Radiology
Panoramic Radiography
Panoramic imaging (also called pantomography ) is a technique for producing a
single tomographic image of the facial structures that includes both the maxillary
and mandibular dental arches and their supporting structures.
Principles of panoramic radiography
Paatero and Numata were the first to describe the principles of panoramic
radiography. x-ray source rotates around the patient’s head and in opposite direction
to the rotation of image receptor and collimator. Lead collimators in the shape of a
slit, located at the x-ray source limit the central ray to a narrow vertical beam.
Another collimator between the objects and the receptor reduces scattered
radiation.
Indications
1. Overall evaluation of dentition
2. Evaluation of intraosseous pathology such as cysts, tumors and infections.
3. Gross evaluation of tempromandiular joints
4. Evaluation of impacted teeth, dental implant, and orthodontic treatment
5. Evaluation of permanent teeth eruption and mixed dentition.
6. Dentomaxillofacial trauma such as fracture.
7. Developmental disturbances of maxillofacial skeleton.
Advantages of Panoramic radiograph
1. Broad coverage of facial bones and teeth
2. Low radiation dose
3. Ease of panoramic radiographic technique
4. Can be used in patients with trismus or in patients who cannot tolerate intraoral
radiography
5. Quick and convenient radiographic technique
6. Useful visual aid in patient education and case presentation
Disa
dvantages
1. Lower-resolution images that do not provide the fine details provided by
intraoral radiographs
2. Magnification across image is unequal, making linear measurements
unreliable
3. Image is superimposition of real, double, and ghost images and requires
careful visualization to decipher anatomic and pathologic details
4. Requires accurate patient positioning to avoid positioning errors and artifacts,
so it is not suitable for children under 5 years or on some disabled patients.
5. Difficult to image both jaws when patient has severe maxillomandibular
discrepancy
Focal Trough (Image Layer)
is a wide, three-dimensional curved zone, where the structures lying within this layer
are reasonably well defined on panoramic image. The structures seen on a
panoramic image are primarily those located within the image layer. Objects outside
the image layer are blurred, magnified, or reduced in size and are sometimes
distorted to the extent of not being recognizable.
Focal trough
Real, Double, and Ghost images
Because of the rotational nature of x-ray source and receptor, the x-ray beam
intercepts some anatomic structures twice. Depending on their location, objects may
cast three different types of images:
1. Real images: object that lie between the center of rotation and the receptor form
a real image (all the objects within focal trough cast relatively sharp images). (figure
D)
2. Double images: objects that lie posterior to the center of rotation and that
intercepted twice by the x-ray beam form double images (figure E).
3. Ghost images: objects that located between the x-ray source and center of
rotation, can cast ghost images. The ghost image appear on the opposite side of it’s
true anatomic location and at higher level. (figure F)
Technique, Patient Positioning and Head Alignment
This technique utilizes a narrow vertical negatively angled beam. The angle can be
(−4 to −7°), so the beam exposes the patient just below the occipital bone. The beam
is shaped by a lead collimator which is long, narrow slit located at the X-ray source
and the image receptor (film or digital plate).
Proper patient preparation and positioning within the focal trough are essential to
obtaining diagnostic panoramic radiographs.
1. Dental appliances, earrings, necklaces, hairpins, and any other metallic
objects in the head and neck region should be removed.
2. Demonstrate the machine to the patient by cycling it while explaining the
need to remain still during the procedure. This is particularly true for children, who
may be anxious. Children should be instructed to look forward and to not follow the
tube head with their eyes
3. The anteroposterior position of the patient head is achieved typically by
place the incisal edges of their maxillary and mandibular incisors into a notched
positioning device (the biteblock).
4. The midsagittal plane must be centered within the focal trough without
any lateral shift in the mandible
5. The patient’s chin and occlusal plane must be properly positioned to avoid
distortion. The occlusal plane is aligned so that it is lower anteriorly.
6. Patients are positioned with their backs and spines as erect as possible and
their necks extended.
7. Ask the patient to swallow and hold the tongue on the roof of the mouth.
This raises the dorsum of the tongue to the hard palate, eliminating the air space and
providing optimal visualization of the apices of the maxillary teeth
Placement of the patient either too far anterior or too far posterior relative to
the focal trough results in significant dimensional errors in the images for example:
- Too far posterior results in magnified mesiodistal dimensions through the
anterior sextants and resulting “fat” teeth ( D ). Too far anterior results
in
reduced mesiodistal dimensions through the anterior sextants and resulting
“ thin ” teeth ( F ).
- Failure to position the midsagittal plane lead to rotational midline results
in a radiograph showing right and left sides that are unequally magnified
in the horizontal dimension . Poor midline positioning is a common error,
causing horizontal distortion in the posterior regions, excessive tooth
overlap in the premolar regions and, on occasion, nondiagnostic, clinically
unacceptable images.
- If the chin is tipped too high, the occlusal plane on the radiograph appears
flat or inverted, and the image of the mandible is distorted (A). In addition,
a radiopaque shadow of the hard palate is superimposed on the roots of the
maxillary teeth. While If the chin is tipped too low, the occlusal plane
shows an exaggerated smile line, the teeth become severely overlapped,
the symphyseal region of the mandible may be cut off the film, and both
mandibular condyles may be projected off the superior edge of the film
(B ).
A
B
- improperly positioned patient. Patients don't sit straight and align or don't
stretch their back leading to large radiopaque region in the middle
(vertebral shadow)
Interpretation of Panoramic Images
Interpretation of normal anatomical structures, ghost image and pathological
conditions on a panoramic image can be complex. As a general rule, images
should be viewed in dim light room using a viewer box or a computer monitor.
An operator should always analyses a panoramic image for any possible
technique or processing errors.
it is important to know a good panoramic radiograph the mandible is "U"
shaped, the condyles are positioned about an inch inside the edge of the film and
1\3 of the way down from the top edge of the film. The occlusal plane exhibits a
slight curve or "smile line", upwards. The roots of the maxillary & mandibular
anterior teeth are readily visible.
interpretation of Normal Anatomical landmarks in the panoramic radiograph