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Successful Panoramic Radiography

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Successful Panoramic Radiography Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants. Successful Panoramic Radiography A Peer-Reviewed Publication Edited by Dr. Robert A. Danforth d e nta l PennWell is an ADA CERP Recognized Provider CE digest Go Green, Go Online to take your course This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives signed by panoramic machine manufacturers as the ideal Upon completion of this course, the clinician will be able to do patient position to produce the optimum image. Distortion the following: of the image quality occurs when patients are not properly 1. Understand what constitutes a normal panoramic radio- positioned—such as if the chin is tipped up or down too graph and the anatomical structures that can be identified much, midline rotated off machine center, anterior teeth/ on panoramic radiographs jaws too far forward or back. These result in vertical and 2. Know the steps required to take a good panoramic horizontal magnification and distortion, superimposition of radiograph and how to avoid errors anatomical structures, and some structures being projected 3. Understand the methods by which digital panoramic out of the field of view. In such cases, the interpretation of radiographs are captured, stored, retrieved and printed the resultant image is severely compromised. 4. Understand how to detect possible carotid artery calcifica- tions on panoramic radiographs Figure 1. Focal trough — Abstract The panoramic radiograph continues to offer today’s dentist a unique patient view—covering the entire dentition and surrounding structures, the facial bones and condyles, and parts of the maxillary sinus and nasal complexes. The equip- ment used to obtain panoramic radiographs has continued to improve with recent advances, including automatic exposure and multiple image programs. However, achieving diagnostic panoramic images requires attention to the basic steps and correct patient positioning. This course will address the basic steps, problems, and errors that may occur when mistakes are made at any of these, allowing the practitioner to determine Figure 2 from the radiograph the point at which the error occurred in the image creation process. Once the error has been assessed, possible solutions to the problem are suggested. The result will be panoramic radiographs with the maximum diagnostic detail and information that the equipment and technique allow. The Normal Panoramic Radiograph Before discussing various errors that can occur, it is important to know what a normal panoramic radiograph should look like. In a good panoramic radiograph the mandible is “U” shaped, the condyles are positioned about equal distance from the inside 1 edges of the image and ⁄3 of the way down from the top edge of the image. The occlusal plane exhibits a slight curve or “smile line,” upwards. The roots of the maxillary and mandibular anterior teeth are readily visible with minimal distortion. Mag- nification is equal on both sides of the midline (Figures 1, 3). These mistakes can only be remedied by a retake of the image with the patient in the proper position. This requires an additional patient exposure, further emphasizing the reason for following the patient alignment instructions provided by the system’s manufacturer. Aside from radiation concern, the size of the focal trough/ image plane is critical for a successful image. Machines are designed so that the focal trough/image plane is adjustable for patient size and programmed exposure parameters to coincide with the adjustments. Older panoramic machine adjustments were more manual. Current machines are more automated. Preset icons represent- ing a range of large to small, or adult or child can be selected, automatically adjusting for arch width and focal trough/image Panoramic Theory plane size and the accompanying exposure factors. Many digi- Why is panoramic radiography inherently technique sensi- tal machines also have automatic exposure control that vary the tive? Panoramic radiography is a modified type of tomog- amount and energy of the X-rays during the actual exposure. raphy or image layer radiography. The patient’s dental arch Such automation facilitates imaging various size patients while must be positioned within a narrow zone of sharp focus reducing the potential of operator mistakes and assuring opti- known as the “focal trough”/imaging plane (Figure 2), de- mal patient dose. 2 www.ineedce.com Figure 3 16 33 17 22 12 20 18 3 19 13 21 14 24 11 25 1 15 4 2 23 31 35 30 5 8 9 32 6 29 28 34 26 7 1. Coronoid Process 12. Glenoid Fossa 23. Inferior Border of Max. Sinus 32. Oropharyngeal Air Space 2. Sigmoid Notch 13. Articular Eminence 24. Posterolateral Wall of Max. Sinus 33. Nasal Air Space 3. Mandibular Condyle 14. Zygomatic Arch 25. Malar Process 34. Mental Foramen 4. Condylar Neck 15. Pterygoid Plates 26. Hyoid Bone 35. Hard Palate 5. Mandibular Ramus 16. Pterygomaxillary Fissure 27. Cervical Vertebrae 1–4 6. Angle of Mandible 17. Orbit 28. Epiglottis 7. Inferior Border of Mandible 18. Inferior Orbital Rim 29. Soft Tissues of Neck 8. Lingula 19. Infraorbital Canal (Look Vertically For Carotid 9. Mandibular Canal 20. Nasal Septum Artery Calcifications Here) 10. Mastoid Process 21. Inferior Turbinate 30. Auricle 11. External Auditory Meatus 22. Medial Wall of Max. Sinus 31. Styloid Process Patient Positioning Most panoramic machines offer positioning guides such as lights or plastic guides to position the patient along three major axes: anterior-posterior (too far forward or back), vertically (alartragus, Frankfort plane, or cantho-meatal lines), and mid- sagittal alignment (patient twisted or rotated). Teeth and structures lying outside this zone of sharp focus will exhibit blurring, distortion or other artifacts. Therefore, all panoramic machines will have some mechanism for properly positioning the patient’s dentition within the focal trough. The trough on older systems can be as narrow as 3mm in width in the anterior region or as wide as 17mm on newer panoramic systems, therefore following the manufacturer’s guidelines for proper patient positioning is critical in obtaining a quality radiograph (Figure 4). As a general rule, the wider the anterior focal trough the easier it is to position the patient. Proper patient positioning in the focal layer/plane of the panoramic machine is critical for producing successful images. Manufacturers have built into their machines a variety of align- ment devices to help ensure the patient positioning process is easy and well visualized by the dental operator. Figures 5 and 6 show the typical alignment aids provided. The chin rest and the incisal guided bite-block assist position- ing the anterior teeth into the smallest region of the focal layer/ plane. Lateral/temporal or frontal skull head support bars fur- Figure 4. Positioning guides; note the bite rod, head guides, and aiming light www.ineedce.com 3 The following chart (Figure 8), plots resolution versus magnification for four X-ray tube focal spot sizes. The area of interest is between 120 percent and 160 percent in magnification, typical of most panoramic and tomographic machines. The curves show conclusively that a smaller focal spot and minimal magnification will decrease blurring or image fuzziness. Radiation Dosage Figure 5 Figure 6 Generally, intraoral digital radiography is touted as requir- ing 70 percent to 90 percent less radiation than that for tradi- ther assist posterior patient positioning and help to reduce head tional film radiography. Making such claims is not necessarily tilting and horizontal misalignment. Light beam reference lines valid. The key to understanding these reductions is knowing provide the final visualization for proper patient alignment. what is being compared. The 70 percent to 90 percent reduc- tions compare to Ultra speed “D” film, the slowest film used in Light Alignment dentistry today. If comparison is made to faster “F” film, such Light alignment has three components: mid-sagittal head and reductions are negated and the exposure is in a similar range for skull plane, Frankfort plane, and canine/corner base of nose digital radiography. reference line. Patient size influences the amount of radiation necessary to The mid-sagittal line is an imaginary plane centered produce a diagnostically useful radiographic image. Larger pa- over the midline of the head which divides the anatomy into tients require more radiation than smaller, meaning an increase equal right and left sections when directed between the eyes or decrease in both the X-ray energy (kVp) and the amount of along the midline of the nose and lips or between the maxil- X-ray as determined by either the milleamperage (mA) and/or lary central incisors, assuming the centrals are present and in exposure time. an acceptable clinical position. This helps to ensure that the Recent studies comparing the effective patient dose for patient’s midline will be centered in the machine and prevents digital to conventional panoramic radiography have reported such errors as midline horizontal shift or sideways tilting of varied results. Reported effective doses for digital are 4.7µSv the head.1 to 14.4, 5 µSv8,9 and 45µSv6. For conventional film panoramic The Frankfort plane line is used to position the patient’s radiography, effective values are 16–21 µSv2 and 54µSv.7 head tilt in the vertical plane. The Frankfort plane is an external Results from Visser and Gijbels are similar and indicate a head reference plane which projects an imaginary line between digital advantage ranging from a 13 percent to 77 percent the superior border of the external auditory meatus or upper reduction.8, 9 The actual dose values reported by Kiefer are portion of the tragus of the ear to the lower infraorbital rim of greater than for the other studies but the digital advantage the eye.
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