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L12 PR1

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6 min read

Radiologic Interpretation Panoramic Radiograph Part 11

Radiologic Interpretation - Panoramic Radiograph Part 1.

Dr Dayea Oh OMF Radiologist

Learning Objectives2

  • Revise Panoramic radiographic anatomy and artefacts
  • Review indications for panoramic imaging / OPG
  • Understand basic interpretation skills
    • Radiographic features of dento-alveolar findings
    • Use appropriate radiology terminology
  • Follow systematic approach

Radiographic Anatomy and Interpretation Principles

Anatomical Landmarks of the Maxilla34

Note the double image of palate, hyoid & spine

  1. Pterygomaxillary fissure
  2. Posterior border of maxilla
  3. Maxillary tuberosity
  4. Maxillary sinus
  5. Floor of the maxillary sinus
  6. Medial border of maxillary sinus/lateral border of the nasal cavity
  7. Floor of the orbit
  8. Infraorbital canal
  9. Nasal cavity
  10. Nasal septum
  11. Floor of the nasal cavity
  12. Anterior nasal spine
  13. Incisive foramen
  14. Hard palate/floor of the nasal cavity
  15. Zygomatic process of the maxilla
  16. Zygomatic arch
  17. Articular eminence
  18. External auditory meatus
  19. Styloid process
  20. Mandibular condyle
  21. Sigmoid notch
  22. Coronoid process
  23. Posterior border of ramus
  24. Angle of mandible
  25. Hyoid bone
  26. Inferior border of mandible
  27. Mental foramen
  28. Mandibular canal
  29. Cervical vertebrae
  30. Epiglottis

Atlas of Oral and Maxillofacial Radiology BERNARD KOZUNG WILEY Blackwell

Anatomy Revision

General Indications for Panoramic Radiography5

General dental screening? OPGs are NOT accurate for caries assessment.

  • Heavily compromised dentition - gross caries, multiple periapical inflammatory lesions
  • Periodontal screening (periodontal bone loss)
  • Impacted third molars
  • Mixed dentition status
  • Orthodontics
    • Crowding, impacted canines, etc.
  • Dental anomalies
  • Jaw (intrabony) Pathology
  • TM Joints (gross morphological change)
  • Trauma (esp. mandibular fracture)

Medicolegal Responsibilities and Reporting6

  1. Radiation dosages with CBVT and panoramic film must be explained
  2. There is an increased duty to explain dosages and risks of radiographs on dentist’s own premises
  3. Dentists who record panoramic radiographs need to take responsibility for all non-dental diagnosis or have them assessed by or referred to a DMF radiologist or radiologist
  4. Dentists who record small volume CBVT need to assess whether a referral to a DMF radiologist/radiologist is appropriate
  5. Dentists who record large volume CBVT need to refer all data sets to DMF radiologists/radiologists for review, as they have the highest medicolegal risk
  6. There needs to be thorough discussion of dosage of CBVT for paediatric patients
  7. If the dentist has a CBVT on-site, it is not advisable to expose paediatric patients to CBVT
  8. Dentist “self-reports” must be held to a similar standard as a specialist report

Radiology Report Statistics7

  • All dental images MUST have radiology reports
  • ~ 40% of dental imaging is self-reported by dentists
    • 1.5% unreported
    • ~40% reported by medical radiologists
    • ~20% are reported by DMF radiologists

Ref: Selim, DG, C. Sexton, and P. Monsour. “Dentomaxillofacial Radiology in Australia and Dentist Satisfaction with Radiology Reports.” Australian Dental Journal 63, no. 4 (2018): 402-13.

Referral Pathways for Radiology Reports8

  1. Request scan & report to an imaging clinic (Medicare Rebate)
    • Patient details
    • Referrer details
    • Select imaging modality (e.g., OPG / Occlusograph / CT / …)
    • Write reasons for referral (i.e., clinical indications / history)
  2. Report only (Private)
    • Teleradiology (online referral with enclosed image)

Key Points of Interpretation9

  • Review the initial indication for OPG
  • Identify OPG artefacts
  • Must know normal radiographic anatomy of maxillofacial region
    • So, abnormal changes to normal anatomy can be identified
  • Study radiographic features of various jaw pathologies
  • Systematic approach
    • Have a routine

Panoramic Radiograph Artefacts10

  • Foreign materials (e.g., earrings, necklace, denture left in situ, etc.)
  • Ghost images
  • Incorrect patient positioning
    • Chin down
    • Chin up
    • Head tilting
    • Head rotation
    • Movement
      • Horizontal (following the beam or opposite to the beam direction)
      • Vertical
  • Swallowing
  • Soft tissue position
    • Tongue to the palate
    • Lips closed
  • Focal trough position
    • Head in front of the focal trough
    • Head behind the focal trough
  • Neck extension
  • Collision with shoulder

Systematic Approach to Interpretation11

  1. Any Technical or Positional Error?
  2. Address Clinical Concerns
  3. Dentoalveolar
    • Count teeth & identify ectopic and/or impacted teeth
    • Dental Anomalies (Position, Shape,…)
    • Periodontal bone loss
    • Dental pathology (non-caries tooth loss, caries, fracture, periapical pathologies, etc.)
  4. Maxilla and Mandible
    • Abnormal (radio)lucencies
    • Abnormal (radio)opacities
    • Altered trabecular pattern
    • Fractures
    • Jaw Asymmetry
  5. Maxillary sinuses (esp. mucosal changes)
  6. TM Joints (esp. morphological change of condyles)
  7. Soft Tissues (swelling, soft tissue calcifications e.g., tonsiloliths, salivary gland stones, etc.)
  8. Other sites: Spine, orbits, etc. (structural changes)

Clinical Case Studies12

OPG CASES

Case 1 Heavily Compromised Dentition131415

Case 1.

Reason for Scan: Heavily compromised dentition

  1. Count teeth including root remnants
  2. Identify impacted teeth – give brief description
  3. Periodontal bone loss
  4. Existing restoration
  5. Caries
  6. Existing endodontic therapy
  7. Inflammatory lesions

Relationship with adjacent vital structures eg. Maxillary Sinuses and Mandibular Canals

Case 1. Reason for Scan: Heavily compromised dentitionCase 2. Periodontal Disease

OTHER FINDINGS - Systematic Approach16

Case 2 Periodontal and Peri-Implant Bone Loss171819

Case 2 Main Focus: Periodontal Bone Loss

  1. Count teeth
  2. Count implants
  3. Peri-implant bone loss
  4. Periodontal bone loss
  5. Existing restoration
  6. Caries
  7. Existing endodontic therapy
  8. Inflammatory lesions
    • Relationship with adjacent vital structures eg. Maxillary Sinuses and Mandibular Canals
Periodontal Disease #Case 3. Impacted third molars & incidental finding of a supernumerary tooth

OTHER FINDINGS - Systematic Approach20

Case 3 Impacted Third Molars and Supernumerary Teeth21222324

Third molar impaction – Winter’s Classification

Case 3 Main Focus: Impacted Third Molars

  1. Count teeth including supernumerary
  2. Describe the supernumerary tooth
  3. Describe the impacted teeth
  4. Periodontal bone loss
  5. Existing restoration
  6. Caries
  7. Existing endodontic therapy
  8. Inflammatory lesions
    • Relationship with adjacent vital structures eg. Maxillary Sinuses and Mandibular Canals
VERTICAL MESIOANGULAR HORIZONTAL DISTOANGULAR INVERTED
Impacted third molars #Episodic Pain from Mandibular Third Molars

OTHER FINDINGS - Systematic Approach25

Case 4 Mixed Dentition and Development262728

Case 4.

Case 4 Main Focus: Mixed Dentition

  1. Count teeth
  2. Check permanent teeth development and position
  3. Is the dentition appropriate for age?
  4. Crowding and rotated teeth
  5. Check Dental Anomalies
  6. Periodontal bone loss
  7. Existing restoration
  8. Caries
  9. Inflammatory lesions
    • Relationship with adjacent vital structures eg. Maxillary Sinuses and Mandibular Canals
Mixed dentition – Permanent Teeth Development and PositionMixed dentition #2 – Permanent Teeth Development and Position
Mixed dentition #3 - Permanent Teeth Development and PositionMixed dentition #4 – Permanent Teeth Development and Position

OTHER FINDINGS - Systematic Approach29

Case 5 Submerged Deciduous Molars

Mixed dentition #5 – Submerged Deciduous Molars + Permanent Teeth Development and Position

Footnotes

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