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Case Study: Limitations of Panoramic Radiography in the Anterior Mandible

Article in Dental update · December 2009

DOI: 10.12968/denu.2009.36.10.620 · Source: PubMed

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 Radiology

This article counts towards

one of the five core
subjects
introduced
Cameron Walker
in 2007 by the
Donald Thomson and Gerald McKenna

Case Study: Limitations of

Panoramic Radiography in the
Anterior Mandible
Abstract: Dental Panoramic Tomography (DPT) is a widely used and valuable examination in dentistry. One area prone to
artefacts and therefore misinterpretation is the anterior region of the mandible. This case study discusses a periapical
radiolucency related to lower anterior teeth that is discovered to be a radiographic artefact. Possible causes of the artefact
include a pronounced depression in the mental region of the mandible or superimposition of intervertebral spaces. Additional
limitations of the DPT image include
superimposition of radio-opaque structures, reduced image detail compared to intra-oral views and uneven magnification. These problems
often make the DPT inappropriate for imaging the anterior mandible.
Clinical Relevance: Panoramic radiography is often unsuitable for radiographic examination of the anterior mandible.
Dent Update 2009; 36: 620–623

Radiographic examination of patients
is an important resource for clinicians,
often necessary for diagnosis and
treatment planning.1-10 Correct use and
interpretation of radiographs is critical
to ensure appropriate subsequent
management of the patient.2 In
addition, justification and evaluation
are requirements set out by The
Ionising Radiation (Medical Exposure)
Regulations 2000, IR(ME)R 2000.11
This paper aims to
highlight potential problems
associated with imaging and
interpretation of the anterior mandible
on Dental Panoramic Tomographs.
Dental Panoramic
Tomography (DPT) is a widely used
examination6 with applications in many
Cameron Walker, BDS, MFDS RCSEd,
SHO, Donald Thomson, BDS, FDS
RCSEd, DDR RCR, Consultant in
Dental and Maxillofacial Radiology
and Gerald McKenna, BDS, MFDS
RCSEd,
620 SHO,
DentalUpdate
Dundee Dental Hospital, Park
areas of dentistry. The image prone to artefacts and therefore
produced, however, is quite complex misinterpretation is the anterior
and may have several limitations.6 mandible. This is due to the
These include superimposition of hard combination of the complex anatomy that
tissues, soft tissues and also air the X-rays must pass through to reach the
spaces on to the image.1-8 Ghost receptor and the method used to produce
images created by the patient’s a tomographic image.3
anatomy or foreign objects such as
jewellery may obscure detail
or cause confusion.1-8 Magnification
of the entire image and of structures
separately within the image, related
to patient positioning during
exposure, can cause distortion and
limit the usefulness of measurements
taken from the radiograph.1-7 Also,
compared to intra-oral films,
resolution is poorer owing mainly to
the use of intensifying screens.1-5
These factors can make
interpretation and use of all the
available information on the
radiograph relatively challenging.1
An area particularly
December
2009
 Radiology

Case report
A 56-year-old man
was referred by his general dental
practitioner to a dental hospital for a
periodontal consultation. The
patient was medically fit and well.
He was complaining of bleeding
from his gingivae on brushing and
tooth mobility, particularly
associated with his lower right
incisors. These symptoms had
increased over the previous six
months, despite regular attendance
with his general dental practitioner
and periodic ultrasonic cleaning.
A comprehensive
periodontal examination was
carried out which included
assessments of probing depths,
bleeding on probing, tooth mobility,
furcation involvement and gingival
recession.12 These assessments
revealed increased probing depths
in all quadrants, with associated
bleeding on
probing, no evidence of furcation
lesions, and up to 3 mm of gingival
recession throughout the mouth. The
examination also highlighted that both
LR1 and
LR2 were Grade II mobile. In
addition, suppuration was
present from the

December DentalUpdate 621

2009

Figure 1. A Dental Panoramic Tomograph of a 56-year-old patient taken as part of a periodontal
examination.
Figure 2. Periapical radiograph of LR2 to LL1.
pockets associated with these
mobile teeth.
As a result of the clinical
findings, a full-mouth DPT (Figure 1)
was taken of the patient, which
complies with local guidelines and
selection criteria for generalized
moderate to severe periodontitis and
may offer a dose advantage compared
to multiple intra-oral films.7,10 This
radiograph showed up to 50%
horizontal bone
Figure 3. Periapical radiograph of LL1 to LL3.
loss throughout the mouth, particularly
associated with posterior teeth. A
the apices of LL2 and LL3. Owing to
these findings in the anterior mandible,
where assessment of alveolar bone
level is particularly difficult on a DPT,7
intra- oral periapical films of the lower
anterior teeth were requested to
provide higher quality images of this
area (Figures 2 and 3).
The periapical radiographs
showed a single, well defined, well
circumscribed area of radiolucency
associated with LR1 and LR2. In
addition, heavy calculus deposits were
present and loss of apical tooth tissue
due to external inflammatory root
resorption can be seen on LR2. There
was no evidence of pathology
associated with the apices of any other
lower anterior teeth.
The clinical findings and
those on the intra-oral films confirmed,
as expected, the presence of pathology
related to LR1 and LR2, most likely a
combined perio-endo lesion.13 They also
showed that the radiolucency visible on
the panoramic radiograph apparently
related to LL2 and LL3 was artefactual
and that these teeth were actually free
of periradicular pathology.
Discussion
An artefact such as this
on a DPT in the anterior portion of
the mandible may have a number of
explanations.
The method of image
production plays a role in these
explanations and a brief summary of
this method may be of use. The in-
focus images on a DPT are produced
by the structures present in the focal
trough (roughly corresponding to the
shape
of the dental arches) that is created by
number of vertical bony defects were also
observed which corresponded with the
clinical findings. The radiographic report
supported a diagnosis of chronic
generalized adult periodontitis.
In addition to the general
features of the radiograph, a
circumscribed area of radiolucency
measuring 1.5 cm in diameter was
observed associated with the apices of
LR1 and LR2 and a second circumscribed
area of radiolucency, measuring a similar
diameter, was observed associated
with
the rotation of the DPT machine.1-5
The speed and arc of rotation
affects the depth of the focal
trough, which is often narrower in
the anterior region than in the
posterior regions.4 Structures
outside the focal trough also appear
on the image but are less clearly
defined.1-5
For this reason, correct
patient positioning in the panoramic
machine is critical to ensure a
radiograph of good quality.1-5,7
Although Figure
1 does not appear to be
subject to positioning errors, it
should not be

Figure 4. A dental panoramic tomograph clearly showing the cervical vertebrae.
Figure 5. Odontoid peg view demonstrating the
C1−C2 intervertebral space.
completely discounted as a cause of
the artefact as positioning often has a
marked effect on the anterior region.
This is partly due to the narrower in-
focus layer anteriorly, which makes it
easier
for important structures to lie outside
the focal trough.1,5 This could arise as a
result of poor antero-posterior position,
asymmetric or rotated head position or
incorrect Frankfort and occlusal plane
alignment.1,5
The relevant anatomy
potentially involved in this type of
artefact includes the cervical spine
and the shape of the mandible itself.3
On a DPT image the cervical spine
is superimposed on the anterior
mandible.1-7 This generally appears as a
poorly defined radio-opaque band
and it should be possible to understand
how these may cause confusion when
interpreting an image, especially related
to the lower anterior teeth. Also of note
on Figure 1 is the visibility of the C1−C2
intervertebral space superior to the
apices of the upper incisors; this appears
as a radiolucent inverted v-shape. Figure
5 is an odontoid peg view that more
clearly illustrates this radiographic
anatomy.
A second explanation of this
artefact is due to the anatomy of the
mandible. The external surface of the
anterior mandible has a depression close
to the midline and superior to the mental
protuberance. This depression is the
mental fovea and, in some individuals,
may be quite marked.3 This is
demonstrated
in the lateral cephalometric radiograph
labelled Figure 6. Note the depth of the
depression of the mandible between
the lower incisors and prominence of
the chin. When a significant depression
such as this occupies a large
proportion of the relatively narrow focal
trough in a DPT,
it can be visible on the radiograph as a
clearly defined radiolucency overlying
the lower anterior teeth.3 This
appearance could potentially be further
altered in terms of size or location by a
patient positioning error.5
Although a panoramic
radiograph was taken for this patient, it
is worth mentioning that there is
generally considered to be insufficient
evidence
to support definitive guidelines for
radiographs in periodontal assessment.9,10
Bitewings and selected paralleling
Figure 6. A lateral cephalometric radiograph
illustrating the pronounced concavity in the
mental region of the mandible present in some
individuals.
between the canines, which often
obscures detail in this area.7 The
intervertebral spaces in the cervical
spine may be visible as radiolucencies
in this region, which can present near
the apices of the lower anterior teeth.3
Figure 4 is a clear
example of the cervical vertebrae on
a DPT.
Visualization of these is improved as
the patient is edentulous in this area
and has very resorbed ridges. The
radiolucent intervertebral spaces are
clearly visible
technique periapicals have been
suggested to provide improved fine
detail compared to extra-oral views and
also optimal projection geometry.1,5,9
This is because the X-ray beam is
perpendicular to the receptor and the
long axis of
the teeth, which results in the truest
representation of alveolar bone levels
in relation to the dentition.1,5,7 This is
not usually the case with a DPT as
the beam has an 8 degree upwards
angulation5 which could result in an
inaccurate
view of the relation of the bone and the
dentition. It has also been suggested
that this approach can offer a lower
radiation dose than a panoramic image,
which needs to be supplemented with
intra-oral radiographs.14
Further problems which

Figure 7. DPT demonstrating a number of artefacts in the anterior region.
Figure 8. DPT of a patient with a marked Class II skeletal discrepancy.
can limit the usefulness of panoramic
radiography in imaging the anterior
mandible are illustrated in Figures 7
and 8. Figure 7 is a DPT taken
following treatment of a fractured
mandible and shows a selection of
technique errors which can affect the
anterior region.
The anterior mandible is obscured by
the cervical spine and the image of the
patient’s necklace, which has been left
on during the exposure. In addition to
this, the lower incisors are positioned
with only the crowns inside the focal
trough and, therefore, the incisor roots
are almost entirely absent from the
image. Any pathology in this area, such
as a further fracture of the mandible,
damage to the incisor roots or periapical
pathology would be very difficult to see.
This effect on the incisors may have
been caused by poor positioning but is
also seen in patients with abnormal
dental or skeletal relationships.
supplementing this with intra-oral views
in areas of particular interest to ensure
all pathology is identified and to avoid
misdiagnosis.7,9,10 This is especially true
of the anterior mandible but can be
applied throughout the dentition.
References
1. Whaites E. Essentials of Dental
Radiography and Radiology. 4th
edn. Edinburgh: Churchill
Livingstone, 2006.
2. Brocklebank L. Dental Radiology:
Understanding the X-ray Image.
Oxford: Oxford University Press,
1997.
3. Pasler FA. Radiology.
Stuttgart: Thieme, 1993.
4. Langland OE. Principles and
Practice of Panoramic Radiology.
Philadelphia: Saunders, 1982.
5. White SC. Oral Radiology:
Principles and Interpretation. 5th
edn. St Louis: Mosby, 2004.
6. Rushton VE, Horner K. The use
of panoramic radiology in dental
practice. J Dent 1996; 24:
185−201.
7. Mol A. Imaging methods in
periodontology. Periodontology
2000 2004; 34: 34−48.
8. Boeddinghaus R, Whyte A. Dental
panoramic tomography: an
approach for the general
radiologist. Aust
Figure 8 is a DPT of a patient
with a large radiolucent area in the lower
right quadrant which was found to be
related to a squamous cell carcinoma.
The patient also has a marked Class II
skeletal relationship resulting in a badly
distorted image of the anterior mandible. It
is unlikely that any useful information can
be gained from this anterior area
of the image and it would be possible to
miss pathology without the aid of
another view.
Summary
The potential for artefacts to
occur in DPT images of the anterior
mandible, in addition to the problems
such as reduced image detail mentioned
earlier, means that other views are
preferable when imaging this area
alone. When a DPT is indicated for
other
reasons, consideration should be given
to
Radiol 2006; 50: 526−533.
9. Victoria University of
Manchester. Radiation
Protection 136: European
Guidelines on Radiation
Protection in Dental
Radiology. European
Commission, 2004.
10. Pendlebury ME. Selection
Criteria for Dental
Radiography. FGDP, 2004.
11. Ionising Radiation (Medical
Exposure) Regulations 2000
(Statutory Instrument 2000 No
1059). London: HMSO, 2000.
12. Armitage G. The complete
periodontal examination.
Periodontology 2000 2004; 34:
22−33.
13. Corbet EF. Diagnosis of the
acute periodontal lesion.
Periodontology 2000 2004;
34: 204−216.
14. Jenkins WMM, Brocklebank
LM, Winning SM et al. A
comparison of two
radiographic assessment
protocols for patients with
periodontal disease. Br Dent J
2005;
198: 565−569.