RESEARCH REPORTS

2. K ane, M .A., a n d L e tta u , L.A. T ran sm issio n o f
H B V fr o m d e n ta l p e r s o n n e l to p a tie n ts . JA D A
110(4):634-636, 1985.
3. S a b a tin i, B.M . D o n ’t let it h a p p e n to you—
P rec a u tio n s ag ain st h e p atitis B an d o th e r infectious
diseases. J M ich D e n t Assoc 6 7:72-73, 1985.
4. R ad u e , J .T .; U n g e r, J.W .; a n d M olinari, J.A .
A v oiding cro ss-co n tam in atio n in im m ed iate d e n tu re
tre a tm e n t. J P ro sth e t D e n t 4 9 :5 7 6 , 1983.
5. S te rn , M .A ., a n d W h itacre, R.J. A voiding cross­
c o n ta m in a tio n in p ro s th o d o n tic s . J P ro s th e t D en t
4 6 :1 20-122, 1981.
6. B aker, C .H ., a n d H aw kins, V .L. Law in th e d e n ­
tal w orkplace: legal im plications o f h ep atitis B fo r th e
d e n ta l professio n . JA D A 110(4):637-642, 1985.
7. L eu n g , R .L ., a n d S ch o n feld , S.E. G ypsum casts as
a p o te n tia l so u rce o f m icrobial cro ss-co n tam in atio n . J
P ro sth e t D en t 49:2 1 0 -2 1 1 , 1983.
8. P leasure, M .A.; D u e rr, E .L.; a n d G o ld m an , M.
E lim in atin g a h e alth h a za rd in p ro sth o d o n tic tre a t­
m e n t o f p a tie n ts w ith p u lm o n a ry tuberculosis. J P ro s­
th e t D ent 9:818-824, 1959.
9. Rowe, A .H ., a n d F o rre st, J .O . D ental im p res­
sions: th e p ro b ab ility o f c o n ta m in atio n an d a m e th o d
o f disin fectio n . B r D e n tJ 145:184-186, 1978. w ith d isinfection solutions. Sw ed D en t J 6:177-180,
10. S h illin g b u rg, H .T ., J r.; H obo, S.; a n d W hitsett,
L.D . F u n d a m e n ta ls o f fixed p ro sth o d o n tic s, ed 2,
C hicago, Q u in tessence P ublishing Co, 1981.
11. C ouncil o n D ental T h e ra p e u tic s, a n d C ouncil
o n P ro sth etic Services an d D ental L ab o rato ry R ela­
tions. G uidelines fo r infection co n tro l in th e d e n ta l
office an d th e com m ercial d e n ta l lab o rato ry . JA D A
110(6):969-972, 1985.
12. In fec tio n control in th e d e n ta l office a n d labo­
ra to ry . D ent A b str 30:220-223, 1985.
13. T rev e ly a n , M.R. T h e prosth etic tre a tm e n t o f
h e p a titis B a n tig e n p o sitiv e p a tie n ts . B r D e n t J
137:63-64, 1974.
14. S to re r, R ., a n d M cC abe, J.F . A n investigation o f
m e th o d s available fo r sterilising im pressions. B r D e n t
J 151:217-219, 1981.
15. B erg m a n , M.; O lsson, S.; an d B erg m a n , B. Elas-
to m e ric im p ression m aterials: dim en sio n al stability
a n d su rfa c e d etail sh arp n ess follow ing tre a tm e n t with
d isin fectio n solutions. Sw ed D e n tJ 4:161-167, 1980.
16. O lsson, S.; B erg m an , B.; a n d B erg m a n , M. Zinc
o x id e-eu g en o l im pression m aterials: d im e n sio n al sta ­
bility a n d surface d etail sh arp n ess follow ing tre a tm e n t
1982. <
17. C en ters fo r D isease C o ntrol, US D ep t o f H e alth ,
E du catio n a n d W elfare. H epatitis surveillance, R e p o rt J
no. 41, 1977.
18. C ouncil on D ental T h e ra p e u tic s. S terilization
o r d isinfection o f d e n ta l in stru m e n ts. In C ouncil on
D ental T h e ra p e u tic s. A ccepted d e n ta l th e ra p e u tics,
e d 40. C hicago, A m erican D ental A ssociation, 1984.
19. R u d d , R.W ., an d o th e rs. S terilization o f com - ^
plete d e n tu re s w ith sodium h y pochlorite. J P ro sth e t
D ent 51:318-321, 1984.
20. B o n d , W .W ., a n d o th e rs. Inactivation o f h e p a ti­
tis B virus by interm ediate-to-high-level d isin fe c tan t
chem icals. J Clin M icrobiol 18:535-538, 1983.
21. M erch an t, V.A., a n d o th e rs. P relim in ary inves­
tigation o f a m e th o d fo r d isinfection o f d e n ta l im p re s ­
sions. J P ro sth e t D en t 52:877-879, 1984. *
22. Setcos, J.C .; Peng, L.; a n d P alenik, C .J. T h e
effe c t o f disinfection p ro c e d u re s o n an alg in ate im- ^
pression m aterial. J D en t Res 6 3 :235, 1984.
23. S etco s, J .C ., a n d o th e rs . D is in fe c tio n o f a
p o ly e th e r d e n ta l im p ressio n m a te ria l. J D e n t Res
64:244, 1985.

Identified were the most common errors made in a sample o f panoram ic film s and compared
was the frequency o f errors recognized in thosefilm s with the frequency o f errors foun d in film s
made by a trained radiology technician. Positioning errors occurred with greater frequency
than d id technical errors. The percentage o f errors was lessf o r thefilm s made by the technician
than it was fo r the sample film s. The results emphasize the im portance o f training in the use o f
panoram ic radiographic equipment and a quality assurance regimen including the correction
o f errors.

Common positioning and technical errors in

panoramic radiography
T hom as Schiff, DMD
Joseph D ’A m brosio, DDS
B irgit Junfin Glass, DDS, MS
Robert P. Langlais, DDS, MS
W. D oss M cDavid, PhD

T raditionally, most dentists have re­
lied on conventional periapical
a n d b itew in g ra d io g ra p h s fo r
radiographic diagnosis. With the advent
o f panoram ic radiography, more practi­
tioners are using this tech n iq u e.1,2 O f
1,066 dentists in Virginia and 1,191 den­
tists in Florida, 57.6% an d 62.2% had
panoram ic machines, respectively.3
Panoram ic radiographs have many ad­
vantages. On panoram ic radiographs, the
image includes most o f the mandible and
maxilla as well as the surrounding struc­
tures such as the maxillary antrum , nasal
fossa, tem porom andibular joint, styloid
process, hyoid bone, and the pharyngeal
air spaces.4,5 T he radiation dose to the
bone marrow o f the patient is equivalent to
that received from four bitewing film ex­
posu res.6,7 With the use o f rare earth
film-screen systems (Kodak Lanex regular
screen), this dose may be reduced by an
additional 38% (Kodak OG film) and 47%
(Kodak T-M at G film).8 T he technique is
easy and rapid, with the rotation cycle o f
most machines being between 14 and 22
seconds.6 A radiograph may be obtained
o n p a tie n ts w ho c a n n o t o p e n th e ir
m ouths.6
Several disadvantages o f the panoram ic
image also have been reported. Panoramic
and conventional intraoral surveys were
com pared for their relative ability to show
dental caries and other pathological condi- ^
tions in patients seeking routine dental
care.9"15 Although it generally is agreed >
th a t p a n o ra m ic ra d io g ra p h s p ro v id e
broader coverage o f anatomic structures,
it also was fo u n d th a t p an o ram ic ra-
d io graphs lack image sharpness w hen
c o m p ared with in tra o ra l film s.2’11,13, '
i4,i6-i8 Distortions in the image have been
discussed by T ronje and others.19'24 In
addition, a num ber o f relative radiolucent
and radiopaque areas are present in the
panoram ic rad io g rap h because o f the
superim position o f real, double, or ghost
im a g e s25 a n d b ec au se o f so ft tissu e

422 ■ JADA, Vol. 113, September 1986


shadows and air spaces.26 T hese relative
'•* radiolucent and radiopaque areas m ust be
recognized to in terpret the film properly.4
v T h e value o f panoram ic radiographs is
reduced when the films are o f poor diag­
nostic quality. Poor diagnostic quality usu­
ally is not a result o f an inherent limitation
with the equipm ent but ra th e r is a result of
errors made by the operator in the posi-
tioning o f patients and in the film h an ­
dling.4 A lthough all dental radiographs
are dependen t on good technique, atten­
tion to detail is m andatory for optim um
quality in panoram ic radiography. It also
* is im perative to recognize that certain pa­
tients have physical differences that pre-
A elude their being positioned properly at
panoram ic machines.
This study identifies the most common
e r ro rs in a re p re s e n ta tiv e sam p le o f
panoram ic films and com pares the fre­
quency o f errors found in a random ly
A selected sam ple o f films with the fre ­
quency o f errors found in a group o f films
m ade by a trained radiology technician
using one panoramic machine.
k Methods and materials
k For the first objective o f this study, 1,000
panoram ic films were selected from inactive pa­
tient files at the dental school o f the university.
T h e radiographs were m ade on several types o f
panoram ic machines (Panorex I, Panorex II,
Panelipse, Panoral, and O rthopantom ograph
OP-5) either by dental students, dental auxilia-
y. ries, dental radiology technicians, o r faculty
m em bers. No attem pt was m ade to identify who
^ m ade each film or on which specific panoramic
m achine the film was m ade. Also, no attem pt
was m ade to preselect the films, and the films,
in ste a d , w ere chosen at ra n d o m . T h e r a ­
diographs then were num bered and reviewed
by one rater who had been trained to identify
p anoram ic erro rs according to criteria d e ­
scribed by Langland and others.4,26
Positioning errors
Patient too far forward. I f the patient’s head is too
far forward on the chin rest, a narrow, blurred
image o f the anterior teeth, a blurred image of
the bony structures in this region, and a super­
imposition o f the spine on the ram us bilaterally
will be found. Also, an increased overlap of the
teeth in the region o f the first prem olars often is
noticed.
Patient too far back. A wide, blurred image o f the
an terior teeth and a blurred image o f the bony
structures in this region will be found if the
patient’s head is too far back.
Chin tipped too low. Excessive curvature o f the
occlusal plane; indistinct o r no root structure
RESEARCH REPORTS
46.8%
Zero errors
O ne erro r
Two errors
27.9%
T hree errors
0%
F our erro rs •
2.7%
o%
Five erro rs -
0 .2 %
Film s m ade by
0% trained technician
Six erro rs -
0%
Film s selected
0% at random
Seven erro rs -
0 .1%
i i i i i r
0 5 10 15 20 25 30 35 40 45 50
R adiographs (%)
Fig 1 ■ M ultiple erro rs found in panoram ic radiographs. I n m any instances, m ultiple e rro rs occurred
in panoram ic im aging, but e rro rs occurred w ith less frequency when the film s were m ade by a single,
train ed technician.
image o f the m andibular anterior teeth; n a r­ Head tilted. A patient’s head’s being tilted results
row ing o f the intercondylar distance, which in an unequal distance between the right and
may result in the loss o f the condyles at the top left inferior border o f the m andible and the
o f the film; and pronounced overlapping of inferior edge o f the film and often causes a loss
posterior tooth contacts will occur if the pa­ o f one condyle o ff the top o f the film, increased
tient’s chin is tipped too far downward. overlap o f tooth contacts, and unequal magnifi­
cation o f right and left structures.
Chin raised too high. If the patient’s chin is tipped
too far upw ard, flattening o f the occlusal plane; Slumped position. A ghost image o f the spine in
indistinct o r no root structure image o f the the middle of the film and, therefore, a relative
maxillary anterior teeth; lengthening o f the radiopaque area in this region will be seen if a
intercondylar distance, which may result in the patient’s neck is not completely vertical. This
loss o f the condyles at the side o f the film; and image is wider at the inferior edge o f the film
the superim position o f the hard palate over the and tapers superiorly.
roots o f the maxillary anterior teeth will result.
Chin not in rest. I f a patient’s chin is not posi­
Head turned. An unequal magnification o f the tioned properly on the rest, an exaggerated dis­
ram i and posterior teeth will occur if the pa­ tance between the m andible and the chin rest
tient’s head is turned. Structures closer to the and loss of the superior portion o f the sinus
film ap p ear narrow er than they do normally, image will result. This same finding may be
and structures closer to the X-ray source ap p ear noticed when the film position is too low on the
w ider than they do normally. Excessive over­ patient’s neck, which could occur when using
lapping o f the prem olars on the side fu rth er machines that allow the film and chin rest to be
from the film. moved independently.
Schiff-Others : POSITIONING AND ERRORS IN PANORAMIC RADIOGRAPHY ■ 423
RESEARCH REPORTS

Bite guide not used. I f a bite guide is not used, the
film will show an overlap o f the maxillary and
m andibular teeth.
Machine too high. I f the machine is too high, the
inferior border o f the mandible from the lower
edge o f the film will not appear on the film. This
same finding may be noticed when a 5-inch film
is loaded into the u p p er 5 inches o f a 6-inch
cassette.
Tongue not raised against palate. If a patient’s
tongue is not raised against the palate, there will
be found on the film a superimposition of a
radiolucent shadow of the palatoglossal air
space over the roots of the maxillary teeth. This
air space is not always symmetrical, especially if
the patient swallows and momentarily drops the
tongue away from the hard palate.
Lips open. When the patient’s lips are parted, a
relative radiolucent area on the coronal portion
o f the maxillary and m andibular anterior teeth,
especially the incisal third, will be seen.
Patient movement. Movement by a patient results
in a distorted image, which is localized to the
region being scanned by the rotating beam at .
the m om ent that the patient moves. An im por­
tant sign o f this erro r is a discontinuous or wavy
image o f the inferior border o f the mandible.
Prosthesis left in place. If a patient’s prosthesis is
left in the mouth, superim position o f the out­
line o f the metallic and porcelain portions of the
prosthesis over the teeth and bony structures
will be found. Acrylic resins that contain opaque
ingredients also will interfere with panoramic
imaging.

Technical errors

Not starting at home base. T h e clinician’s not

14.4% starting at home base results in a blank portion a
Chin too low
31.7% on the film and, thus, a loss o f some of the
desired structures from the image, even though
T ongue 34.7% the patient has been exposed to the full am ount
not raised 25.7% o f radiation.
v
Slum ped Cassette resistance. Several dark vertical bands
position 12.9% on the film will be found as a result o f overexpo- k
sure o f the areas o f the film w here the cassette
lags.
H ead tilted

Paper or lint between film and intensifying screen.

f
A radiopaque area in the image will be found if
H ead turned
a foreign object comes between the film and the >
screen because the object will prevent exposure
o f the film in that area.
Lips open
4%
Film crimping. If the film is bent while loading or
Too far 4.2% unloading the cassette, a crescent-shaped ra­
forw ard diolucent area will result. C ontrary to common
belief, this erro r rarely is caused by fingernail
Bite guide pressure.
not used
Static electricity. Static electricity will cause a <
Chin too high variable pattern to appear that can resemble
radiolucent dots or branched, lightning-like ra­
diolucent areas. Such available p attern is caused
M achine
by an electrical charge that occurs in a dry atm o­
too high
sphere when the film is slid into o r out of the
film box or cassette too rapidly.
Prosthesis
left in Incorrect exposure. White light exposure results
in all or p art o f the film’s being too dark or
Film s made by fogged. Double exposure results in two or more
T oo far back
trained technician images superim posed on one film. U nderexpo­
sure results in films that are too light and often
C hin not 0% Film s selected cannot be used for diagnosis o f hard tissue ’ '
in rest
0% at random changes. However, the image o f the soft tissues
is enhanced, especially soft tissue lesions en­
Patient 3% croaching on airspaces. O verexposure results in
m ovem ent 0% a uniformly dark film that may be useful for
diagnosis only when viewed with a variable in­
tensity floodlight or lightened with a chemical
I I i ----------- 1------- I reducer solution. f
0 10 15 20 25 30 35
j
E rrors (%) Film crooked in cassette. A skewed image on the
film and, often, a loss o f p art o f the anatomy
Fig 2 ■ Relative frequency o f positioning erro rs. T h e distribution of frequencies varies betw een the
may be the result o f the film’s being crooked in
tw o groups. the cassette. This erro r occurs most frequently
when a 5-inch film is loaded into a 6-inch cas­
sette.

424 ■ JADA, Vol. 113, September 1986

 RESEARCH REPORTS

sample, positioning erro rs (98.1%) occurred

with g reater frequency than did technical e r­
rors (17.4%). For the sample o f radiographs
made by the trained radiology technician, the
total percentage o f positioning erro rs was less
U nderexposure
7.3% than it was for the random ly selected films (Fig
1). However, some positioning erro rs occurred
o% with g reater frequency on the rad iographs
O verexposure made by the trained technician (Fig 2). With the
2.9% exception o f underexposure, the trained tech­
nician m ade no o th er technical erro rs (Fig 3).
0%
Film crim ping
2.5%
Discussion
Leaded apron 0%
show ing Although many of the limitations o f con­
2.5%
ventional extraoral radiography that re ­
W rong profile 0% late to superimposition o f anatom ic struc­
index % tures are overcome in panoram ic radiog­
0.7%
raphy, the technique is susceptible to a
Not starting 0% variety of unique errors, as is disclosed by
at hom e base the results of this study. T he patient’s not
0.4%
positioning the tongue in the roof o f the
0% m outh for the duration o f the exposure
Film in
crooked
was the single most common e rro r for
1 0>4% both groups combined. This produces a
radiolucent shadow over the apexes o f the
Light 0%
maxillary teeth and, thus, ren d e rs in­
exposure I 0.3% terpretation o f the periapical region dif­
ficult. More importantly, this e rro r does
Cassette 0% not always occur bilaterally and, some­
resistance 0.2% times, produces an image that resembles a
periapical or another pathological condi­
Static 0% tion, such as the globulomaxillary cyst. In
electricity such instances, other types o f radiographs
0 .2% Film s m ade by
trained technician are needed to rule out suspected patholog­
0% ical conditions, which increases radiation
P ap er or lint
0% Film s selected exposure to the patient. A lthough in­
at random structing the patient to swallow and then
Double 0% to keep the tongue on the roof o f the
exposure m outh until the machine stops is helpful, it
0%
does not guarantee that the patient will
rem em ber to do so. This is evidenced by
T the high frequency o f tongue movement
0 1 7 10 occurring in the sample o f radiographs
made by the trained radiology technician.
E rrors (%)
It is possible that patients are m ore atten­
tive to instructions given by providers of
Fig 3 ■ Relative frequency o f technical errors. W ith the exception o f underexposure, th e technician dental care than they are to instructions
m ade no other technical errors. given by technicians.
T h e time spent in properly positioning
the patient in the machine is the most im ­
Wrong profile index. If the profile index is not Nevertheless, the task was simplified by using portant factor in preventing a cascade of
matched to the reading at the bite guide holder, the guidelines presented. errors, as multiple mistakes may follow au­
an image o f the bite guide holder will be seen on For the second objective o f the study, 120 tomatically from the first m istake. For
the film. I f the w rong profile index is selected a radiographs taken on one machine (Panoral) by exam ple, in this study, it was observed that
variety o f distortions will appear. a trained dental radiology technician were eval­
positioning the chin too low usually re ­
uated for the same errors. T he erro rs made on
these films then were com pared with the errors sulted in the p a tie n t’s also being in a
Leaded apron. If the patient wears a leaded a p ­
found in the first part o f the study. slum ped position. Equally im p o rta n t,
ron, a unilateral o r bilateral radiopaque image
o f the apron near the middle o f the lower edge h o w e v e r, is th e n e e d fo r a r e g u la r
o f the film results. Results m onitoring o f films m ade to identify re­
In this study, these errors sometimes were curring errors and to suggest m ethods to
difficult to separate from one another, as m ul­ O f the 1,000 random ly selected films viewed, re m e d y those e r r o r s .27 T h is ty p e o f
tiple errors often occur if a single erro r is made. 20.3% were erro rfree. A dditionally, in this m onitoring may not have been in effect

Schiff-Others : POSITIONING AND ERRORS IN PANORAMIC RADIOGRAPHY ■ 425

RESEARCH REPORTS
A Ithough a small percentage of technical errors occur because the patient is positioned improp­
erly, most technical errors are within the control of the operator and can be eliminated completely
by attention to detail.
d u ring the time at which the trained tech­
nician m ade the films for the second part
o f this study.
Panoramic radiography may be unsuit­
able for some patients because their physi­
cal stature, facial asymmetry, o r inability to
follow directions make it difficult to posi­
tion them properly at the m achine. A
higher frequency o f errors was observed
on the radiographs m ade o f patients who
have short or thick necks, are extremely
overweight, or are unusually tall. These
e r r o r s re s u lte d fro m im p ro p e r ch in
p lacem ent, slum ping, u n d e re x p o su re ,
an d cassette resistance in some films.
E ither m ore care should be taken when
p o s i t i o n i n g th e s e p a t i e n t s a t th e
panoram ic m achine or conventional ra ­
diographs should be made.
A lthough a small percentage o f techni­
cal errors occur because the patient is posi­
tio n e d im p r o p e r ly — su c h as u n d e r ­
exposure in the anterior region as a result
o f slum ping and attenuation of the beam
by the cervical spine—most technical e r­
rors are within the control of the operator
and can be elim inated completely by atten­
tion to detail. This is evidenced in the
study’s sample by the lower frequency o f
technical errors recorded for the trained
technician (2%) versus those recorded for
the random ly selected group (17.4%) (Fig
3). In any case, fewer errors are likely to be
m ade when a quality assurance regim en,
which includes the recognition and correc­
tion o f errors, is followed. Quality assur­
ance procedures are effective and neces­
sary w herever radiographs are m ade, in­
cluding in institutions, schools, and p ri­
vate offices.
Conclusions
T h e most common errors in panoram ic
radiography were identified in this study.
T h e results indicate that the patient’s not
keeping the tongue raised during the ex­
426 ■ JADA, Vol. 113, September 1986
p osure occurs most often. A lthough a
lower percentage of errors was noticed
when the radiographs were made by a
trained technician, the study emphasizes
the im portance of both pro p er training in
the use o f panoram ic radiograph equip­
m ent as well as the need to m onitor the
quality of the film being made to correct
erro rs that occur regularly.
----------------------J !0 )A \------------------------
In fo rm a tio n a b o u t the m a n u f a c tu re rs o f th e p ro d ­
ucts m e n tio n e d in this article m ay be available fro m the
au th o rs. N e ith e r th e a u th o rs n o r th e A m erican D ental
A ssociation has any com m ercial in terests in th e p ro d ­
ucts m e n tio n e d .
D r. S c h iff is associate p&>fessor, d e p a r tm e n t o f
d ia g n o sis a n d ra d io lo g y , W a s h in g to n U n iv e rs ity
School o f D ental M edicine, St. Louis. D r. D’A m brosio
is assistant p ro fessor, d e p a rtm e n t o f o ra l m edicine,
S tate U niversity o f New Y ork a t B uffalo School o f
D entistry, B uffalo. Dr. Glass is associate p ro fe sso r, D r.
Langlais is p ro fesso r, a n d D r. M cD avid is associate
p ro fesso r, d e p a rtm e n t o f d e n ta l d iagnostic science,
U niversity o f T e x a s H e alth Science C e n te r D ental
School, 7703 Floyd C u rl D r, San A ntonio, T X 78284.
A d d re ss re q u e sts fo r re p rin ts to D r. Glass.
1. P e ttit, G .G . P a n o ra m ic ra d io lo g y . D e n t Clin
N o rth A m 15(1): 169-182, 1971.
2. H o rto n , P.S., a n d o th e rs. Analysis o f in te rp r e ta ­
tions o f fu ll-m o u th an d p an o ra m ic surveys. O ra l S u rg
44(3):468-475, 1977.
3. K au g ars, G.E. T h e V irginia-F lorida survey. P re ­
s e n te d a t th e a n n u a l m e e tin g o f th e A m e ric a n
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