Panoramic Technique Errors K. Hock, RDH, MAdEd DHY 202 Clinical Radiology I Dental Hygiene Department William Rainey Harper College

Introduction It is important to look at other anatomical features besides the teeth when assessing diagnostic quality of a panoramic radiograph.

Assessing The Diagnostic Quality of Panoramic Radiographs Divide the panoramic radiograph into six zones: three are in the midline and three are bilateral Zone 2 Zone 4 Zone1 Zone 5 Zone 6 Zone 3

Technique Errors Client Client Positioning Preparation Film Handling Operational Exposure

Client Positioning Errors Antero- posterior Horizontal/ Midsaggital Vertical/ Occlusal Cervical Spine

Client Preparation Errors Objects Unsharpness Air Space Artifacts

Exposure Errors Under Exposed Over Exposed Double Exposure

Operational Errors Incomplete Exposure Cassette Resistance Not Starting at Home Base

Film Handling & Processing Errors Static Electricity Debris/ Scratched Screens White Light Exposure Film Crimping

Technique Errors Client Client Positioning Preparation Film Handling Operational Exposure

Client Positioning Errors Antero- posterior Horizontal/ Midsaggital Vertical/ Occlusal Cervical Spine

Client Positioning Errors Antero- posterior Client too far forward Client too far back

Client Too Far Forward b.Client positioned too far back Image: · Zone 1- Dentition: Anterior teeth widened; may appear blurred; “pudgy-posterior” · Zone 2- Nose-Sinus: Soft tissue image of nose cartilage is seen. The lower turbinate and meati are spread out across the maxillary sinus bilaterally. · Zone 3- Mandibular Body: Inferior border of mandible should be smooth and continuous. No image of the hyoid. · Zone 4- Condyles: Appear close to or off the lateral edges of the film. Soft tissue outline of cartilage of pinna of ear and earlobe can be seen. · Zone 5- Ramus-Spine: Ghost images of the contralateral rami are superimposed on the posterior molars and rami symmetrically bilaterally. · Overall: Client’s image appears to large for the film; excessive ghosting of each ramus and the spine. Correction: · Move head forward toward the film · Teeth should be end-to-end in bite groove

Client Too Far Forward PANORAMIC TECHNIQUE ERRORS · CLIENT POSITIONING 1.Anteroposterior head plane errors a. Client positioned too far forward Image: · Zone 1- Dentition: Anterior teeth narrowed; may appear fractured; “anorexic-anterior” · Zone 5- Ramus-Spine: Cervical spine superimposed on ramus & condyles symmetrically on both sides · Overall: Whole client appears narrowed; may be severe overlapping of teeth and spine may be superimposed over the ramus area. Correction: · Move head back toward xray source · Teeth should be end-to-end in bite groove

Client Too Far Forward

Client Too Far Back

Client Too Far Back 2. Horizontal or midsagittal head plane errors a. Client head is twisted, turned or rotated in machine Image: · Zone 1- Dentition: Posterior teeth on one side are widened and overlap interproximally. On the other side the teeth are narrowed. · Zone 2- Nose-Sinus: On the side with the side ramus, the inferior turbinate and meati are spread-out across the maxillary sinus; the opposite maxillary sinus may have an improved image. · Zone 4- TMJ: On the side with the wide ramus, the earlobe can be seen. · Zone 5- Ramus-Spine: On the side with the wide posterior teeth, the ramus is widened; on the other side, the ramus is narrowed and intersected by the ghost image of the contralateral ramus-the spine may approach or superimpose on the ramus on this side. · Overall: Side rotated toward film is narrowed while side toward xray source is widened and overlapped. Correction: · Center midsaggital plane and align it perpendicular to the floor · Remind client to close eyes or focus on floor during beam rotation

Client Too Far Back

Client Positioning Errors Antero- posterior Horizontal/ Midsaggital Vertical/ Occlusal Cervical Spine

Client Positioning Errors Horizontal- Midsaggital Client head twisted, turned or rotated Client head tilted

Client Head is Twisted, Turned or Rotated

Client Head is Twisted, Turned or Rotated 2. Horizontal or midsagittal head plane errors a. Client head is twisted, turned or rotated in machine Image: · Zone 1- Dentition: Posterior teeth on one side are widened and overlap interproximally. On the other side the teeth are narrowed. · Zone 2- Nose-Sinus: On the side with the side ramus, the inferior turbinate and meati are spread-out across the maxillary sinus; the opposite maxillary sinus may have an improved image. · Zone 4- TMJ: On the side with the wide ramus, the earlobe can be seen. · Zone 5- Ramus-Spine: On the side with the wide posterior teeth, the ramus is widened; on the other side, the ramus is narrowed and intersected by the ghost image of the contralateral ramus-the spine may approach or superimpose on the ramus on this side. · Overall: Side rotated toward film is narrowed while side toward xray source is widened and overlapped. Correction: · Center midsaggital plane and align it perpendicular to the floor · Remind client to close eyes or focus on floor during beam rotation

Client Head is Twisted, Turned or Rotated

Client Head is Tilted · Overall: Side toward film is narrowed while side toward xray source is wider with premolar overlap, one side is higher than the other. In general and especially through the upper 1/3 of the image, the bony details appear fuzzy or streaked, rendering them anatomically indistinguishable. Correction: · Center midsaggital plane and align it perpendicular to the floor

Client Head is Tilted b.Client head is tilted in machine Image: · Zone 1- Dentition: The posterior teeth may be slightly widened on one side, with a widening gap between the upper and lower teeth in a posterior dentition; on the other side the interocclusal gap is narrowed. · Zone 3- Mandible-Body: The lower edge of the mandible on one side is almost horizontal; on the side with the widened interocclusal gap, the mandible is enlarged and the lower edge appears to be directed upward above the horizontal plane. · Zone 4- TMJ: On the side with the widened interooclusal gap, the condyle is enlarged and above the contralateral condyle, which is smaller and lower in the image. · Zone 5- Ramus-Spine: On the side with the wide posterior teeth, the ramus is widened; on the other side, the ramus is narrowed and intersected by the ghost image of the contralateral ramus-the spine may approach or superimpose on the ramus on this side.

Client Head is Tilted

Client Positioning Errors Antero- posterior Horizontal/ Midsaggital Vertical/ Occlusal Cervical Spine

Client Positioning Errors Client head /chin is tipped or tilted downward or too low Vertical head or occlusal plane Client head /chin is tipped or tilted upward or too high Client head /chin is not on the chin rest

Client Head is Tipped/Tilted Downward or Too Low

Client Head is Tilted 3. Vertical head plane or occlusal plane errors a. Client head/chin is tipped/tilted downward/too low Image: · Zone 1- Dentition: The “smile” line created by the interocclusal gap is exaggerated. The apices of the mandibular anterior teeth are “cut-off.” The maxillary anterior teeth are better than in the normal projection. · Zone 3- Mandible Body: The mandible is widened vertically in the anterior region, and there is poor imaging of the trabecular pattern. The mandible is transversed by the elongated doubl image and/or ghost of the hyoid bone. · Zone 4- TMJ: The condyles approach the upper edge of the film or are cut-off by the upper edge of the film symmetrically bilaterally. · Overall: Lower teeth are blurred and widened with short, distorted apices, condyles may be cut off top of the film, severe grin to the occlusal plane. “Jack-O-Lantern” smile. Correction: Move head up Align occlusal plane parallel to floor

Client Head is Tipped/Tilted Downward or Too Low

Client Head is Tipped/Tilted Upward or Too High b. Client head/chin is tipped/tilted upward/too high Image: · Zone 1- Dentition: The “smile” line created by the interocclusal gap is lost entirely; the occlusal plane appears flat or even in reverse curve or “sad” configuration. The apices of the maxillary anterior teeth are “cut-off.” The mandibular anterior teeth are better than in the normal projection. · Zone 2- Nose-sinus: The real, double and ghost images of the palate form a widened, prominent, radiopaque line which is projected downward to approximate or superimpose on the apices of the maxillary teeth. · Zone 4- TMJ: The condyles approach the lateral edges of the film or are projected off the edges of the film symmetrically bilaterally. · Overall: Maxillary teeth are blurred and larger in width, hard palate is superimposed over the maxillary teeth apices, condyles may be cut off, occlusal plane is flat or has a frown configuration; flat or reversed occlusal plane. Correction: · Move head down · Align occlusal plane parallel to floor

Client Head is Tipped/Tilted Upward or Too High

Client Head is Tipped/Tilted Upward or Too High

Client Head/Chin is not on the Chin Rest

Client Head/Chin is not on the Chin Rest c. Client head/chin is not on the chin rest Image: · Zone 1- Dentition: This error has no effect on the dentition · Zone 3 & 6- Mandible Body & Hyoid: These zones across the bottom one third of the film do not contain the structures; instead, only soft tissue shadows and sometimes the · Zone 2 &4- Nose Sinus & TMJ: These zones across the upper one third of the film contain structures from lower down that are “cut-off” by the upper edge of the film. The lower edge of the film corresponds with the lower edge of the chin rest; naturally, when the radiographer asks the client to stand upright; the chin can come off the chin rest. The chin must now be brought up to meet the chin. · Overall: Images appear too high on film. Correction: · Make sure chin is stabilized on chin rest.

Client Head/Chin is not on the Chin Rest

Client Positioning Errors Antero- posterior Horizontal/ Midsaggital Vertical/ Occlusal Cervical Spine

Cervical Spine Error

Cervical Spine Error Client spinal column is slumped 4. Cervical Spine Errors a. Client’s spinal column is slumped Image: · Zone 1- Dentition: The anterior teeth are difficult to see, especially the lowers, as the ghost radiopaque image of the spine has superimposed on this area and obliterated it. There are no effects on any other zones with tis errors. Slumped measn the patient’s neck is stretched forward on a slant; this causes a ghost image to be produced in the middle of the film. · Zone 3 - Mandible Body: The ghost image of the spine extends downward beyond the mandibular teeth to obscure the midportion of the mandible. · Overall- Creates a pyramid to column-shaped radiopacity superimposed over the anterior teeth. Correction: · Instruct client to sit or stand with spine erect · Make sure chin rest is high enough to maintain a straight spine position

Cervical Spine Error

Technique Errors Client Client Positioning Preparation Film Handling Operational Exposure

Client Preparation Errors Objects Unsharpness Air Space Artifacts

Client Preparation Errors Objects Prostheses, Jewelry & Removable Item Artifact Apron/Thyroid Shield Artifact

Object Artifacts Jewelry chain=black arrow Ghost image=arrowhead · CLIENT PREPARATION 1.Objects a. Prostheses, jewelry & removable items Image: · Radiopaque artifacts created ·Intraorally, removable items such as complete and partial dentures should be removed, but if located in the anterior region may be left in to better position the client in the machine and to create desired interocclusal gap between max and mand teeth. · Extraorally, eyeglasses, earrings, nose jewelry, neck chains & napkin chains must be removed. · Eye prostheses, hearing aids and wigs can be left on, although sometimes they interfere with the image. Correction: Instruct client to remove objects and store safely during procedure Jewelry chain=black arrow Ghost image=arrowhead

Object Artifacts Prostheses

Lead Apron Artifact b.Apron/Thyroid Shield Artifact Image: · Triangular shaped radiopacity artifact created when incorrect (intraoral style) apron is used because apron parts extend onto the neck, especially at the sides and back. Correction: · Use poncho style panoramic apron not intraoral style. · Do not use thyroid shields because they will project also (10 times less radiation to thyroid from panoramic than with intraoral CIS-long, round PID with E+)

Client Preparation Errors Objects Unsharpness Air Space Artifacts

Client Preparation Errors Unsharpness 2.Unsharpness a. Client movement Image: · Zone 1- Dentition. This area is minimally affected. · Zone 3- Mandibular body. Along the inferior cortex of the mandible an interruption in its continuity can be seen, especially in the molar area. Also a wavy image of the inferior cortex. Unsharpness throughout the vertical dimension of the image. · Overall: Blurred image. Make sure client is capable of cooperating with the procedure Correction: · Instruct client to remain still during entire procedure-focus eyes on floor or close eyes Client Movement

Unsharpness

Unsharpness

Client Preparation Errors Objects Unsharpness Air Space Artifacts

Client Preparation Errors Air Space Artifact 3.Air Space Artifact a.Tongue not on palate and lips open Image: · Zone 1- Dentition. The crowns of the upper and lower anterior teeth are obscured by the air between the parted lips. The apical region of the maxillary teeth is obscured by the dark air space between the dorsum of the tongue as well as th e hard and soft palates. · Zone 2-Nose-Sinus. The maxillary apical alveolar bone is obscured by the palatoglossal air space. · Overall: A radiolucent air space artifact is created in the maxillary apical region. Correction: · Instruct client to swallow and place/press the tongue against the roof of the mouth; close lips around the bitepiece. Tongue not on palate and lips open

Tongue not on palate and lips open Air Space Artifact Tongue not on palate and lips open

Air Space Artifact

Technique Errors Client Client Positioning Preparation Film Handling Operational Exposure

Exposure Errors Under Exposure Over Exposure Double Exposure

Underexposure · EXPOSURE ERRORS 1.Underexposed Image: · Results in low density or light film Correction: · Increase kVp/mA, check for large client size · Also could be caused by darkroom errors, e.g. exhausted developer solution, low darkroom processing temperature

Exposure Errors Under Exposure Over Exposure Double Exposure

Overexposure 2.Overexposed Image: · Results in high density or dark film Correction: · Reduce kVp/mA, check for small client size · Also could be caused by darkroom errors, e.g. film fog, white light exposure, high darkroom processing temperature

Exposure Errors Under Exposure Over Exposure Double Exposure

Double Exposure 3.Double Exposure Image: · Bizarre pattern of superimposed images with high density appearance Correction: · Process films immediately after exposure · Keep unexposed and exposed cassettes separated from each other

Technique Errors Client Client Positioning Preparation Film Handling Operational Exposure

Operational Errors Incomplete Exposure Cassette Resistance Not Starting At Home Base

Incomplete Exposure or Not Starting At Home Base · OPERATIONAL ERRORS 1.Incomplete exposure Image: · Results in partially exposed image ·Correction: · Maintain constant press on the exposure button until the cycle of the machine rotation is complete 3.Not starting at “home base” · Panoramic cone cut-only part of client is imaged and remainder of film is blank because it is unexposed · Occurs when cassette holder is not aligned with correct starting point Correction: · Make sure cassette is aligned at starting point.

Operational Errors Incomplete Exposure Cassette Resistance Not Starting At Home Base

Cassette Resistance 2.Cassette resistance Image: · Produces alternating white and black vertical bands or lines from the rubbing against the client’s shoulder Correction: · Make sure the client’s spine is straight, head is erect and shoulders down · Avoid placing the inferior aspect of the cassette against the client’s shoulder

Cassette Resistance

Technique Errors Client Client Positioning Preparation Film Handling Operational · FILM HANDLING & PROCESSING ERRORS 1.Static Electricity Image: · Tree or branch-like in shape due to friction or rough handling Correction: · Handle film carefully when loading and unloading · Avoid friction created by rapid removal of film from box or lsiding film against screens · Use screen cleaner to reduce static electricity on screens Exposure

Film Handling & Processing Errors Static Electricity Debris/ Scratched Screens White Light Exposure Film Crimping 2.Debris or scratch on cassette screens Image: · Small white artifacts due to powder or lint attracted to screens or scratch on the cassette that block light production and interferes with latent image production. Correction: · Handle cassette and film with clean, dry hands · Use screen cleaner to reduce static electricity on screens 3.Partial or complete white light exposure of film · Black zone or completely black image where white light has exposed the film. · Inspect cassette seams and latching mechanism, replace as needed · Store film carefully make sure box lid is tight and in place after 4.Film crimping · “Fingernail artifact” result of mishandling film by causeing the film to crimp as it is pressed firmly between the thumb and index finger, then bent as it is withdrawn from the box or cassette. Correction:· Handle film gently Black, tree-like artifacts White artifacts Finger-nail artifact Black zone