ISSN 0975-8437

INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(4):47-49

CASE REPORT
Panoramic radiograph a valuable diagnostic tool in dental practice-Report of three cases
Mathew Jose, Jomy Varghese

Abstract
Many pathologic conditions remain asymptomatic and observed only when they cause soft or hard
tissue expansion or is secondarily infected. Routine panoramic views very often reveal hidden lesions other than
those related to the patients chief complaint. The present case series reports three cases wherein pathologic
conditions remain undetected due to lack of appropriate radiographic evaluation even after multiple dental
procedures.
Key Words: Panoramic Radiographs; Dental; Diagnostic Yield
impacted
right
maxillary third molar
Introduction
radio
opacity and
in the right maxillary
was
Routine panoramic views very often revealradiolucency
sinus close to medial
hidden lesions other than those related to the patientsobserved apical to 25
wall
with
well
chief complaint. There have been sporadic case reportsand 26 pushing the
circumscribed
sinus
of such incidental discovery of lesions.(1-3) Many maxillary
radiolucency
pathologic conditions remain asymptomatic andsuperiorly.
surrounding the crown
observed only when they cause soft or hard tissue Horizontally Impacted
of the impacted tooth.
expansion or is secondarily infected. This delay in 18 was also observed
Lesion was enucleated
detection increases morbidity and mortality associated deep to the alveolar
along with removal of
Lesion
was
with the disease and treatment. It is prudent to evaluate crest.
the
tooth
and
enucleated
under
indicated cases with radiographs prior to dental
histopathology report
treatment
which
might
reveal
incidentalGeneral anesthesia and
confirmed
it
as
pathologies/findings helping to achieve early diagnosissubmerged 18 was also
dentigerous cyst.
and treatment. The present manuscript reports three removed.
Case 3
cases where pathologic conditions remain undetectedHistopathology
A 31 year
examination
of
the
even after multiple dental visits along with a discussion
female
patient
revealed
a
on the versatility of panoramic radiograph in screeninglesion
complex odontoma.
and early detection of many clinical problems.
presented
with
Case 2
abnormal mobility of
Case 1
A 33 year old
two lower teeth (36
A 44 year old female patient reported to our
and 37) on left side
center with a complaint of dull aching continuous pain female patient was
in the left side of face for last two years. She had two presented with pain
which was restored
decayed teeth in the left side of maxilla and underwent and swelling on the
five years back and had
root canal treatment in a dental clinic. As the pain right side of maxilla.
no
history
of
noticed
the
persisted she was referred to a maxillofacial surgeon forShe
extraction. Her left
the management of temporomandibular joint pain. TMJ swelling one month
third
molar
was
being found to be clinically normal she was referred to back
and
took
missing clinically.
a periodontist who ruled out any periodontal antibiotics as per her
involvement.
dentists advice. She
had one of her lower
tooth extracted 4 years
back, oral prophylaxis
was done two years
back and amalgam
filling on two teeth a
year back.
Clinical examination revealed fractured 25, 26
and mild obliteration of the upper buccal vestibule on
the left side. Panoramic radiograph was advised which
revealed endodontically treated 25, 26. Well
circumscribed lesion with mixed
Panoramic
radiograph
of
the
patient
revealed

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INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(4):47-49

can obscure the image

particularly in the
region.(6)
Panoramic radiograph was advised whichincisor
et
al
revealed a very extensive multilocular radiolucent Rushton
the
lesion extending from second premolar till suggested
clinical
condyle. Root resorption was noted on 35, 36 andfollowing
factors
as
being
the
37. The 38 was found close to the coronoid
process.
Incisional
biopsy
revealed
anbest predictors of a
diagnostic yield of
ameloblastoma of follicular type.
significance
to
Discussion
Clinical
Panoramic images are useful clinically fortreatment.
those patients requiring broad coverage of the jaws, suspicion of teeth with
such as evaluation of trauma, extensive dental or periapical pathology,
osseous disease, known or suspected large lesions,presence of partially
teeth,
location of third molars, evaluation of missingerupted
evident
teeth, teeth development and eruption status, clinically
retained tooth and root tips in edentulous patients,caries lesions swelling
clinically
maxillary sinus and temporomandibular jointand
suspected
unerupted
afflictions and developmental anomalies like
prognathism and retrognathism. Panoramicteeth.(7) Asaumi et al
imaging is often used as the initial evaluationobserved lesions in
12.8% among 1092
image that can provide the required insight and
patients
in
a
assist in determining need for other projections.
retrospective study in
One of the strengths of the panoramic
pediatric population
image is the demonstration of the completeand among this 47.1
dentition
and
allows
diagnosing
gross%
had
different
abnormalities in number, position and anatomy of lesions from those
the teeth. Panoramic radiographs reveal theunderlying the chief
proximity of impacted teeth with vital structures complaint.(1)
like inferior alveolar canal, floor and posterior wall Panoramic
of maxillary sinus, maxillary tuberosity and radiographs are a
adjacent teeth. Above all patients readilyvaluable tool in early
understand the image and are useful visual aid in identification
of
patient education.
problems in dental
In all three cases patients have visiteddevelopment during
dental clinics for various dental problems and takenthe mixed dentition
routine dental treatments like oral prophylaxis,stage. This gives
restorations, root canal treatments and extractions.information regarding
Number of visits ranged from three to more than dental
maturity,
ten. None of the cases was evaluated with leeway space, the
panoramic radiographs even in those patients with eruption of permanent
missing wisdom teeth and over retained deciduous teeth, anomalies and
teeth.
developmental
Panoramic radiographs cover a broad areadisturbances.(8)
of facial bones and teeth with low radiation dose.
Panoramic
(4) Relative exposures dose from panoramicradiographs are used
radiography has been estimated at 6.7 microSv andin assessment of root
26microSv carrying an associated risk of inducinglength and tooth axis
fatal cancer of 0.21 and 1.9 cases per million prior to orthodontic
examinations respectively.(5)
treatment. It has been
The main disadvantage of panoramicobserved that the
radiology is that the images does not display the mean length measured
fine anatomic details and so it cannot replace were higher than the
periapical radiograph or bite wing radiography in actual length by 22%
detecting small carious lesions or early periodontal for maxillary teeth
and periapical lesions. Other problems includeand 1% by mandibular
unequal magnification and geometric distortionteeth.(9) There is a
across the image. The presence of cervical spine chance of overlooking
significant
dental
abnormalities in the
premaxillary area in a

panoramic radiograph
even
though
the
chance is 43%.(10)
Panoramic
radiographs are used
in
forensic
age
estimation
of
unaccompanied
minors, but this should
be combined with
hand and collar bone
radiographs for better
accuracy.(11) Mucosal
thickening
and
mucosal antral cysts in
the maxillary sinus are
very
frequent
incidental finding in
panoramic
radiographs,
dental
infections are highly
correlated with antral
mucosal thickening.
(12)
Panoramic
radiographs
reveal
calcified carotid artery
atheromatous lesions
in diabetic patients
and help the dentist
for appropriate referral
for diabetic care.(13)
Alteration
of
mandibular
inferior
cortical width and
shape in panoramic
radiographs in postmenopausal women is
an accepted predictor
of spinal osteoporosis.
(14)
A
reliable
diagnostic accuracy in
panoramic
radiographs
is
observed
in
preoperative
evaluation of the
relationship between
third molars and the
inferior alveolar canal.
(15)
Careful
observation
of
panoramic
radiographs
could
reveal
temporomandibular
joint pathologies like
aneurismal bone cyst,
traumatic bone cyst,
and
synovial
chondramatosis and
TMJ arthrosis.(16)
Conclusion

Panoramic radiographs are indeed a involved

in
the
valuable tool in early detection of lesions in the panoramic
maxillofacial area. Considering the radiation dose radiograph, and its

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diagnostic
yield,
routine examination
by panoramic

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INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(4):47-49

10. Mattick
radiograph on the initial clinical visit may be useful
in early detection of various pathologic conditions.
Authors Affiliations: 1. Dr. Mathew Jose, Professor and
Head, 2. Dr. Jomy Varghese, Senior Lecturer, Dept. of
OMFS, Sree Mookambika Institute of Dental Sciences,
Kulasekharam, Kanyakumari Dist, Kerala, India.
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Address for
Correspondence
D
r
.
M
a
t
h
e
w
J
o
s
e
,
M
D
S
,
P
r
o
f
e
s
s
o
r
a
n
d
H
e
a
d
,
D
e
p
t
.
o

f OMFS,
Sree Mookambika Institute of Dental Sciences,
Kulasekharam,
Kanyakumari Dist.
Email: matjosein@yahoo.co.uk

Source of Support: Nil, Conflict of Interest:

None Declared

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