Identification of the Mandibular Vital Structures: Practical Clinical Applications of Anatomy and Radiological Examination Methods
Identifieur interne : 000690 ( Pmc/Corpus ); précédent : 000689; suivant : 000691Identification of the Mandibular Vital Structures: Practical Clinical Applications of Anatomy and Radiological Examination Methods
Auteurs : Gintaras Juodzbalys ; Hom-Lay WangSource :
- Journal of Oral & Maxillofacial Research [ 2029-283X ] ; 2010.
Abstract
The purpose of this article was to review the current available clinical techniques and to recommend the most appropriate imaging modalities for the identification of mandibular vital structures when planning for oral implants.
The literature was selected through a search of PubMed, Embase and Cochrane electronic databases. The keywords used for search were mandibular canal, mandibular incisive canal, mental foramen, anterior loop of the mental nerve, radiography, dental implants. The search was restricted to English language articles, published from January 1976 to January 2010.
In total 111 literature sources were obtained and reviewed. The peculiarities of the clinical anatomy of mandibular canal, mandibular incisive canal, mental foramen and anterior loop of mental nerve were discussed. Radiological diagnostic methods currently available for the identification of the mandibular vital structures when planning for oral implants were presented. Guidelines for the identification of the mandibular vital structures in dental implantology were made.
The proposed guideline provides clinicians a tool in proper identifying the important mandibular vital structures thus minimizing the potential complications during implant surgery.
Url:
DOI: 10.5037/jomr.2010.1201
PubMed: 24421966
PubMed Central: 3886050
Links to Exploration step
PMC:3886050Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Identification of the Mandibular Vital Structures: Practical Clinical Applications of Anatomy and Radiological Examination Methods</title><author><name sortKey="Juodzbalys, Gintaras" sort="Juodzbalys, Gintaras" uniqKey="Juodzbalys G" first="Gintaras" last="Juodzbalys">Gintaras Juodzbalys</name><affiliation><nlm:aff id="aff1"><institution>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></nlm:aff></affiliation></author><author><name sortKey="Wang, Hom Lay" sort="Wang, Hom Lay" uniqKey="Wang H" first="Hom-Lay" last="Wang">Hom-Lay Wang</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24421966</idno><idno type="pmc">3886050</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886050</idno><idno type="RBID">PMC:3886050</idno><idno type="doi">10.5037/jomr.2010.1201</idno><date when="2010">2010</date><idno type="wicri:Area/Pmc/Corpus">000690</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000690</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Identification of the Mandibular Vital Structures: Practical Clinical Applications of Anatomy and Radiological Examination Methods</title><author><name sortKey="Juodzbalys, Gintaras" sort="Juodzbalys, Gintaras" uniqKey="Juodzbalys G" first="Gintaras" last="Juodzbalys">Gintaras Juodzbalys</name><affiliation><nlm:aff id="aff1"><institution>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></nlm:aff></affiliation></author><author><name sortKey="Wang, Hom Lay" sort="Wang, Hom Lay" uniqKey="Wang H" first="Hom-Lay" last="Wang">Hom-Lay Wang</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Oral & Maxillofacial Research</title><idno type="eISSN">2029-283X</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The purpose of this article was to review the current
available clinical techniques and to recommend the most appropriate imaging modalities
for the identification of mandibular vital structures when planning for oral implants.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>The literature was selected through a
search of PubMed, Embase and Cochrane electronic databases. The keywords used for
search were mandibular canal, mandibular incisive canal, mental foramen, anterior
loop of the mental nerve, radiography, dental implants. The search was restricted
to English language articles, published from January 1976 to January 2010.</p></sec><sec sec-type="results"><title>Results</title><p>In total 111 literature sources were obtained and reviewed.
The peculiarities of the clinical anatomy of mandibular canal, mandibular incisive
canal, mental foramen and anterior loop of mental nerve were discussed. Radiological
diagnostic methods currently available for the identification of the mandibular
vital structures when planning for oral implants were presented. Guidelines for
the identification of the mandibular vital structures in dental implantology were
made.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>The proposed guideline provides clinicians a tool
in proper identifying the important mandibular vital structures thus minimizing
the potential complications during implant surgery.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Givol, N" uniqKey="Givol N">N Givol</name></author><author><name sortKey="Taicher, S" uniqKey="Taicher S">S Taicher</name></author><author><name sortKey="Halamish Shani, T" uniqKey="Halamish Shani T">T Halamish-Shani</name></author><author><name sortKey="Chaushu, G" uniqKey="Chaushu G">G Chaushu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kalpidis, Cd" uniqKey="Kalpidis C">CD Kalpidis</name></author><author><name sortKey="Setayesh, Rm" uniqKey="Setayesh R">RM Setayesh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Abarca, M" uniqKey="Abarca M">M Abarca</name></author><author><name sortKey="Van Steenberghe, D" uniqKey="Van Steenberghe D">D van Steenberghe</name></author><author><name sortKey="Malevez, C" uniqKey="Malevez C">C 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="iso-abbrev">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="publisher-id">JORM</journal-id><journal-title-group><journal-title>Journal of Oral & Maxillofacial Research</journal-title></journal-title-group><issn pub-type="epub">2029-283X</issn><publisher><publisher-name>Stilus Optimus</publisher-name><publisher-loc>Kaunas, Lithuania</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24421966</article-id><article-id pub-id-type="pmc">3886050</article-id><article-id pub-id-type="publisher-id">v1n2e1ht</article-id><article-id pub-id-type="doi">10.5037/jomr.2010.1201</article-id><article-categories><subj-group subj-group-type="heading"><subject>Literature Review</subject></subj-group></article-categories><title-group><article-title>Identification of the Mandibular Vital Structures: Practical Clinical Applications of Anatomy and Radiological Examination Methods</article-title></title-group><contrib-group><contrib id="contrib1" contrib-type="author" corresp="yes"><name><surname>Juodzbalys</surname><given-names>Gintaras</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib id="contrib2" contrib-type="author"><name><surname>Wang</surname><given-names>Hom-Lay</given-names></name><xref ref-type="aff" rid="aff1">2</xref></contrib></contrib-group><aff id="aff1" rid="aff1"><sup>1</sup><institution>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></aff><aff id="aff2" rid="aff2"><sup>2</sup><institution>Department of Periodontics and Oral Medicine, University of Michigan, Ann Arbor Michigan</institution><country>USA.</country></aff><author-notes><corresp>Gintaras Juodzbalys,
<addr-line>Vainiku 12, LT-46383, Kaunas</addr-line><country>Lithuania</country><phone>+370 37 29 70 55</phone>Fax: +370 37 32 31 53
<email>gintaras@stilusoptimus.lt</email></corresp></author-notes><pub-date pub-type="collection"><season>Apr-Jun</season><year>2010</year></pub-date><pub-date pub-type="epub"><day>1</day><month>7</month><year>2010</year></pub-date><volume>1</volume><issue>2</issue><elocation-id>e1</elocation-id><history><date date-type="received"><day>1</day><month>3</month><year>2010</year></date><date date-type="accepted"><day>17</day><month>3</month><year>2010</year></date></history><permissions><copyright-statement>Copyright © Juodzbalys G, Wang HL. Published in the
JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH (http://www.ejomr.org), 1 July 2010.</copyright-statement><copyright-year>2010</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article, first published in the JOURNAL OF
ORAL & MAXILLOFACIAL RESEARCH, distributed under the terms of the
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License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link>), which permits unrestricted non-commercial use, distribution, and
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cited. The copyright, license information and link to the original
publication on <ext-link ext-link-type="uri" xlink:href="http://www.ejomr.org">http://www.ejomr.org</ext-link> must be included.</license-p></license></permissions><self-uri xlink:type="simple" xlink:href="http://www.ejomr.org/JOMR/archives/2010/2/e1/e1ht.htm"></self-uri><abstract><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The purpose of this article was to review the current
available clinical techniques and to recommend the most appropriate imaging modalities
for the identification of mandibular vital structures when planning for oral implants.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>The literature was selected through a
search of PubMed, Embase and Cochrane electronic databases. The keywords used for
search were mandibular canal, mandibular incisive canal, mental foramen, anterior
loop of the mental nerve, radiography, dental implants. The search was restricted
to English language articles, published from January 1976 to January 2010.</p></sec><sec sec-type="results"><title>Results</title><p>In total 111 literature sources were obtained and reviewed.
The peculiarities of the clinical anatomy of mandibular canal, mandibular incisive
canal, mental foramen and anterior loop of mental nerve were discussed. Radiological
diagnostic methods currently available for the identification of the mandibular
vital structures when planning for oral implants were presented. Guidelines for
the identification of the mandibular vital structures in dental implantology were
made.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>The proposed guideline provides clinicians a tool
in proper identifying the important mandibular vital structures thus minimizing
the potential complications during implant surgery.</p></sec></abstract><kwd-group><kwd>mandible</kwd><kwd>chin</kwd><kwd>inferior alveolar nerve</kwd><kwd>cross-sectional anatomy</kwd><kwd>radiography</kwd><kwd>dental implants.</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>Today, oral implants are routinely used in the oral rehabilitation. Yet, the
frequent placement of oral implants has raised the number of neurosensory disturbances
and haemorrhages, even in the anterior mandible, which was previously considered
as a safe region without vital neurovascular bundles [<xref ref-type="bibr" rid="B1">1-4</xref>]. It
is essential to obtain appropriate information about the mandible vital structures
prior to implant placement [<xref ref-type="bibr" rid="B5">5</xref>]. Knowledge of anatomy and their
variations are essential to ensure precise surgical procedures to safeguard patient's
vital structures [<xref ref-type="bibr" rid="B6">6-8</xref>]. Prior to commencement of implant surgery,
careful and detailed planning is required to indentify mandibular vital structures
as well as the shape and dimensions of the bone, so the implants can be properly
orientated and placed. During the planning phase of treatment, the recipient bed
is routinely assessed by visual examination and palpation, as well as the available
medical imaging modalities. When adequate occlusoapical bone height is available
for endosteal implants, the buccolingual width and angulation of the available bone
are the most important criteria for implant selection and success [<xref ref-type="bibr" rid="B9">9</xref>].
Radiographic images provides the information about topography and location of the
anatomical structures [<xref ref-type="bibr" rid="B10">10</xref>], and estimation of the quantity and
quality of alveolar bone, which are essential in assessing the ideal position, number
and dimensions of implants [<xref ref-type="bibr" rid="B11">11</xref>,<xref ref-type="bibr" rid="B12">12</xref>]. Many imaging options have
been recommended for implant treatment planning, including intraoral radiography,
conventional extraoral radiography, tomography, computed tomography (CT) [<xref ref-type="bibr" rid="B13">13-16</xref>],
cone beam computed tomography (CBCT) [<xref ref-type="bibr" rid="B17">17-23</xref>]. However, neither
buccollingual width nor angulation or assessment of the location of mandibular vital
structures can be properly visualized on most traditional radiographs [<xref ref-type="bibr" rid="B9">9</xref>].</p><p>The purpose of this article was to review the current available clinical techniques
and to recommend the most appropriate imaging modalities for the identification
of mandibular vital structures when planning for oral implants.</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><p>Literature was selected through a search of PubMed, Embase and Cochrane Central
Register electronic databases. The keywords used for search were mandibular canal,
mandibular incisive canal, mental foramen, anterior loop of the mental nerve, radiography,
dental implants. The search was restricted to English language articles, published
from January 1976 to January 2010. Additionally, a manual search in the major anatomy,
dental implant, prosthetic and periodontal journals and books was performed. The
included publications were clinical and human anatomy studies. To make it easier
for readers, the peculiarities of the clinical anatomy of mandibular canal, mandibular
incisive canal, mental foramen and anterior loop of mental nerve and radiologic
diagnostic methods currently available for the identification of the mandibular
vital structures when planning for oral implants were presented as two entities.</p><p><bold>Clinical and radiological evaluation of the mandibular anatomy for implantation</bold></p><p>Surgical dental implant installation requires understanding of associated anatomical
structures. Planning should be done on three-dimensional edentulous jaw segment
(EJS) pattern. This is because the EJS consists of alveolar and basal bone. In addition,
EJS describes planned implant bed relation to present anatomical borders such as
mandibular vital structures (<xref ref-type="fig" rid="fig1">Figure 1A</xref>) [<xref ref-type="bibr" rid="B24">24</xref>].</p><fig id="fig1" orientation="portrait" position="float"><label>Figure 1</label><caption><p>A = mandible is divided
into edentulous jaw segments that consists of alveolar and basal bone for
planned implant bed.</p><p>B = the vertical dimension (H) of the planned implant
is determined by the distance between the alveolar ridge crest and mental
foramen.</p><p>C = the vertical dimension (H) of the planned implant
is determined by the distance between the alveolar crestal ridge and mandibular
canal. The horizontal EJS dimensions: length (L) in all cases is determined
by the distance between neighbouring teeth or implants and width (W) is
determined by the alveolar process width measured at the level of 3 mm (W1)
and 6 mm (W2) from the crest of alveolar ridge.</p></caption><graphic xlink:href="jomr-01-e1-g001"></graphic></fig><p>The vertical dimension of the planned implant site in mandible is determined
by the distance between crestal ridge of the alveolar process and mandibular vital
structures (EJS height) such as mental foramen (MF) (<xref ref-type="fig" rid="fig1">Figure 1 B</xref>),
mandibular canal (MC) (<xref ref-type="fig" rid="fig1">Figure 1 C</xref>), mandibular incisive canal
(MIC), anterior loop (AL) of mental nerve. The horizontal dimensions are determined
by the distance between neighbouring teeth or implants (EJS length) and width of
alveolar process (EJS width) (<xref ref-type="fig" rid="fig1">Figure 1 B</xref> and <xref ref-type="fig" rid="fig1">C</xref>).</p><p>Consequently, it should be done clinically and radiologically by identifying
and depicting mandibular anatomical landmarks and position of important vital structures,
when planning for dental implant operation.</p><p><bold>Peculiarities of mandibular canal (MC) clinical anatomy</bold></p><p>MC is one of the most important anatomical structures in mandible, because it
carries inferior alveolar neurovascular bundle: inferior alveolar nerve (IAN), inferior
alveolar artery, vein, and lymphatic vessels [<xref ref-type="bibr" rid="B25">25</xref>]. Clinicians
should be aware of the variation in course of the MC as it runs through the jaw,
because the MC may present in different anatomical configurations in vertical plane.
For example, the canal may run lower when it proceeds anteriorly, or may have sharp
decline, or drape downward in catenary's fashion [<xref ref-type="bibr" rid="B26">26</xref>]. Furthermore,
Nortje et al. [<xref ref-type="bibr" rid="B27">27</xref>], on the panoramic radiographs, showed that
the vertical MC position can be divided into four categories: 1) high MC (within
2 mm of the apices of the first and second molars), 2) intermediate MC, 3) low MC,
and 4) other variations – these includes duplication or division of the canal, apparent
partial or complete absence of the canal or lack of symmetry. Otherwise, it should
be recognized that the mean vertical distance between crestal ridge of the alveolar
process and MC or MF reported in different classifications may not apply to any
particular patient because of the different degree of alveolar bone atrophy. Moreover,
because the crest of alveolar process is often thin, it is necessary to reduce it,
so it can have wider base for the planned implant installation. In such cases, the
heights of EJS would have been shortened by 1 to 3 mm at least; this reduction had
to be considered when calculating the available bone height [<xref ref-type="bibr" rid="B24">24</xref>]
(<xref ref-type="fig" rid="fig2">Figure 2 A</xref>). Clinicians should take care of the thin crestal
bone smoothing and drill countersinking without losing the support of crestal cortical
bone. Another implant treatment option is crestal ridge preservation by performing
alveolar ridge augmentation (<xref ref-type="fig" rid="fig2">Figure 2 B</xref> and <xref ref-type="fig" rid="fig2">C</xref>).</p><fig id="fig2" orientation="portrait" position="float"><label>Figure 2</label><caption><p>A = Thin crestal ridge was
reduced to create wide recipient bed for planned implant installation. In
such cases, the heights of EJS would have been shortened by 1 to 3 mm at
least. B and C = another implant treatment option: crestal ridge preservation
and dental implant surgical placement with subsequent alveolar process augmentation.</p></caption><graphic xlink:href="jomr-01-e1-g002"></graphic></fig><p>Furthermore, the ridge may appear to have adequate vertical dimension for an
implant in panoramic radiograph, but the reality is often different (<xref ref-type="fig" rid="fig3">Figure
3</xref>).</p><fig id="fig3" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Asymmetry or reshape of
the crestal bone influences the height (H1 and H2) of bone, apparently available
for the implant accommodation above the canal (C), as it was seen on the
panoramic film.</p></caption><graphic xlink:href="jomr-01-e1-g003"></graphic></fig><p>It was reported that MC might have different anatomic configurations in the horizontal
plane. Usually the MC crosses from the lingual to the buccal side of the mandible
and in most cases the midway between the buccal and lingual cortical plates of bone
is by the first molar [<xref ref-type="bibr" rid="B28">28-30</xref>]. Age and race were statistically
associated with MC position relate to the mandibular buccal cortical bone (P < 0.05).
Older patients and Caucasian patients, on average, have less distance between the
buccal aspect of the canal and the buccal mandibular border [<xref ref-type="bibr" rid="B31">31</xref>].
Placement of implant buccally or lingually to the MC is a risky approach and should
not be attempted unless the clinicians have the aid of computed tomography (CT)
and is confident of executing the surgery [<xref ref-type="bibr" rid="B6">6</xref>].</p><p>In panoramic radiograph, the position of MC in horizontal plane can influence
the apparent amount of bone available for implant placement [<xref ref-type="bibr" rid="B32">32</xref>].
For example, if the MC lies close to the lingual cortex, it will be projected higher
on the film and therefore appear higher in the arch than it really is (<xref ref-type="fig" rid="fig4">Figure
4</xref>). In case, where a large mandibular torus is present, it may project significantly
to the lingual side of the mandibular body, and its shadow will project upward onto
the film, giving a misleading impression of the available bone height [<xref ref-type="bibr" rid="B32">32</xref>].</p><fig id="fig4" orientation="portrait" position="float"><label>Figure 4</label><caption><p>The position of mandibular
canal (C1 and C2) in horizontal plane influences the apparent height (H1
and H2) of bone available for implant accommodation.</p></caption><graphic xlink:href="jomr-01-e1-g004"></graphic></fig><p><bold>Radiological detection of mandibular canal (MC)</bold></p><p>The location and configuration of MC are important in imaging diagnosis for the
proper dental implant placement in the mandible [<xref ref-type="bibr" rid="B33">33-36</xref>]. The
MC is usually identifiable on radiographs as a narrow radiolucent ribbon bordered
by radio-opaque lines. Periapical radiographs have been used for many years to assess
the jaws pre- and post-implant placement [<xref ref-type="bibr" rid="B37">37</xref>]. The long cone
paralleling technique for taking periapical X-ray is the technique of choice for
the following reasons: reduction of radiation dose; less magnification; a true relationship
between the bone height and adjacent teeth is demonstrated. It should be noted that
for the long cone paralleling technique, it should be taken with a film-focal distance
of approximately 30 cm [<xref ref-type="bibr" rid="B38">38</xref>]. One of the shortcomings of the present
method is the use of film. Since the film is highly flexible, literally and figuratively,
its processing can be suboptimal and it often leads poor image. Furthermore, maintaining
a darkroom requires space and time as well as the additional environmental expenses
[<xref ref-type="bibr" rid="B37">37</xref>]. </p><p>During the last decade, many dental practices replaced the film with digital
imaging systems. Common reasons for making this transition included improved patient
education, lower exposure, greater speed of obtaining images, and the perception
of being up to date in the eyes of patients [<xref ref-type="bibr" rid="B12">12</xref>,<xref ref-type="bibr" rid="B34">34</xref>].</p><p>Nevertheless, the biggest concern of periapical radiographs is in 28% of patients
that MC could not be clearly identified in the second premolar and first molar regions
[<xref ref-type="bibr" rid="B38">38</xref>]. Furthermore, the angulation of the periapical film can
affect the perceived location of the canal with respect to the bone crest [<xref ref-type="bibr" rid="B39">39</xref>].
In case, when X-ray beam is perpendicular to the canal, but not the film, elongation
occurs, and the canal appears further from the crest than it really is. Conversely,
when the X-ray beam perpendicular to the film, but is not parallel to the canal,
foreshortening happens [<xref ref-type="bibr" rid="B4">4</xref>].</p><p>When a specific region that is too large to be seen on a periapical view, panoramic
radiograph can be the method of choice. The major advantages of panoramic images
are the broad coverage of oral structures, low radiation exposure (about 10% of
a full-mouth radiographs), and relatively inexpensive of the equipment. The major
drawbacks of panoramic imaging are: lower image resolution, high distortion, and
presence of phantom images. These can artificially produce apparent changes thus
may hide some of important vital structures [<xref ref-type="bibr" rid="B12">12</xref>]. For example,
cervical spine images often overlap on the anterior mandible.</p><p>Wadu et al. [<xref ref-type="bibr" rid="B40">40</xref>], studying MC appearance on the panoramic
radiographs, found that the number of cases of radio-opaque border was either disrupted
or even absent. The superior border was more prone to disruption than the inferior
border (<xref ref-type="fig" rid="fig5">Figure 5</xref>).</p><p>In osteoporotic or thin trabeculae mandible, the best method for properly identifying
the MC is either via CT cross-sectional or CBCT images or scalloping of the cortical
plate on the endosteal surface. This is because when in close proximity of lingual
cortical plate, the MC may lie in a groove in the endosteal aspect of the cortical
bone. On some occasion, the MC will not appear as a circumscribed area of reduced
density, but as a circumscribed area of increased density [<xref ref-type="bibr" rid="B5">5</xref>].</p><fig id="fig5" orientation="portrait" position="float"><label>Figure 5</label><caption><p>The orthopantomograph shows the disrupted
(arrows) superior border of mandibular canal and cancellous bone which has
few and thin trabecullae.</p></caption><graphic xlink:href="jomr-01-e1-g005"></graphic></fig><p>Though the contrast enhancement application to the digital images improved significantly
diagnostic image quality [<xref ref-type="bibr" rid="B41">41</xref>], but the use of digital panoramic
images did not improve the depiction of the MC [<xref ref-type="bibr" rid="B36">36</xref>]. Furthermore,
Naitoh et al. [<xref ref-type="bibr" rid="B36">36</xref>] concluded that the MC borders depiction on
digital panoramic images was related to the bone density in alveolar region assessed
using multislice CT images. They found that MC visible in superior and inferior
wall was only 36.7%. Similarly, Lindh et al. [<xref ref-type="bibr" rid="B42">42</xref>] reported that
the MC of specimen cadavers was clearly visible in 25% of panoramic radiographs
(range 12 to 86%). Klinge et al. [<xref ref-type="bibr" rid="B43">43</xref>] also reported that the
MC of specimen cadavers was not visible in 36.1% of panoramic radiographs.</p><p>CT values (Hounsfield units: HU) and bone mineral densities obtained by medical
CT were used to assess the bone density of jaws [<xref ref-type="bibr" rid="B44">44-46</xref>]. Norton
and Gamble [<xref ref-type="bibr" rid="B45">45</xref>] measured the bone density in the posterior mandible
using SimPlant software (3D Diagnostix, Boston, MA, USA) and concluded that the
mean CT value was 669.6 HU. Misch [<xref ref-type="bibr" rid="B44">44</xref>] classified cancellous
bone density into 5 grades: D1: > 1250 HU; D2: 850 to 1250 HU; D3: 350 to 850 HU;
D4: 150 to 350 HU; and D5: < 150 HU. In the conversion of CT values (HU), the mean
value in the molar region was 4.5 x 10<sup>2 </sup>(D3): in the first molar region
it was 5.2 x 10<sup>2 </sup>(D3), in second molar region 4.3 x 10<sup>2 </sup>(D3),
and in the third molar region it was 0.7 x 10<sup>2 </sup>(D5).</p><p>The measurements of bone density in designed sites are critical in presurgical
planning when using CBCT for dental implant treatment. However, the pixel or voxel
values obtained from CBCT images are not absolute values. Naitoh et al. [<xref ref-type="bibr" rid="B36">36</xref>]
reconstructed the cross-sectional images of cone-beam and multislice CT and calculated
the values of regions-of-interest in 16 images. A high-level correlation between
voxel values of CBCT and bone mineral densities of multislice CT was observed (r
= 0.965). They concluded that voxel values of mandibular cancellous bone in CBCT
could be used to estimate bone density.</p><p>Another attempt to improve depiction of the MC was by changing the thickness
of double-oblique computed tomography images [<xref ref-type="bibr" rid="B47">47</xref>]. A total of
38 sites in the mandibular molar region were examined using multislice helical CT.
The thicknesses of the double-oblique images using multislice helical CT scans were
reconstructed in 4 conditions: 0.3 mm, 0.9 mm, 1.6 mm, and 4.1 mm. In the alveolar
crest and the entire MC, highest value was obtained with 0.9 mm thick images; however,
there was no significant difference between 0.3 mm and 0.9 mm thick images. Authors
then concluded that the description of superior wall of MC cannot be improved by
changing the thickness of images.</p><p>However, the measurements obtained from computed tomographic images are more
consistent with direct measurements than the measurements obtained from panoramic
radiographic images or conventional tomographic images (<xref ref-type="fig" rid="fig6A">Figure 6 A</xref>and <xref ref-type="fig" rid="fig6B">B</xref>). This conclusion was made by Peker et al. [<xref ref-type="bibr" rid="B48">48</xref>] after
the comparison of efficiency of panoramic radiographs, conventional tomograms, and
computed tomograms for location of the MC for 12 regions of 6 dry adult human skulls.
Furthermore, Rouas et al. [<xref ref-type="bibr" rid="B49">49</xref>] reported that the atypical MC
such as bifid MC, in most cases can be identified using only three-dimensional imaging
techniques. It was thought that the bifid MC is often left unrecognized [<xref ref-type="bibr" rid="B50">50</xref>].
Although, duplication or division of the canal was found, via panoramic radiographs,
in about 1% of patients [<xref ref-type="bibr" rid="B27">27</xref>,<xref ref-type="bibr" rid="B51">51-53</xref>]. Naitoh
et al. [<xref ref-type="bibr" rid="B54">54</xref>] reconstructed 122 two-dimensional images of the various
planes in mandibular ramus region to the computer program using three-dimensional
visualization and measurement software. Bifid MC in the mandibular ramus region
was observed even in 65% of patients.</p><fig id="fig6A" orientation="portrait" position="float"><label>Figure 6A</label><caption><p>Computed tomographic images: mental foramen (arrow) detection.</p></caption><graphic xlink:href="jomr-01-e1-g006A"></graphic></fig><fig id="fig6B" orientation="portrait" position="float"><label>Figure 6B</label><caption><p>Computed tomographic images: mandibular canal detection (arrow).</p></caption><graphic xlink:href="jomr-01-e1-g006B"></graphic></fig><p>When the periapical radiography, panoramic radiography, tomography, or CT were
compared for their efficiency in the identification of the MC, the CBCT seems to
have the most potential while reduces radiation exposure considerably. Angelopoulos
et al. [<xref ref-type="bibr" rid="B55">55</xref>] compared CBCT reformatted panoramic images with direct
(charge-coupled device-based) panoramic radiographs and digital panoramic radiographs
based on a storage phosphor system. They concluded that the CBCT reformatted panoramic
images outperformed the digital panoramic images in the identification of the MC.
Due to the fact that the CBCT images were reformatted slices of the mandible, they
were free of magnification, superimposition of neighbouring structures, and other
problems inherent to the panoramic radiology. It has also been shown that the CBCT
had more accuracy and reproducibility of measurements of MC when compared to direct
digital calliper measurements [<xref ref-type="bibr" rid="B56">56</xref>]. Basically, the intraclass
correlation coefficients for CBCT and the direct digital calliper ranged from 0.61
to 0.93 for the first observer and from 0.40 to 0.95 for the second observer.</p><p><bold>Peculiarities of mental foramen (MF) clinical anatomy</bold></p><p>One of the most challenged regions for implantation in mandible is MF region.
This is because there are many variations with regards to the size, shape, location
and direction of the opening of the MF. The shape of MF can be round or oval: diameter
ranges from 2.5 to 5.5 mm [<xref ref-type="bibr" rid="B57">57-59</xref>,<xref ref-type="bibr" rid="B60">60-64</xref>]. The location of MF differs
in the horizontal and vertical planes. The most popular method for the identification
of MF in the horizontal plane was proposed by Green [<xref ref-type="bibr" rid="B65">65</xref>]. The
position of MF was recorded as either in the line with the longitudinal axis of
a tooth or as lying between the two teeth. It was shown in number of studies that
the location of MF is related with race. For example, the position of MF in the
Mongoloid population was in the line with longitudinal axis of the second lower
premolar. Their positions in Caucasoid samples were just mesial to those in Chinese,
Melanesian, Asian Indians, Thai, Korean, Saudi and Tanzanian samples [<xref ref-type="bibr" rid="B34">34</xref>,<xref ref-type="bibr" rid="B57">57</xref>,<xref ref-type="bibr" rid="B58">58</xref>,<xref ref-type="bibr" rid="B63">63</xref>,<xref ref-type="bibr" rid="B66">66-70</xref>].</p><p>When planning dental implant operation, clinicians should identify vertical MF
position, because after the extraction of teeth and resorption of alveolar bone,
the MF is closer to the alveolar crest [<xref ref-type="bibr" rid="B59">59</xref>,<xref ref-type="bibr" rid="B71">71</xref>].
In extreme degrees of resorption, the mental nerve and the final part of inferior
alveolar nerve were found directly under the gums. In such cases the initial incision
should be made more lingually and a full-thickness flap is elevated until the MF
is identified [<xref ref-type="bibr" rid="B72">72</xref>].</p><p>When examined the vertical MF position in relation to the premolars root apices
of 936 patients, Fishel et al. found that the MF was situated coronal to the apex
in 38.6% of cases, at the apex in 15.4% of cases, and apical to the apex in 46.0%
of cases [<xref ref-type="bibr" rid="B66">66</xref>]. For second premolar, MF was coronal to the apex
in 24.5% of cases, 13.9% at the apex, and 61.6% apical to the apex. Due to 25% to
38% of the foramen is located coronal to the premolars apex, this may create challenge
in immediate implant placement especially in the premolar areas [<xref ref-type="bibr" rid="B66">66</xref>].
The opening of MF can be done in many different locations such as superiorly, posterosuperiorly,
labially, mesially (anteriorly), and posteriorly [<xref ref-type="bibr" rid="B58">58</xref>,<xref ref-type="bibr" rid="B62">62,63</xref>,<xref ref-type="bibr" rid="B73">73</xref>,<xref ref-type="bibr" rid="B74">74</xref>].</p><p>In addition, it was reported, that MF can be more than 1 and this is often related
to the race [<xref ref-type="bibr" rid="B68">68</xref>,<xref ref-type="bibr" rid="B75">75</xref>,<xref ref-type="bibr" rid="B76">76</xref>,<xref ref-type="bibr" rid="B77">77</xref>]. For example, the
accessory MF was found less frequently in American White (1.4%) and Asian Indian
(1.5%) populations when compared to African Americans (5.7%) and pre-Columbian Nazca
Indians (9.0%). [<xref ref-type="bibr" rid="B75">75</xref>]. CBCT has showed that accessory MF tended
to exist in the apical area of the first molar and posterior or inferior area of
the MF [<xref ref-type="bibr" rid="B76">76</xref>]. If the MF is in close proximity to the alveolar
crest or has atypical anatomy radiographically, to locate the MF properly and to
avoid mental nerve damage, it should be done surgically. Some clinicians [<xref ref-type="bibr" rid="B48">48</xref>,<xref ref-type="bibr" rid="B79">79</xref>]
are proposing nerve transposition during the implant placement when there is insufficient
EJS dimension. Nevertheless, this approach is not popular due to a high rate of
sensory dysfunction postoperatively [<xref ref-type="bibr" rid="B80">80-82</xref>].</p><p><bold>Radiological mental foramen (MF) detection</bold></p><p>Periapical radiograph is a good tool for the MF detection not only because it
reduces skin dose, limits magnification, but it also can be used to establish a
true relationship between the bone height and adjacent teeth. However, they are
shortcomings associated with periapical radiographs. First of all, a slight image
distortion can occur due to angulation and this may account for inability to detect
the foramen [<xref ref-type="bibr" rid="B60">60</xref>]. Secondary, when MF is located below the apex,
it can be difficult to show [<xref ref-type="bibr" rid="B66">66</xref>]. Third, in thin mandibular bone
it cannot properly identify the MF due to a lack of radiographic contrast [<xref ref-type="bibr" rid="B57">57</xref>,<xref ref-type="bibr" rid="B60">60</xref>].
Because of the above shortcomings, MF can be identified around 47 - 75% cases [<xref ref-type="bibr" rid="B66">66</xref>,<xref ref-type="bibr" rid="B83">83</xref>].
To overcome this problem, a combination of horizontal periapical film together with
a panoramic image has been suggested [<xref ref-type="bibr" rid="B84">84</xref>].</p><p>In contrast, Yosue and Brooks [<xref ref-type="bibr" rid="B60">60</xref>] detected the MF on 87.5%
(n = 297) of panoramic radiographs, and it was distinct 64% of the time. They classified
the appearance of the MF on panoramic radiographs as a continuous, separated, diffuse,
or unidentified type. In a sample of 297 patients, the most frequent appearance
was separated (43%), followed by diffuse (24%), continuous (21%), and unidentified
(12%). Similarly, Jacobs et al. [<xref ref-type="bibr" rid="B85">85</xref>] detected the MF on 94% (n
= 545) of panoramic radiographs, but the clear visibility was attained only 49%
of the time. After comparison of the anatomical and radiological assessment of 4
cadaver skulls, Yosue and Brooks [<xref ref-type="bibr" rid="B60">60</xref>] concluded that the panoramic
and periapical films reflected the actual position of foramen in the skulls < 50%
the time. Furthermore, Sonick et al. [<xref ref-type="bibr" rid="B86">86</xref>] found that the average
linear errors occurred during routine bone assessments (n = 12) for panoramic films
were 24% (mean 3 mm; range 0.5 to 7.5 mm), for periapical
films were 14% (mean 1.9 mm; range 0.0 to 5.0 mm) and only 1.8% (mean 0.2 mm; range
0.0 to 0.5 mm) for CT scans. Hence, it is concluded that CT scans are more accurate
than conventional radiographs [<xref ref-type="bibr" rid="B43">43</xref>,<xref ref-type="bibr" rid="B85">85-88</xref>].
However, the limitations of cross-sectional imaging are: limited availability, high
cost and the need for image interpretation [<xref ref-type="bibr" rid="B89">89</xref>,<xref ref-type="bibr" rid="B90">90</xref>]. However,
CBCT is often recommended for clinical usage, especially in cases there the vital
structures are difficult to detect due to its high accuracy and low radiation exposure
[<xref ref-type="bibr" rid="B17">17</xref>,<xref ref-type="bibr" rid="B18">18</xref>,<xref ref-type="bibr" rid="B19">19</xref>,<xref ref-type="bibr" rid="B91">91</xref>]. For example, Naitoh et al.
[<xref ref-type="bibr" rid="B77">77</xref>] studied CBCT images of 157 patients and found the accessory
MF observed in 7% of patients. There was no significant difference regarding the
sizes of MF between accessory MF presence and absence. Also, the mean distance between
the mental and accessory MF was 6.3 mm (SD 1.5 mm).</p><p>The main advantage of CBCT is a low dose scanning system, which has been specifically
designed to produce three-dimensional images of the maxillofacial skeleton [<xref ref-type="bibr" rid="B92">92,93</xref>].
Remarkably, in most systems scan times of less than 20 seconds can be achieved using
personal computers. Hence, a major difference between CT and CBCT is how the data
are gathered: CT acquires image data using rows of detectors, CBCT exposes the whole
section of the patient over one detector [<xref ref-type="bibr" rid="B92">92</xref>,<xref ref-type="bibr" rid="B93">93</xref>].</p><p><bold>Peculiarities of anterior loop (AL) of mental nerve clinical anatomy</bold></p><p>When inferior alveolar nerve arises from the MC, it runs outward, upward and
backward to open at the MF then it was called as AL [<xref ref-type="bibr" rid="B94">94-98</xref>].
This means that the MN, however, may extend beyond the MF boundary as an intraosseous
AL. The most objective evidence for the presence of AL is examination of dissected
cadaver mandibles. For example, Solar et al. [<xref ref-type="bibr" rid="B73">73</xref>] AL detected
in 60% (22 of 37) of dissected cadaver mandibles, ranging in length from 0.5 to
5 mm (mean 1 mm); Neiva et al. [<xref ref-type="bibr" rid="B57">57</xref>] AL detected in 88% (n = 22),
ranging in length from 1 to 11 mm (mean 4.13 mm); Rosenquist [<xref ref-type="bibr" rid="B97">99</xref>]
detected AL in 24% (15 of 58) ranging in length from 0 to 1 mm.</p><p>In clinical practice possible presence of an AL should be identified radiographically
before the implant placement. Additionally, clinician can probe the MF to ascertain
if there is an AL during surgical operation. In this regard, a curved probe (e.
g., Naber's 2N probe) can be gently placed into the foramen to assess if its distal
aspect is open. If it is not open, then the nerve entered on the mesial side, and
this denotes that an AL is present [<xref ref-type="bibr" rid="B6">6</xref>]. Otherwise, it is not possible
to distinguish between the patency of the mesial aspect of the MF leading to the
incisal region and an AL because those two structures feel similar [<xref ref-type="bibr" rid="B97">97</xref>].
Furthermore, neurologic damage can be induced to the nerve when the length of an
AL is not clear. If there is no possibility to obtain accurate information about
mental nerve with CT or CBCT, it was recommended to place the implant 6 mm anterior
to the MF to avoid causing the nerve damage [<xref ref-type="bibr" rid="B73">73</xref>].</p><p><bold>Radiological anterior loop (AL) of mental nerve detection</bold></p><p>Using radiographic methods to assess an anterior mental loop revealed large variations.
Bavitz et al. [<xref ref-type="bibr" rid="B97">96</xref>] reported that the AL was present in 54% (17
of 35) of periapical radiographs taken of hemi-mandibles. However, this finding
was only confirmed by dissection in 11% (4 of 35) of the corresponding cadaver specimens.
Loop sizes ranged from 0.0 to 7.5 mm on periapical radiographs and from 0 to 1.0
mm among cadaver specimens. Mardinger et al. [<xref ref-type="bibr" rid="B97">100</xref>] assessed 46
hemi-mandibles using periapical films and dissection with physical evaluation. No
correlation was found between the radiographic image and the anatomical shape of
the loop. Also, 70% of the radiographically diagnosed loops, 40% were not seen in
anatomical examination.</p><p>Yosue and Brooks [<xref ref-type="bibr" rid="B60">60</xref>] examined 297 panoramic radiographs and
noted that an AL (termed continuous type MF in their study) was present only 21%.
Misch and Crawford [<xref ref-type="bibr" rid="B97">101</xref>] noted an AL average length was 5 mm
in 12% of 324 patient's panoramic radiographs. Arzouman et al. [<xref ref-type="bibr" rid="B95">95</xref>]
looked at the 25 adult skulls using panoramic, with and without radiopaque markers
placed into the MC and AL. The AL was also recorded directly using flexible tubing
(2 mm in diameter). Significantly fewer loops were detected in radiographs as compared
with anatomical assessment (P < 0.001). A significant loop (> 2 mm) was identified
in 92% to 96% of the direct measurement, whereas panoramic radiographs identified
only 56% and 76% with and without radiopaque markers, respectively. The average
length of the AL based on direct measurements was 6.95 mm, whereas radiographic
measurements were 3.18 mm and 3.45 mm using different panoramic machine. Kuzmanovic
et al. [<xref ref-type="bibr" rid="B97">98</xref>] compared visual interpretation of the panoramic radiographs
with anatomical dissection findings in 22 cadavers. AL of the mental canal was only
identified in 6 panoramic radiographs (27%) (range 0.5 to 3 mm) and 8 (35%) in anatomical
measurements. Jacobs et al. [<xref ref-type="bibr" rid="B85">85</xref>] examined 545 patient's panoramic
radiographs and found an AL in 11% of cases, but was well visualized in only 3%
of the detected loops. Ngeow et al. [<xref ref-type="bibr" rid="B70">70</xref>] reported that the AL
was only visible in 39 (40.2%) panoramic radiographs. Authors then concluded that
the panoramic is not sufficient for presurgical implant planning in the mental region
and there is a need for other additional images. Jacobs et al. [<xref ref-type="bibr" rid="B97">102</xref>]
examined 230 spiral CT scans taken for preoperative planning of implant placement
in the posterior mandible where the AL appeared in 7% of cases. However, according
to Rothman [<xref ref-type="bibr" rid="B97">103</xref>] the appearance of AL on CT scans can be described
precisely. Uchida et al. supported Rothman's point of view [<xref ref-type="bibr" rid="B97">104</xref>],
who used CBCT in 4 cadavers and dissected 71 cadavers. The anatomical measurements
revealed the mean AL size of 1.9 ± 1.7 mm (range 0.0 to 9.0 mm). The average discrepancies
between CBCT and anatomical measurements were 0.06 mm or less.</p><p>Investigations that compared radiographic and cadaveric dissection data with
respect to identifying the AL reported that radiographic assessments result in a
high percentage of false-positive and false-negative findings [<xref ref-type="bibr" rid="B95">95</xref>,<xref ref-type="bibr" rid="B96">96</xref>,<xref ref-type="bibr" rid="B98">98-100</xref>].
Varied findings might be attributed to different criteria used to define the AL,
dissimilar diagnostic techniques, and diverse findings in patients [<xref ref-type="bibr" rid="B4">4</xref>].</p><p><bold>Peculiarities of mandibular incisive canal (MIC) clinical anatomy</bold></p><p>MIC, a continuation of MC, has been identified in several reports [<xref ref-type="bibr" rid="B71">71</xref>,<xref ref-type="bibr" rid="B85">85</xref>,<xref ref-type="bibr" rid="B97">105</xref>,<xref ref-type="bibr" rid="B106">106</xref>].
Mraiwa et al. [<xref ref-type="bibr" rid="B71">71</xref>] reported MIC was macroscopically observed
in 96% of 50 cadavers' mandibles with mean (SD) inner diameter of 1.8 (0.5 mm).
The MIC was located on average 9.7 mm (SD 1.8 mm) from the lower cortical border
and continued towards the incisor region in a slightly downward direction, with
a mean (SD) distance to the lower cortical border of 7.2 (2.1) mm. The canal was
narrowing crossing the midline and reached only the midline in 18% of cases. The
MIC was terminating apically to the lateral incisor and sometimes apically to the
central incisor. The diameter of MIC ranged from 0.48 to 6.6 mm. Mardinger et al.
[<xref ref-type="bibr" rid="B97">100</xref>] found MIC in all 46 cadavers' specimens, travelling within
the canal. De Andrade with co-authors [<xref ref-type="bibr" rid="B97">106</xref>] concluded that, the
MIC is a normal structure that typically extends closer to the mandibular midline.
The incisive nerve supplies innervation to first bicuspid, canine, lateral incisors
and central incisors.</p><p>In case of large MIC, a patient may experience discomfort during osteotomy or
experience postoperative pain that requires no implant insertion or implant removal
[<xref ref-type="bibr" rid="B97">107-109</xref>].</p><p><bold>Radiological mandibular incisive canal (MIC) detection</bold></p><p>Mardinger et al. [<xref ref-type="bibr" rid="B97">100</xref>] defined the anatomic and radiographic
courses of MIC in 46 cadavers' hemi-mandibles. They distinguished the canals into
complete (n = 10), partial (n = 27), or no (n = 9) bony cortical borders. Furthermore,
the canal was either well defined (n = 11, 24%), poorly defined (n = 15, 32%), or
undetectable (n = 20, 44%) using the panoramic radiography. It was concluded that
statistically significant correlation was found between the anatomic structure of
the MIC bony borders and its radiographic detectability (P = 0.043). However, Jacobs
with co-workers [<xref ref-type="bibr" rid="B97">102</xref>] reported that the MIC was identified only
in 15% of the 545 panoramic radiographs, with good visibility of only 1%. In contrast,
canal was observed on 93% of CT scans with a good visibility in 22% of cases.</p><p>Uchida et al. found that the MIC diameter ranged from 1.0 to 6.6 mm with SD of
2.8 ± 1.0 mm [<xref ref-type="bibr" rid="B97">104</xref>] and confirmed the reliability of CBCT in detecting
MIC. Pires et al. [<xref ref-type="bibr" rid="B97">110</xref>] later agreed with Uchida et al. and reported
that the MIC parameters are better determined by CBCT (83%) than by panoramic radiography
(11%). The range of MIC diameter was from 0.4 x 0.4 mm to 4.6 x 3.2 mm. The mean
length of canal was 7 ± 3.8 mm. The distance from the inferior border of mandible
to the canal was 10.2 ± 2.4 mm, and the mean distance to the buccal plate was 2.4
mm. The apex-canal distance (in dentate subjects) was 5.3 mm. Therefore, it is recommended
to use conventional tomographs or CBCT for better imaging of the interforaminal
area.</p><p><bold>Guidelines to identify mandibular vital structures</bold></p><p>The goal of planning for dental implant operation is that clinicians should have
clear three-dimensional vision of the EJS. This can be achieved by combining the
practical knowledge of basic mandibular anatomy and data obtained from clinical
and radiological examination. The following are recommendations for properly planning
implant surgery in the mandible especially in the areas of vital structures.</p><p><bold><italic>Mandibular canal region</italic></bold></p><p>1. Consider the influence of bony crestal anatomy. If there is a need to re-shape
the crestal ridge in order to accommodate future implant placement then it is important
to deduct 1 to 3 mm from the calculation or plan to perform ridge augmentation.</p><p>2. Buccolingual position of the crestal peak of bone can influence the
reliability on intraoral or panoramic radiograph in vertical plane.</p><p>3. The buccolingual position of the MC can influence MC position in vertical
plane on panoramic radiograph.</p><p>4. If large mandibular torus is present it may create false impression on the
amount of the available bone height as well as difficult to depict MC borders.</p><p><bold><italic>Mental foramen region</italic></bold></p><p>6. In cases where the extreme ridge resorption existed, the initial incision
should be made more to the lingual and a full-thickness flap is elevated until the
MF is identified.</p><p>7. Be aware of 25% to 38% of cases, the MF is located coronal to the premolars
apex.</p><p>8. The best approach to locate MF is surgical access.</p><p><bold><italic>Anterior loop of the mental nerve region</italic></bold></p><p>9. The MN may extend beyond the MF boundary.</p><p>10. Clinician should probe MF gently to ascertain if there is an AL during surgical
operation. </p><p>11. If CT or CBCT cannot provide accurate information on mental nerve location
and its pathway, the distal aspect of dental implant should be placed 6 mm anterior
to the MF to avoid potential nerve damage.</p><p><bold><italic>Mandibular incisive canal region</italic></bold></p><p>12. The large MIC should be taken into account in patients who developed discomfort
during osteotomy or after implant placement.</p><p>Many radiographic methods, including periapical, panoramic, conventional CT [<xref ref-type="bibr" rid="B13">13</xref>],
and CBCT [<xref ref-type="bibr" rid="B16">16-19</xref>], have been recommended for the pre-implant treatment
planning. The CT scan was developed to overcome the drawback, lack of cross-sectional
information, noted in the conventional radiography (periapical and panoramic) [<xref ref-type="bibr" rid="B9">9</xref>,<xref ref-type="bibr" rid="B14">14</xref>,<xref ref-type="bibr" rid="B97">111</xref>].
Due to the ability of precisely identifying anatomical landmarks, high accuracy
and low radiation exposure, CBCT has been suggested to be the main method for radiographic
pre-implant planning tool [<xref ref-type="bibr" rid="B16">16-19</xref>].</p><p>The following recommendations are made with regards to radiographical assessment
during the implant presurgical planning.</p><p><bold><italic>Periapical radiography</italic></bold></p><p>1. The long cone paralleling technique is the technique of choice for taking
periapical radiographs. To be accurate, a film-focal distance should not go beyond
30 cm.</p><p>2. The drawback for periapical radiography is using film. Because the film is
highly flexible, literally and figuratively, it's processing is often suboptimal,
with deleterious consequences to the image quality.</p><p>3. The angulation can cause distortion.</p><p>4. 28% of patients, MC could not be clearly identified in the second premolar
and the first molar regions. </p><p>5. In cases where the MF is located in low position, periapical film or digital
sensor cannot properly locate its position.</p><p><bold><italic>Panoramic radiography</italic></bold></p><p>6. Panoramic can provide wide coverage of the oral structures, relatively low
radiation exposure (as compared to full-mouth periapical X-rays), and moderately
low expense of the equipment.</p><p>7. The major limitations of panoramic are: lower resolution, higher distortion,
potential of overlapping anatomical structures, image is often related to the bone
density and difficult to accurately identify vital structures.</p><p>8. To compensate distortions, a pre-known marker is needed for calculation of
magnification %.</p><p>9. A minimal of 2 mm safety zone away from the vital structures is often recommended
to avoid future nerve damage.</p><p><bold><italic>Computer tomography and cone beam computer tomography</italic></bold></p><p>10. So far, computed tomographic (CT or CBCT) images are more consistent with
direct measurements. The advantages of CBCT are: low exposure, high accuracy, three-dimensional
image, and a low dose scanning system.</p><p>11. The main limitations of cross-sectional imaging are: limited availability,
difficulty in image interpretation, and high cost.</p><p>12. The CT and CBCT differ in how the data are gathered: CT acquires image data
using rows of detectors and CBCT exposes the whole section over one detector.</p></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>Prior to commencement of the implant surgery, careful and detailed planning is
required to identify mandibular vital structures as well as the shape and dimensions
of the bone. The decision on which image is the most appropriate for each case should
be based upon the radiation involved, the cost, and the reliability of each examination
method. At current, it appears the cone beam computed tomography showed the great
potential for proper pre-implant planning. The guidelines proposed here serve as
a tool to assist clinicians in properly identifying mandibular vital structures
while providing information related to the current used radiographic techniques.</p></sec></body><back><ack><sec sec-type="acknowledgments and disclosure statements"><title>ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS</title><p>The authors report no conflicts of interest related to this study.</p></sec></ack><ref-list><title>REFERENCES</title><ref id="B1"><label>1</label><element-citation publication-type="other"><person-group person-group-type="author"><name><surname>Givol</surname><given-names>N</given-names></name><name><surname>Taicher</surname><given-names>S</given-names></name><name><surname>Halamish-Shani</surname><given-names>T</given-names></name><name><surname>Chaushu</surname><given-names>G</given-names></name></person-group><source>Risk
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