Panoramic

Radiography

:Panoramic radiography
It is an extra-oral radiographic
technique that produces a single image
of the facial structures including the
maxillary and the mandibular arches
.and their supporting structures
It utilizes the principles of scanography
(slit beam scanography) and
.tomography

:Scanography
A radiographic technique where a
radiograph is made of an object
using a thin moving beam of x-rays.
A slit-shaped collimator is used to
produce a narrow beam of x-rays
and the x-ray tube moves to scan
different parts of the object onto a
moving film.

:Scanography

:Tomography
A radiographic technique that allows the
imaging of a layer or section of the body by
intentionally blurring images of structures in
other planes (above, below, in front-of and
behind).
During exposure, the x-ray source and the film
move in a synchronized movement parallel to
each other in opposite directions in a fixed
relationship while the patient remains
stationary.
The plane of the object that is not blurred is
called the focal trough or the image
layer.

: Focal trough
It is a three dimensional curved zone in which
structures are clearly demonstrated on the
panoramic radiograph. Structures that lie in
the focal trough appear well defined while
those positioned out of the focal trough are
blurred out of recognition and are not clearly
visible on the final radiograph. The quality of
the resultant radiograph depends on the
correct positioning of the patients teeth
within the focal trough and how closely the
patients jaws confirm to the average focal
.trough designed for the average jaw

sharpest

less sharp

minimal visibility*

* The images of objects with minimal tissue density

are blurred and are not easily seen on film. Dense
objects, such as a bullet fragment, will still be seen.

:Rotation center
It is the axis around which, the film or
cassette carrier and x-ray tube
rotate during an exposure. The
center of rotation changes as the
film and tube head rotate around the
patient to allow the image layer to
confirm to the elliptical shape of the
dental arches ( sliding center
.rotation)

anterior
rotation
center

path of
sliding
rotation
center

lateral
rotation
center

In general, all panoramic x-ray units consist of :

- X-ray tube head
- Head positioner
- Exposure parameters control

The panoramic exposure

The panoramic exposure occurs by the
curved synchronized movement of the x-ray
tube head in one direction and the film in
the opposite direction. As the tubehead
rotates around the patient, the cassette
carrier is rotating so that it is always lined
up with the x-ray beam. The film also moves
inside the cassette carrier made of lead
except for a slit left opened. As the film
moves inside this carrier, only the part of
the film opposite to the slit will be exposed
during the x-ray cycle followed by another
part of the film and so on till the whole film
.is exposed

film/cassette
movement

Fundamentals
cassette shield with
narrow vertical slit

tubehead
rotation

tubehead angled
upward

film

rotation center

Tubehead Rotation
As the tubehead rotates around
the patient, the cassette holder is
also rotating so that it is always
lined up with the x-ray beam. The
x-ray beam passes through a
narrow vertical opening in the
cassette shield, which allows only
a small portion of the film to be
exposed at a time. The
film/cassette rotates within this
shield, constantly exposing
different parts of the film as the
whole unit rotates.

film/cassette
rotation

cassette shield with

narrow vertical slit
(see below)

tubehead
rotation

cassette shield with

narrow vertical slit

As the tubehead rotates around the patient, the x-ray beam

passes through different parts of the jaws, producing multiple
images that appear as one continuous image on the film
(panoramic view). When you click the mouse, the tubehead
will rotate around the patient and produce the images. The red
dots represent the sliding rotation center.

The film above shows the left side of the patient on the
left. We normally look at the film as if we were facing
the patient, so that the patients right side is on our
left. Click the mouse to rotate the film into the correct
orientation for viewing .
Click the mouse to align and merge these individual
images into one continuous image.

Patient
preparation
1. Prepare film inside flexible or rigid cassette
with intensifying screens
2. Remove all metallic appliances or accessories
the patient might be wearing
3. Place lead apron without a thyroid collar

Hold intensifying
screens in tight
contact with film

Rigid metal cassette

Rigid (metal) or
soft (vinyl)
Flexible vinyl cassette

Panoramic Patient Positioning

1. Incisors placed in notch of the bitestick

2. Mid-sagittal plane
centered
perpendicular to the floor
3. Frankfort Plane
parallel to floor
4. Patient standing upright with the
(see next two slides)
spinal column straight

MSP
centered

FP
parallel to
floor

teeth in notch of bitestick

Correct

Patient standing upright

with spinal column
straight

Incorrect

Patient slouched

5. Palatoglossal Air Space

Right before exposing the film, the patient is asked to swallow

(to feel the tongue elevate to contact the palate) and to keep
the tongue against the palate during the entire exposure. This
will help to eliminate the palatoglossal air space (see red
arrows above). If this radiolucent band appears on the film, it
may mask periapical radiolucencies that might be present .

Indications of panoramic
:radiography

Overall view of teeth and facial bones . 1

Assessment of the presence of impactions . 2
and their position
Assessment of jaws before implant planning . 3
for evaluation of alveolar bone and
relationship to vital structures
Assessment of. 4
fractures of the mandible
Assessment of gross. 5
pathological lesions as
cysts or tumors

It shows a view for the maxillary. 6

sinus and floor of the orbit
It demonstrates periodontal disease. 7
in an overall way
Orthodontic assessment and. 8
evaluation of eruption patterns and
growth assessment
Demonstration of carotid artery. 9
calcifications

:Advantages
1. Provides a large area of coverage of teeth and
both dental arches with a low amount of radiation
( app one third less than a full mouth survey).
2. Requires minimal patient cooperation with the
least discomfort
3. The technique is rapid, simple and easy to
perform in comparison to periapical techniques
4. Panoramic radiography is used with patients
suffering from trismus
5. The image is easily understood thus it is helpful
in case presentation and patient education
6. The radiograph is useful in comparing both sides
of the maxilla and the mandible

:Disadvantages or limitations
1. There is lack of definition due to the use
of intensifying screens and faster films as
well as the tomographic movement.
2. There is a certain amount of image
magnification and distortion present on
the resultant radiograph due to increased
object film distance which varies with
different machines
3. Due to superimposition of the spine
there is always lack of image clarity in
the central potion of the film

Patients with facial asymmetry or who . 4

do not confirm to the focal trough will
not produce a satisfactory image
Soft tissues and air shadows can. 5
superimpose the image of the hard
palate
The technique is expensive in . 6
comparison to periapical machines
The technique is not suitable for . 7
children under five years old
Incipient caries and changes in the . 8
alveolar bone height cannot be
diagnosed due to lack of image
sharpness and detail

Types of Panoramic Images

Single Real Image
Double Real Image
Ghost Images

Single Real Image

Only one image results from a given
anatomical structure. The structure is
located between the rotation center
and the film and the x-ray beam only
passes through the structure one time.
Most images seen on a panoramic film
are of this type.

Double Real Image

Two images of a single object are
seen on the film. Double real images
are produced by structures located in
the midline. The x-ray beam passes
through these objects twice as the
tubehead rotates around the patient.
Structures that result in double real
images are the hard and soft palates,
the hyoid bone and the cervical spine.

Ghost Image
Ghost images are formed by dense objects
located between the tubehead and the
rotation center. These ghost images
usually result from external objects such
as earrings, but they may be produced by
dense anatomical structures such as the
mandible.
ghost image of earring
(between lines)

Panoramic
Radiography

Patient
preparation
1. Remove all metallic appliances or accessories
the patient might be wearing as well as any
I.O removable metallic device
2. Place lead apron without a thyroid collar

Panoramic Patient Positioning

1. Incisors placed in notch of the bitestick

2. Mid-sagittal plane
centered
perpendicular to the floor
3. Frankfort Plane
parallel to floor
4. Patient standing upright with the
(see next two slides)
spinal column straight

MSP
centered

FP
parallel to
floor

teeth in notch of bitestick

Correct

5- Patient standing
upright with spinal
column straight

Incorrect

Patient slouched

6- The patient is asked to swallow

(to feel the tongue elevate to
contact the palate) and to keep
the tongue against the palate
during the entire exposure.
7- Ask the patient to remain still
without movement.

Panoramic
technique errors

Ghost image of the patients earrings:. 1

Appears as a larger , higher and blurred image in

GHOST IMAGE
Opaque shadow of an object (jewelry,
anatomy) located between where the
tubehead starts and where it stops can
produce ghost images. The object lies
between the tubehead and the center of
rotation.

Ghost Image
Ghost images are formed by dense objects
located between the tubehead and the
rotation center. These ghost images
usually result from external objects such
as earrings, but they may be produced by
dense anatomical structures such as the
mandible.
ghost image of earring
(between lines)

Ghost Image:
Opposite side
Same shape
Larger
Projected higher on film
Less distinct

Ghost shadow of the earring appears on

the opposite side of the film enlarged

2. Failure to remove dentures and eye glassess:

Leaving partial dentures in the mouth for a panoramic film
will usually obscure important diagnostic information as seen
in the above film.
Note the hearing aid in the left ear (green arrow) and its ghost
image overlying the right orbit (red arrows).

Failure to remove complete upper denture before exposre. This is

usually not a problem since the denture acrylic is not dense
enough to block the image of the maxillary bone.

Failure to remove glasses.

3. Lead apron shadow, usually from thyroid

collar within the pathway of the primary beam

4. Shadow of vertebral column, usually

from patient not standing straight

:Bite block position. 5

a. Teeth too anterior on the bite
block (anterior to the center of the focal
trough)
Anterior teeth appear blurred and narrow
b. Teeth too posterior on the bite
block (posterior to the center of the focal
trough)
Anterior teeth appear blurred and widened

a
.

b. Teeth too posterior

Anterior teeth wider and blurred

.6

Structures smaller on the side opposite to which head is

turned (closer to the film-right side); larger on other side
(towards which the head is turned-left side).

wider ramus on the side towards

which the head was turned

Position of the Frankfort. 7

: plane

The head position is adjusted so that

the Frankfort plane is parallel to the
.floor
a. If the head is tipped down
: (Frankfort plane downwards)
The mandibular incisors appear. 1
blurred and shortened
The mandible appears v-shaped. 2
(exaggerated smile line)

a. HEAD TIPPED DOWN

Mandibular incisors shortened, V-shaped mandible

b. If the head is tipped high up

(Frankfort plane upwards)
1. The maxillary teeth appear blurred
2. The mandible appears squared off ( a
reverse smile line)
3. The hard palate is superimposed
over the roots of the maxillary
teeth

b. HEAD TIPPED UP

Squared-off mandible, palate superimposed over maxillary teeth

8. Palatoglossal air space superimposed on

apices of anterior teeth: The patient did not
hold his tongue against the roof of the mouth
during exposure.

Blurred image due to Movement of. 9

the patient

10.Static electricity; caused by removing film from

box or cassette too quickly, creating static
discharge

Exposure. 11
errors

Over-exposure

Under-exposure

Panoramic Anatomical
Landmarks

Articular eminence.1

2.Glenoid fossa

Hard palate / floor of nasal fossa.4

(conchae )Inferior nasal turbinate.6

Malar process.8

Maxillary sinus.10

Maxillary tuberosity.11

Nasal fossa.12

Nasal septum.13

Orbit.14

Zygomatic arch.15

16.Condyle

Coronoid process.17

.18 Cervical vertebrae

External oblique ridge.19

Genial tubercles.20

21.Hyoid bone

.Inferior border of mandible 22

Internal oblique ridge.23

Mandibular canal.25

Mandibular foramen.26

27.Mental foramen

Mental ridge.28

Sigmoid notch.30

Submandibular fossa.32

Tongue.38

Soft palate.37

Glossopharyngeal air space.33

Nasopharyngeal air space.34

Palato-glossal air space.36

11

16

15

13

12

17

10

6
14
24

23

8
19

21

18

3
4

25

32
26

20

22

27

29

33

37

39
30

35
38

31

36

34

28

47
40
46

41

42
44

45

43

Panoramic Anatomy Key

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.

maxillary sinus
pterygomaxillary fissure
pterygoid plates
hamulus
zygomatic arch
articular eminence
zygomaticotemporal suture
zygomatic process
external auditory meatus
mastoid process
middle cranial fossa
lateral border of the orbit
infraorbital ridge
infraorbital foramen
infraorbital canal
nasal fossa
nasal septum
anterior nasal spine
inferior concha
incisive foramen
hard palate
maxillary tuberosity
condyle
coronoid process

25. sigmoid notch

26. medial sigmoid depression
27. styloid process
28. cervical vertebrae
29. external oblique ridge
30. mandibular canal
31. mandibular foramen
32. lingula
33. mental foramen
34. submandibular gland fossa
35. internal oblique ridge
36. mental fossa
37. mental ridges
38. genial tubercles
39. hyoid bone
40. tongue
41. soft palate
42. uvula
43. posterior pharyngeal wall
44. ear lobe
45. glossopharyngeal air space
46. nasopharyngeal air space
47. palatoglossal air space

Maxillary tuberosity.11