JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No.

1 (113 - 117): Locating the Mandibular Canal in Panoramic Radiographs Sun

Locating the Mandibular Canal in Panoramic

Radiographs
Sunder Dharmar, MDS

The entire course of the mandibular canal is normally not visible on a panoramic radiograph.
Locating the course of the mandibular canal at the site of implant placement is important.
This study was carried out to determine whether the course of the mandibular canal can be
more clearly visualized by tilting the patient’s head approximately 5 degrees downward with
reference to the Frankfort horizontal reference bar of the Orthopantomogram machine. In
91% of the radiographs taken in this position, the mandibular foramen, mandibular canal,
and mental foramen were visible. The angulation of the patient’s head reduced the chances of
superimposition on the contralateral sides, making these structures clearly visible.
(INT J ORAL MAXILLOFAC IMPLANTS 1997;12:113–117)
Key words: implant, mandible, mandibular canal, panoramic radiograph

T he use of implants is gaining prominence in today’s dental practice and provides a reliable
alternative to conventional denture restorations. Placing implants in partially edentulous and
single-tooth replacement situations in the posterior part of the mandible is more challenging because
the mandibular canal is likely to be endangered in such situations.
Detailed knowledge of the anatomy of the man dible, the amount of vertical bone available above the
canal, and the buccolingual width of the mandible are of paramount importance in the placement of
implants above or to the side of the mandibular canal. Although the buccolingual width of the man dible
cannot be obtained in the panoramic view, panoramic projection (pantomograph) is commonly used for
diagnostic purposes by all disciplines of dentistry. However, an ordinary panoramic radiograph is not
always helpful in identifying the course of the mandibular canal and the location of the mental
foramen.1-3
The mandibular foramen can be difficult to discern on a panoramic radiograph because of the
superimposition of the structures on the contralateral side of the jaw. Exceptions do occur when the
mandibular foramen is more inferior than normal and therefore is visible.4 Very often the clinician must
rely on more costly computerized tomograms and reformatted images to visualize the buccolingual width
of the mandible and assess the space avail-able for the placement of implants in the posterior mandible.
The aim of the present study was to determine whether it is possible to locate the anteroposterior
course of the mandibular canal and the mental foramen more clearly on panoramic radiographs by tilting
the patient’s head downward approximately 5 degrees with reference to the Frankfort horizontal plane
(FHP) of the Orthopantomogram (OPG) machine (Panex-EC, J. Morita, Tokyo, Japan).
Materials and Methods
Ideally the study should be based on two panoramic radiographs of the same patient. One panoramic
view would be taken with the standard setting as prescribed by the manufacturer, ie, the FHP of the
patient kept parallel to the FH reference plane of the OPG machine. For the second radiograph, the

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (113 - 117): Locating the Mandibular Canal in Panoramic Radiographs Sun

patient’s FHP would be kept at a 5-degree angle downward to the reference bar of the machine.
However, the decision was made to use separate patient populations so as to avoid exposing the same
individual to multiple radiographic examinations.
Previously taken diagnostic panoramic radiographs that were available in the Departments of Ortho
dontia and Oral Surgery of the SDM College of Dental Sciences, Dharwad, India, were examined to
locate the course of the mandibular canal from the mandibular foramen to the mental foramen. These
radiographs had been taken earlier with the FHP of the patient kept parallel to the FH reference plane of
the OPG machine, as advocated by the manufacturer. These were designated position 1 radiographs, and
they served as controls.
Of the 175 radiographs taken in position 1, a total of 66 were from males (mean age 19.7 years) and
109 were from females (mean age 18.7 years). Twenty-one of these records belonged to a mixed
dentition group. All radiographs were taken within a period of 6 months.
Position 2 radiographs were taken by positioning the patient’s head 5 degrees downward relative to
the FH reference plane of the OPG machine. These radiographs were taken over a period of 3 months, as
the Departments of Orthodontia and Oral Surgery made requests for diagnostic purposes. Of the 75
radiographs taken with position 2, 40 were from males (mean age 18.6 years) and 35 were from females
(mean age 16.4 years). Seventeen records belonged to patients with a mixed dentition. All radiographs
were taken by the same radiographer and were developed in the manner prescribed by the manufacturer.
The radiographs were read by the author for location of the mental foramen, mandibular foramen, and the
entire course of the mandibular canal on both right and left sides.
Results
A total of 175 radiographs were taken with position 1 serving as the control (Fig 1). They were examined
for the visibility of mandibular foramen, the entire length of the mandibular canal, and the mental
foramen on both the right and left sides of the mandible. A partially visible mandibular canal was not
taken into consideration. Of the 175 radiographs, 21 belonged to the mixed dentition group. This group
did not demonstrate all of the structures under consideration in any of the radiographs; hence, all mixed
dentition radiographs were excluded from the statistical analysis. Of the remaining 154 radiographs, only
17 (11.00%) radiographs showed the presence of all the structures.
Of the 75 position 2 radiographs, 17 were from patients with a mixed dentition. None of these radio-
graphs demonstrated all the structures under consideration (Fig 2). Therefore, mixed dentition radio
graphs were eliminated from statistical analysis. Of the remaining 58 radiographs, 53 (91.38%)
radiographs revealed all structures (Fig 3). Figure 4 shows the individual structures that were visible on
both right and left sides for the mental foramen, mandibular foramen, and the mandibular canal in
orthopantomographs, comparing position 1 and position 2.
Discussion
Three types of shadows can be identified on pantomographs. Structures inside and outside the trough,
whose long axis is parallel to the direction of the beam (ie, structures near the midsagittal plane), form
distinct images called primary shadows. Dense structures outside the focal trough, whose long axis is
perpendicular to the direction of beam movement, form indistinct images called secondary shadows.
Their appearance results from the beam passing the right and left jaw arches simultaneously, so that the
jaw side nearest the film forms the primary shadows, while the jaw side nearest the x-ray source
produces secondary shadows. The secondary shadows are reversed when the structures near the x-ray

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source are located behind the center of the beam rotation. Superimposition of secondary and primary
shadows can produce apparent radiolucencies caused by contrast. These images are called false shadows
because they lack anatomic basis.5-7
The main disadvantage of panoramic radiographs is that the resultant image does not resolve the fine
anatomic detail that may be seen on intraoral periapical radiographs. Other problems associated with
panoramic radiographs include the magnification of geometric distortion and overlapped images of teeth,
especially in the premolar region. In addition, objects whose recognition may be important for the
planning of therapy may be situated outside the section or plane of focus (called focal trough), resulting
in their images being distorted or obscured on the resultant radiograph.8-10
Panoramic radiographs usually show the mental foramen; on periapical dental films, the foramen is
often not visible. Fishel et al11 found the mental foramen visible on 47% of dental films, with bilateral
findings in only 30% of cases. Packota et al,1 in their study of 374 OPG films, reported that only 309
demonstrated the mental foramen well, even when the entire mandible was imaged on all films. They
further concluded that the mental foramen was not always clearly demonstrated radiographically. In the
present study, the mental foramen on the right side was visible in 60% of the position 1 radiographs; on
the left side, the mental foramen was visible in 58% of the patient 1 radiographs. Of the position 2
radiographs, 94% showed the mental foramen on the right side, and 93% showed the mental foramen on
the left side.
The course of the mandibular canal is usually clearly visible from the mandibular foramen to the
second molar region. From there to the mental foramen, it is seldom visible. This is because of the
porosity of the mandibular canal walls, the superimposition of the highly radiolucent submaxillary
fossae, and the lack of trabeculation. The mental foramen, which is located buccally, is superimposed by
bony lingual structures and is seldom visible.2 In our study, this observation has been verified by the
results from the control group wherein only 17 of 154 radiographs showed all the structures under
consideration.
Examination of the mandibular foramen, mandibular canal, and mental foramen in panoramic
radiographs is also complicated because of the additional effect of superimposition of the mandibular
ramus at the angle of the mandible on the opposite side. The structures of the body of the mandible and
the retromolar region are usually targeted too steep caudally when dental x-ray equipment is used. In
addition, the long axes of the molars are inclined lingually. Pan oramic radiographs provide a less
distorted view of these structures because the central ray is targeted lingually and slightly below the
molar region. If the mandibular canal and mental foramen are visible despite the summation effect, the
distance from these structures to the crest of the ridge is more faithfully reproduced.2
In the present study, the patient’s head was angled 5 degrees downward. Of the 58 radiographs taken
in this position, the mandibular foramen, mandibular canal, and mental foramen were visible in 53
radiographs. This angulation of the patient’s head reduced the chances of superimposition on the contra
lateral sides, thereby making these structures clearly visible inspite of mandibular canal porosity. Too
steep an inclination downward would provide unsatisfactory results. The maxillary premolars would
appear superimposed on each other, and the temporomandibular joints would be projected upward. 11 In
addition, the hyoid bone would be become superimposed over the mandible, and the mandibular anterior
teeth would be blurred out of the focal trough.2

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Because of the inherent problem of magnification of the pantomographic image,13-15 vertical height
measurements from the residual alveolar ridge to the upper border of the mandibular canal are not
reliable for selecting the exact length of an implant. However, visualizing the mandibular canal can
greatly assist the implant surgeon in choosing an appropriate implant if the magnification of the
radiograph is known prior to the surgery.
An additional observation of this study was the absence of these pertinent anatomic structures in the
radiographs of the mixed dentition group. This finding was the result of the presence of calcified crowns
of the erupting permanent dentition that were superimposed over the highly porous mandibular canal.
Conclusion
Locating the mandibular canal for the placement of dental implants in the posterior region of the man-
dible is important. The canal is normally not visible on a panoramic radiograph. By tilting the patient’s
head 5 degrees downward with reference to the Frankfort horizontal bar of the OPG machine, the
mandibular canal can possibly be made more visible.
Acknowledgments
The author expresses his sincere thanks to Mr Basker Shetty, the radiographer; Mrs Poojar, for the
statistical analysis; and his colleagues at the Department of Prosthodontics, SDM College of Dental
Sciences, Dharwad, India.

Sunder Dharmar

Associate Professor, Department of

Prosthodontics, SDM College of Dental Sciences
and Hospital, Dharwad, India.

FIGURES

Footnotes 4
Figure 1

Fig. 1 Panoramic radiograph taken when the standard head position is maintained, as
recommended by the manufacturer. The canals are most often not visible in their entire course.

Figure 2

Fig. 2 The mandibular canal is not normally visible in patients with a mixed dentition, in both the
standard position and when the head is tilted 5 degrees downward.

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (113 - 117): Locating the Mandibular Canal in Panoramic Radiographs Sun

Figure 3

Fig. 3 Entire mandibular canal visible from the mandibular foramen to the mental foramen on
both sides, when the head is tilted 5 degrees downward.

Figure 4

Fig. 4 Percentages of radiographs with structures that were visible on the position 1 and
position 2 radiographs (structure location 1 = mandibular canal on right side, 2 = mandibular
canal on left side, 3 = mental foramen on right side, 4 = mental foramen on left side, 5 =
mandibular foramen on right side, 6 = mandibular foramen on left side).

References 6
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (113 - 117):

Locating the Mandibular Canal in Panoramic Radiographs Sunder Dharmar

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