What is the Better X-ray for Wisdom Teeth, the Panoramic or the Cone Beam Scan?

The cone beam scan is by far the better of the two if you are just basing the question off which gives you more information (J Oral Maxillofac Surg 77:1968, 2019).  The panoramic is a two-dimensional x-ray picture of the jaw structure, and the cone beam imaging is a three-dimensional reconstruction of multiple scans, and the computer can create multiple planes of view of the same area, giving us much more information and 3-D “views” of a given area of the jaws and teeth.

The cone beam scan (CBS) uses a higher dose of radiation, and the equipment is much more expensive, so the cost per scan is typically more.  The skill of the practitioner should also be taken into account.  A cone beam scan read by a head and neck radiologist versus an oral and maxillofacial surgeon versus a general practitioner may well yield different levels of information.

At the time of his writing, the CBS has not yet been recognized as the standard of care for evaluation of impacted third-molar teeth (wisdom teeth).  In my practice, I will generally insist on a CBS if there are significant questions about the relationships of the adjacent vital structures, such as the neurovascular bundles to the impacted third-molar teeth, or if there are lesions associated where we would benefit from quantification of the lesional extent.  This process usually involves a discussion and explanation and a reasonable decision process with the patient and/or their guardians or their advocates.

The cone beam imaging gives us a much better visualization, pretreatment, which helps to make better surgical decisions.  This is especially true if there is associated pathology and/or proximity to vital structures.