Common Panoramic Errors

1What this is & why it matters

Same game, different image.

Bitewing errors mostly come from processing and placement. Panoramic errors mostly come from patient positioning — the machine rotates around a fixed focal trough, so if the patient's chin, spine, or midline isn't exactly where it should be, the image distorts in a very specific, recognizable way.

Same exam strategy as bitewing errors: don't memorize definitions — learn to recognize the look, and the cause follows automatically.

2Fingerprint

Tongue not on palate

Panoramic radiograph showing a dark radiolucent shadow from the palatoglossal air space washing out the maxillary anterior tooth roots, from the tongue not pressed against the palate during exposure.

Look: a dark shadow washes out the maxillary anterior roots — the single most common panoramic error.

Fix: tongue pressed firmly against the roof of the mouth for the whole exposure.

3Fingerprint

Ghost image

Panoramic radiograph showing a real earring on one side and a larger, blurred ghost duplicate of the same earring higher up on the opposite side, near the ramus/condyle region.

Look: a blurry, enlarged double of a metal/dense object — higher and on the opposite side from the real one.

Fix: remove glasses, jewelry, and any removable metal before exposure.

4Fingerprint

Chin tipped too high

Look: the occlusal plane reverses into a "frown" curve; condyles may run off the top; upper incisors blur and magnify.

Fix: re-level so the Frankfort planeAn imaginary line from the top of the ear canal to the bottom of the eye socket. It should be parallel to the floor for a panoramic. is parallel to the floor.

5Fingerprint

Chin tipped too low

Look: an exaggerated "smile" curve; lower incisors blur with shortened-looking roots; the spine shows up more.

Fix: same as above — re-level the Frankfort plane, chin down brought back up.

6Fingerprint

Head not centered

Panoramic radiograph taken with the head rotated off-center: one side's teeth and ramus appear enlarged and blurred while the opposite side looks smaller and sharper, showing clearly uneven left-to-right magnification.

Look: uneven magnification — one side's teeth/ramus look bigger and blurrier, the other side smaller and sharper.

Fix: align the midsagittal plane perpendicular to the floor; center the midline light between the maxillary centrals.

7Fingerprint

Spine not straight

Panoramic radiograph of a slumped patient: a broad radiopaque white column from the cervical spine runs up the center of the image and washes out the anterior teeth.

Look: a radiopaque (white) shadow wipes out the anterior teeth in the center of the image.

Fix: patient stands/sits as tall as possible, shoulders down — no slumping.

8Fingerprint

Lead apron / thyroid collar artifact

Panoramic radiograph with a large, bright, cone-shaped radiopaque blob across the lower center of the image, blocking the mandibular anterior teeth — the shadow of a lead thyroid collar mistakenly left on during the panoramic exposure.

Look: a big radiopaque blob blocking the anterior region — because a thyroid collar was worn.

Fix: no thyroid collar on a panoramic — it sits right in the beam's path and blocks the anterior teeth. (A lead apron alone, without the collar, is fine.)

9Make it stick

The trap everyone falls for.

The pair the exam loves to swap is chin too high vs. chin too low. Here's the hook that locks it forever:

Chin UP → Frown  ·  Chin DOWN → Smile

Chin too high flattens and reverses the arch curve into a frown — think "chin up, corners down." Chin too low does the opposite: it exaggerates the curve into a big smile. Same logic either direction: the occlusal plane tips the way the chin didn't.

🙂

Picture the two emoji: chin jammed up toward the ceiling gives you a flat, tired ⌢ (frown); chin tucked down toward the chest gives you an exaggerated ⌣ (smile). The image copies whichever face the chin is making.

10Spot it on the exam

DANB describes the look — you name the cause.

"dark shadow over the maxillary anterior roots"→tongue not on the palate

"blurry duplicate object, higher up, opposite side"→ghost image → remove metal first

"reverse smile line, condyles cut off"→chin tipped too high

"exaggerated smile line, spine prominent"→chin tipped too low

"one side magnified, other side sharp/small"→head not centered

11Check yourself

A panoramic shows the condyles cut off at the top of the image and a reversed, "frowning" occlusal curve. This was most likely caused by:

Chin too high. Chin UP → Frown — the curve flattens and reverses, and the condyles can run off the top of the image.

11Check yourself

A panoramic shows a large radiopaque blob blocking the anterior teeth in the center of the image. The patient was wearing a lead apron with a thyroid collar. The cause is:

Thyroid collar artifact. Unlike intraoral images, a panoramic's beam path runs right through the neck/collar area — so a thyroid collar blocks the anterior region. A lead apron alone (no collar) doesn't cause this.

Recap

The whole thing in 7 lines.

✓Tongue not on palate → dark shadow over maxillary anterior roots → the single most common panoramic error.
✓Ghost image → blurry duplicate, higher & opposite side → remove metal/jewelry first.
✓Chin too high → frown-line curve, condyles cut off. Chin too low → exaggerated smile curve, spine shows.
✓Head not centered → uneven left/right magnification.
✓Spine not straight → radiopaque shadow over the anterior teeth → stand up straight, no slumping.
✓Thyroid collar artifact → radiopaque blob blocking the anterior region → no thyroid collar on a panoramic.