28-Feb-20

PANORAMIC
RADIOGRAPHY

Dr. Walid Samir

BDS, MS, MHPE, DDSc
Assistant Prof., Oral Surgery Department

Panorama
Is an unobstructed view in every
direction

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In case of a lesion bigger than the periapical film

size how can we make a radiographic examination?

Panoramic radiography is an extra-oral

radiographic procedure that produce a
single image of the facial structures,
including the maxillary and mandibular
arches and their supporting structures.

White and Pharoah (2005)

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 creates an image that is the equivalent of

spreading out the facial structures in 2
dimensions

Langland and Langlais (1997)

Terminology

• PANORAMIC RADIOGRAPH

• Orthopantomgram – “OPG” - Germany

• Panoramic radiograph - “pan” - USA

• Dental panoramic tomograph – “DPT” - UK

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History
 x-rays discovered in 1896
 earliest panoramic work - Japan early 1930s
 prototype machine was built in Finland 1951
 early machines had internal x-ray source
 now all machines use external x-ray source
 film-based and digital

Purpose & Use

•In case presentation and as a survey for the patient
•Evaluate impacted tooth.
•Evaluate eruption pattern.
•Detect diseases, lesions, and conditions of the jaw.
•Examine the extent of large lesions
•Evaluate trauma.
•Examination of the TMJ
•Inability to tolerate intraoral films
•Assessment for surgical procedures
•Demonstrate carotid artery calcifications.

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Panoramic X-ray is introduced in

1959, and is produced by applying the
principle of scanography &
tomography on curved structure.

Scanography:
Is the process by which an X-ray source
(with narrow beam) and the dental film
rotate around a fixed object (patient head)
during exposure, where both of them
moves in opposite direction.

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Tomography:
It is a form of radiography where it is possible
to radiograph only a section or layer within
an object by focusing on this layer while
images of above and below structures are
made invisible by blurring.
N.B.: The name “Tome” is Greek and means a
“section or cut”.

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There are 2 types of tomography:

•Linear
•Curved

Panoramic radiography used the

curved tomography.

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Rotation center:

It is the pivot point around which the

cassette carrier and X-ray head rotate.
There are 3 basic rotation center used in
panoramic x-ray machine:
•Double center
•Triple center
•Moving center

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In all cases moving of the rotation center

allow the image layer to conform to the
elliptical shape of the arch.

The location and number of rotation center

influence the size and shape of the focal
trough.

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Focal Trough:
Definition: A three-dimensional curved zone
in which structures are clearly demonstrated
on a panoramic radiograph.
The structures located within the focal
trough appear in focus and very sharp on
the resultant radiograph, while other
structures will appear blurred or out of
focus.

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The size and shape of the focal trough vary

with the manufacturer of the panoramic X-
ray unit, and this depends on………..
Each manufacturer provides specific
instruction about patient positioning to
ensure that the teeth are positioned within
the focal trough.

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Equipment:
•Panoramic X-ray unit
•Screen film
•Cassette

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Panoramic X-ray unit

The main components of the Panoramic

X-ray unit include:
•X-ray tube head
•Head positioner
•Exposure control

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Panoramic X-ray unit:

X-ray tube head
The main difference between the panoramic unit
head and the intraoral head is the collimator.
The collimator in the intraoral unit is?
That’s for panoramic unit is formed of lead plate
with an opening in the shape of a narrow vertical
slit the film also moves inside the cassette carrier
which is made of lead except for a slit which is left
opened

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The tube rotates behind

the patient head while
the film rotate in front of
the patient.

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Panoramic X-ray unit:

Head positioner
The head positioner used to align the
patient’s teeth as accurately as possible in
the focal trough.
It consist of:
•Chin rest
•Bite-block
•Forehead rest
•Lateral head support

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Panoramic X-ray unit:

Exposure control

The milliampirage and Killovoltage

setting are adjustable.
In the new machines the time also can
be changed.

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Screen film:
It is sensitive to light emitted from intensifying
screen.
There is two types of screen:
1. Conventional screen: emit blue light e.g.
crystalline calcium tungestate.
2. Rare-earth screen: emit green light e.g.
gadolinium and lanthanum
N.B. The film size is 5*12 or 6*12’’

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Cassette:

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Advantages
•Broad anatomical coverage
•Well-tolerated by patients
•Minimal time to expose when compared to intraoral
radiographs
•Relatively low patient dose
•Allow comparing both sides of the mandible and
maxilla.
•Useful for patient education (although never exposed
only for that purpose!)

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Disadvantages:

•Resolution is not as good as intraoral films due to the

intensifying screen. This results in decreased detail
•Only objects in focal trough are seen clearly
•Blurring of the anterior region.
•Distortion of image
– Overlapped teeth
– Magnification
•Equipment cost

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N.B.

If the panoramic radiograph is

used instead of full mouth survey,
it must be augmented with
selected periapical and bite-wing
radiograph whenever indicated.

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Step By Step Procedures:

Equipment preparation:
•Load the panoramic cassette.
•Cover the bite-block with a disposable plastic
cover slip
•Set the exposure factor (kilovolt, milliampirage
& time)

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Patient preparation:

•Explain the procedure to the patient.

•Remove all objects that may interfere
with film exposure.
•Place a lead apron.

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Patient positioning:

•Patient must be as straight as possible

•The patient’s neck should be extended
•Anterior teeth should be in the notch on the
bite-stick (edge to edge position)
•Adjust the mid-sagittal plane
•Instruct the patient to put his tongue on the
palate
•Then told the patient to remain still

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Recognizing a Good Image

inferior border of mandible should be smooth and imaged fully

good penetration of beam through cervical spine area
hard palate should be horizontal
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infraorbital margins should be aligned on a horizontal plane

nasal cavity should be slightly conical and symmetrical

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condyles should be the same size and at same level

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compare width of left and right rami

- should be the same - difference less than 5mm is acceptable
check size of left and right molar teeth
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tongue should be in contact with the hard palate

- not demonstrated here where we see a palatoglossal air space
apices of teeth should be clearly visible
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anterior teeth in focus

no elongation of foreshortening of anterior teeth
no narrowing or widening of anterior teeth

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slight ‘smile’
upper and lower teeth separated
no overlap of crowns - technically impossible in premolar area
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no unnecessary artefacts i.e. removable objects

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Errors due to positioning:

The mid-sagittal plane is not adjusted

The mid-sagittal plane is not adjusted (Head turned to

the right) moving the teeth closer to the film on that
side. The teeth on the left side, being farther from the
film, will be magnified more and appear larger.

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Teeth too anterior

If the incisors are positioned anterior to the

notch in the bite-stick, they will end up closer
to the film and, since they are now slightly
outside the focal trough, the images of the
teeth will be blurred and skinny.
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Teeth too posterior

If the incisors are positioned posterior to the notch in

the bite-stick, they will end up farther from the film
and, since they are now slightly outside the focal
trough, the images of the teeth will be blurred and
fat.

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Head tipped down

If the head is tipped down too much, so that

the Frankfort Plane is angled downward, the
resulting film will show a V-shaped mandible
and shortening of the mandibular incisors.

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Head tipped up

If the head is tipped up too much, so that the

Frankfort Plane is angled upward, the resulting film
will show a squared-off mandible and the hard
palate will be superimposed over the roots of the
maxillary teeth. A “reverse smile” may be seen.

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Vertebral (spinal) shadow

White area in the center of the film represents the

shadow of the vertebral column due to patient
slouching. Although faint, you will usually be able
to see outlines of the teeth and bone in the area.

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Lead Apron shadow

The lead apron should be placed so that it does not

block off the x-ray beam. (A thyroid collar is never
used for panoramic films). If the apron blocks the
beam, a completely radiopaque shadow is produced on
the film overlying a portion of the mandible; no
evidence of teeth or bone is seen in this area.

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Ghost Images

As the x-ray beam passes around the patient, objects such as

jewelry will produce a real image on the side where the
object is located and a “ghost” image on the opposite side.
This ghost image will have the same shape and orientation
as the real image, but it will be larger and projected higher
on the film and will be very blurred.

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Ghost images of earrings. The ghost image has the same

shape and orientation, but is higher, larger and on the
opposite side when compared to the image of the actual
object .

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Palatoglossal Air Space

Right before exposing the film, the patient is asked 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 .

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1. Mandibular condyle. 2. Articular eminence. 3. Coronoid process of mandible.

4. Posterior wall of maxillary sinus. 5. Posterior wall of zygomatic process of
maxilla. 6. Hard palate. 7. Nasal septum. 8. Tip of nose. 9. Dorsum of the
tongue 10. Hyoid bone. 11. Inferior border of maxillary sinus. 12. Image of
cervical spine. 13. Medial bolder of maxillary sinus. 14. infraorbital canal. 15.
Infraorbital rim. 16. Pterygomaxillary fissure. 17. Anterior border of the pterygoid
plates, 18. Lateral pterygoid plate 19. Ear lobe, 20. Inferior border of mandibular
canal. 21. Mental foramen. 22. Posterior wall of nasopharynx. 23. Inferior
border of mandible superimposed from opposite side, 24. Soft palate over
mandibular foramen of mandible.

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Any Question?
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