PANORAMIC

RADIOGRAPHY
ORAL RADIOLOGY LECTURE

FACULTY OF DENTISTRY, SANA A UNIVERSITY

Ass.Pro. Dr. LATIFA AL-NAJJAR

 Indications for Panoramic Radiography

• Evaluate third molars

• Evaluate pathology, trauma, and developmental

anomalies

• Mixed dentition analysis

 Panoramic Radiography Advantages
Compared to a complete intraoral series of periapical films, a
panoramic film:

• Covers a larger anatomical area.

• Exposes the patient to less radiation.

• Requires less technical experience.

• Is more easily tolerated by the patient.

Panoramic Radiography Disadvantages

When compared to intraoral radiographs, a

panoramic film:

• Produces an image that is less sharp (harder to

see details)

• May not reveal objects that are outside the focal

trough ( the area of maximum detail)

• Requires more expensive equipment

 Sharpness

The sharpness or detail seen on a periapical

film (bottom right) is much better than that
seen on a panoramic film (bottom left).

panoramic periapical
A periapical or bitewing film is preferred
over a panoramic film for:

• Caries
• Periodontal involvement
• Early or limited periapical pathology
• Endo treatment
PRINCIPLES OF PANORAMIC
IMAGE FORMATION
A panoramic radiograph presents views from both
sides of the patients face as well as providing a frontal
perspective.
You can best
understand the relative
position of structures
shown in a panoramic
radiograph if you
imagine the image layer
to be bent around the
patient’s face
The lateral and more
posterior structures are
The anterior structures
projected to each side of
are shown in the midline
the panoramic radiograph.
of the standard
panoramic projection
Panoramic Machines
 Obtained by rotating a
narrow beam of
radiation in the
horizontal plane.

 The film is rotated in

the opposite direction
of the beam while the
object (jaws) is
stationary.
Focal Trough

The focal trough is a three-

dimensional curved zone or
image layer in which
structures are reasonably
well defined. Through the
design of the panoramic
machine, this zone
corresponds to the shape of
the upper and lower jaws.
 Ghost image
A ghost image is the opaque shadow of a dense object
(jewelry, anatomy) located on the opposite side of the
patient. E.g., the ghost image of an earring in the
patient’s right ear will be seen in the maxillary left
region on the film.
Bilateral earrings casting ghost images
 Characteristics of a Ghost Image

A ghost image will be:

• located on the opposite side from the image of

the actual object
• the same shape as the actual object
• larger than the image of the actual object
• projected higher on the film
• less distinct (less sharpness; “ghostlike”)
 Ghost Image
The dotted line below outlines the shape of the ghost
image of the left side of the mandible. Because it is
very dense bone, this normal anatomy can produce a
ghost image.

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 Patient Preparation

 Ask the patient to remove glasses, jewelry, dentures, and

hearing aids.
 Basically, remove anything between the neck and the top of the
ears.

 Place the lead apron on the patient (no

thyroid collar; it might block part of the x-
ray beam).
 Make sure the apron is positioned low on
the back of the patient’s neck (arrow) so
that it does not block the beam as the tube
head rotates behind the patient.
 Patient Positioning
No matter the type of panoramic machine, there are four
basic steps in patient positioning.

1. The maxillary and mandibular incisors are placed in

the notch of the bitestick. This positions the anterior
teeth in the focal trough.

2. The Frankfort Plane should be parallel to the floor.

3. The Midsagittal Plane is perpendicular to the floor and

centered on the bitestick.

4. The vertebral column should be straight.

 Reference Lines

Frankfort Plane: represented

by a line from the inferior
border of the orbit to the top
of the external auditor meatus.

Midsagittal Plane: divides the

head into right and left halves
 FP
MSP parallel to
centered floor

teeth in notch of bitestick

 Correct Incorrect

Patient standing upright

with spinal column straight
Advise patient to swallow to feel tongue contact
palate. Tell patient to keep the tongue against
the palate the entire time of exposure (20
seconds).

Set correct exposure

factors. Depress
exposure button (red
arrow) and hold down
until the machine
completes its rotation.
 Infection Control

The cover is placed on the bitestick before

patient positioning. After exposure, the cover is
removed and discarded. Following this, the
bitestick and all surfaces that contacted the
patient’s head should be wiped with a
disinfectant.
 Positioning Errors

 Head tipped up
 Head tipped down
 Head turned
 Teeth in front of notch or behind notch
 Teeth Too Anterior
If the teeth are positioned in front of the notches in the
bitestick (see diagram below left), the anterior teeth will
appear narrower and will be blurred (less sharp than
normal). If the teeth are in front of the notches, they are
closer to the film, resulting in less magnification
horizontally (narrowing). Being out of the focal trough
makes the images less sharp.
 Teeth Too Anterior
This film shows the blurring and narrowing
of the anterior teeth.

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 Teeth Too Anterior

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 Teeth Too Posterior
If the teeth are positioned behind the notches in the
bitestick (see diagram below left), the anterior teeth will
appear wider and will be blurred (less sharp than
normal). If the teeth are behind the notches, they are
farther from the film, resulting in more magnification
horizontally (widening). Being out of the focal trough
makes the images less sharp.
 Teeth Too Posterior

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 Teeth Too Posterior

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 Head Turned
If the head is turned slightly to the side (not
centered on the bitestick), the structures on one
side will be closer to the film and the structures
on the other side will be farther from the film. In
the diagram below, the head was turned to the
right and the teeth are closer to the film on that
side.
 Head Turned
The teeth are smaller on the side to which the head is
turned. (When the teeth are closer to the film, there is
less magnification horizontally). The teeth that are
farther from the film are wider because there is
increased magnification horizontally.
 Head Turned
In this patient, the molars on the patient’s right side are
noticeably wider than the molars on the patient’s left.
Which way was the head turned?
To the left. Left side closer to film, less magnification.

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 Head Turned
On this film, not only are the teeth wider on one side, but the
ramus is also wider on that side. (The black arrows are the
same length on both sides). Which side was farthest from the
film?
The patient’s right side; farther from the film, more
magnification.

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 Head Turned
In this film, the patient’s head was turned to the right,
resulting in a widening of the teeth and ramus on the
patient’s left side.

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 Head Tipped Down

If the head is positioned so that the Frankfort Plane is

inclined downward (see diagram below left), the mandibular
incisors will appear shortened and the mandible will be V-
shaped (Exaggerated smile).
 Head Tipped Down
Notice how short the mandibular incisors appear. The
rest of the teeth are relatively normal.

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 Head Tipped Down
Again we see shortened mandibular incisors, V-
shaped mandible.

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 Head Tipped Up
If the Frankfort Plane is angled upward, the mandible
will be “squared-off” (angle of the mandible
approximately 90 degrees) and the hard palate will be
superimposed over the roots of the maxillary teeth. May
have the appearance of a “reverse” smile.
 Head Tipped Up

In the film below, the hard palate (red arrows) is covering the
roots of the maxillary teeth. Note the reverse smile.

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 Head Tipped Up
This film shows the reverse smile and it is difficult to
see the root areas of the maxillary teeth.
 Lead Apron
If the lead apron is improperly positioned so that it is
located high on the back of the patient’s neck, it may
block part of the beam and result in a clear (appears
white on the viewbox) area on the film.

Lead apron shadow

Lead Apron
A lead apron raised up on the right shoulder has cast a radio-opaque image on
the left side of the image in the premolar region.
 Cervical Vertebrae (Spine)
If the patient is not standing straight, the cervical
vertebrae may block the x-ray beam as the tube-head
travels behind the patient at an upward angle. This
results in a radiopaque area that extends up through the
middle of the film (arrows below). The teeth/bone are
faintly visible in the radiopaque area (not completely
blocked out as with the lead apron).
 Palatoglossal Air Space
The Palatoglossal Air Space (black area below) is caused by
failure to keep the tongue against the palate during exposure.
This makes it difficult to diagnose periapical pathology, which
also is dark, in the maxillary area. Many patients have
difficulty complying with the instructions to keep the tongue
against the palate during exposure and this space is often seen.
As long as you instruct the patient, this would not be
considered an error.
 Palatoglossal Air Space
The arrows in the film below identify the
palatoglossal air space.

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 Static Electricity
Static electricity appears as black lines or dots on
the film, often having a tree-branch appearance. It
is caused by removing the film from the box or
cassette too quickly, creating static discharge.
 Failure to Remove Appliances
As part of patient preparation, appliances should be removed
from the mouth. In this patient, the complete upper denture was
left in the mouth. This would not require a retake, since the acrylic
of the denture base allows x-rays to pass through and the bone is
clearly visible.

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 Failure to Remove Appliances
In this patient, both upper and lower removable
partial dentures were left in the mouth. In this case
the metal frameworks obscure large areas of the teeth
and the film should be retaken.

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 Glasses
Glasses should routinely be removed for panoramic
exposures. The bottom part of the frame/lenses may
obscure the periapical area of the maxillary anterior teeth.
What other error is evident on this film?
The head is tipped up too much. Notice the reverse
smile and the proximity of the hard palate to the roots
of the maxillary teeth.

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 Patient Movement
It is important for the patient to remain still during
a panoramic exposure. This film shows excessive
patient movement (unknown cause) and must be
retaken.

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 Patient Movement
This film shows much more subtle movement (arrow),
resulting in an uneven inferior border of the mandible.
This might be misinterpreted as being the result of a
fracture.

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 Incorrect Exposure Settings
If incorrect exposure factors are selected for a patient
(kVp, mA), a film that is too light (underexposed) or too
dark (over-exposed) may result. The film would
normally be retaken.

overexposure underexposure