
of carcinomatous invasion of the posterior wall of the maxillary sinus. As assess-
ment of the posterior wall of the maxillary sinus is very important for the
treatment of carcinoma of the maxilla and its prognosis. Conventional t,omog-
Volume 37 Panoramic innominate line and related awtomy 137
Number 1

raphy is used for this purpose, but we are convinced that panoramic radiography
is able to take this role over effectively.
The panoramic radiograph has unaroidable superimposed shadows. The
tomographic principle of this roentgenographic technique explains the shadows.
In this experiment, the metallic indicators attached to the right side of the skull
cast shadows on both the right and left sides of the radiograph. It is true that
the metallic object exaggerates this phenomenon, and O’Carrol12 describes this
fact.
SUMMARY
To study the panoramic roentgen anatomy of the facial bones, radiopaque
markers were attached to a human dry skull and radiographed with the Panex
(Japanese-made ellipsopantomographic unit). The upper half of the facial bones
was well radiographed in the chin-down position of the skull. The chin-up
position was not good for visualization of the maxillary antra. The posterior wall
of the maxilla was clearly outlined on the panoramic view, but not the lateral
wall. The panoramic innominate line was named. This line crosses the outer third
of the maxillary sinus vertically on the panoramic radiograph and corresponds
to the cross section of the posterior surfaces of the zygomatic process of the
maxilla and the frontal process of the zygoma.
CONCLUSIONS
1. The chin-down position of the head is suitable for panoramic radiography
of the upper half of the facial bones.
2. The posterior wall of the maxilla is seen clearly in the panoramic view.
3. The panoramic innominate line is defined, and this line should not be
confused with the posterior or lateral wall of the maxilla.
REFERENCES
1. Knight, Norris: Anatomic Structures as Visualized on the Panorex Radiograph, ORAL SURG.
26: 326-331, 1968.
2. O’Carroll, M. K.: Interpretation of Panorex Radiographs, J. Oral Med. 26: 86-92, 1971.
3. Domarus, H. V.: Die RGntgen-Panorama-Darstellung des Mittelgesichtes mit zintralem
Fokus, Fortschr. Geb. Roentgenstr. Nuklearmed. 116: 205210, 1972.
4. Cardini, E., and Vecchi, A. De: Orthopantomography, Radiographica 24: 35-89, 1970.
5. Langland, 0. E., and Sippy, F. H.: Anatomic Structures as Visualized on the Orthopantomo-
gram, ORAL SURG.24: 475-484, 1968.
6. Shapiro, Robert, and Jansen, A. H.: Normal Skull, New York, 1960, Paul B. Hoeber, Inc.,
p. 71.
7. Shrameck, J. M., and Rappaport, I.: Panoramic X-ray Screening for early detection of
maxillary Sinus Malignancy, Arch. Otolaryngol. SO: 347-351, 1969.
8. Greenbaum, E. I., Rappaport, I., and Gunn, W.: The Use of Panoramic Radiography in
Detection of Posterior Wall Invasion by Maxillary Antrum Carcinoma, Laryngoscope 72:
256-263, 1969.
9. Hirose! T., and Tokoshima, H.: Application of Panorex in the Field of Otolaryngology;
a Prebminary Report, Otolaryngology 42: 581-588, 1970.

Reprint requests to :
Dr. Hitoshi Katayama
Radiology Department
School of Medicine
Jutendo University
2-1-l Hongo, Bunkyo-ku
Tokyo, Japan 113