1. The following slides identify the anatomical structures found on Panoramic Radiographs. 0 Panoramic Anatomy In navigating through the slides, you should click on the left mouse button when you see the mouse holding an x-ray tubehead or you are done reading a slide. Hitting “Enter” or “Page Down” will also work. To go back to the previous slide, hit “backspace” or “page up”.

2. Types of Panoramic Images Single Real Image Double Real Image Ghost Image

3. Single Real Image Only one image results from a given anatomical structure. The structure is located between the rotation center and the film and the x-ray beam only passes through the structure one time. Most images seen on a panoramic film are of this type.

4. Double Real Image Two images of a single object are seen on the film. Double real images are produced by structures located in the midline . The x-ray beam passes through these objects twice as the tubehead rotates around the patient. Structures that result in double real images are the hard and soft palates, the hyoid bone and the cervical spine .

5. Ghost Image Ghost images are formed by dense objects located between the tubehead and the rotation center . These ghost images usually result from external objects such as earrings, but they may be produced by dense anatomical structures such as the mandible. (For more information, see self-study module “Panoramic Technique”). ghost image of earring (between lines)

6. 24 23 28 18 17 19 14 13 15 20 8 10 9 7 29 37 38 33 30 39 3 5 11 21 6 1 12 16 31 32 25 4 26 34 35 36 22 2 41 44 43 42 27 40 Panoramic Anatomy The numbers on the diagram below and on the next slide (air spaces) correspond to the numbers on the key (slide 9).

7. 46 45 47 45 Air Spaces

9. The following slides show anatomical structures seen on panoramic films. See what other structures you can identify that are not labeled. At the end of this presentation there are 11 test slides.

10. 9 5 25 28 14 33 12 18 17 19 13 22 7 39 6 33 25 5 28 9 12 14 18 17 19 22 13 7 6 39

11. 8 20 11 15 1 16 3 30 44 32 23 2 31 26 38 34 24 8 20 11 15 1 2 3 30 44 32 23 31 38 34 16 24 26 4 36 36

12. 40 43 43 42 42 41 21 40 21 46 46 41 45 45 47 47

13. 36 41 38 7 11 1 43 47 46 45 R L

14. 2 8 19 17 18 6 16 21 Red arrows point to ghost image of hard palate 23 39 R L

16. 28 17 44 43 20 2 R L

17. 2 31 transverse foramen atlas R L

18. 15 34 27 6 46 47 19 R L What head positioning error is seen on this film? The anterior teeth are positioned behind the notch in the bitestick (farther from the film), resulting in the widening of the anterior teeth (the maxillary central incisors are as wide as the molars). 0

19. 15 17 8 1 32 N N = soft tissue of nose R L What head positioning error is seen on this film? The head is tipped down too much, resulting in shortened mandibular incisors and a V-shaped mandible. 0

20. 40 27 36 E LN LN = calcified lymph node E = epiglottis R L

21. What positioning error is seen on this film? The patient’s head is turned to the side. Note the width of the ramus on each side (The red arrows are the same length). Which direction was the patient’s head turned (left or right)? The head was turned to the left, bringing that side closer to the film and decreasing the width of the ramus on that side. The green arrow points to the biteblock, centered on the contact between the right central and lateral incisors. ? 40 2 18 8 45 R L 0 ? Identifies calcification, possibly in carotid or in lymph node

22. 33 8 7 46 47 E E = epiglottis R L 0

23. 3 21 29 32 11 34 The black dots result from static electricity, caused by removing the film too quickly from the cassette or from the box of film (creates friction, which results in a static discharge). R L What causes the black dots identifed by the red arrow? What positioning error is seen on this film? 0 The chin is tipped up too much, giving a more squared off appearance to the mandible, creating a reverse smile and causing the hard palate to be superimposed on the roots of the maxillary teeth.

24. 3 30 9 27 1 16 44 20 36 42 10 G G = ghost of right mandible R L 0

25. 14 27 nose 24 47 39 The lead apron was placed too high on the back of the patient’s neck. R L What caused the white (radiopaque) area indicated by the red arrow? 0

26. 9 23 26 7 12 air cell Air cell in zygomatic arch. R L 0

27. 7 27 26 24 22 38 30 R L

28. ghost of mandible 47 45 10 6 5 R L

29. 7 39 15 21 23 9 30 Note the relatively inferior location of the mandibular canal (30), providing plenty of room for the implant. R L 5 44

30. 1 29 31 24 26 Pattern on right side of film (patient’s left) caused by excessive oil on patient’s hair. R L

31. red arrow identifies fracture 28 28 7 R L

32. Green arrow identifies “pseudo-fracture” caused by palatoglossal air space. Red arrows point to odontogenic keratocyst. 34 44 27 R L

33. Ghost images of earrings R L

34. Ghost images of earrings 15 2 R L

35. Hearing aid (red arrow) with ghost (green arrow). 27 28 28 R L

36. Ghost image of metal used to restore left angle of mandible R L

37. Ghost images of mandibles (dotted line outlines ghost of left ramus-angle over right side of mandible) R L

38. Identify the anatomical structures on the following slides.

39. Slide # 1 A B C D E F G R L A B C D E F G Cervical vertebra External oblique ridge Zygomatic process Maxillary sinus Mandibular foramen Lingula Zygomaticotemporal suture 0

40. A D E F G H I J K Slide # 2 C R L A B C D E F G H I J K Ear lobe External auditory meatus Submandibular gland fossa Nasal septum Hard palate Mental foramen Hyoid bone Mandibular canal Pterygoid plates Articular eminence Pterygomaxillary fissure 0 B

41. Slide # 3 A E D B C R L A B C D E Palatoglossal air space Middle cranial fossa Lateral border of the orbit Condyle Mental fossa 0

42. Slide # 4 K J I H G F E D C B A L R L 0 A B C D E F G H I J K L Cervical vertebra Zygomaticotemporal suture Zygomatic process Nasal septum Inferior concha Soft tissue of nose Hard palate Post. wall of maxillary sinus External auditory meatus Posterior pharyngeal wall Mental foramen Mental fossa

43. Slide # 5 A B C D E F G H I J Glossopharyngeal air space Styloid process Nasopharyngeal air space Pterygoid plates Condyle Infraorbital canal Infraorbital foramen Soft palate Mandibular canal Lingula 0 A I H G F E D C B J R L

44. Slide # 6 A B C D E F G Mental foramen Incisive foramen Soft tissue of nose Anterior nasal spine Pterygoid plates Ear lobe Hyoid bone G F E A E D C B R L The radiolucency (red arrows) seen in the ramus and third molar area on the patient’s right side is an ameloblastoma. (Differential includes dentigerous cyst, radicular cyst, OKC). 0

45. Slide # 7 D C B A R L A B C D Posterior border of maxillary sinus Inferior border of orbit Inferior concha Inferior border of maxillary sinus The radiolucency (red arrows) seen in the ramus on the patient’s left side is a squamous cell carcinoma. 0

46. Slide # 8 A B C D E Maxillary tuberosity Hard palate Coronoid process Floor of middle cranial fossa Posterior pharyngeal wall 0 This child has a condition known as cherubism. The mandibular lesions involve both rami, extending into the coronoid process (the condyle is rarely involved). The maxillary lesions are located in the tuberosity regions, causing anterior displacement of 2nd and 3rd molars. E D C B A R L

47. Slide # 9 F E D C B A R L A B C D E F Zygomatic arch External oblique ridge Palatoglossal air space Soft palate Pterygomaxillary fissure Styloid process This patient has multiple supernumerary premolars in the mandible (#’s 21, 28 and 29 were extracted). 0

48. Slide # 10 A B C D E F Mandibular canal Soft tissue of nose Nasal fossa Hard palate Mandibular foramen Styloid process This patient has impacted mandibular third molars that have migrated up into the coronoid processes. Note also the long, thin condylar necks and small condyles. 0 F E D B A C R L

49. Slide # 11 D C B E A R L A B C D E Sigmoid notch Nasal septum Coronoid process Articular eminence Mental foramen (on crest of ridge) The green arrows identify a calcified stylohyoid ligament. If there is associated neck pain, the condition is known as Eagle’s Syndrome (recent history of neck trauma or surgery) or Stylohyoid Syndrome (no history of trauma/surgery). The red box outlines several radiopacities which represent tonsillar calcifications. 0

50. This concludes the section on Panoramic Anatomy. Additional self-study modules are available at: http://dent.osu.edu/radiology/resources.htm If you have any questions, you may e-mail me at: [email_address] Robert M. Jaynes, DDS, MS Director, Radiology Group College of Dentistry Ohio State University 0