Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2012; 57:(1 Suppl): 40–45

doi: 10.1111/j.1834-7819.2011.01655.x

Interpretation of panoramic radiographs

S Perschbacher*
*Department of Radiology, Faculty of Dentistry, The University of Toronto, Ontario, Canada.

ABSTRACT
Panoramic radiography has become a commonly used imaging modality in dental practice and can be a valuable diagnostic
tool in the dentist’s armamentarium. However, the panoramic image is a complex projection of the jaws with multiple
superimpositions and distortions which may be exacerbated by technical errors in image acquisition. Furthermore, the
panoramic radiograph depicts numerous anatomic structures outside of the jaws which may create additional interpretation
challenges. Successful interpretation of panoramic radiographs begins with an understanding of the normal anatomy of the
head and neck and how it is depicted in this image type. This article will describe how osseous structures, soft tissues, air spaces
and ghost shadows contribute to the final panoramic image. A systematic and repeated approach to examining panoramic
radiographs, which is recommended to ensure that critical findings are not overlooked, is also outlined. Examples of
challenging interpretations, including variations of anatomy, artefacts and disease, are presented to illustrate these concepts.
Keywords: Dental radiology, orthopantomograph.

may be less clear how the other structures of the head

INTRODUCTION
and neck become captured on the image. It is often
Panoramic radiography has become a commonly used these superimposing hard and soft tissues and airways
imaging modality in dental practice and can be a that create confusing shadows which cause challenges
valuable diagnostic tool in the dentist’s armamentar- in interpretation.
ium. However, the panoramic image is a complex
projection of the jaws with multiple superimpositions
The panoramic perspective
and distortions which may be exacerbated by technical
errors in image acquisition. Furthermore, the pano- The first step in understanding panoramic anatomy is to
ramic radiograph depicts numerous anatomic structures appreciate the perspective from which each part of the
outside of the jaws which may create additional image is presented. Because the image is captured by an
interpretation challenges. Successful interpretation of X-ray tube which rotates around the patient’s head,
panoramic radiographs begins with an understanding rather than from a stationary source, this perspective
of the normal anatomy of the head and neck and how it changes from the posterior regions of the jaws to the
is depicted in this image type. This article will describe anterior area. The right and left posterior parts of the
how osseous structures, soft tissues, air spaces and image represent lateral views, looking at the patient
ghost shadows contribute to the final panoramic image. from the side; the anterior part of the image represents
A systematic and repeated approach to examining an anterior-posterior view, looking at the patient from
panoramic radiographs, which is recommended to the front (Fig. 1). The entire panoramic image is
ensure that critical findings are not overlooked, is also analogous to a composite of portions of two lateral
outlined. Examples of challenging interpretations, and one anterior-posterior skull views, except without
including variations of anatomy, artefacts and disease, as many superimpositions.
are presented to illustrate these concepts.
Osseous anatomy
Anatomy of a panoramic radiograph
With the panoramic perspective in mind, the osseous
Although it is obvious that a panoramic radiograph structures of the maxillofacial region can be reviewed.
depicts the teeth and jaws in a single convenient view, it The structures around the posterior maxilla, which
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 Interpretation of panoramic radiographs

Fig 1. Top – composite photograph depicting the osseous anatomy of the maxilla and surrounding bones from the panoramic perspective. The
anterior region is viewed from the front while the posterior regions are viewed from the side. Bottom – a panoramic radiograph divided to match the
regions represented by the photograph above. a and black dotted outline = pterygoid plate; b = pterygomaxillary fissure; c = zygomatic process
of maxilla; d = zygomatic arch; e = temporal component of temporomandibular joint; f = mastoid process of temporal bone (not imaged in
panoramic radiograph); g = lateral and inferior orbital rim; h = infraorbital canal; i and white dotted outline = inferior concha ⁄ turbinate;
j = hyoid bone.

include the sphenoid, zygomatic and temporal bones,

are likely the least familiar for many dental practitio-
ners but contribute an important part of the panoramic
image. The pterygoid plates of the sphenoid bone
articulate with the posterior wall of the maxilla and,
together, form the pterygomaxillary fissures (Fig. 1a
and b). The zygomatic processes of the maxilla are
thick buttresses of bone extending laterally from the
maxilla bilaterally and are seen as J-shaped shadows
superimposed over the maxillary sinuses (Fig. 1c). They
articulate with the zygomatic bones which, in turn, Fig 2. Mastoid air cells are seen bilaterally where they have pneu-
matized the articular processes of the temporal bones creating
articulate with the zygomatic processes of the temporal rounded, radiolucent loculations (black arrows). This is a variation of
bones to form the zygomatic arches (Fig. 1d). The normal anatomy.
zygomatic arches can be followed posteriorly to where
the temporal bones form the superior components of sinuses (Fig. 1g). Each infraorbital canal may be seen as
the temporomandibular joints (Fig. 1e). Sometimes the thin parallel cortices, extending inferiorly and medially
mastoid processes of the temporal bones, containing from the floor of the orbit (Fig. 1h). The inferior
multiple radiolucent air cells, are imaged posterior and turbinates of the nasal fossa create surprisingly large
inferior to the temporomandibular joints (Fig. 1f). shadows across a large portion of the maxillary sinuses
Occasionally, the mastoid air cells may extend anteri- (as seen from the lateral perspective). They are also seen
orly and pneumatize the roof of the temporomandib- in the middle part of the image on either side of the
ular joint (Fig. 2). This is a normal anatomic variation nasal septum (seen from the anterior perspective)
but may seem to mimic pathology due to the multiloc- (Fig. 1i). The hyoid bone, which is normally seen
ular appearance produced. The lateral and inferior inferior to the mandible, may create confusion when it
orbital rims of the orbits are seen as thick, curved, becomes superimposed over the inferior border because
linear radiopaque structures superior to the maxillary of patient positioning (Fig. 1j).
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S Perschbacher

Soft tissues and air spaces

The osseous structures of the maxillofacial region are
surrounded by the soft tissues of the face, neck and oral
cavity. These soft tissues create indistinct radiopaque
shadows which superimpose over the osseous and
dental structures. The external nose may be seen over
the apices of the maxillary incisors with the ala curving
laterally from the midline (Fig. 3a). The soft tissues of
the external ear are often seen superimposed over the
mandibular condyle with the earlobe forming a Fig 3. Panoramic radiograph with major soft tissue structures (a–f)
rounded radiopacity posterior to the ramus (Fig. 3b). and airways (1–5) traced. a = external nose; b = external ear;
c = tongue; d = lingual tonsils on posterior tongue; e = epiglottis;
The largest intraoral shadow is created by the tongue, f = soft palate; 1 = nasal fossa; 2 = nasopharynx; 3 = oropharynx;
whose dome-shaped image occupies a large proportion 4 = oral cavity; 5 = oral orifice.
of the panoramic radiograph (Fig. 3c). In the posterior
parts of the radiograph, the posterior region of the
tongue may have a more irregular surface due to the
lingual tonsils (Fig. 3d). The epiglottis can often be seen
as a thin finger-like projection extending from the
posterior tongue, below the angles of the mandible
(Fig. 3e). The soft palate is seen from a lateral
perspective on both sides of the panoramic image as
an oval or inverted tear-drop shape extending off the
hard palate (Fig. 3f). Its inferior surface is superior and
approximately parallel to the tongue.
The upper airway includes the nasal fossa, oral cavity Fig 4. The air shadow of the oral cavity may create a thin radiolucent
and pharynx, all of which are imaged on the panoramic line superimposed over the mandibular ramus, which may be mistaken
radiograph as radiolucent passages. These radiolucen- for a fracture if not properly identified (open black arrows). Careful
examination of the periphery of the radiograph is done to avoid
cies may be confused for bone destroying pathology or missing findings in the tissues surrounding the jaws. An elongated
fractures (Fig. 4). The nasal fossa is seen in the midline, styloid process (black arrow) and submandibular calcification (white
superiorly, and extends bilaterally across the region of arrow), most likely representing a submandibular gland sialolith, are
detected in this patient.
the maxillary sinuses (Fig. 3,1). Posteriorly, it opens
into the nasopharynx. The nasopharynx is seen poster-
ior to the maxilla and superior to the soft palate the left side of the mandible is being imaged, the film or
(Fig. 3,2). It is continuous with the oropharynx inferi- sensor is positioned close to this side. However, the X-
orly, which occupies the region anterior to the cervical ray source is positioned on the right side of the patient
spine and posterior to the tongue (Fig. 3,3). The oral and the beam must pass through the right mandible in
cavity may be seen as a variably-sized radiolucent strip order to image the left side. Because the right side is at a
between the superior surface of the tongue and the greater distance from the film, its image is enlarged and
palate (Fig. 3,4). The increased radiolucency of the oral indistinct. Hence there is a ghost shadow of the right
cavity may obscure the roots of the anterior teeth due to mandible seen superimposed, in a slightly superior
overexposure. This effect may be minimized by having position and a reversed orientation, over the left
the patient place his or her tongue flat against the palate mandible. Of course, the same is true for the contra-
during imaging. The oral orifice, or space created lateral side (Fig. 5a). The cervical spine may be seen in
between the upper and lower lips, may be seen as a focus on a panoramic radiograph on the most posterior
‘kiss-shaped’ radiolucency over the crowns of the parts of the image. However, a ghost shadow of the
maxillary and mandibular incisors (Fig. 3,5). Having cervical spine is formed when the anterior teeth are
the patient close his or her lips around the bite-stick can imaged because the X-ray beam originates from behind
prevent overexposure of this area. the patient’s head. This shadow may obscure a clear
view of the anterior region of the jaws (Fig. 5b). Having
a patient stand as tall as possible with his or her cervical
Ghost shadows
spine extended maximally helps minimize this super-
Ghost shadows are shadows of structures imaged when imposition. Foreign objects, such as earrings or facial
they are not within the focal trough. Because these jewellery, may also create ghost shadows which can
structures are outside the plane of focus, they appear obstruct visualization of the underlying anatomy if they
increasingly magnified and blurry. For example, when are not removed (Fig. 6).

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 Interpretation of panoramic radiographs

appearing bilaterally are generally anatomic. Compar-

ing the left and right sides may also allow detection of
any asymmetries that may be indicative of disease or a
developmental condition.
The following steps are an example of an approach to
analysing the complex projection of the anatomic
structures on a panoramic radiograph:
1. Assess the periphery and corners of the image
• Start here to avoid zoning in on the teeth and
neglecting important findings in the tissues
surrounding the jaws (Fig. 4).
Fig 5. The ghost shadows produced by the contralateral mandible (a)
and cervical spine (b) are traced on this panoramic radiograph. The • Structures that may be seen in this area include
shadows of these structures are indistinct because they are so far the:
outside the focal trough when imaged. – orbits
– articular processes of the temporal bones (at the
temporomandibular joints)
– cervical spine
– styloid processes
– pharynx
– hyoid bone.
2. Examine the outer cortices of the mandible
• Trace the periphery of the bone starting at one
spot and completing a circuit which includes:
– anterior and posterior rami
Fig 6. Earrings worn by this patient during image acquisition have
created ghost shadows. The right earring is seen superimposed over the
– coronoid processes
left maxillary sinus (white arrow) and the left earring is projected over – condyles and condylar necks
the right zygomatic arch (black arrow). – inferior border.
• Look for continuity and evenness of the cortices
(Fig. 7).
3. Examine the cortices of the maxilla
An approach to reading panoramic radiographs
• This includes the posterior and medial walls and
The interpretation of a panoramic image follows the floor of each maxillary sinus.
same principles as with any other image or image • While examining the posterior wall of the sinus,
series. A systematic and repeated process is used to also look at the:
ensure that all significant findings are identified. An – zygomatic process of the maxilla
observer cannot count on abnormalities to present – pterygomaxillary fissure
themselves. Rather, one must be vigilant in assessing
all anatomic structures to ensure they are present
and normal. In the systematic approach recom-
mended here the osseous structures and surrounding
soft tissues are assessed first. Second, the alveolar
processes are examined. Finally, the teeth are
evaluated.

Osseous structures and surrounding soft tissues

Compared to intraoral radiographs, the panoramic
image depicts a much larger area of anatomic structures
of the oral and maxillofacial region. More time will
therefore be required to assess these structures, though Fig 7. Careful examination of this panoramic radiograph reveals that
once a routine is established a practitioner will find that the inferior cortex of the mandible is not seen clearly on the left side,
compared to the right. Assessment of the bone pattern also reveals
this becomes a quick and natural process. It is critical to increased trabecular bone density in the posterior left mandible. This
have a good understanding of the normal anatomy in has caused the mandibular nerve canal to appear relatively more
order to identify the presence of any abnormalities. It is prominent. The path of the nerve canal is also altered in a superior
direction. These findings are consistent with fibrous dysplasia. This
useful to compare the left and right sides of the image image cannot portray the buccal-lingual expansion that is character-
when deciding if a finding is normal, since structures istic of this condition.

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S Perschbacher

Alveolar processes and teeth

The spatial resolution of a panoramic image is much
lower than intraoral radiographs, making detailed
assessment of the alveolar processes and teeth more
difficult. Nonetheless, full evaluation is required to
avoid missing disease. These structures should be
viewed in a systematic manner. A sequence from the
posterior of the first quadrant to the posterior of the
fourth quadrant in a clockwise direction, repeated for
each finding to be evaluated, is recommended.
The following steps are suggested as an approach to
Fig 8. Examination of the cortical lines in the posterior maxillary this part of the interpretation: (1) assess the crestal bone
regions of this image would allow the observer to detect that the position of the alveolar processes to identify any
posterior wall of the left maxillary sinus is absent (open black arrows
indicate where the cortex should be seen). This destruction was caused periodontal bone loss; (2) examine the periodontal
by a malignancy within the sinus. The white lines formed by the ligament spaces and lamina duras around each tooth
zygomatic process of the maxilla and posterior boundary of the for signs of inflammatory disease; (3) don’t forget to
pterygomaxillary fissure, which should be assessed at the same time as
the posterior wall of the maxilla, are still visible. examine the follicles and papillae of developing teeth
for anything affecting their size, position or cortical
- The thin radiopaque lines produced by these boundaries. These changes could be indicative of
structures run roughly parallel to the posterior wall of developing pathology; (4) evaluate the teeth for pres-
the maxillary sinus, and may be confused with it. ence ⁄ absence ⁄ eruptive or positional abnormalities, car-
Destructive disease affecting the maxillary sinus may ies, inadequate restorations, calculus, developmental or
erode the posterior wall, which can be easily missed if acquired abnormalities.
all three lines are not identified (Fig. 8).
4. Examine the zygomatic bones and arches
• Follow where they extend posteriorly from the Interpretation of pathology on panoramic
zygomatic processes of the maxilla to the radiographs
temporal bones. The panoramic radiograph is especially useful when
5. Assess the internal density of the maxillary sinuses examining regions of the jaws which cannot be imaged
• Compare left and right sides. with intraoral radiographs, such as the temporoman-
• Opacification is most commonly a sign of dibular joints and third molar regions. Due to distor-
inflammatory disease but could be a sign of tion and a limited two-dimensional view, the temporo-
more serious pathology. mandibular joint cannot be assessed in detail, however,
6. Assess the structures of the nasal cavity and the a general overview is provided which allows major
palates abnormalities to be ruled out. When a lesion in the jaws
• Examine the nasal floor ⁄ hard palate and con- needs to be studied, it is important to be able to
chae extending horizontally along both sides examine its entire boundary, which may be best
of the image. achieved on a panoramic image. Usually the location,
• Examine the nasal septum in the midline. periphery and shape, internal density and effects on the
• Note the soft palate seen bilaterally extending surrounding structures of lesions in the jaws can be
from the posterior aspect of the hard palate appreciated on panoramic images. However, this
and into the oropharynx. modality is limited by the numerous superimpositions
7. Examine bone the pattern of the maxilla and projected on the image, especially in the maxillary sinus
mandible and palate regions, and by its inability to demonstrate
• Assess the density and pattern of the trabeculae medial-lateral changes (Fig. 7). Advanced imaging,
for abnormalities (Fig. 7). such as computerized tomography, cone beam comput-
• Keep in mind that some metabolic conditions erized tomography or magnetic resonance imaging may
may present with a generalized alteration in be required to provide multidimensional views to
bone pattern and therefore comparing left supplement the information obtained from a panoramic
and right sides may not be helpful. radiograph.
• In the mandible examine the size, position,
cortication and symmetry of the:
CONCLUSIONS
– inferior alveolar nerve canals
– mandibular foramina Panoramic radiographs have many useful applications
– mental foramina. in dentistry but require diligence on the part of the

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 Interpretation of panoramic radiographs

observer to examine the image thoroughly. For this Address for correspondence:
reason, a systematic approach is recommended for the Dr Susanne Perschbacher
interpretation of this image type. Understanding the Department of Radiology
perspective of the anatomy on a panoramic radiograph Faculty of Dentistry
as well as the many superimpositions and distortions 124 Edward Street
produced will help the practitioner to be more success- Toronto
ful at this task. Ontario M5G 1G6
Canada
Email: [email protected]

ª 2012 Australian Dental Association 45