APPEARANCE OF ANATOMIC STRUCTURES ON PANORAMIC IMAGE

MAXILLARY LANDMARKS

ARTICULAR TUBERCLE OF THE TEMPORAL BONE ZYGOMA ZYGMOID PROCESS OF MAXILLA PTERIGOMAXILLARY FISSURE ORBITAL RIM HARD PALATE INFERIOR NASAL SPINE NASAL SEPTUM ANTERIOR NASAL SPINE

FLOOR OF THE MAXILLARY SINUS EAR LOBE CERVICAL VERTEBRAL BODY STYLOID PROCESS

MANDIBULAR LANDMARKS

MANDIBULAR CONDYLE NECK OF MANDIBULAR CONDYLE CORONOID PROCESS OF MANDIBLE INFERIOR ALVEOLAR CANAL INFERIOR BORDER OF MANDIBLE MENTAL FORAMEN SUBMANDIBULAR FOSSA MANDIBULAR ANGLE SIGMOID NOTCH EXTERNAL OBLIQUE RIDGE

NECK,SPINAL AND SOFT TISSUE

NASOPHARYNX OROPHARYNX SOFT PALATE AND UVULA POSTERIOR SURFACE IF THE TONGUE POSTERIOR PHARYNGEAL WALL HARD PALATE HYOID BONE

THE MANDIBLE

The clinician should be able to able to follow a cortical border around the entire bone, with the exception of the dental areas. This border should be smooth, without interruptions & should have symmetrical thicknesses in comparable anatomic areas. The trabeculation of the mandible tends to be more plentiful in the anterior regions, whereas the marrow comparment increases toward the angle and into the ramus However theses trabecular patternsand densities should be relatively symmetric.

The mandibular condyle is generally slightly anteroinferior to its normal closed positioned because the patient has to slightly open & protrude the mandible to engage the positioning of the device in most panoramic machines. The TMJ can be assessed for gross anatomic changes of the condylar head & the glenoid fossa. The soft tissue articular disc & posterior ligamentous attachment cannot be assessed. More definitive assessment of TMJ can be done by CBCT,MRI,CT.

Shadows of other structures superimposed on the mandible ramal area.

Pharyngeal airway shadow Posterior wall of the nasopharynx Cervical vertebrae Ear lobe & ear decorations Nasal cartilage and nasal decorations Soft palate and uvula Dorsum of the tongue and tongue decorations Ghost shadows of the opposite side of the mandible and metallic decorations

From the angle of the mandible,viewing should be continued anteriorly toward the symphyseal region The fracture often manifests as a discontinuity as the in the inferior border;a sharp change in the level of the occlusal plane indicates that the fracture passes through the tooth-bearing area, whereas a cant in the entire occlusal table without a step disformity in the occlusal plane indicates that the fracture is posterior to the tooth-bearing area. The width of the cortical bone at the inferior border of the mandible should be at least 3mm in adults and of uniform density

Asymmetry of size may result from improper patient positioning or conditions such as hemifacial hyperplasia or hypoplasia. The hyoid bone may be projected below or onto the inferior border of the mandible. Trabeculation is most evident within the alveolar process. The mandibular canals and mental foramina are usually clearly visualized in yhe ramus and body of the mandible. When only one border of the canal is seen,it is typically the inferior border. The canals usually rise to meet the mental

foramina, often looping several millimeters anterior of the mental foramina; this is termed the anterior loop of the mandibular canal, and its position and extent are considerations when planning dental implants in the mandibular canine regions. The mandible should be examined for radiolucencies or opacities. The midline is more opaque because of the mantal protuberance, increased trabecular numbers, and attenuation of the beam as it passes through the cervical spine Depressions on the lingual surfaces of the mandible ,which are occupied by submandibular and sublingual glands appear more radiolucent.

MIDFACIAL REGEION
The midface is a complex mixture of bones, air cavities & soft tissues, all of which appear on the panoramic images. Bones appearing on panoramic images are temporal, zygoma, mandible, frontal, maxilla, sphenoid, ethamoid, vomer, nasal, turbinate and palate. The maxilla can be compartmentalized into major sites of examination:

a. b. c. d. e. f. g.

Cortical boundary of maxilla. Pterygomaxillary fissure Maxillary sinus Zygomatic complex Nasal cavity and conchae TMJ Maxillary dentition and supporting alveolus.

The posterior border of the pterygomaxillary fissure is the pterygoid spine of the sphenoid bone. Pterygomaxillary fissure has an inverted teardrop appearance; it is inportant because

It is inportant because maxillary sinus mucoceles and carcinomas will destroy the posterior maxillary border , which is then menifested as loss of the anterior border of pterygomaxillary fissure. Lefort fractures of the maxilla by defination involve the pterygoid plates, and this will often inittially diagnosed by disturbances of integrity of the pterygomaxillary fissure on the panoramic image. Maxillary sinuses are usually well visualized on panoramic image. The mesial border of the maxillary sinus is not demonstrated on the panoramic image.

The superior border of the maxillary sinus is demonstrated on the panoramic image. The posterior aspect of the sinus is more opaque because of superimposition of zygoma. Zygomatic complex or butteress is a very complex anatomic area with contributions from zygomatic, frontal, maxillary bones. maxillary sinus can pneumatize the zygomatic processs of maxilla upto zygomaticomaxillary suture. This can result in appearance of the elliptical, corticated radiolucency in maxillary sinus, possibly superimposed over the roots of the molar tooth, on a panoramic image.

The Zygomaticotemporal suture lies in the middle of the zygomatic arch and may stimulate a fracture if visualized on image. The mastoid cells will pneumatize the temporal bone all the way to zygomaticotemporal suture , giving the glenoid fossa of the TMJ multilocular appearance or soap-bubbly radiolucency.

THE SOFT TISSUE

A number of opaque soft tissue structures may be identified on panoramic radiographs, including the tongue arching across the film under the hard palate,lip markings,the soft palate extending posteriorly from the hard palate over each ramus, nose, ear lobes. Nasal fossa, nasopharynx, oral cavity and oropharynx superimpose radiolucent shadows. The epiglottis and thyroid cartilage are often seen in panoramic images.

DENTITION
Panoramic image is a demonstration of the complete dentition. It is particularly important to closely examine the impacted third molar,there relationship to critical anatomic structures mandibular canal, floor and posterior wall of maxillary sinus, the maxillary tuberosity,pericoronal and periradicular bone.