About this exercise

This program provides an introduction to identification of the normal patient anatomy seen in intraoral radiographs.
A working knowledge of normal anatomy of the oral-facial region as it appears radiographs is essential in assessing
the information contained these images. The purpose of this self-instructional material to enable you to recognize
normal radiographic anatomy, as a basis both for evaluating film quality and for detecting variations from normal
when they appear in radiographic examinations.

Mandibular Anatomy

To understand this part of the program well, you should already be familiar with the basic shape, and anatomical
features of the mandible, and you should know the meaning of certain anatomical descriptive terms such as fossa,
ridge and foramen.

Dental and Periodontal Anatomy

First of all, several structures of the tooth and periodontium must be clearly identifiable in any periapical radiograph.
These structures, labeled in the drawing, include the enamel, dentin, pulp, periodontal membrane and alveolar bone.
In a periapical radiograph, the enamel, which is the hardest substance in the human body, appears as the most
radiopaque (lightest) part of the crown of the tooth. The dentin is a less-mineralized hard structure of the tooth
between the enamel and the pulp and is not as radiopaque as the enamel. The pulp is the radiolucent (dark) area in
the center of the root and crown where the soft tissues, which include the nerves and blood supply, are located. The
periodontal membrane appears in a periapical radiograph as a space, or dark radiolucent line, adjacent to the tooth
root. Next to the periodontal ligament space there is a thin light or radiopaque line called the lamina dura ,which is
the radiographic representation of the outer cortex of the alveolar bone. Finally, the radiograph also shows the
alveolar bone, the supportive housing for all of the dentition.

As you progress through this program, you'll see many different radiographs which all show normal features. You'll
note that even normal features don't have the same appearance or distinctiveness in every patient. You'll also see
many features that are not labeled or discussed specifically. Examine each radiograph carefully. Try to identify each
feature, and compare different views of similar features. Remember that you're using this program to teach yourself,
so start now to develop your interpretive and analytical skills.

The mandible forms the skeleton of the lower jaw and houses the lower dentition. Since the mandible is an
articulated bone, it is movable, and thereby capable of providing necessary movements for the mastication of food
and the production of speech. To facilitate this movement the mandible has several areas of attachment for the
muscles participating in mastication and speech. These bony prominences for muscle attachments are often referred
to as ridges and tubercles. This drawing demonstrates where some of these muscles are located. More will be said
about these areas later in the program.

The lower border of the mandible is the thick cortical plate that forms the lower edge of the mandible. The solid
thickness of bone along the inferior border of the mandible is seen in the radiograph as a uniform wide radiopaque
band at the margin of the mandible.

The mental ridges are elevated ridges of bone located along the anterior aspect of the mandible. The ridges are also
known as the mental tubercles and fuse at the midline to form the mental protuberance, the anteriormost aspect of
the mandible. This periapical radiograph demonstrates the radiopaque margin of the mental ridges. Study these and
compare the varying appearance of these landmarks.
The genial tubercles are small bony spines found on the lingual aspect of the mandible adjacent to the midline at the
attachment of the geniohyoid and genioglossus muscles. In this close-up view you can clearly see the genial
tubercles on the lingual midline. Notice also the small opening right in the middle of the tubercles. This is called
the lingual foramen, an opening in the lingual midline of the mandible for a small vessel. This illustration
demonstrates the function of the genial tubercles, or mental spines as they are sometimes called, as a locus for the
attachment of the geniohyoid and genioglossus muscles. This occlusal radiograph of an edentulous mandible depicts
the genial tubercles as seen in an axial plane. If you look closely here you can also discern the attached muscles,
which make up the floor of the mouth. In this periapical radiograph of the mandibular anterior region, the genial
tubercles appear as a distinct circular radiopacity, an area of dense bone, near the midline below the apices of the
teeth. The lingual foramenappears as a small circular radiolucent area surrounded by the genial tubercles.

The soft tissues of the superior margin of the lower lip will often be projected onto the anterior periapical radiograph
and are seen as a horizontal step or change in the general radiopacity of crowns of the teeth. The darker side of the
step is toward the incisal edge of the crowns and represents the air space above the lip. Sometimes this lip line is
projected lower and will be superimposed over the free gingival margin or the crest of the alveolar ridge. In some
individuals, a particularly prominent lower lip may produce a second horizontal line which delineates the rolled
portion of the lip from the thinner soft tissues of the face between the lip and above the chin. The lower arrows in
this image denoted the inferior margin of the lower lip. Note that the soft tissues of the face immediately below the
inferior margin of the lip are not as thick and appear slightly more radiolucent. The top most arrows in this image
point to the superior margin of the lip.

Another soft tissue shadow that occasionally appears on mandibular anterior periapical films is the margin of
the soft tissue of the chin. This feature tends to appear on radiographs of individuals who have prominent chins and
in those situations where the central ray parallels the upper "shelf" of the chin. The difference in thickness of soft
tissues of the chin shelf and those just below the lip are sufficient to cause an abrupt change in density or a "density
step" on the image. The chin soft tissue margin, delineated by the white arrows, should not be confused with the
mental ridges, demonstrated by the black arrows, which appear as radiopaque bands below the soft tissue border of
the chin.

In the mandible, as in the cranium shown here, nutrient canals, which hold blood vessels, run along the inner surface
of the bone cortex, where they lie in slight depressions. These are visible radiographically because the bone is
proportionately thinner where it is displaced by a vessel and thus appears more radiolucent.
Radiographically, nutrient canals appear as uniform thin radiolucent lines. The margin of these lines is often slightly
more radiopaque than the adjacent bone. Sometimes these canals can be seen running toward the apices of teeth as
accessory branches of the inferior alveolar canal. In this instance the canals contain both blood vessel and nerve
supplies to the tooth and are termed accessory canals. Nutrient canals are most noticeable when they appear between
roots or within edentulous areas where they lie against the bony wall and reduce the thickness of bone in the area of
the vessel.

Another anatomical feature you will encounter occasionally is shown in this clinical intraoral image. The rounded
protuberances on the lingual surfaces of the alveolar process are called mandibular tori, or singularly, a mandibular
torus. This fairly common feature is a hard, bony enlargement of the alveolar cortex. Radiographically, mandibular
tori appear as large rounded radiopacities in the area of the roots of the teeth, usually the canines and premolars. The
tori are quite distinct in these two anterior periapical projections.

The mental foramen is an opening in the facial aspect of the mandible in the premolar area. This photograph of the
mandible demonstrates the usual location of the mental foramen. You can see that its position will cause it to appear
radiographically near the apex of the lower second premolar. As this drawing demonstrates,the mental foramen
provides the exit point from within the mandible for the mental nerve, as well as the inferior alveolar artery. In
periapical radiographs the mental foramen appears as a rounded radiolucency in the apical region distal to the canine
and mesial to the first molar. Often it is not as distinct as some other landmarks, but recognizing it is important.
Sometimes the mental foramen will be superimposed on the apex of a premolar, and will give the appearance of
pulpal pathology. The best way to differentiate periapical disease from the mental foramen is to identify the
periodontal membrane space to see if it is confluent with the radiolucent opening. If the apical radiolucency is due to
periapical pathology, the periodontal membrane will appear to join the radiolucency, but if the lucent area is due to
the mental foramen, then the periodontal membrane space will remain intact, and can be distinctly followed around
the tooth apex. Notice the difference in appearance of the pathology at the apex of the distal root of the first molar
and the radiolucency of the mental foramen which superimposes on the apex of the second premolar.

In discussing the next feature it is important to remember the arrangement of the blood and nerve supply to the
mandible. As you can see from this drawing, the trigeminal nerve and the maxillary artery supply the mandible and
give rise to the inferior alveolar nerve and the inferior alveolar artery respectively. The inferior alveolar nerve and
artery pass through the mandible through a structure called the mandibular canal. The mandibular canal extends
from the mandibular foramen, on the lingual aspect of the ramus, through the body of the mandible under the roots
of the molar teeth. The canal terminates at the mental foramen, where the mental nerve branches buccally through
the cortex to innervate the soft tissues of the lower lip and chin area. The rest of the inferior alveolar nerve extends
mesially to innervate the canines and incisors. This anterior extension of the inferior alveolar canal is called
the anterior loop. In this premolar radiograph, the mandibular canal is delineated by black arrows, the mental
foramen by a white circle, and the anterior loop by white arrows. In this posterior lingual view of the mandible, you
can clearly see the mandibular foramen, which is the proximal or posterior opening of the mandibular canal. This
view illustrates the route followed by the mandibular canal from the lingual posterior to the facial anterior at the
mental foramen. The mandibular canal appears radiographically as two roughly parallel radiopaque lines traversing
the body of the mandible. In this radiograph you can see the mandibular canal clearly below the apicies of the molar
teeth. Look closely to distinguish the radiolucent mental foramen, at the anterior extent of the canal.
You'll frequently see the mandibular canal in periapical radiographs of the body of the posterior mandible. The tube-
like nature of this structure gives it the characteristic radiographic appearance seen here. The radiographic
appearance of the mandibular canal is due to the fact that the X-ray beam passes through the denser cortices of the
outer edges of the canal to produce radiopaque lines, while the center, without so much superimposition of bone,
retains a radiolucent characteristic.

The internal oblique ridge (or mylohyoid line) is an eminence of bone extending along the lingual aspect of the
mandible. It serves as the attachment point for the chief muscle of the mouth floor, the mylohyoid muscle.
This drawing shows the location and direction of the mylohyoid muscle, which is attached to the mandible at the
internal oblique ridges.
Radiographically the internal oblique ridge appears as a radiopaque band extending from the terminal molar region
to the premolar area, as seen in this periapical projection. Note that part of the mandibular canal is visible just below
the mylohyoid line and is often superimposed on the image of the internal oblique ridge.

Directly below the internal oblique ridge is a depression in the lingual aspect of the mandible called
the submandibular fossa. This concavity is visible radiographically since the thickness of bone is substantially
reduced in this area. The submandibular fossa is the location of the submandibular salivary gland, as you can see
from this drawing. The radiolucent appearance of the submandibular fossa is well demonstrated in this periapical
molar view. It is important to recognize this as normal anatomy because this is another feature which may resemble
pathology such as tumors or cysts. When a steep upward projection geometry is used to produce the periapical
image, the shape of the internal oblique ridge produces a distinct opaque band that delineates the superior border of
the submandibular fossa. When a flatter vertical projection geometry is used the submandibular fossa appears as a
dark area with indistinct borders as seen in this image.

The external oblique ridge is a ridge of bone located along the facial aspect of the mandible, which extends from the
superior aspect of the posterior body of the mandible down to the necks of the molar teeth. It runs in the same
direction as the internal oblique ridge, but is located on the facial, or external surface of the mandible. The external
oblique ridge serves as the attachment point for the buccinator muscle, as demonstrated in this drawing. The next
two periapical projections demonstrate the radiographic appearance of the external oblique ridge. To distinguish
radiographically between the internal and external oblique ridges, note that the external ridge is always superior to
the internal oblique ridge. In this image the external oblique ridge is denoted by white arrows while the internal
oblique ridge is demarcated by black arrows.

This concludes the textual material on normal radiographic anatomy of mandibular periapical projections. You can
review this material using the list of Mandibular features in the frame on the left if you wish. When you are ready,
take the short review quiz to help you make sure that you've mastered the material that has been presented.

This quiz will help you review the anatomic features presented in this program. It should be easy for you but if not,
use it as a guide to what you should study further. You'll be shown a number of radiographs and asked to key in the
names of the delineated features.

Maxillary Anatomy

This unit continues with an introductory identification of the normal anatomy seen in maxillary periapical
radiographs. When you complete this portion of the program, you should be able to name the normal anatomic
structures shown in a maxillary periapical radiograph and to point out any normal structure in the image. In all there
are 26 structures you'll learn to recognize and identify. When you have completed this material, a quiz is offered to
help you review and make sure you've reached these objectives.

The nasal fossa, sometimes called the nasal antrum, is in the air passage just behind the soft tissues of the nose. In
this front view of a skull you can see clearly the open space in the area of the nose, which is the nasal fossa.
Actually, there are two spaces, or fossae, one on either side of a thin septum at the midline. This is a periapical
projection of the central incisor region. The two radiolucent areas delineated in red are the nasal fossae. The shapes
of the fossae are determined in part by adjacent structures including the nasal septum and the inferior conch.

The nasal septum is the thin wall of bone in the midline of the face that separates the right and left nasal fossae. This
skull photograph shows the nasal septum as well as the bony floor of the nasal fossae. In this periapical projection of
the central incisor region, the nasal septum extends vertically at the top, between the right and left nasal cavities.
Identify these features, and locate the radiopaque lines marking the floor or inferior border of the nasal fossae.

The anterior nasal spine is the triangular protuberance of bone that extends forward from the inferior aspect of the
nasal cavity at the midline. This image demonstrates the diamond shaped radiopacity of the anterior nasal spine.
This bony feature serves as an attachment point for the nasal cartilage.

The mid-palatine suture is the line down the center of the maxilla where embryonic palatal shelves joined at the
midline to form the hard palate. That line is apparent on this skull. In this frontal view of a skull, you can see
the mid-palatine suture as it extends anteriorly between the two halves of the maxilla. Also you are looking straight-
on at the anterior nasal spine. This is the perspective of most central incisor projections. The mid-palatine
sutureappears in this central incisor periapical projection as a dark, or radiolucent, line at the midline (white arrows).
You can also see the more radiopaque inverted triangle at the top of the image that represents the anterior nasal
spine.

Several structures of the tooth and periodontium should be clearly identifiable in any periapical radiograph. These
structures, labeled in this drawing, include the enamel, dentin, pulp, periodontal membrane, and alveolar bone.

In a periapical radiograph, the enamel appears as the most radiopaque part of the crown of the tooth. The dentin, a
less mineralized area of the tooth between the enamel and the pulp is not as radiopaque. The pulp is the radiolucent
area in the center of the root and crown where the soft tissues which include the nerve and blood supply are located.
Study this radiograph to identify precisely the location and extent of these features.
The periodontal membrane appears in a periapical radiograph as a space, or radiolucent line adjacent to the tooth
root. Next to the periodontal membrane space you can see a thin radiopaque line, called the lamina dura, which is
the radiographic representation of the outer cortex of the alveolar bone surrounding the tooth root. Finally, the
radiograph also shows the alveolar bone, the bony housing for all the dentition.

The incisive foramen is the opening in the midline of the palate just posterior to the central incisors. Here an anterior
occlusal view of a skull demonstrates the incisive foramen. This view also shows the posterior extent of the
nasal septum.

This drawing illustrates how the incisive foramen gives passage to the nasopalatine artery and nerve which course
through the incisive canal and foramen to innervate the anterior palatal soft tissues.

In the central incisor periapical projection shown here, the white arrows indicate the appearance of the incisive
canal while the black arrows indicate the incisive foramen.

Several soft tissue shadows often appear in the maxillary anterior region. The border of the nose produces a well-
defined density difference step. The delineation of the border of the nose produces a symmetrical bow-like shape on
the central incisor periapical image. The alar cartilage of the nose is seen as a rounded soft tissue radiopacity in the
canine lateral projection.

The border of the lip will occasionally project across the crowns of the teeth as a linear density step. If the lip line is
projected across the contact area of a crown, the radiolucent / radiopaque step may simulate a carious lesion.

Another common soft tissue shadow is the nasolabial fold. This fold marks the anterior border of the thicker soft
tissues of the cheek including the buccal fat pad. The fold produces a linear step density that courses from the region
above the apicies of the canine or lateral incisor to the occlusal plane in the premolar region.

The maxillary sinuses are pyramid-shaped cavities in the mid-facial aspect of the skull. As the frontal view drawing
shows, the maxillary sinuses are bilateral structures, located beside each nasal fossa. You can see from the side view
how the sinus extends posteriorly near the roots of the maxillary teeth. Parts of the maxillary sinus may appear in
many of the maxillary periapical projections.

In this periapical view of the canine region, the anterior wall of the maxillary sinus is identified by the white arrows.

Another view of the canine region demonstrates an important landmark: the antral Y or inverted Y formation. This
landmark is formed by the intersection of the floor of the nasal cavity and the anterior wall of the maxillary sinus.
Because the inverted Y represents the superimposition of two features projected radiographically over each other the
formation may appear different in different projections.

The next two features of normal anatomy are the incisive fossa and the canine fossa. These are indentations in the
maxillary alveolar process, shown in shadow in this skull view, which may result in a radiolucent region on the film.
The incisive fossa is the indentation between the roots of the central and lateral incisors, and the canine fossa is
between the roots of the lateral incisor and canine.

The incisive fossa is demonstrated radiographically in the incisor projection shown on the left here (white arrows).
Note how this radiolucency is set off by the radiopaque boundaries of the central incisor, lateral incisor, and border
of the nose (black arrows). The same type of defined radiolucency may be produced by the canine fossa as is evident
in this lateral-canine projection. These fossae appear radiographically as teardrop-shaped areas of less radiopaque
alveolar bone, located between and a little above the roots of the incisors (incisive fossa), or between the roots of the
lateral incisor and canine (canine fossa).

The maxillary sinus, which you've already identified in some anterior projections, is also a common feature in
several posterior maxillary periapical projections. The sinuses are radiolucent, air-filled cavities which occupy a
large portion of the maxilla above the posterior teeth on each side. Notice in this front view how close the maxillary
sinus typically comes to the molar roots. In this cutaway side view of the maxilla, you get a clearer idea of where
the sinus is located relative to the posterior teeth. Study this view and imagine how the maxillary sinus, and
particularly its lower border, will appear in periapical radiographs. The dotted line shows where a periapical film
packet might be placed. This lateral cephalometric radiograph demonstrates the location and appearance of the entire
maxillary sinus.

This periapical view of the maxillary molar region demonstrates the maxillary sinus and its inferior border. The
inferior border or "floor"of the maxillary sinus appears as a radiopaque line representing the denser bony cortex of
the margin of the sinus.

Sometimes, the maxillary sinus will fill an extraction site and present the radiographic appearance you see here. This
extension of the air-filled sinus beyond its typical boundaries is called pneumatization.

The tendency for the maxillary sinus to pneumatize and form multiple lobes may give rise to the appearance of
radiopaque lines extending from the floor of the sinus into the radiolucent interior. These white lines represent
cortical extensions of the wall of the sinus and represent the wall of a smaller compartment within the sinus.
Because these walls subdivide the sinus they are termed sinus septa or septum (singular). Although this anatomic
feature looks somewhat like the inverted Y formation, you can distinguish the two by their locations. The inverted Y
would rarely appear this far posterior in periapical projections.

The malar process is the portion of the maxilla that protrudes to meet the zygomatic bone, or cheekbone. The area of
this junction, or suture, is shown well in this skull view; however, the suture is rarely seen in periapical views.

In this view from below you can see even more clearly how the zygomatic arch stands out from the skull, and how
the malar process extends to join the arch. The pencil is pointing to the suture between the maxilla and zygomatic
bones. This view approximates the perspective of the periapical radiograph. You can see how the malar process,
where the zygomatic bone attaches to the maxilla, would show up radiographically as the characteristic curved
radiopaque shape. In this periapical view of the malar process you can also see a portion of the zygomatic bone
extending toward the posterior. The margin of the broad radiopaque area delineated by black arrows, represents the
zygomatic bone (cheekbone) which is connected with the U shaped malar process (delineated by white arrows).

You should recognize the maxillary tuberosity as it appears radiographically. The maxillary tuberosity is the
rounded bony eminence just posterior to the most distal molar, at the distal end of the maxillary alveolar ridge. This
photograph shows both tuberosities well. This inferior view shows the area of the tuberosities, as indicated by the
pencil. It is a little difficult to see the rounded shape of the maxillary tuberosity from this view. This periapical
radiographic projection of the maxillary second molar region clearly demonstrates the maxillary tuberosity area.

Often the posterior border of the maxillary sinus will pneumatize or extend, into the tuberosity area, as seen in this
radiograph. The white arrows indicate the oral boundary of the tuberosity. The black arrows indicate the floor of the
sinus that has pneumatized into the area where a third molar has been extracted.

The lateral pterygoid plate, pointed out in this frame, is a thin, bony extension of the sphenoid bone, to which are
attached the lateral pterygoid muscle as well as muscles of the throat.

The hamulus, shown here, is a small bony spine extending downward below the lateral pterygoid plate. Note that
both of these features are part of the sphenoid bone, and lie posterior to the maxillary tuberosity. The radiographic
appearance of these features is occasionally visible in periapical views of the posterior area. The hamulus is
delineated with white arrows in this image.

Take a moment to identify anatomical features visible in this palatal view of a skull. This view shows well the
zygomatic bones or cheekbones, and the malar processes of the maxilla. Just posterior to the last molars are the
rounded maxillary tuberosities. You can see the thin, wing-shaped lateral pterygoid plates, especially the one on the
right side, that stands out against shadow. Incidentally, our word "pterygoid" comes from the Greek word meaning
"wing-shaped." In this molar periapical view the lateral pterygoid plate is visible just posterior to the tuberosity.

Lining the walls of the maxillary sinus are numerous blood vessels which are ultimately branches of the internal
maxillary artery. Notice the size and location of these vessels in the wall of the maxillary sinus, shown in this
drawing. Sometimes blood vessels running along a bony surface lie in slight depressions in the bone, as you can see
in this view of the interior of the cranium. The vessels in the wall of the maxillary sinus lie in similar depressions,
and it is these that are visible radiographically, since the bone is slightly thinner and thus more radiolucent,
there. Radiographically, you can see the location of vascular channels in the wall of the maxillary sinus as a
radiolucent line, indicated in this periapical projection of the molar region.

Another landmark you should know is the posterior floor of the nasal fossa or hard palate. In this lateral
cephalometric radiograph, you can distinguish the two parallel radiopaque lines which represent these features. The
hard palate, indicated by the black arrows is the roof of the oral cavity. The floor of the nasal fossa, indicated by the
white arrows, is immediately above the palate. Sometimes only a single line is apparent, depending on the
angulation of the projection. Notice that due to the vault of the palate, the hard palate and posterior floor of the nasal
fossa usually appear radiographically above the floor of the maxillary sinus.

The posterior floor of the nasal fossa, or hard palate, can also be seen in this posterior periapical projection, as the
thin radiopaque line extending horizontally along the top of the image. The nasal fossa is projected above the floor
of the maxillary sinus, which you see near the apices of the teeth here. You should also note in this radiograph
the sinus septum and the J-shaped malar process.

A common variation in the roof of the palate that may be seen in as many as 20% of patients is the presence of a
bony swelling along the midline of the middle palate. This excess bone is called a torus palatinus. A torus may
consist of several lobes of dense bone as noted by the white arrows here. The radiopaque zygoma is outlined with
black arrows and extends off the distal portion of this image. A torus may also appear in anterior maxillary views as
denoted by the black arrows in this image. White arrows denote the alar cartilage of the nose in this image. Note
how much less radiopaque the soft tissues of the nose are in relation to the dense bone of the torus palatinus.

Another cartilaginous radiopacity that may appear on anterior maxillary radiographs is the inferior conch or inferior
nasal turbinate. There are actually three turbinates on each side of the nasal antrum; however, only the most inferior
of these is routinely projected onto the periapical view of the incisor region. Notice how the conch appearance,
which is outlined by white arrows, is similar to the previous image of the torus. Principle differences are that the
conch is not as highly calcified as the torus and appears only slightly more radiopaque than the alar cartilage of the
nose. Also the conch lies within the more radiolucent nasal fossa and is circumscribed by the border of the fossa and
the nasal septum whereas the torus palatinus crosses the nasal midline and may appear to extend below the floor of
the nasal fossa.

The last anatomical landmark to be presented in this program is the coronoid process of the mandible. This is the
thin triangular prominence off the upper part of the mandible. You can see from this perspective how the tip of
the coronoid process may appear in some maxillary molar projections. The coronoid process of the mandible serves
as an attachment for certain muscles of mastication, as you can see in this drawing. The black arrows depict the tip
of the coronoid process in this periapical radiograph of the molar region. The white arrows in this image depict the
margin of rounded homogenous radiopacity arising from the floor of the maxillary sinus. This morphologic pattern
and radiopacity is characteristic of an assymptomatic pathologic condition called mucous retention cyst of the
maxillary sinus. In the absence of sinus symptoms this condition only requires recognition and no further treatment.
The tip of the coronoid process is also a homogenous radiopacity that may project on the posterior sinus region.
Because the mouth is partially opened to accommodate the image receptor holder, the coronoid process rotates
forward and downward. The resulting position allows the tip of the coronoid to be projected onto the tuberosity of
the maxilla. Occasionally this geometry produces an image where the conical form of the coronoid resembles a third
molar root.

REVIEW QUIZ SECTION

  Select the designation that represents your student status from the drop down menu.
 Click on the number beside each answer space in the list that follows to view the image of the anatomy.
 Click in the text box next to the number.
 Type in the name of the anatomic feature depicted by the arrows.
 Click on the image to toggle back and forth between the identifying arrows and the feature of interest.
 When you have completed all items in the quiz, click on the submit button at the end. You may have to
scroll down the quiz window to see this.

Activating the SUBMIT button will return a list of your responses and a matching set of correct responses. Take
some time to review any items that you have missed.

ANATOMY OF THE PANORAMIC RADIOGRAPH

About this exercise

This self instructional module covers normal radiographic anatomy as seen in

panoramic projections. The purpose of this module is to enable the dental health
sciences student to recognize the appearance of normal anatomy in the panoramic
image, as a basis for distinguishing variations from normal when they appear in
images of their patients. The student may utilize this module in a number of ways.
Topics may be explored sequentially by following the text which appears in this
frame. First time viewers of this material may find this approach most helpful. A non-
linear approach may be preferred by some students. Using the submenues of the main
menu shown in the frame on the left provides lists of radiographic features. The
student may move at will from item to item and between menus. This approach may
be most helpful for the experienced student who wishes to review material. Review
quizes may be especially helpful for students preparing for course examinations.

Instructions
Setting up your web browser

Optimal display of the material in this program requires a minimal monitor resolution
of 800 by 600 pixels and a color depth of 24 bits (tru-color ). At 800 by 600 resolution
you will find it helpful to close unneaded components of your browser. For Microsoft
Explorer users, go to the view menu and make sure that only "Button Bar" is checked.
Unchecking other elements in the view menu can be accomplished by clicking on the
item. For Netscape users the Location and Navigation tool bars can be concealed by
clicking on these items in the view menu or clicking on the vertical strips at the left
end of these tool bars.
Using the program
This program will present many different images of normal skeletal anatomy and
associated panoramic radiographic features. Clicking on a highlighted phrase in the
text will bring up an image with this feature identified on it. Clicking in the image
window on "Show Feature" will identify the same feature on the opposite side and
remove the delineation of the feature that was seen in the initial image. On each
radiograph you'll see many features which are not labeled or discussed specifically.
You should examine and try to identify features that have been previously discussed,
and compare different views and appearances of the same feature. Keep in mind as
you view that nearly all of the structures occur bilaterally, though they may be evident
only on one side of the radiograph. Be sure to look on both sides of the radiograph for
features marked just on one side. As you explore this module, keep the following
objectives in mind:
1. You should be able to name normal anatomic structures labeled on a panoramic
radiograph;
2. Point out or trace on a panoramic radiograph the anatomic structures named; and
3. Name and point out on a given panoramic radiograph the anatomic structures
identified in pictures of a skull.

Although this is a stand-alone exercise, it may be helpful for you to review text
chapters on dental anatomy and the bones of the head to fully integrate the material
into your knowledge of clinical anatomy. Material on dental anatomy and head and
neck anatomy can be found in a number of sources including several web locations
listed on the Other Web Resources page of this program.

Panoramic Principles

Panoramic images provide the dental clinician with a survey of anatomy of the jaws.
All of the structures seen in a full mouth periapical series are found in the panoramic
image. In addition anatomy of the maxillary sinuses, temporomandibular joint, and
submandibular region are also seen in the panoramic image. As diseases of the oral
facial complex may involve these regions, their inclusion in a radiographic survey of
the dentition may be most helpful in a diagnostic work-up of the patient. Because
panoramic imaging is used in the majority of dental practices in the US, it is
imperative that the dental health sciences student be familiar with the unique
characteristics of this imaging modality and the normal appearance of anatomy in
these images.

Before starting this module it will help you to be familiar with the location and
arrangement of the basic anatomical features of the head, and you should know the
meaning of basic anatomical and radiographic descriptive terms such as mesial, distal,
radiolucent, and radiopaque. Review of a text chapter on the bones of the head may
assist your understanding of the material which follows.
In describing the anatomy seen in a panoramic image, it is helpful to consider how a
panoramic image is made, and what the image represents. The panoramic machine
consists of: 1) a film carriage or sensor holder, 2) a chin rest / incisal guide assembly,
3) mid-sagittal centering guides, 4) and the x-ray tube head. Patient positioning guides
occasionally show up on images, where they are referred to as "artifacts."

The panoramic radiograph represents the visualization of a patient's oral and facial
tissues spread out across a flat film plane, much like a map of the world represents the
curved surface of our globe. Some distortion occurs in the process, as illustrated by
this analogy. Due to the motion of the panoramic x-ray beam around the patient's
head, an image of anatomy within a narrow zone of focus is produced. This horse
shoe shaped zone of acceptably sharp anatomic structure is termed a "focal trough". A
single plane in the center of the focal trough produces optimal sharpness of the
anatomic layer and is called the "focal plane". Anatomy to either side of the focal
plane becomes progressively more blurred and distorted as it is displaced further from
the focal plane. Structures far enough from the focal plane become sufficiently blurred
as to be indistinguishable. This property of panoramic imaging is what allows the
dental structures of interest to be displayed without being obscured by superimposing
anatomy as would be the case with conventional fixed beam projections. Sometimes
superimposing anatomy is incompletely blurred and produces a blurry but
recognizable artifact termed a "ghost."

Keep in mind that the panoramic image represents a flattened "wraparound" view.
Because of this, features close to the patient's midline such as the spinal column and
hyoid bone may be visualized on both right and left sides of the image. The
appearance of the same anatomical feature twice in the same radiograph is termed a
"double image".

Maxillary and Skull Anatomy

The maxillary sinuses are pyramid-shaped, air-filled cavities which occupy a large
portion of the maxilla above the posterior teeth on each side. As the frontal view here
shows, the maxillary sinuses are located on each side beside the nasal fossa. You can
see from the side view how the sinus extends posteriorly near the roots of the
maxillary teeth.

Radiographically, the sinus appears as a radiolucent area of space demarcated by thin

radiopaque lines. This cephalometric radiograph demonstrates the superior, inferior,
anterior, and posterior walls which make up the borders of the maxillary sinus.
The panoramic radiographic appearance of the maxillary sinus is shown here. In
viewing the sinus, be sure you can identify all of its borders, as changes in these
borders, especially the posterior border, can have serious diagnostic implications.

Frequently the sinus will "pneumatize" or extend into old extraction sites, as seen in
the periapical radiograph (top view), into the maxillary tuberosity, or into old
extraction sites. The border of the maxillary sinus still appears as a thin radiopaque
line.

The pterygomaxillary fissure is a space between the posterior border of the maxilla
and the lateral pterygoid plate of the sphenoid bone of the skull. This fissure is
anatomically significant as it allows structures such as the maxillary artery to pass
from the infratemporal fossa to the pterygopalatine fossa (where the trigeminal nerve
exits the skull).

The pterygomaxillary fissure appears in the panoramic radiograph as a teardrop-

shaped radiolucency outlined anteriorly by the posterior border of the maxillary sinus
and posteriorly by the lateral pterygoid plate. Examine this appearance as outlined and
try to locate it on the opposite side.

The lateral pterygoid plate is a thin bony extension of the sphenoid bone. The lateral
pterygoid muscle as well as muscles of the throat attach here. The mandible is
removed here to provide a clear view of this feature. The radiographic appearance of
the lateral pterygoid plate is outlined here. Be sure to find the unmarked lateral
pterygoid plate on the opposite side as well as on the marked side. Don't forget to
examine each radiographic view for features you can identify.

The hamulus is a small bony spine extending downward below the lateral pterygoid
plate. Note that both the hamulus and the lateral pterygoid plate are part of the
sphenoid bone, and lie posterior to the maxillary alveolar process.

The zygomatic arch is composed of processes of the maxilla bone, anteriorly, the
zygoma bone centrally, and the temporal bone, posteriorly. Important features of the
arch, which you can identify radiographically are:
1. The superior border of the arch, formed mostly by the zygomatic process of the
temporal bone and zygomatic process of the frontal bone;
2. the glenoid fossa, in which the condyle of the mandible rests when the jaws are
closed;
3. the articular eminence, involved as a surface upon which the condyle glides during
articulation;
4. the zygomatico-temporal suture, or union between the zygomatic and temporal
bones; and
5. the zygomatic bone itself.

On the panoramic radiograph, the zygomatic arch usually appears as a triangular-

shaped radiopacity which extends from near the posterior region of the maxillary
sinus toward the upper corner of the radiograph. Often you will be able to identify
radiographically the features shown on the skull in the previous frame. Study the
image to be sure you can name and identify these five features on the unmarked
panoramic image.

While the density of the zygomatic arch is typically fairly homogeneous, a number of
features may produce variations in this pattern. Occasionally areas of pneumatization
or air cells may be present as well defined round radiolucencies within the temporal
component of the zygomatic arch. These zygomatic air cells may be single or multiple
and are often bilateral.The zygomatico-temporal suture appearing as a distinct
radiolucent line could be confused with a non-displaced fracture of the zygomatic
arch. Remember that this is the junctionbetween the temporal process of the
zygomatic bone and the zygomatic process of the temporal bone.

Near the anterior portion of the zygomatic arch, the zygomatic bone is joined to the
maxilla at the malar process of the maxilla. The malar process typically appears as a j-
shaped (left side image) or c-shaped (right side image) thick radiopaque line located
just above the apices of the maxillary first or second molar. In the panoramic
radiograph, you can locate this radiopaque j-shaped feature at the base of the
triangular zygomatic arch. Find the malar process on both sides, and be sure to
distinguish it from the posterior border of the maxillary sinus.

The posterior end of the zygomatic arch originates at the lateral aspect of the glenoid
fossa. The fossa is the seat of the mandibular condyle when the jaw is in closed and
rest positions. The panoramic image doesn't usually provide a clear image of this
structure due to superimposition of the adjacent petrous portion of the temporal bone.
However, an outline of the fossa can sometimes be seen. The exit of the auditory
canal from the skull can sometimes be seen posterior to the glenoid fossa. This
structure is called the external auditory meatus and appears as a round to ovoid
radiolucency.

Just distal to and below the external auditory meatus is the bony mastoid process of
the temporal bone. Note that generally the mastoid process is filled with air cells,
giving it a bubbly or waffled appearance. On occasion these air cells can be found
extending into the zygomatic arch up to the articular eminence. The mastoid
process projects downward from the base of the skull and serves as the attachment
point of the sternocleidomastoid muscle. The anterior portion of the mastoid process
is sometimes seen in panoramic images of smaller patients where more of the
anatomy distal to the TMJ may be captured by the panoramic scan. In this image of an
eight year old child the entire mastoid is visible but is partially obscured by the spinal
column.

In some cases the dense bony base of the middle cranial fossa may appear in a
panoramic radiograph. The cranial base and middle cranial fossa will appear superior
to the zygomatic arch in the upper corner of the panoramic radiograph. Usually there
is little diagnostic information to be gained from this region, but it is useful to know
what the anatomy represents.

In most panoramic radiographs, some or all of the orbit can be seen. The orbit serves
as the location of the eyeball and is surrounded by ridges of bone which protect the
eye. The orbit appears radiographically as a circular-shaped radiolucent space located
superior to the maxillary sinus and surrounded by a thin radiopaque line. Generally
only the lower one-half to one-third of the orbit will be shown. The ridge which lies
below the orbit is called the infraorbital ridge, and appears on most panoramic
radiographs. As a radiopaque line along the inferior border of the orbit, usually
located near the superior aspect of the maxillary sinus. Study both sides of this image,
and be sure before proceeding that you can distinguish between the orbit and the
maxillary sinus in the panoramic radiograph.

Inferior to the infraorbital ridge is the infraorbital foramen which is the opening of the
infraorbital canal. Through this canal course the infraorbital artery and also the
infraorbital nerve, which arises from the second division of the trigeminal nerve and
innervates the region lateral to the nose and superior to the upper lip.

The infraorbital canal is seen in panoramic radiographs as a usually faint pair of

parallel radiopaque lines extending from the elliptical opening of the infraorbital
foramen superiorly and laterally across the intraorbital ridge into the area of the
maxillary sinus.

The nasal fossa, sometimes called the nasal cavity, is the air passage of the nose. In
this front view of a skull you can see clearly the open space in the area of the nose,
which is the nasal fossa. Actually there are two spaces, or fossae, one on either side of
a thin wall at the midline. Notice that the same radiopaque line delineates the lateral
border of the nasal fossa and the anterior border of the maxillary sinus.

The nasal septum is the thin wall of bone in the midline of the face which separates
the right and left nasal fossae. The nasal septum is not always straight or symmetric.
The nasal turbinates are thin shelves of bone projecting off the lateral wall of the nasal
fossa. They are important structures to identify because in panoramic projections they
tend to be superimposed on the maxillary sinus and may be confused with abnormal
anatomy or a pathological process.

This sagittal section view of a skull demonstrates how the inferior nasal
turbinate extends the entire anterior-posterior length of the nasal fossa, tapering
posteriorly. From this view you can understand how the turbinates often superimpose
on the maxillary sinus.

The incisive foramen is an opening in the midline of the palate just posterior to the
central incisors. The incisive foramen provides the exit of the nasopalatine nerve and
artery from the palatine bone. The incisive nerve innervates the anterior palatal soft
tissues. Here, a posterior-occlusal view of a skull demonstrates the incisive foramen.
The incisive foramen generally appears in most panoramic radiographs, though not
with the clarity seen in periapical radiographs. The pear-shaped radiolucency between
the apices of the central incisors can be mistaken for periapical pathology or cyst
formation. Only in a very few radiographs will the incisive canal, or nasopalatine
canal, be visible. If you look very carefully, you may be able to pick out the parallel
faint radiopaque lines of the nasopalatine canal extending from the nasal fossa to the
middle of the alveolar ridge.

The hard palate (or floor of the nasal fossa) is always identifiable on the panoramic
radiograph as a thick radiopaque band. Sometimes a double line image is seen, in
which the superimposition of the contralateral ghost image appears as a line just
superior to the true hard palate image. In 5% to 10% of the population a thickening of
the palatal bone called torus palatinus is found. This may appear in the panoramic
image as variable amounts of increased radiopacity and thickness of the radiopaque
band.

At the distal end of the maxillary alveolar ridge, just posterior to the most distal
molar, is the rounded bony eminence called the maxillary tuberosity. The maxillary
sinus may extend into the tuberosity -- a process called pneumatization.

Finally, of course, panoramic images show the number and position of the entire
dentition. These radiographic projections are good for revealing position of
supernumerary teeth, impactions, alveolar bone pathology, and a variety of other
abnormalities. The image allows the dentist to "survey" the patient and develop ideas
about comprehensive care. Generally speaking, however, the image sharpness is not
sufficient to identify the initial caries and periodontal disease which periapical
radiographs can reveal.
As you have learned, there is much more information on the panoramic film than just
a display of dentition. It is important to inspect the total film beginning at the
periphery and proceeding in a logical fashion to systematically view all the anatomy
displayed. Don't be trapped into immediately looking at the teeth; instead, train
yourself to examine every detail available to you on the film.

In order to make judgements about abnormalities found on panoramic films, we need

to become quite familiar with what "normal" anatomy looks like, in all of its diverse
appearances. The next part of this module is a review quiz, to help you make sure
you've mastered the material presented thus far. Before the quiz, consider each of the
features listed here. If there are any you don't remember, take the time to go back to
the frame associated with that anatomy for a review.

Mandibular and Cervical Anatomy

The next section of this material examines the anatomy of the mandibular region.
Additional material on anatomy in the region of the ear and neck are also offered.
Finally, common artifacts that may be seen in panoramic images are presented.

Our examination of mandibular anatomy begins with the condyle. The mandibular
condyle rests in the glenoid fossa of the temporal bone to form the
temporomandibular joint. The condyle consists of a head and neck portion.

The radiographic appearance of the condyle is very different in different types of

projections and may differ in appearance from patient to patient. Patient position will
also affect the appearance of the condyle in the panoramic projection. Notice how the
shape differs on the films, depending upon the individual patient's anatomy and
position in the panoramic device. Study these films, and the others that follow, and
learn to recognize the shape of the condyle and appreciate its variability. Be sure to
examine both sides of the film for symmetry, as some conditions can cause condylar
hypertrophy (enlargement of the condyle).

The coronoid process of the mandible is the thin triangular prominence off the upper
part of the mandible. As this drawing shows, the coronoid process of the mandible
serves as a place of attachment for certain muscles of mastication, chiefly the
temporalis muscle.

The notch formed between the condyle and coronoid process is known as the sigmoid
notch . About 10% of panoramic radiographs dysplay an ovoid or wedge shaped
radiolucency extending from the margin of the depth of the sigmoid notch into the
ramus. This radiolucency is due to a concavity in the medial surface of the ramus
termed the medial sigmoid depression.
This view of a skull is from an angle similar to that of the x-ray beam in a panoramic
projection. You can see from this view that the coronoid process of the mandible is
lined up with the zygomatic arch and the lateral pterygoid plate of the sphenoid bone.
This means that sometimes two or more of these features may be superimposed
radiographically.

This panoramic image demonstrates superimposition of the coronoid process over the
lateral pterygoid plate. The lateral pterygoid plate may produce a false image of a
fracture across the coronoid process. This is only an illusion, and does not represent a
true fracture. Indeed, fractures of the coronoid process are very rare. Watch for this
phenomenon in other panoramic images presented in this module.

Sometimes, depending on the position of the patient, the zygomatic arch may also be
superimposed on the coronoid process and/or the lateral pterygoid plate. The
zygomatico-temporal suture may give the appearance of a fracture line across the tip
of the coronoid process. Keep in mind the possible overlap of these features.

The ramus is the vertical component of the mandible, which makes up its posterior
structure. The angle of the mandible, is formed by the junction of the ramus and body
of the mandible.

Don't forget to use each radiograph in this program as an opportunity to observe

anatomic features, and develop your knowledge of "normal" anatomy. For example
this image demonstrates the external auditory meatus and mastoid process, the head
and neck of the mandibular condyle, the ramus and angle of the mandible, and the
superimposition of the zygomatic arch and the zygomatico-temporal suture across the
coronoid process of the mandible.

The styloid process is a slender projection of bone arising out of the temporal bone.
Note in the skull photograph the appearance and location of this feature. The styloid
process arises from the base of the mastoid process and courses downward toward the
angle of the mandible. As this drawing shows, the styloid process serves as an
important attachment point. Both the stylohyoid ligament and the stylomandibular
ligament originate from the styloid process, and attach to the hyoid bone and the angle
of the mandible respectively.

On occasion, the stylohyoid ligament will contain one or more small bones
called ossicles. These ossicles even appear to form joints at times. Ossicles should be
differentiated from dystrophic calcification of the ligament, a condition which can
produce symptomatic limitation of neck or jaw movement. Distrophic calcification
doesn't display a cortical border and internal trabeculation that is characteristic of an
ossicle.
Distal to the mandible, the most peripheral structures to appear in panoramic
radiographs are the cervical vertebrae of the spine. In this lateral cephalometric
projection, you can see the anatomic relation of the spinal vertebrae to the mandible
and the base of the cranium.

The cervical vertebrae of the spine is a variable finding on the panoramic image.
Usually the detail is not good enough for diagnostic quality, but it is a good idea to be
able to recognize the structure as normal when it does appear. If you look closely you
can also find the styloid process between the mastoid process and the posterior border
of the ramus, extending at an angle across the ramus.

The inferior border of the mandible is the thick cortical plate of bone composing the
lower aspect of the mandible. From the bony contours of the skull photograph and
from the cross-section drawing, you can get an idea of the solid thickness of bone
along the inferior border. It is important to be able to visualize the extent of this
structure fully and to recognize any changes which might occur due to pathology such
as border expansion (a benign process) or border destruction (a possibly-malignant
process).

Note in this image how the cortex thins out in the region of the angle of the mandible.
Varying types of pathology can affect the appearance of this structure. In addition,
shadows from adjacent soft tissues and air spaces produce patterns which may
simulate pathology in some instances. These artifacts will be discussed in detail later
in this exercise.

The external oblique ridge is a ridge of bone located along the facial, or external,
surface of the mandible, which begins at the anterior ramus and courses obliquely
downward into the molar region of the body of the mandible. The external oblique
ridge serves as a point of insertion for the buccinator muscle. The external oblique
ridge is seen as a radiopaque line extending from the anterior border of the ramus to
the coronal aspect of the roots.

The mandibular canal is a radiographically visible structure through which the inferior
alveolar nerve and artery pass. This canal through the mandible typically begins in the
middle of the internal or lingual aspect of the ramus at the ramus' narrowest mesio-
distal dimension. This entry of the canal into the mandible is called the mandibular
foramen. The location of the entry point displays some variability in the mesio-distal
dimension. The foramen may be located anywhere between the middle of the ramus to
the posterior border of the ramus. The mandibular canal extends through the body of
the mandible beneath the roots of the molar teeth, to open anteriorly on the facial
surface at the mental foramen. The inferior alveolar nerve and artery arise from the
trigeminal nerve and maxillary artery respectively and pass through the mandibular
canal. At the mental foramen, the mental nerve branches off to innervate the soft
tissues of the lower lip and chin area while the rest of the inferior alveolar nerve
extends mesially to innervate the canines and incisors.

The tube-like mandibular canal is normally surrounded by a cortex of bone, whose

edges you can see in this cross-section. It is these outer edges which appear on a
radiograph as two roughly parallel radiopaque lines. The x-ray beam passes through a
greater thickness of bone at the edges of the canal, producing the image of parallel
lines on the film. Sometimes it is difficult to visualize the full extent of the mandibular
canal because of an area of radiolucency caused by the submandibular fossa.
Nevertheless, you should attempt to identify this structure, whose appearance may
vary considerably from patient to patient. Unilateral distortion of the mandibular canal
may be indicative of tumor expansion.

Identification of the mental foramen is important because its appearance may often
mimic inflammatory pathology at the apex of the first or second premolar.

The submandibular fossa is a rounded depression in the lingual aspect of the body of
the mandible. This concavity is visible radiographically since the thickness of bone is
less in this area. The submandibular fossa is the location of the submandibular
salivary gland, as you can see from this drawing. The superior margin of the
submandibular fossa is bounded by a ridge of bone where the mylohyoid muscle
attaches. This ridge appears in the panoramic image as a varibly well defined
radiopaque band extending from the mid-root area of the third molar to the apical area
of the premolars. This anatomic feature is called internal oblique ridge or mylohyoid
line.

Generally the submandibular fossa appears as an oval radiolucent area in the posterior
body of the mandible below the roots of the dentition. Remember to note how the
radiographic appearance of the feature varies in other panoramic films. The
submandibular fossa is often confused with various types of bone pathology,
especially since a radiolucent artifact appears in the same region.

The mental ridges are elevated ridges of bone located along the anterior aspect of the
mandible. The ridges, also known as the mental tubercles, fuse at the midline to form
the mental protuberance, the anterior most aspect of the mandible. The mental ridges
appearance is similar to that found in the periapical radiograph; usually the mental
ridges appear as a thick radiopaque bilateral structure near the midline. Like many
other anatomic structures, these features are variable and may be more pronounced in
some patients, or films, than in others.
The genial tubercles are small bony spines found on the lingual aspect of the mandible
adjacent to the midline. You may recall that the genial tubercles surround a tiny
opening called the lingual foramen. This drawing demonstrates the function of the
genial tubercles (or mental spines, as they are sometimes called) as a point of
attachment for the geniohyoid and genioglossus muscles, which help make up the
floor of the mouth. The genial tubercles are often difficult to visualize on panoramic
films and may be more pronounced in periapical projections, and in panoramic films
of edentulous mandibles, which are frequently atrophied.

The hyoid bone, located inferior to the mandible, serves as the point of attachment for
a number of ligaments and muscles, including the suprahyoid muscle and the
infrahyoid muscle. This bone is horseshoe-shaped and is supported entirely by
ligaments and opposing muscular forces. The appearance of the hyoid is quite
variable. Depending on the length of the patient's neck or the degree of downward
tipping of the occlusal plane, images may vary from not displaying the hyoid at all to
having the body of the hyoid superimpose on the body of the mandible. In this image
the body of the hyoid bone appears as a triangular radiopacity at the inferior border of
the body of the mandible.

There are several normal cartilagenous structures that may appear in the cervical area
and that are important to distinguish from other radiopacities produced by pathologic
processes. As a rule, cartilage appears less radiopaque than bone and lacks the linear
border that cortical bone produces. The epiglottis is the structure which covers the
pharyngeal airway during swallowing. It is seen as an homogenous radiopaque arch
that arises from the lower border of the image and bends anteriorly.

Occaisionally the posterior wall of the thyroid cCartilage is visible in panoramic

images. This is inferior and posterior to the epiglottis when the two structures are
visible. The thyroid cartilage is just anterior to the spine and appears as a vertically
oriented homogeneous radiopaque band. In this image the thyroid cartilage is outlined
in yellow while the epiglottis is outlined in red. A small round to ovoid radiopacity is
sometimes present between the tip of the thyroid cartilage and the tip of the greater
horn of the hyoid bone. This structure is called the triticial cartilage or trititium. In a
close-up of the cervical area the greater horn of the hyoid bone is outlined in red, the
triticium is outlined in green, and the thyroid is outlined in yellow.

The cartilagenous structures described above are generally not of any clinical
importance in dentistry. However, the presence of calcification in the carotid artery
(carotid atheroma) must be differentiated from these normal structures because it has
potentially very serious clinical importance.
Lastly, our inspection of normal anatomy in the panoramic projection brings us to the
mandibular alveolar processes and dentition. The number and position of the teeth
should be assessed. Generally speaking, the image quality is insufficient for the
identification of incipient proximal caries. This is largely due to overlapping of
proximal surfaces in the premolar regions. Early changes associated with periodontal
disease such as loss of crestal cortication may also be dificult to visualize on the
panoramic image. The panoramic film is best utilized to gain a general assessment of
the patient's overall oral health, and to screen for intrabony pathology.

Airway and Soft Tissue Anatomy

There are numerous soft tissue structures which cast shadow images on the panoramic
film and may confuse the practitioner. Some may lead to the false impression of
fractures or tumors. In addition, other misleading images known as artifacts may
appear on the film due to parts of the panoramic machine itself or to the panoramic
technique.

The soft tissues of the tongue produce a variable feature in panoramic images. This is
due to the flexibility and variability in positioning of this muscle. Ideally the tongue is
positioned tightly against the palate so that it is indistinguishable from the soft tissues
of the palate. Often however, patients are not instructed to position their tongue tightly
against the roof of their mouth or they fail to understand operator instructions. This
leads to the presence of a well defined radiolucency between the tongue and the palate
that is called the palatoglossal air space. The palatalglossal air space is one portion of
a continuous radiolucent shadow that is given different names at different points
depending on the adjacent soft tissue structures. The posterior portion of the
palatoglossal air space is seperated from the nasopharyngeal air space by the soft
palate. This structure varies from patient to patient. Because the position of this
muscular structure moves during speach and swallowing its appearance can vary
significantly over a short period of time such as may be encountered when alternately
imaging the palate as a left and right side structure during the course of the panoramic
exposure. Typically the soft palate appears as a well defined homogenous ovoid
radiopacity originating at the posterior hard palate and extending posteriorly and
inferiorly.

The posterior border of the pharynx is defined by the soft tissues of the posterior
pharyngeal wall. The posterior pharyngeal wall is one of those structures that is seen
as an homogeneous soft tissue density overlying the cervical
spine. The nasopharyngeal air space (in the nasal fossa) and the palatoglossal air space
combine at the back of the throat to form the glossopharyngeal air space. Because
there is less density of tissue through these spaces, they sometimes result in
identifiable dark, or radiolucent, shadows. Study this drawing of the "airway space"
and be sure you can identify the spaces by their names.

As with many other structures, the airway spaces are highly variable from patient to
patient. When reviewing this program, take care to note the variable appearance of the
nasopharyngeal, palatoglossal, and glossopharyngeal air spaces. As you can see,
airway shadows may simulate the appearance of fractures through the maxilla and
mandible. When you study this appearance carefully you will usually be able to trace
the linear pattern beyond the cortical margin of the bone. This indicates that the line is
a soft tissue / airway shadow overlying the bone rather than a fracture within the bone.

Another commonly seen soft tissue density is that of the ear. Its radiographic
appearance is less radiopaque, and usually lower, than the denser mastoid process.
This ear image, too, can imitate soft tissue tumors or other radiopacities, especially if
superimposed over the adjacent ramus.

Just as in periapical radiographs, the soft tissue shadows of the nose and lips can be
imaged on the panoramic film.

The opening of the lips is sometimes demarcated in panoramic radiographs, as in

anterior periapical projections, by lines across the crowns of anterior teeth. Be sure
not to confuse them with fracture lines.

The demarcation between the thicker soft tissues of the cheek, which include the
buccal fat pad, and the less thick musculature of the upper lip and area just lateral to
the nose is termed the nasolabial fold. In some individuals this feature shows up as a
distinct density difference as seen in this example. The white arrows point to the
nasolabial fold while the black arrows point to the ghost of the opposite side ramus
which is described below. The nasolabial fold can be distinguished from the similar
appearance of the ramus ghost because it terminates at the level of the mouth. The
ghost of the ramus bends distally and extends posteriorly at the level of the body of
the mandible.

Panoramic Artifacts

Most panoramic radiographs display non-anatomical images, or artifacts, as a result of

the radiographic equipment itself. As you can see from the photograph the parts of the
panoramic machine which appear in the path of the x-ray beam during scanning of the
patient include the lateral positioning guides, which are used to center the patient's
mid-sagittal plane in the unit, and the anterior positioning guide, which guides the
anterior-posterior alignment of the patient in the panoramic machine. Some anterior
positioning guides are designed to have the patient close the central incisors edge to
edge on the guide. Other guides are designed to be positioned on the patient's upper
lip just below the patient's nose. Some guides position the patient's chin.

Lateral positioning guides are used to center the mid-sagittal plane of the patient in the
panoramic unit. Some designs extend from the top of the unit while other designs
extend from lower part of the unit. The edges of these plastic elements are often
visible in the image but are usually easily identified as artifacts.

The ramus of the opposite side ramus often produces a visible ghost image which
superimposes on maxillary and mandibular structures. This ghost of the opposite
ramus varies considerably from patient to patient and with changes in position of the
same patient. Sometimes patient earrings are not removed prior to making the
panoramic image. This typically results in ghost image of the
metalic earring projected on the sinus area of the opposite side. A key to
distinguishing a ghost from anatomy that is within the image layer is the presence of
blurring. The lateral edges of the ghost demonstrate this most dramatically. Because a
ghost is often magnified in the horizontal dimension it may produce destinct
horizontal boundaries, but the lateral borders of these boundaries are always blurred.
When a real object and its ghost are depicted in the same image, the ghost appears
accross the midline, somewhat higher in the horizontal plane, and somewhat
magnified and blurred in the vertical plane.

Three midline structures frequently produce mid-line ghost images. The posterior hard
palate produces a distinct linear radiopaque ghost just above the "real" image of the
contralateral side. The hard palate ghost appears progressively higher above the real
image of the hard palate as the patient's chin is tipped increasingly farther down. The
spine usually produces a midline ghost image. The spine ghost is least accentuated
when the spine is perpendicular to the central rays of the x-ray beam. If the patient is
kyphotic of slumps, the axis of the cervical spine is less than perpendicular to the x-
ray beam and more of the spine appears in the path of the beam. This produces a more
prominent spine shadow. This fact illustrates the importance of obtaining as erect
patient posture as possible for highest image quality.

Like the spine, the hyoid bone is seen as a bilateral structure and occasionally as a
midline ghost. When a hyoid ghost is present it often projects accross the midline of
the mandible.

Because the image focal trough is narrowest through the anterior region of the jaws,
distortions in anatomy lying just outside the focal trough are relatively common. An
example of this is the mandibular facial midline depression which may be on the
source side of the image layer especially if there is excessive downward tipping of the
chin. This area appears as an indistinct midline radiolucency bordered by a thick but
blurred radiopaque band. The radiopaque band represents the facial cortex at the inner
edge of the focal trough. The central readiolucency represents the soft tissue and air
over the midline depression which is outside of the focal trough. This artifact is
somtimes called mandibular midline pseudo-cyst.

The final elements of this program are three review quizes to help you make sure
you've mastered the material that has been covered. Before taking a quiz, consider
each of the features listed in the relevant Anatomy frame on the left. If there are any
features you don't remember, take the time to revisit that anatomy for a review.