PRINCIPLES OF PANORAMIC IMAGE FORMATION

Paatero and, independently, Numata were the first to describe the principles of panoramic
radiography. Figure 10-2 shows a schematic view of the relationships between the x-ray source, the
patient, the secondary collimator, and the image receptor during panoramic image formation. The
following illustrations explain the formation of the focal trough in a panoramic machine. Imagine an
assembly containing a disk with upright physical objects (represented by letters) and an image
receptor (Fig. 10-3). The receptor travels upward through the beam at the same speed as objects A
through C rotate through the beam. A lead collimator in the shape of a slit located at the x-ray
source limits the x-rays to a narrow vertical beam. Another collimator between the objects and the
image receptor reduces scattered radiation from the objects to the image receptor. Consider first
radiopaque objects A through C. As the disk rotates, their radiographic images are recorded sharply
on the receptor that also moves through the beam at the same direction and speed. The spatial
relationship of the shadows of these objects correctly represents the relationship of the actual
objects. Because the source-receptor distance is constant and the objectreceptor distance is the
same for each object, all objects are magnified equally. Now consider objects D through F. They are
located on the opposite side of the disk, between the x-ray source and the center of rotation of the
disk. These objects move in the opposite direction of the receptor, so their shadows are reversed on
the receptor. Because these objects are much closer to the x-ray source, their images are greatly
magnified. Figure 10-4 shows that the same relationship between the rotating receptor and objects
can be achieved if the disk is held stationary but the x-ray source and the receptor are rotated
around the center of rotation in the disk. The x-ray beam still passes through the center of the disk
and sequentially through objects A through C. Similarly, the receptor is still moved through the beam
and at the same rate as the beam passes through A through C. In this situation, as before, objects A
through C move through the x-ray beam in the same direction and at the same rate as the receptor.
Objects D through F continue to be blurred, just as before. Figure 10-5 shows that a patient may
replace the disk and objects A through F represent teeth and surrounding bone. The illustration
demonstrates the positions of the x-ray source and the receptor early in an exposure cycle. The
center of rotation is located off to the side of the arch, away from the objects being imaged. The rate
of movement of the receptor is regulated to be the same as that of the x-ray beam sweeping
through the dentoalveolar structures on the side of the patient nearest the receptor. Structures on
the opposite side of the patient (near the x-ray tube) are distorted and appear out of focus because
the x-ray beam sweeps through them in the direction opposite that in which the image receptor is
moving. In addition, structures near the x-ray source are so magnified (and their borders so blurred)
that they are not seen as discrete images on the resultant image. These structures appear only as
diffuse phantom or ghost images. Because of both of these circumstances, only structures near the
receptor are usefully captured on the resultant image. Contemporary panoramic machines use a
continuously moving center of rotation rather than multiple fixed locations (Fig. 10-6). This feature
optimizes the shape of the focal trough to reveal best the teeth and supporting bone. This center of
rotation is initially near the lingual surface of the right body of the mandible when the left TMJ
region is being imaged. The rotation center moves anteriorly along an arc that ends just lingual to
the symphysis of the mandible when the midline is imaged. The arc is reversed as the opposite side
of the jaws is imaged. This basic principle of image formation remains the same, regardless of the
type of detector used to record the image. In the case where the receptor is a charge-coupled device
(CCD) array, the film is replaced by a two-dimensional CCD array. Each column of the array is read
out to construct the image. The key is to read out the columns at the same rate as an imaginary
moving film would move past the array. The CCD array is read out continuously as the x-ray source
and receptor travel around the patient. The resulting geometric projection characteristics are the
same as if film or a photostimulable phosphor plate (PSP) had been used; this holds true for
geometric distortions such as magnification and elongation, the presence of ghost images,
superimposition of the cervical spine over midline structures, overlap of teeth, and leftright size
variations from lack of proper positioning of the patient’s sagittal plane in the instrument.

FOCAL TROUGH The focal trough is a three-dimensional curved zone, or “image layer,” where the
structures lying within this zone are reasonably well defined on the final panoramic image (Fig. 10-
7). The structures seen on a panoramic image are primarily those located within the focal trough.
Images are most clear in the middle and become less clear further from the central line. Objects
outside the focal trough are blurred, magnified, or reduced in size and are sometimes distorted to
the extent of not being recognizable. The shape of the focal trough varies with the brand of
equipment used as well as with the imaging protocol selected within each unit. The shape and width
of the focal trough is determined by the path and velocity of the receptor and x-ray tube head,
alignment of the x-ray beam, and collimator width. The location of the focal trough can change with
extensive machine use, so recalibration may be necessary if consistently suboptimal images are
being produced. In some panoramic machines, the shape of the focal trough can be adjusted to
conform better to the shape of the patients’ maxillomandibular anatomy or to show specific
anatomic areas better, such as the TMJ or the maxillary sinuses. This adjustment is accomplished
through varying the shape of the moving center of rotation and allows better imaging of children,
unusually shaped patients, or specific anatomic sites of interest. For example, in some units, the
rotational arc of the x-ray source-receptor movement is decreased to modify the focal trough size to
pediatric jaws. The decreased rotational arc also results in reduced patient radiation exposure. In
some panoramic units, the projection angle of the x-ray beam is modified to yield images with
decreased overlap of adjacent teeth and with minimal superimposition of structures from the
opposite side of the jaw.

IMAGE DISTORTION The panoramic image necessarily produces distortion of the size and shape of
the object. These distortions make the panoramic image highly unreliable for linear or angular
measurements. The image distortion is influenced by several factors, including x-ray beam
angulation, x-ray source-to-object distance, path of rotational center, and position of the object
within the focal trough. These parameters vary among panoramic units and among different regions
of the jaws for the same unit. They are also strongly dependent on patient anatomy and positioning
of the patient in the unit. These variables make it impossible to apply preset magnification factors
that can be used to make reliable measurements on panoramic radiographs. Horizontal
magnification is determined by the position of the object within the focal trough. The magnitude of
the horizontal distortion depends on the distance of the object from the center of the focal trough
and thus is strongly influenced by patient positioning. Figure 10-8 illustrates the influence of patient
positioning on image size and shape. Figure 10-8, A and B, shows a mandible supporting a brass ring
properly aligned in the middle of the focal trough. Note the even magnification of the ring and the
images of the anterior teeth in proper proportion. Figure 10-8, C and D, shows the same mandible
positioned 5 mm posterior to the middle of the center of the focal trough. This position causes
distortion of the ring in the horizontal dimension, with the ring appearing broader and a
commensurate increased width of the images of the teeth. Figure 10-8, E and F, shows the same
mandible positioned 5 mm anterior to the middle of the focal trough. The horizontal distortion
results in the ring appearing narrow and a commensurate decreased width of the projected teeth.
On these images, the vertical dimension, in contrast to the horizontal dimension, is little altered.
These distortions result from the horizontal movements of the receptor and x-ray source. Thus, as a
general rule, when the structure of interest, in this case the mandible, is displaced to the lingual side
of its optimal position in the focal trough, toward the x-ray source, the beam passes more slowly
through it than the speed at which the receptor moves. Consequently, the images of the structures
in this region are elongate horizontally on the image, and they appear wider. Alternatively, when the
mandible is displaced toward the buccal aspect of the focal trough, the beam passes at a rate faster
than normal through the structures. In the example shown, because the receptor is moving at the
proper rate, the representations of the anterior teeth are compressed horizontally on the image,
and they appear thinner. The same principle applies to the patient’s sagittal plane being rotated in
the focal trough. The posterior structures on the side to which the patient’s head is rotated are
magnified in the horizontal dimension because the posterior structures are moved away from the
image receptor, whereas posterior structures on the opposite side are moved closer to the image
receptor and are reduced in horizontal dimension. The resulting image has horizontally large molar
teeth and mandibular ramus and severe premolar overlap on one side and horizontally smaller
molar teeth and mandibular ramus on the other side. This imaging appearance must not be
confused with a congenital or developmental facial asymmetry (this positioning artifact is
demonstrated in Fig. 10-9). The magnitude of horizontal distortion varies between the anterior and
posterior regions of the jaws. In the anterior region, horizontal magnification increases markedly as
the object moves away from the center of the focal trough. The degree of this magnification in the
posterior regions is less than that in the anterior region. Two identical objects located in the anterior
and posterior regions may have different horizontal magnifications. Thus, overall horizontal
measurements made on panoramic radiographs are unreliable. Special attention must be paid to
these considerations in following the progress of a bony lesion, especially in the anterior region. As a
result of improper patient positioning, the lesion may appear greater (enlarging) (see Fig. 10-8, D) or
reduced (healing) (see Fig. 10-8, F) on successive images. The importance of careful alignment and
positioning of the patient’s dental arches within the area of the focal trough is apparent. Vertical
magnification is determined by distance between the x-ray source and the object, similar to
conventional radiography. In some panoramic radiographs, this distance is maintained constant
through the exposure cycle, and the vertical magnification is relatively constant through the
different areas of the image in these units. However, despite this, assessment of vertical
relationships in a panoramic radiograph is unreliable. The orientation of the panoramic x-ray beam
has a slight caudocranial inclination. As a result of this beam angulation, structures that are
positioned closer to the source are projected higher up on the image, relative to structures that are
positioned further away from the source of radiation. Thus, the spatial relationships between the
objects in the vertical dimension may not accurately represent true anatomic relationships. Figure
10-10 shows a mandibular molar and the mandibular canal. Three different positions of the
mandibular canal are indicated, from lingual to buccal. All three positions are in the same horizontal
plane (see Fig. 10-10, A). However, owing to the angulation of the x-ray beam, the image of the
lingually positioned canal (orange) is projected closer to the apex of the molar, whereas the image of
the buccally positioned canal (green) is projected further away from the root apex. Thus, the
distance between the root apex and the mandibular canal can be misrepresented on a panoramic
radiograph.

REAL, DOUBLE, AND GHOST IMAGES Because of the rotational nature of the x-ray source and
receptor, the x-ray beam intercepts some anatomic structures twice during each exposure cycle.
Depending on their location, objects may cast three different types of images, as follows: • Real
images: Objects that lie between the center of rotation and the receptor form a real image. Within
this zone, objects that lie within the focal trough cast relatively sharp images, whereas images of
objects located away from the focal trough are blurred. Figure 10-11, A and C, shows the positions of
the x-ray source during imaging of the left and right sides of the mandibular ramus, respectively. In
Figure 10-11, A, the left ramus lies between the center of rotation and the receptor and casts a real
image. Because it is within the focal trough, its image is sharp. Also demonstrated in Figure 10-11, A,
is the formation of the real images of the hyoid bone and cervical spine. However, because these
structures are away from the focal trough and closer to the x-ray source, their images are blurred
and magnified. Figure 10-11, D, shows in blue the anatomic region that makes real images. • Double
images: Objects that lie posterior to the center of rotation and that are intercepted twice by the x-
ray beam form double images (green region in Fig. 10-11, E). This region includes the hyoid bone,
epiglottis, and cervical spine, all of which cast images on both sides and form double images. • Ghost
images: Some objects are located between the x-ray source and the center of rotation. These objects
cast ghost images. On the panoramic image, ghost images appear on the image on the opposite side
of its true anatomic location and at a higher level because of the upward inclination of the x-ray
beam. Because the object is located outside of the focal plane and close to the x-ray source, the
ghost image is blurred and significantly magnified. Several anatomic structures cast ghost images
(orange region in Fig. 10-11, F). For example, in Figure 10-11, A, the right mandibular ramus lies
between the x-ray source and the center of rotation, and its ghost image is superimposed over the
left side of the image. Similarly, the ghost image of the left ramus is superimposed over the right side
of the image (see Fig. 10-11, C). The hyoid bone and cervical spine also form ghost images when the
anterior regions of the jaws are imaged (see Fig. 10-11, B). Additionally, metallic accessories, such as
earrings, necklaces, and hairpins, form ghost images, which appear as blurred radiopaque images
that can obscure anatomic details, mask pathologic changes, or mimic pathologic changes. Figure 10-
12 shows a panoramic image of half a cadaver head and all the associated ghost images. Some
anatomic zones form both real double and ghost images.