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Panoramic

Radiography

Introduction

Commonplace in dental practice


Considered essential in radiographic diagnosis
30% of dental units sold are panoramic

Introduction

Panorama means unobstructed view of a region in any direction


Panoramic radiograph show greater coverage than periapical and
bitewing radiographs

Introduction

New technique
Introduced in 1959
Employs scanography (slit beam) & curved surface rotational
tomography

Client Dose from Panoramic


Radiography

10 times less radiation than a complete intraoral survey using long,


round PID & E+ film
4 time less radiation than a bitewing survey using long, round PID and
E+ film

Indications

Pathology-cysts, tumors
Trauma-fractures
Growth & development
Client management
Edentulous
Localization: anatomy, objects, implant placement
Carotid artery condition

Advantages of Panoramic Radiography


Field size
Quality control
Simplicity
Time & rapidity of the procedure
Client cooperation
Dose
Minimal infection control
Gross anatomy & pathology visible

Disadvantages of Panoramic
Radiography

Image quality
Focal trough limitations
Equipment costs
Overuse

Disadvantages of Panoramic
Radiography

Image quality
Magnification
Distortion
Poor definition compared to intraoral
Overlap
Superimposition & ghost images

Disadvantages of Panoramic
Radiography

Poor image quality due to


Tomographic process
Increased object-film distance
Use of intensifying screens
Faster film with larger crystals

Disadvantages of Panoramic
Radiography

Focal Trough (Image Layer)


Areas outside are not visible
Size & shape limits imagery to those structures which fit into the
image layer
Size & shape not adjustable so not all clients arches image equally
well

Disadvantages of Panoramic
Radiography

Distortion
Vertical & horizontal distortion with variations causes uneven
magnification

Disadvantages of Panoramic
Radiography

Superimposition & Ghost Images


All objects in the field of the beam, even those outside of the image
layer are projected onto the film but most are not seen.
Objects with the greatest density are projected in two places on the
film
Intended (useable image)
Ghost image (reversed, higher, blurred)
Frommer 2001

Disadvantages of Panoramic
Radiography

Superimposition & Other Imaging Quirks


Ghost images may hide pathosis
Soft tissue shadows may mimic pathosis

Panoramic Imaging :
General Principles

Employs scanography (slit beam) & tomography

Panoramic Imaging :
General Principles

Tomography: allows radiographing in one plane of an object while


blurring or eliminating images from structures in other planes.
Tomo is Greek for section
View sections or radiographic slices

Panoramic Imaging :
General Principles

Client remains
stationary while xray
source & film move in
opposite directions in
a fixed relationship
through one or a
series of rotation
points. Rotation points
can be inside or
outside of the focal
trough

Panoramic Imaging :
General Principles
Focal trough in
pantogram
Width & thickness
governed by many factors
Objects lying within the
focal spot are shown
clearly; objects outside
are blurred

Panoramic Imaging :
General Principles
Curved
surface
A panoramic radiograph or
pantomogram is produced using
curved-surface tomography.

Flat
surface

Panoramic Imaging :
General Principles
Rotational panoramic
radiography is
accomplished by rotating a
narrow beam of radiation
in the horizontal plane
around an invisible pivot
point/axis positioned
intraorally.
Film & tube travel in
opposite directions around
the client

Panoramic Imaging :
General Principles

Client remains stationary as xray tube and film


cassette-holder (which are connected) both
rotate around the client

Panoramic Imaging :
General Principles

A vertical, narrow beam is used


compared with the larger, circular
or rectangular beam used in
conventional intraoral radiography

Panoramic Imaging : General Principles

The pivot point/axis is called the rotation center


The center of rotation changes as the film and tubehead rotate which
allows the image layer to conform to the elliptical shape of the dental
arches

Panoramic Imaging:
Projection in the Vertical Plane
Vertical dimension unaffected by horizontal rotation
Vertical angulation same as conventional intraoral
projection
Slight negative angulation; passes beneath occipital
area (-4 to -7 degrees)

Panoramic Imaging:
Projection in the Horizontal Plane

Horizontal image affected by horizontal rotation of the beam


Xrays appear to diverge from intraoral source but really originate
outside of the client
Apparent intraoral source is called the center of rotation

Panoramic Imaging:
Projection in the Horizontal Plane

True intraoral source &


focus of projection

Uniform magnification

Effective focus of
projection

Rotating beam
projected on
stationary film

Panoramic Imaging:
Projection in the Horizontal Plane

Discrepancy in
horizontal versus vertical
magnification eliminated
by using a moving film
to equalize the
magnification in the
horizontal dimension
with the vertical

Film moves in direction


opposite to the
horizontal rotation of the
beam

Rotating beam and


moving film has
proportions restored

Panoramic Imaging:

Image Layer Formation

The image layer is called the focal


trough

Panoramic Imaging:
Image Layer/Focal Trough Defined
The image layer is a three dimensional curved zone , or focal
truogh , where the structuer line within this layer are reasonably
well defined on final Panoramic Image.
Object outside image layer are blurred, magnified, reduced in
size and are sometimes distorted to an extent of not being
recognizable.
Shape of image layer varies with brand of machine used
Determines where dental arches must be positioned to achieve
clearest image

Panoramic Imaging:
Width of the Image Layer

Determined by

Distance from center of rotation to central plane of image layer

Longer the distance between the rotation centre and the center of
image layer ,wider will be focal through

Width of long, narrow slit beam

The narrower the beam , the wider the image layer

Panoramic Imaging:
Position of the Image Layer

Changes in film speed alter the position of the image layer

Increased film speed = image farther away from rotation center

Decreased film speed = image closer to rotation center

This is how the image layer is shaped to center the jaws (anteriors
narrower)

Panoramic Imaging:
Image Layer Analysis

Objects closest to film will be narrowed


Objects closest or toward the source will be widened
Buccal objects projected lower
Lingual objects projected higher
Objects in the center of the layer are magnified 20-30%

Panoramic Imaging:
Image Layer Analysis
Less definition than than intraoral film
More horizontal than vertical
magnification
All objects, even those outside the focal
trough are projected onto the film, but
most are not seen
Objects with the greatest density are
displayed in two places: intended image
and ghost image

PANORAMIC MACHINES
Number of companies manufacture high quality film
based and digital panoramic machines.
Following are the highly versatile machines :ORTHOPANTOGRAPH 100 (Instrumentarium)
ORTHOPHOS PLUS (Sirona)
ORTHORALIX S (Gendex division, dentsply
international)
PROMAX ( PLANMECA )
OTRHOPANTOGRAPH
100
ORTHOPANTOGRAPH 200

In
addition
to
producing
standard
panoramic images of the jaws they have
the capability of adjusting to various sizes
as well as making frontal and lateral
images of TMJ.
Capable of producing tomographic view
through sinuses and cross sectional views
of maxilla and mandible.
PROMAX (PLANMECA) acquires the news
views by using linear tomography program
designed to use SCARA ( Selectively
Compliant Articulated Robotic Arm )
movements with Promax software and
pivoting cassette movements.

PROMAX

ORTHOPHOS PLUS

ORTHORALIX

Some machines further have the capability of


automatic exposure control.
Accomplished by measuring the amount of radiation
passing through patients mandible.
There are now computer controlled multimodality
machines in which the direction and speed of
movement of tube head and films are highly variable
This allows the machines to be programmed to make
tomographic views through major areas of head.
These machines have much greater versatility than
the conventional panoramic machines and are more
expensive

PATIENT POSITIONING AND


HEAD ALIGNMENT
Remove dental appliances,
earrings, necklaces hairpins,
and any other metallic
objects in the head and neck
region.
It is wiser to demonstrate the
machine to the patient by
cycling it while explaining the
need to remain still during
the procedure.
CHIN POSITIONING WHILE
TAKING OPG

This is particularly true for


children who may be anxious.

The anteroposterior position radiograph of the patient is


typically achieved by having patients place their incisal
edges of maxillary and mandibular incisors into notched
positioning device(BITE BLOCK)
Midsaggital plane must be centered within the image
layer of the particular x-ray unit.
Failure to position it correctly results in a radiograph
which is showing right and left sides that are unequally
magnified in the horizontal dimension.

A simple method to evaluate the degree of horizontal distortion


of image is to compare the apparent width of the mandibular first
molars bilaterally.
The smaller side is too close to the receptor, and the larger side is
too close to the x-ray source.
Patients chin and occlusal plane must be properly positioned to
avoid distortion.
The occlusal plane is aligned so that it is lower anteriorly, angled
20 to 30 degrees below the horizontal plane.
Guide to chin placement is to position the patient so that a line
from the tragus of the ear to the outer canthus of the eye is
parallel to the floor.

If chin is tipped too high, the occlusal plane on


the radiograph appears flat or inverted and the
image of the mandible is distorted.
In addition a radiopaque shadow of the hard
palate is superimposed on the roots of the max.
teeth.
If the chin is tipped too low, teeth become
severely overlapped, the symphyseal region of
the mandible may be ccut off the film,and both
the mandibular condyles maybe projected off the
superior edge of the film.

Patients are positioned with their backs and


spines erect and neck extended.
Having patients place their feet on a foot
support and using cushion for back support may
facilitate proper positioning.
Proper neck extension is is best accomplished
by using a gentle upward force on mastoid
eminences .
Finally after patients are positioned in the
machine ,instruct them to swallow and hold the
tongue on the roof of the mouth which
eliminates the air space and provides optimal
visualization of the apices of maxillary teeth.

Evaluating &
SELECTION CRITERIA
OF the Image

Evaluating the Image


Extraoral images should first be evaluted for
overall quality. Proper exposre and processing will
result n an image with good contrast and density.
Proper patient positioning prevents unwanted
superimpositions and distortions and facilitates
identification of anatomic landmarks. Interpreting
poor-quality images can lead to diagnostic errors
and subsequent treatment errors.
The first step in the interpretation of radiographic
images is the identification of anatomy.

Abnormalities cause disruptions of normal


anatomy.
Interpretation of extraoral radiographs
should be though, careful, and meticulous.
A systematic, methodical approach should
be used for the visual exploration or
interrogation of he diagnostic image.
A method for the visual interrogation of
extraoral projections is presented below.

Lateral projection

LATERAL PROJECTION

Step 1 Evaluate the base of the skull and calvarium.


Identify the mastoid are cells, clivus, clinoid
processes, sella turcica, sphenoid sinuses, and roof
of the orbit. In the clavarium, assess vessel grooves,
sutures, and diploic space. Look for intracranial
calcifications.
Step 2 Evaluate the upper and middle face. Identify
the orbits, sinuses (frontal, ethmoid, and maxillary),
pterygomaxillary
fissures,
pterygoid
plates,
zygomatic processes of the maxilla, anterior nasal
spine, and hard plate (floor of the nose). Evaluate
the soft tissues of the upper and middle face, nasal
cavity (turbinates), soft plate, and dorsum of tongue.

Step 3 Evaluate the lower face. Follow the


outline of the mandible, starting from the
condylar and coronoid processes, to the rami,
angles, and bodies, and finally to the anterior
mandible. Evaluate the soft tissue of the lower
face.
Step 4 Evaluate the cervical spine, airway, and
area of the neck, Identify each individual
vertebra, confirm that the skull- C1 and C1-C2
articulations are normal, and assess the
general alignment of the vertebrae. Assess soft
tissues of the neck, hyoid bone, and airway.
Step 5 Evaluate the alveolar bone and teeth.

SMV PROJECTION

SMV PROJECTION
Step1 Evaluate the calvarium and posterior
cranial fossa. Assess the foramen magnum,
atlas dens, and occipital condyles. Identify the
petrous ridge of the right and left temporal
bones, the external auditory canals, and the
mastoid air cells. In this and all subsequent
steps, compare the right and left sides and look
for symmetry.
Step 2 Evaluate the middle cranial fossa. Identify
the foramina ovale and spinosum. Assess the
slivus and sphenoid sinuses.

Step 3 Evaluate the upper and middle face.


Assess the nasal cavity, nasal septum,
maxillary and ehtmoid sinuses, and orbits.
Assess both the bony borders and antra or
contents of these structures.
Step 4 Evaluate the mandible. Follow the
outline from the right condylar head,
coronoid process, ramus, angle, and body
through the anterior mandible to the left
body, angle, ramus, coronoid process, and
condyle.

WATER PROJECTION

WATER PROJECTION

Step 1 Evaluate the calvarium and sutures, starting


in the left temporal area over the supraorbital
ridges to the right temporal area. Look for
intracranial calcifications. In this and all subsequent
steps, compare the right and left sides and look for
symmetry.
Step 2 Evaluate the orbits and the frontal sinuses.
Identlify the supraorbital and infraorbital rim, te
inferior orbital foramen, the floor of the orbit, the
zygomaticofrontal sutures, and the innominate line
of the infratemporal fossa crossing on the lateral
aspect of each orbit.

Step 3 Evaluate the maxillary sinuses and nasal


cavity. Identify the superior, medial, and lateral
walls and the floor of the maxillary sinuses; the
nasal septum; and the floor and lateral walls on
nasal cavity. Try to identify foramen rotundum
projected toward the mesial wall of the sinus.
Step 4 Evaluate the zygomatic arches. Identify
the frontal, maxillary, and temporal processes
of the zygoma and the zygomaticofrontal
suture. Confirm continuity of outlines and
symmetry with the contralateral side.
Step 5 Evaluate the condylar and coronoid
processes of the mandible. This is one of the
best PA views of the coronoid process.

POSTEROANTERIOR PROJECTION

POSTEROANTERIOR PROJECTION
Step 1 Evaluate the calvarium, sutures, and
diploic space starting in the area of the left
external auditory meatus (EAM), over the top of
the calvarium, to the right EAM. Look for
intracranial calcifications. Identify the mastoid
are cells and petrous ridge of the right and left
temporal bones. In this and all subsequent
steps, compare the right and left sides and look
for symmetry.
Step 2 Evaluate the upper and middle face.
Identify the orbits, sinuses (frontal, ethmoid,
and maxillary), and zygomatic processes of eh
maxilla. Assess the nasal cavity, middle and
inferior turbinates, nasal septum, and hard
plate.

Step 3 Evaluate the lower face. Follow the


outline of eh mandible starting from the right
condylar and coronoid processed, ramus,
angle, and body through the anterior
mandible to the left body, angle, ramus,
coronoid process, and condyle.
Step 4 Evaluate the cervical spine. Identify the
dens, the superior border of C2, and the
inferior border of C1.
Step 5 Evaluate alvcolar bone and teeth.

REVERSE TOWNE PROJECTION

REVERSE TOWNE PROJECTION


Step 1 Evaluate the calvarium and look for
intracranial calcifications. Identify the foramen
magnum and the posterior arch o the atlas. In
this and all subsequent steps, compare the
right and left sides and look for symmetry.
Step 2 evaluate the middle crainal fossa,
perrous ridges, and mastoid air cells. The
anatomy in this area is difficult to discren.
Look
for
displacement, interruption of
outlines, and loss of symmetry. Identify the
odontoid process (dens) of the axis (C2) in
the midline.

Step 3 Evaluate the nasal cavity. Identify


the outlien of he nasal cavity, the nasal
septum, and the inferior and middle
turbinates.
Step 4 Evaluate the condylar and coronoid
process. In the open mouth projection, the
condylaer head, including its superior
sruface and condylar neck, should be
identified.

Selection Criteria

Selecting the appropriate extraoral


radiographic examination is the just step in
obtaining and interpreting a radiograph.
Extraoral radiographs are used to examine
areas not fully covered by intraoral films or
to evaluate the cranium, face (including the
maxilla and mandible), or cervical spine for
diseases, trauma, or abnormalities. Before
an extraoral radiograph is obtained, it is
essential to evaluate the patients
complaints and clinical signs in detail.

The clinician must first decide which


anatomic structures need to be evaluated
and then select the appropriate projection.
Usually, at least two radiographs taken at
right angles to each another are obtained
for spatial localization of pathologic
conditions.

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