INTERPRETING PANORAMIC IMAGES

As with all image viewing, one should mask out extraneous light from around the image, dim the
room lights, and, when possible, work seated in a quiet room. These recommendations apply
equally to viewing digital images on a computer display and traditional film radiographs on a
viewbox. When interpreting the image, the starting points are systematic analysis of the image
and a thorough understanding of the appearances of the normal anatomic structures and their
variants on the image. Panoramic images are quite different from intraoral images and demand a
disciplined and focused approach to their interpretation. Recognizing normal anatomic structures
on panoramic radiographs is challenging because of the complex anatomy of the midface, the
superimposition of various anatomic structures, and the changing projection orientation with
real, double, and ghost images. The many potential artifacts associated with machine and patient
movement, patient positioning, and unusual patient anatomy must be identified and understood.
The absence of a normal anatomic structure may be the most important finding on the image.
Thus, it is essential to identify the presence and integrity of all the major anatomic structures.
Most images in dentistry are two-dimensional representations of three-dimensional structures.
On a posteroanterior skull film, orbital rims, nasal conchae, teeth, cervical vertebrae, and petrous
ridges are all in sharp focus on the image, although they may be 8 inches apart from each other.
As panoramic views are curved image “slices” of the mandibulofacial tissues, there is less
superimposition of structures and thus less of an interpretation problem. There is still a thickness
to the tomogram that must be considered, however, and the clinician must relate the structures on
the image to their relative positions in the midfacial skeleton. An example of this three-
dimensionality is the relative positioning of the external oblique and mylohyoid ridges in the
mandible: on the panoramic image, they generally both appear sharp, whereas physically the
external oblique ridge is on the mandibular buccal surface and the mylohyoid ridge is on the
mandibular lingual surface, separated by several millimeters. When panoramic images are
viewed, it is important for the clinician to remember this principle and to attempt to visualize the
structures three-dimensionally in his or her mind. It is helpful to view the image as if looking at
the patient, with the structures on the patient’s right side positioned on the viewer’s left (Fig. 10-
16). Thus, the image is presented in the same orientation as that of periapical and bitewing
images, making the interpretation more comfortable. It is extremely important to recognize the
planes of the patient that are represented in different parts of the panoramic image. The
panoramic image represents the curved jaw that is unfolded onto a flat plane. In the posterior
regions, the panoramic image depicts a sagittal (lateral) view of the jaws, whereas in the anterior
sextant, it represents a coronal (anteroposterior) view.
DENTITION
A strength of the panoramic image is the demonstration of the complete dentition. Although
there is a rare situation where positioning of the patient or an ectopic tooth places the tooth out of
the focal trough, all the teeth are generally seen on the image. Thus, the interpretation must
always include identification of all erupted and developing teeth (Fig. 10-17). The teeth should
be examined for abnormalities of number, position, and anatomy. Existing dentistry, including
endodontic obturations, crowns, and other fixed restorations, should be noted. Excessively wide
or narrow anterior teeth suggest malposition of the patient in the focal trough. Similarly, teeth
that are wider on one side than the other suggest that the patient’s sagittal plane was rotated.
Gross caries and periapical and periodontal disease may be evident. However, the resolution of a
panoramic radiograph is lower than that of intraoral radiographs, and additional intraoral
radiographs may be needed to detect subtle disease. The proximal surfaces of the premolar teeth
often overlap, which interferes with caries interpretation. It is particularly important to examine
impacted third molars closely. The orientation of the molars; the numbers and configurations of
the roots; the relationships of the tooth components to critical anatomic structures, such as the
mandibular canal, floor and posterior wall of the maxillary sinus, maxillary tuberosity, and
adjacent teeth; and the presence of abnormalities in the pericoronal or periradicular bone must be
carefully studied. However, given the two-dimensional nature of the panoramic image, such
findings may need additional imaging with cone-beam computed tomographic (CT) imaging to
define precisely the spatial relationships of the roots of the impacted molars to the vital
structures.

FIGURE 10-16  The bones of the mandible, midface, cervical spine, and skull base as they appear on a
panoramic image. The image is composed of left and right lateral views of the facial bones posterior to
the canines and a view anterior to the premolars.
 FIGURE 10-17  Panoramic image showing late mixed dentition of an 8-year-old patient. The
panoramic image can be useful in identifying the presence or absence of the permanent dentition as well
as assessing its developmental status. Note impacted and inverted mesiodens in the maxillary midline and
malalignment of incisors.
MIDFACIAL REGION
The midface is a complex mixture of bones, air cavities, and soft tissues, all of which appear on
panoramic images (Fig. 10-18). Individual bones that may appear on the panoramic image of the
midface include temporal, zygoma, mandible, frontal, maxilla, sphenoid, ethmoid, vomer, nasal,
nasal conchae, and palate; thus, it is a misnomer to refer to the midfacial region on the panoramic
image as “the maxilla.” Maintaining the discipline and focus of a systemic examination of all
aspects of the midfacial images is difficult and critical in the overall examination of the
panoramic image.
The maxilla can be compartmentalized into major sites for examination (see Fig. 10-18), as
follows:
• Cortical boundary of the maxilla, including the posterior border and the alveolar ridge
• Pterygomaxillary fissure
• Maxillary sinuses
• Zygomatic complex, including inferior and lateral orbital rims, zygomatic process of
maxilla, and anterior portion of zygomatic arch
• Nasal cavity and conchae
• TMJ (also viewed in the mandible, but visualizing important structures multiple times is
always a good idea in image interpretation)
• Maxillary dentition and supporting alveolus
Examining the cortical outline of the maxilla is a good way to center the examination of the
midface. The posterior border of the maxilla extends from the superior portion of the
pterygomaxillary fissure down to the tuberosity region and around to the other side. The
posterior border of the pterygomaxillary fissure is the pterygoid spine of the sphenoid bone (the
anterior border of the pterygoid plates). Occasionally, the sphenoid sinus may extend into this
structure. The pterygomaxillary fissure itself has an inverted teardrop appearance; it is very
important to identify this area on both sides of the image because maxillary sinus mucoceles and
carcinomas characteristically destroy the posterior maxillary border, which is manifested as loss
of the anterior border of the pterygomaxillary fissure. Also, Le Fort fractures of the maxilla by
definition involve the pterygoid plates, and a Le Fort fracture often is initially diagnosed by
disturbances of the integrity of the pterygomaxillary fissure on the panoramic image. These
disturbances may be the only evidence for such a fracture on the panoramic image. To clarify the
three-dimensional anatomy of the pterygomaxillary fissure, Figure 10-19 shows this structure in
a dried skull, in an axial CT image, and in the panoramic image.
The maxillary sinuses are usually well visualized on panoramic images. The clinician
should identify each of the borders (posterior, anterior, floor, roof) and note whether they are
entirely outlined with cortical bone, roughly symmetric, and comparable in radiographic density.
The borders should be present and intact.
The medial border of the maxillary sinus is the lateral border of the nasal cavity; however, this
interface is not demonstrated on the panoramic image. The superior border, or roof, of the
maxillary sinus is the floor of the orbit; this interface is demonstrated on the panoramic image in
its most anterior aspect. Although it is useful to compare right and left maxillary sinuses when
looking for abnormalities, it is important to remember that the sinuses are frequently
nonpathologically asymmetric relative to size, shape, and presence and numbers of septa. The
posterior aspect of the sinus is more opaque because of superimposition of the zygoma. Each
sinus should be examined for evidence of a mucous retention cyst, mucoperiosteal thickening,
and other sinus abnormalities.
The zygomatic complex, or “buttress” of the midface, is a very complex anatomic area,
with contributions from the frontal, zygomatic, and maxillary bones. It includes the lateral and
inferior orbital rims, the zygomatic process of the maxilla, and the zygomatic arch. The
zygomatic process of the maxilla arises over the maxillary first and second molars. The
maxillary sinus can pneumatize the zygomatic process of the maxilla up to the
zygomaticomaxillary suture. This can result in the appearance of an elliptical, corticated
radiolucency in the maxillary sinus, possibly superimposed over the roots of a molar tooth, on a
panoramic image. The inferior border of the zygomatic arch extends posteriorly from the inferior
portion of the zygomatic process of the maxilla and continues posteriorly to the articular tubercle
and glenoid fossa of the temporal bone. The superior border of the zygomatic arch, which curves
anterosuperiorly to form the lateral aspect of the lateral orbital rim, should also be noted. The
zygomaticotemporal suture lies in the middle of the zygomatic arch and may simulate a fracture
if visualized on the image. Additionally, the mastoid air cells occasionally pneumatize the
temporal bone all the way to the zygomaticotemporal suture, giving the glenoid fossa of the TMJ
the appearance of having a multilocular, or “soap-bubbly,” radiolucency, which is a variant of
normal.
The nasal fossa may show the nasal septum and inferior concha, including both the bone
and its mucosal covering. In the anterior region, the lateral border and anterior rim of the nasal
cavity are seen as a radiopaque line. The anterior nasal spine and the incisive foramen also may
be seen. The floor of the nasal cavity or hard palate is seen as a horizontal radiopacity,
superimposed over the maxillary sinus in the posterior regions; this is often seen as two
radiopaque lines (Fig. 10-20). The lower line is sharp and represents the junction between the
lateral wall of the nasal cavity and hard palate on the tube side. The upper line is more diffuse
and represents the junction on the opposite side. The conchae, composed of an internal bone, the
turbinate, and covering cartilage and mucosa, are seen in a coronal manner in the anterior portion
of the image and in a sagittal manner in the posterior portions of the panoramic image. They can
appear as very large, homogeneous, soft tissue densities superimposed over the maxillary sinuses
and occasionally the anterior nasopharynx.
FIGURE 10-18 A, Properly acquired and displayed panoramic image of an adult patient. The patient’s
left side is indicated on the image, and the image is oriented as if the clinician were facing the patient.
This is the same orientation used with a full-mouth series, making it easier for the clinician to orient
himself or herself and to interpret the image.

FIGURE 10-18 A, B, Drawing of the same panoramic radiograph identifying midfacial and mandibular
anatomic structures.
1. Pterygomaxillary fissure
2. Posterior border of
maxilla
3. Maxillary tuberosity
4. Maxillary sinus
5. Floor of the maxillary
sinus
6. Medial border of
maxillary sinus/ lateral
border of the nasal cavity
7. Floor of the orbit
8. Infraorbital canal
9. Nasal cavity
11. Floor of the nasal cavity 21. Sigmoid notch
12. Anterior nasal spine 22. Coronoid process
13. Incisive foramen 23. Posterior border of
ramus
14. Hard palate/floor of the
nasal cavity 24. Angle of mandible
15. Zygomatic process of 25. Hyoid bone
the maxilla
26. Inferior border of
16. Zygomatic arch mandible
17. Articular eminence 27. Mental foramen
18. External auditory 28. Mandibular canal
meatus
29. Cervical vertebrae
19. Styloid process
30. Epiglottis
20. Mandibular condyle
FIGURE 10-19  Pterygomaxillary fissure, a space between the posterior surface of the maxilla and the
anterior border of the pterygoid plates. A, Inverted teardrop shape of the fissure on a panoramic image
(arrow).

B, The fissure on a dried skull (arrow). C, The approximate image section (dotted line) of the panoramic
focal trough through the pterygomaxillary fissure (arrow) on an axial computed tomographic (CT)
section.
MANDIBLE
Studying the mandible (see Fig. 10-18) can be compartmentalized into the major anatomic areas
of this curved bone, as follows:
• Condylar process and TMJ
• Coronoid process
• Ramus
• Body and angle
• Anterior sextant
• Mandibular dentition and supporting alveolus
The clinician should be able to follow a cortical border around the entire bone, with the
exception of the dentate areas. This border should be smooth, without interruptions (“step
deformities”) and should have symmetric thicknesses in comparable anatomic areas (e.g., angles,
inferior borders of bodies, posterior borders of rami). The trabeculation of the mandible tends to
be more plentiful in the anterior regions, whereas the marrow compartment increases toward the
angle and into the ramus; however, these trabecular patterns and densities should be relatively
symmetric. This is especially true in children, who have very sparse trabeculation throughout the
deciduous and mixed dentition stages.
 FIGURE 10-20  Panoramic radiograph cropped to show the left posterior midfacial region. The
hard palate appears as two radiopaque lines. The lower line (black arrows) represents the junction
between the hard palate and lateral nasal wall on the receptor side of the patient. The upper line (white
arrows) represents the junction between the nasal wall and hard palate on the tube side.

The mandibular condyle is generally positioned slightly anteroinferior to its normal

closed position because the patient has to open and protrude the mandible slightly to engage the
positioning device in most panoramic machines. The TMJ can be assessed for gross anatomic
changes of the condylar head and glenoid fossa; the soft tissues, such as the articular disc and
posterior ligamentous attachment, cannot be evaluated. The glenoid fossa is part of the temporal
bone, and it can be pneumatized by the mastoid air cells. This can result in the appearance of a
multilocular radiolucency in the articular eminence and the roof of the glenoid fossa, which is a
variant of normal. More definitive osseous assessment of the TMJ is accomplished by using
cone-beam CT imaging and CT scan. Magnetic resonance imaging is the examination of choice
for evaluation of the disc and pericondylar soft tissues.
Shadows of other structures that can be superimposed over the mandibular ramal area
include the following:
• Pharyngeal airway shadow, especially when the patient is unable to expel the air and
place the tongue in the palate during the exposure
• Posterior wall of the nasopharynx
• Cervical vertebrae, especially in patients with pronounced anterior lordosis, typically
seen in severely osteoporotic individuals
• Earlobe and ear decorations
• Nasal cartilage and nasal decorations
• Soft palate and uvula
• Dorsum of the tongue and tongue decorations
• Ghost shadows of the opposite side of the mandible and metallic jewelry or piercings
From the angle of the mandible, viewing should be continued anteriorly toward the
symphyseal region. A fracture often manifests as a discontinuity (step deformity) in the
inferior border; a sharp change in the level of the occlusal plane indicates that the fracture
passes through the tooth-bearing area, whereas a cant in the entire occlusal table without a
step deformity in the occlusal plane indicates that the fracture is posterior to the tooth-bearing
area. The width of the cortical bone at the inferior border of the mandible should be at least 3
mm in adults and of uniform density. The bone may be thinned locally by an expansile lesion
such as a cyst or thinned generally by systemic diseases such as hyperparathyroidism and
osteoporosis. The outlines of both sides of the mandible should be compared for symmetry,
noting any changes. Asymmetry of size may result from improper patient positioning or
conditions such as hemifacial hyperplasia or hypoplasia. The hyoid bone may be projected
below or onto the inferior border of the mandible.
Trabeculation is most evident within the alveolar process. The mandibular canals and
mental foramina are usually clearly visualized in the ramus and body regions of the body of
the mandible. Typically, the canals exhibit uniform width or gentle tapering from the
mandibular foramina to the mental foramina. They may be less well seen in the first molar
and premolar regions. When only one border of the canal is seen, it is typically the inferior
border. The canals usually rise to meet the mental foramina, often looping several
millimeters anterior of the mental foramina; this is termed the “anterior loop” of the
mandibular canal, and its position and extent are considerations when planning dental
implants in the mandibular canine regions. A bulging of the canal suggests a neural tumor;
however, slight widening at the point that the canal bends to enter the body of the mandible
from the ramus is a variation of norm al. The mandible should be examined for
radiolucencies or opacities. The midline is more opaque because of the mental protuberance,
increased trabecular numbers, and attenuation of the beam as it passes through the cervical
spine. Many modern panoramic machines automatically increase the exposure factors as they
pass across the cervical spine region in an attempt to minimize this opacity; nevertheless,
some opacity is generally seen in the anterior regions of the image. There are often
depressions on the lingual surfaces of the mandible, which are occupied by the
submandibular and sublingual glands. These depressions are termed the lingual salivary
gland depressions, or fossae, and are often more radiolucent. This anatomic feature is shown
on a panoramic image, periapical image, coronal CT section, and dry skull in Figure 10-21.
SOFT TISSUES
Numerous opaque soft tissue structures may be identified on panoramic radiographs, including the
tongue arching across the image under the hard palate (roughly from the region of the right angle of
the mandible to the left angle), lip markings (in the middle of the film), the soft palate extending
posteriorly from the hard palate over each ramus, the posterior wall of the oral and nasal pharynx, the
nasal septum, the earlobes, the nose, and the nasolabial folds (Fig. 10-22). Radiolucent airway
shadows superimpose on normal anatomic structures and may be demonstrated by the borders of
adjacent soft tissues. They include the nasal fossa, nasopharynx, oral cavity, and oropharynx. The
epiglottis and thyroid cartilage are often seen in panoramic images (Fig. 10-23). Occasionally, the air
space between the dorsum of the tongue and the soft palate simulates a fracture through the ramus or
angle of the mandible (Fig. 10-24).

FIGURE 10-21  The submandibular fossa (lingual salivary gland depression) is a concavity often
found on the posterior lingual surface of the mandible. This triangularly shaped area is bounded by
the mylohyoid ridge superiorly and the inferior border of the mandibular body and lies in the region
of the roots of the molars and premolars. Asterisk indicates the area of the submandibular fossa on the
 various images. A, Panoramic image. B, Photograph of the lingual side of a dried mandible. C,
Coronal computed tomographic (CT) scan through the molar region of the mandible. D, Mandibular
molar periapical image.

FIGURE 10-22  Soft tissue images on a panoramic radiograph. A, Properly acquired panoramic
radiograph.

B, The same panoramic image (processed with an edge filter) with an overlay showing the
position of the radiographically evident orofacial soft tissues.
 C, The same panoramic image with an overlay indicating the components of the airway. The
nasal airway surrounds the turbinates. The nasopharynx is posterior to the turbinates and above the
level of the hard palate. The velopharynx is posterior to the soft palate. The oropharynx is below the
uvula.
 FIGURE 10-23  Normal structures occasionally seen in the neck region on panoramic images.
The superior aspect of the thyroid cartilage (white arrow) can be mistaken for a vascular calcification.
The epiglottis (black arrow) lies posterior to the dorsum of the tongue. Also note the ear decoration
posterior to the mandibular condylar head.
 FIGURE 10-24  Airway shadow superimposed over the mandibular ramus may be mistaken for
a fracture (three white arrows). Also, the ghost image of a metallic earring on the patient’s left side is
superimposed over the right maxillary tuberosity region (single white arrow).