Panoramic Radiography: Interpretation guidelines

A systematic method to review a panoramic radiograph
Reading a panoramic radiograph can be puzzling. How often you may have realized that you have not completely reviewed a pan? Or, realized at a later time that you had missed some findings? Here is an easy way. For a thorough review of a panoramic radiograph, please mentally divide the image into 9 segments as shown below:

Portfolio Single
Segment 1
Review the dentition
First, review the dentition. A systematic way to review the dentition is to start your analysis from tooth #1, then progress one tooth at a time to #16. Then proceed to the mandibular arch, to tooth #17, and analyze one tooth at a time to tooth #32. On the first presentation of a panoramic radiograph, you may see an obvious lesion around tooth #30. Even then, follow the structured review of the image. Start your analysis from tooth tooth #1, progress one by one to #16, then to #17 and finally to #32. This organized method will prevent you from missing a small lesion of equal or even higher morbidity located in a different area. When you analyze a tooth, start from the crown, then observe the crestal bone, and finally analyze the PDL spaces and the surrounding bony areas.
Segment 2
Review the sinuses, nasal fossa and orbits
Evaluate and compare the sizes and densities of the maxillary sinuses. Trace the inferior border of the sinuses, particularly near the roots, to detect continuity of the cortex. Review the nasal septum and its deviation, if any. Compare the turbinates. Follow the outlines of the orbital floors, to rule out any discontinuity.
Segment 3
Review the inferior border of the mandible and the vertebral shadow
Trace the inferior border of the mandible. It should be almost uniformly thick and dense. Look for any discontinuity, displacement or deviation from normal. Carefully review the area superimposed by the shadow of the vertebra.
Segments 4
Review the rami and the vertebra
Both the rami should be of equal size and density. Identify any soft tissue calcifications in this area. Review the margins of the vertebra, and rule out any osteophyte formation. Identify if the stylohyoid ligaments are calcified.
Segments 5
Review the temporomandibular joints
TMJs are difficult to interpret on a panoramic radiograph. These are often superimposed by other bony structures. Both the condyles should be of similar size and shape. Observe any subcortical sclerosis, surface flattening and surface erosion. Osteophytes may be visible only if these are fairly large.
Segments 6
Review the neck and hyoid areas
Review the neck areas to rule out presence of any soft tissue calcifications.
If any lesion is detected, it is important to thoroughly describe it. Most lesions can be described with 7 radiographic features. A thorough description, covering all 7 features, can be written in one or two sentences. The features are :
  • 1) location of the lesion, (e.g., maxillary molar area, bilateral, near the apex)
  • 2) density, (e.g., radiopaque, radiolucent, mixed)
  • 3) border of the lesion, (e.g., well-defined, corticated, irregular, thick, thin)
  • 4) shape, (e.g., oval, circular)
  • 5) size, (e.g., 7 mm x 5 mm, from mesial of #18 to distal of #21)
  • 6) internal content, (e.g., retained root tip, impacted canine, foreign bodies) and
  • 7) effects on the adjacent structures (e.g., crown is displaced, IAC margin is eroded, roots are flared).
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