Radiologic Interpretation - Panoramic Radiograph Part 1. Dr Dayea Oh OMF Radiologist Radiologic Interpretation - Panoramic Radiograph Part 1. Dr Dayea Oh OMF Radiologist # Learning objectives - 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 - 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 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   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 Clinical radiograph (orthopantomogram) showing the maxilla and mandible with teeth. The image displays dental anatomy including the upper and lower arches of teeth, alveolar bone, and surrounding structures such as the maxillary sinuses and mandibular canal. Detailed anatomical diagram of the facial skeleton with numbered callouts pointing to specific landmarks. Labels include: Pterygomaxillary fissure, Posterior border of maxilla, Maxillary tuberosity, Maxillary sinus, Floor of the maxillary sinus, Medial border of maxillary sinus/lateral border of nasal cavity, Floor of orbit, Infraorbital canal, Nasal cavity, Nasal septum, Floor of nasal cavity, Anterior nasal spine, Incisive foramen, Hard palate/floor of nasal cavity, Zygomatic process of maxilla, Zygomatic arch, Articular eminence, External auditory meatus, Styloid process, Mandibular condyle, Sigmoid notch, Coronoid process, Posterior border of ramus, Angle of mandible, Inferior border of mandible, Mental foramen, Mandibular canal, Cervical vertebrae, Epiglottis, Hyoid bone, and Posterior border of ramus. </img> Atlas of Oral and Maxillofacial Radiology BERNARD KOZUNG WILEY Blackwell  Atlas of Oral and Maxillofacial Radiology BERNARD KOZUNG WILEY Blackwell A composite figure containing two labeled radiographic images of the skull and mandible used for anatomy revision. The left panel displays a panoramic radiograph with red leader lines pointing to anatomical landmarks including the external auditory meatus, zygomatic arch, nasal septum, hard palate, and mandibular symphysis. The right panel shows a lateral cephalometric view or similar projection, labeling structures such as the inferior aspect of the orbit, maxillary sinus walls, mandibular condylar head, mandibular canal, and ghost image of the contralateral body. Both images serve to demonstrate and identify specific osseous and soft tissue features in oral and maxillofacial radiology. **General Indications for OPG** "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) 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 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 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 # OPG Radiology Report * 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. - 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. Radiology Report Referral Pathways 1. Request scan & report to an **imaging clinic** (Medicare Rebate) a) Patient details b) Referrer details c) Select imaging modality (eg. OPG / Occlusograph / CT / ...) d) Write reasons for referral (ie clinical indications / history) 2. Report only (Private) a) Teleradiology (online referral with enclosed image) 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 OPG Interpretation - 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 - 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 # OPG artefacts revision - Foreign materials eg. 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 - 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 00. Any Technical or Positional Error? 1. **Address Clinical Concerns** 2. **Dentoalveolar** a) Count teeth & identify ectopic and/or impacted teeth b) Dental Anomalies (Position, Shape,…) c) Periodontal bone loss d) Dental pathology (non-caries tooth loss, caries, fracture, periapical pathologies, etc.) 3. **Maxilla and Mandible** a) Abnormal (radio)lucencies b) Abnormal (radio)opacities c) Altered trabecular pattern d) Fractures e) Jaw Asymmetry 4. Maxillary sinuses (esp. mucosal changes) 5. TM Joints (esp. morphological change of condyles) 6. Soft Tissues (swelling, soft tissue calcifications eg. Tonsiloliths, salivary gland stones, etc.) 7. Other sites: Spine, orbits, etc. (structural changes) 0. Any Technical or Positional Error? 1. **Address Clinical Concerns** 2. **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.) 3. **Maxilla and Mandible** - Abnormal (radio)lucencies - Abnormal (radio)opacities - Altered trabecular pattern - Fractures - Jaw Asymmetry 4. Maxillary sinuses (esp. mucosal changes) 5. TM Joints (esp. morphological change of condyles) 6. Soft Tissues (swelling, soft tissue calcifications e.g., tonsiloliths, salivary gland stones, etc.) 7. Other sites: Spine, orbits, etc. (structural changes) OPG CASES OPG CASES Case 1. Reason for Scan: Heavily compromised dentition  Case 1. Reason for Scan: Heavily compromised dentition A panoramic dental radiograph (orthopantomogram) showing the maxilla and mandible. The image reveals a heavily compromised dentition with multiple missing teeth, particularly in the posterior regions of both arches. Visible pathology includes severe periodontal bone loss, indicated by significant reduction in alveolar bone height around remaining teeth. Several teeth exhibit periapical radiolucencies suggestive of endodontic involvement or abscesses. There is also evidence of tooth mobility and potential root fractures. The caption 'Case 1' and 'Reason for Scan: Heavily compromised dentition' are displayed at the top of the image. **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 OTHER FINDINGS - Systematic Approach  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 #### OTHER FINDINGS - Systematic Approach Dental radiograph (panoramic X-ray) showing the maxilla and mandible. The image displays a full view of the upper and lower jaws with visible teeth, alveolar bone structures, and anatomical landmarks such as the maxillary sinuses and mandibular canals. A white 'L' marker is present in the bottom right corner indicating the left side.  Dental radiograph showing a full-mouth view of the mandible and maxilla with multiple dental implants and restorations. The image is labeled 'Case 2' in the top left corner and 'Periodontal Disease' at the top center. Visible structures include two dental implants in the upper right quadrant, one implant in the lower left quadrant, and various crowns/bridges. Bone density appears reduced around some areas consistent with periodontal disease as indicated by the caption. **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 OTHER FINDINGS - Systematic Approach  **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 #### OTHER FINDINGS - Systematic Approach Clinical radiograph (panoramic X-ray) of the maxillofacial region. The image shows the mandible and maxilla with multiple dental implants visible in the posterior regions. There is evidence of periodontal bone loss around natural teeth and peri-implant bone loss around the implant fixtures. Existing restorations and endodontic therapy are also present.  Clinical radiograph (panoramic X-ray) of the maxillofacial region showing both upper and lower dental arches. The image demonstrates generalized periodontal bone loss affecting multiple teeth, consistent with the caption 'Periodontal Disease #2'. Visible anatomical structures include the mandible, maxilla, temporomandibular joints, and nasal cavity.  Clinical radiograph (panoramic X-ray) displaying the maxilla and mandible with impacted third molars and an incidental supernumerary tooth. Third molar impaction – Winter's Classification   Third molar impaction – Winter's Classification Circular chart illustrating Winter's Classification for third molar impaction. The diagram features a central point representing the second molar and concentric circles indicating angles of inclination (labeled -10, 10, 80, 100, 180). Different tooth orientations are shown within sectors labeled 'VERTICAL', 'MESIOANGULAR', 'DISTOANGULAR', 'HORIZONTAL', 'OTHER', and numerical degree markers. Composite figure containing five separate radiographic illustrations demonstrating different types of third molar impaction: Vertical, Mesioangular, Horizontal, Distoangular, and Inverted. Each panel shows the relative position of the impacted third molar to the adjacent second molar in cross-section view. **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 **OTHER FINDINGS - Systematic Approach**  **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 #### OTHER FINDINGS - Systematic Approach Panoramic dental radiograph (X-ray) displaying the full dentition. The image is pertinent to the text's focus on 'Impacted Third Molars' and finding 'supernumerary teeth'. Visually, the mandibular third molars are impacted in a mesioangular position. A supernumerary tooth is visible in the anterior maxilla, located superior to the central incisors. The radiograph allows for assessment of periodontal bone levels, existing restorations, caries, and endodontic therapy as listed in the slide's checklist.  Clinical radiograph (panoramic X-ray) of the maxillofacial region. The image displays the mandible and maxilla with all permanent teeth visible. Pertinent findings include impacted third molars in both the upper and lower posterior regions, as indicated by the caption.  Clinical panoramic radiograph (orthopantomogram) showing the full dentition and maxillofacial structures. The image demonstrates the mandibular third molars bilaterally. A prominent radiolucent area is visible in the left posterior mandible, consistent with pathology associated with the mandibular third molar region, correlating with the provided caption regarding episodic pain. Case 4.  Case 4. Clinical radiograph (panoramic X-ray) showing a patient's mixed dentition stage. The image captures the full dental arches including developing permanent teeth beneath primary teeth, mandibular condyles, and cervical spine structures. 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 OTHER FINDINGS - Systematic Approach <pubmega-octets-vector-3-embedding/>  **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 #### OTHER FINDINGS - Systematic Approach Panoramic dental radiograph (OPG) showing a mixed dentition stage. The image displays both primary and permanent teeth in the maxilla and mandible. Visible anatomical structures include the maxillary sinuses, mandibular canals, and cervical vertebrae. A 'L' marker is present on the right side of the image indicating the left side of the patient.  Clinical panoramic radiograph (OPG) showing a mixed dentition stage. The image displays both primary teeth and developing permanent teeth. Visible structures include the mandible, maxilla, temporomandibular joints, and cervical spine. Permanent tooth buds are visible in various stages of development within the alveolar bone.  Clinical panoramic radiograph (X-ray) showing the maxillary and mandibular arches in mixed dentition. The image captures permanent teeth developing beneath primary teeth, with visible root formation of erupting molars and incisors.  Radiograph showing mixed dentition stage with developing permanent teeth visible beneath primary teeth. The image includes the mandible, maxilla, cervical spine, and temporomandibular joints. A label 'R' is present in the bottom left corner indicating the right side of the patient. **Mixed dentition #5 – Submerged Deciduous Molars + Permanent Teeth Development and Position**  Clinical panoramic radiograph showing the maxillofacial skeleton and dentition. The image displays a mixed dentition stage with both primary (deciduous) and permanent teeth present. Key findings include submerged deciduous molars where the crowns are covered by overlying bone or gingiva, preventing eruption of the underlying permanent successors. The permanent teeth show varying stages of development, with some roots formed and others still in early stages. The caption provides context for the developmental stage and specific pathological or physiological conditions observed. Part 1 **END**  A close-up photograph of a chessboard with several wooden chess pieces. The image is split visually: the left side features a dark overlay containing the text 'Part 1 END', while the right side shows a focused view of chess pieces (pawns and rooks) on the board against a blurred background. [^1]: Original PDF page 1: [[L12 PR1.pdf#page=1|L12 PR1, p.1]] [^2]: Original PDF page 2: [[L12 PR1.pdf#page=2|L12 PR1, p.2]] [^3]: Original PDF page 3: [[L12 PR1.pdf#page=3|L12 PR1, p.3]] [^4]: Original PDF page 4: [[L12 PR1.pdf#page=4|L12 PR1, p.4]] [^5]: Original PDF page 5: [[L12 PR1.pdf#page=5|L12 PR1, p.5]] [^6]: Original PDF page 6: [[L12 PR1.pdf#page=6|L12 PR1, p.6]] [^7]: Original PDF page 7: [[L12 PR1.pdf#page=7|L12 PR1, p.7]] [^8]: Original PDF page 8: [[L12 PR1.pdf#page=8|L12 PR1, p.8]] [^9]: Original PDF page 9: [[L12 PR1.pdf#page=9|L12 PR1, p.9]] [^10]: Original PDF page 10: [[L12 PR1.pdf#page=10|L12 PR1, p.10]] [^11]: Original PDF page 11: [[L12 PR1.pdf#page=11|L12 PR1, p.11]] [^12]: Original PDF page 12: [[L12 PR1.pdf#page=12|L12 PR1, p.12]] [^13]: Original PDF page 13: [[L12 PR1.pdf#page=13|L12 PR1, p.13]] [^14]: Original PDF page 14: [[L12 PR1.pdf#page=14|L12 PR1, p.14]] [^15]: Original PDF page 15: [[L12 PR1.pdf#page=15|L12 PR1, p.15]] [^16]: Original PDF page 16: [[L12 PR1.pdf#page=16|L12 PR1, p.16]] [^17]: Original PDF page 17: [[L12 PR1.pdf#page=17|L12 PR1, p.17]] [^18]: Original PDF page 18: [[L12 PR1.pdf#page=18|L12 PR1, p.18]] [^19]: Original PDF page 19: [[L12 PR1.pdf#page=19|L12 PR1, p.19]] [^20]: Original PDF page 20: [[L12 PR1.pdf#page=20|L12 PR1, p.20]] [^21]: Original PDF page 21: [[L12 PR1.pdf#page=21|L12 PR1, p.21]] [^22]: Original PDF page 22: [[L12 PR1.pdf#page=22|L12 PR1, p.22]] [^23]: Original PDF page 23: [[L12 PR1.pdf#page=23|L12 PR1, p.23]] [^24]: Original PDF page 24: [[L12 PR1.pdf#page=24|L12 PR1, p.24]] [^25]: Original PDF page 25: [[L12 PR1.pdf#page=25|L12 PR1, p.25]] [^26]: Original PDF page 26: [[L12 PR1.pdf#page=26|L12 PR1, p.26]] [^27]: Original PDF page 27: [[L12 PR1.pdf#page=27|L12 PR1, p.27]] [^28]: Original PDF page 28: [[L12 PR1.pdf#page=28|L12 PR1, p.28]] [^29]: Original PDF page 29: [[L12 PR1.pdf#page=29|L12 PR1, p.29]]