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Formation of Ghost Images Due to Metal Objects on the Surface of the Patient’S Face: a Pictorial Essay

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Formation of Ghost Images Due to Metal Objects on the Surface of the Patient’S Face: a Pictorial Essay Imaging Science in Dentistry 2016; 46: 63-8 http://dx.doi.org/10.5624/isd.2016.46.1.63 Formation of ghost images due to metal objects on the surface of the patient’s face: A pictorial essay Bárbara Couto Ramos1, Bruna Raquel da Silva Izar1, Jéssica Lourdes Costa Pereira1, Priscilla Sena Souza1, Claudia Scigliano Valerio1, Fabrício Mesquita Tuji2, Flávio Ricardo Manzi1,* 1Department of Oral Radiology, School of Dentistry, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil 2Department of Oral Radiology, School of Dentistry, Federal University of Pará, Belém do Pará, Brazil ABSTRACT Panoramic radiographs are a relatively simple technique that is commonly used in all dental specialties. In panoramic radiographs, in addition to the formation of real images of metal objects, ghost images may also form, and these ghost images can hinder an accurate diagnosis and interfere with the accuracy of radiology reports. Dentists must understand the formation of these images in order to avoid making incorrect radiographic diagnoses. Therefore, the present study sought to present a study of the formation of panoramic radiograph ghost images caused by metal objects in the head and neck region of a dry skull, as well as to report a clinical case in order to warn dentists about ghost images and to raise awareness thereof. An understanding of the principles of the formation of ghost images in panoramic radiographs helps prevent incorrect diagnoses. (Imaging Sci Dent 2016; 46: 63-8) KEY WORDS: Panoramic Radiography; X-ray diagnosis; X-ray image; Body Piercing may be advantageous because they involve a reduced Introduction radiation dosage, cost less, and allow a larger area to be Radiographs are an important method of diagnosing imaged. Thus, although these issues have been addressed and monitoring oral diseases, dentofacial development, in prior studies, it is important that dentists understand and the progress or prognosis of therapy.1 Panoramic ra- the mechanisms associated with the formation of real and diography is recommended for patients in several age ghost images in panoramic radiographs. ranges: children with transitional dentition (after eruption The panoramic radiograph technique is based on the of the first permanent tooth); adolescents with permanent principle of computed tomography, since both techniques dentition (prior to the eruption of the third molars); and involve synchronized rotation between an X-ray source adults who are dentate or partially edentulous. Panoramic and an image receptor around the patient’s head that re- radiographs are also recommended in new patients being mains stationary.2 This is a radiological technique that is evaluated for oral diseases and in patients undergoing fol- relatively simple and is commonly used in all dental spe- low-up, based on clinical signs, symptoms, and treatment cialties,3,4 since patients have shown a good tolerance to plans.1 Intraoral radiographs are more accurate than pan- this technique, it is fast and comfortable, and, most impor- oramic radiographs; however, panoramic examinations tantly, it includes the entire maxillomandibular structure (dental arches, temporomandibular joint, and associated 4-6 *This project was supported by the Foundation for Research Support of the State structures) in a single film. It is used in a broad range of Minas Gerais (Fundação de Amparo a Pesquisa do Estado de Minas Gerais - FAPEMIG), and the CAPES Foundation. of clinical settings, including the evaluation of deciduous Received August 12, 2015; Revised November 23, 2015; Accepted December 2, 2015 and permanent teeth; orthodontic evaluations; the eval- *Correspondence to : Dr. Flávio Ricardo Manzi Department of Oral Radiology, School of Dentistry, Pontifical Catholic University of uation of bone lesions, erupted teeth, periodontal bone Minas Gerais. Av. Dom José Gaspar, 500 - Prédio 45, CEP: 30535-901, Belo Hori- supports, third molars, lesions in the maxillary sinus, and zonte, Minas Gerais, Brazil Tel) 55-31-33194341, Fax) 55-31-33194414, E-mail) [email protected] fractures of the mandible; and evaluations of foreign bod- Copyright ⓒ 2016 by Korean Academy of Oral and Maxillofacial Radiology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Imaging Science in Dentistry·pISSN 2233-7822 eISSN 2233-7830 - 63 - Formation of ghost images due to metal objects on the surface of the patient’s face: A pictorial essay ies and the loss of bone mineral density (osteopenia and New York, USA). The skull was positioned in the X-ray osteoporosis); among others.4,6-8 However, this technique device according to standard procedures, with its sagit- also presents certain disadvantages, such as the overlap of tal plane placed in the center of the zone of focus of the the images of certain anatomical structures, the amplifi- X-ray unit and perpendicular to the horizontal plane and cation and reduction of images (geometric distortion), and the Frankfurt plane parallel to the horizontal plane. Ac- the production of ghost images.3,5,6,9,10 cording to the bitewing of the device, the top teeth were Ghost images, or artifacts, are created by anatomical arranged to place the dental arches in the zone of focus or structures or objects that are located outside of the zone image layer. of focus or image layer but have a sufficient density to A round metal object was attached in various areas of attenuate the X-ray beams, in turn producing distorted the skull to assess the formation of real and ghost images radiographic images.2 Although panoramic radiographs (the region around tooth 46, the upper region of the ear, play a crucial role in diagnosis, these ghost images com- the anterior nasal spine, the nasal wing, the lateral pole of plicate the use of panoramic radiographs, since they may the temporomandibular joint, the region around tooth 18, closely resemble the lesions themselves, be confounded the mandibular angle, the earlobe, the hyoid bone, and the with dental structures in inappropriate locations, or mask dorsum of the tongue). One image was taken with no met- anomalies by obstructing the view of subjacent anatomi- al object, which was defined as the control radiograph. cal structures.4 The radiographs were taken using the following exposure Panoramic radiographs of a patient with earrings insert- factors: 60 kV, 2.0 mA, and 14.3 s of exposure. ed in his or her earlobe are one of the most common ex- The present study mapped the maxillomandibular areas amples of how ghost images of non-anatomic origin may according to the diagram proposed by Reuter et al.,11 who be formed.2 In such cases, one can observe images of the demonstrated the formation of one, two, or three similar earrings in the molar region, the coronoid process, the images after the strategic positioning of a metal object in mandibular notch, and/or the mandibular condyle, resem- different anatomic structures of the face. Reuter et al.11 bling an impacted tooth or a cyst, among other abnormali- referred to the zones where the test object was portrayed ties. It is therefore important to understand the appearance once as zone 1A and zone 1B, the zone where the test ob- of anatomical structures and their variations in panoramic ject was portrayed twice as zone 2, and the zone where radiographs,4 with the additional challenge of identifying the test object was portrayed three times as zone 3 (Fig. 1). structures that fall outside of the standards of normality in In the areas corresponding to zone 1A, which comprises order to make correct and coherent diagnoses. the anterior regions of the mandible and the maxilla, the Since many patients have piercings or other metal ob- jects in their facial region, and as these objects can im- pair the quality of the panoramic radiograph image and its interpretation, it is important to understand the errors and artifacts that accompany this radiological technique. Therefore, the aim of the present study was to present a ZONE 1A ZONE 1A study of the formation of ghost images in panoramic ra- diographs caused by metal objects in different regions of the skull, as well as to report a clinical case, in an attempt ZONE 3 ZONE 3 to aid dentists in understanding the mechanisms associ- ated with the formation of real and ghost images in pan- oramic radiographs. ZONE 2 ZONE 2 Materials and Methods ZONE 1B After having received approval for the present study from our institution’s Ethics Committee (CAE: 45441815. 4.0000.5137), we conducted this study using a macerated Fig. 1. The diagram shows zones 1A and 1B (formation of one im- adult skull placed in a Kodak 9000C three-dimensional age), zone 2 (formation of two images), and zone 3 (formation of panoramic device (Eastman Kodak Company, Rochester, three images). - 64 - Bárbara Couto Ramos et al Fig. 2. A panoramic radiograph with a metal sphere attached in the region where the right mandibular first molar is missing (zone 1A) shows a single real image of the metal sphere. formation of one single real image occurs. In zone 1B, tings of 57 kVp, 3.2 mA, and an exposure time of 17.6 s. which includes the most posterior portion of the zone of For the lateral cephalometric radiograph, the X-ray tube focus or image layer (i.e., the regions of the occipital bone was operated with settings of 80 kVp, 10 mA, and an ex- and the foramen magnum), the production of a single ghost posure time of 0.7 s. After radiographic exposure, all films image occurs. The mandibular ramus and angle, the man- were processed in a Macrotec MX-2 automatic processor dibular condyles, the hard palate, and the earlobes are (Macrotec, São Paulo, Brazil) with Picker RP type-S pro- located in the areas corresponding to zone 2, where two cessing chemistry (Eastman Kodak Company, Rochester, images are produced: one ghost image and one real image.
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