Australian Dental Journal 2008; 53:(1 Suppl): S11–S25

doi: 10.1111/j.1834-7819.2008.00037.x

Implant radiography and radiology

PA Monsour,* R Dudhia*
*School of Dentistry, The University of Queensland, Brisbane.

ABSTRACT
The practitioner placing dental implants has many options with respect to pre-implant radiographic assessment of the jaws.
The advantages and disadvantages of the imaging modalities currently available for pre-implant imaging are discussed in
some detail. Intra-oral and extra-oral radiographs are generally low dose but the information provided is limited as the
images are not three-dimensional. Tomography is three-dimensional, but the image quality is highly variable. Computed
tomography (CT) has been the gold standard for many years as the information provided is three-dimensional and generally
very accurate. However, CT examinations are expensive and deliver a relatively high radiation dose to the patient. The latest
imaging modality introduced is cone beam volumetric tomography (CBVT) and this technology is very promising with
regard to pre-implant imaging. CBVT generally delivers a lower dose to the patient than CT and provides reasonably sharp
images with three-dimensional information. A comparison between CT and CBVT is provided. Magnetic resonance imaging
is showing some promise, but the examinations are not readily available, generally expensive and bone is not well imaged.
Magnetic resonance imaging is excellent for demonstrating soft tissues and therefore may be of great use in identifying the
inferior dental nerve and vessels. All of the above technology is of little value if the information required is not obtained and
so information is also provided on imaging of some of the vital structures. Of particular interest is the inferior dental canal,
incisive canals of the mandible, genial foramina and canals, maxillary sinus and the incisive canal and foramen of the
maxilla.
Key words: Radiography, radiology, implants, computed tomography, cone beam volumetric tomography.
Abbreviations and acronyms: CBVT = cone beam volumetric tomography; CT = computed tomography; FOV = field of view; IC = incisive
canal; IDC = inferior dental canal; MRI = magnetic resonance imaging.

INTRODUCTION Intra-oral radiography

It is essential to obtain appropriate information about
the jaws prior to implant placement and this includes
assessment of bone grafts. It is also necessary to obtain
information about consolidation of implants and posi-
tioning following placement of implants in the jaws
or adjacent bones. There are many imaging options
currently available, including intra-oral radiography,
conventional extra-oral radiography, tomography,
computed tomography (CT), cone beam volumetric
tomography (CBVT) and magnetic resonance imaging
(MRI). The appropriateness of each of the imaging
options will be discussed and information will also be
provided on interpretation. In recent times we have seen
the emergence of CBVT units and as with any new
technology many claims have been made to convince
prospective users of the benefits of the new technology.
This paper will examine in some depth the benefits and
failings of CBVT as the technology currently stands.
ª 2008 Australian Dental Association
Periapical radiographs and occlusal radiographs have
been used to assess the jaws pre- and post-implant
placement. The use of the bisecting angle technique
for taking periapical radiographs should be discour-
aged because of the inherent distortion of the
resultant image. The bisecting angle technique relies
on a geometric trick to produce the image, but only a
portion of the structures being imaged are dimension-
ally accurate. The long cone paralleling technique for
taking periapical radiographs is the technique of
choice for the following reasons: reduced skin dose;
less magnification; a true relationship between the
bone height and adjacent teeth is demonstrated; no
superimposition of the zygoma over the upper molar
region. It should be remembered that to get the most
from the long cone paralleling technique it should be
performed with a film-focal distance of approximately
30 cm.
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PA Monsour and R Dudhia

Occlusal radiographs have minimal application in Table 1. Radiation dose

implant dentistry. Cross-sectional occlusal radiographs
MODALITY 1990  (mSv) 2005   (mSv)
of the mandible give some information about the bucco-
39
lingual dimension of the mandible, but this information Background radiation 2.000 n⁄a
(per annum)
is only accurate with regard to the inferior aspect of the Intra-oral radiography
body, not the width of the alveolar ridge where the Long-cone paralleling 0.001–0.010 0.005–0.015
implant is to be placed. The use of cross-sectional periapical radiograph40–42
Full-mouth periapical 0.013–0.150 n⁄a
occlusal radiographs can be helpful when assessing the survey8,10,42,43
position of the implant within the jaw following Occlusal radiograph40,41 0.007–0.008 n⁄a
placement; this applies to both the mandible and maxilla. (mx)

Extra-oral radiography
Rotational panoramic 0.0029–0.026 0.009–0.022
Extra-oral radiography radiograph8,10,11,15,40–46
Lateral Cephalometric 0.002–0.005 0.003
Lateral cephalometric radiographs provide accurate radiographs41,45
information about the available bone in the mid-sagittal Tomography (4 slices)40,42–45,47 0.006–0.134 0.012
region of the maxilla and mandible. Because of the long Tomography (full survey)40,43,44 0.063–0.477 n⁄a
film-focal distances used in cephalometric radiography Cone beam volumetric 0.037–0.847 0.052–1.025
the resultant image has minimal magnification. Figure 1 tomography8,10,11,15,30,46,48
shows a lateral cephalometric radiograph taken with a Multislice computed 0.104–2.100 n⁄a
trial lower denture in place and radio-opaque material tomography8,30,40–44,46,48
defining the proposed implant site in the anterior Low-dose multislice computed 0.100–0.760 0.924
tomography10,40,43,45,46,48
mandible. The cross-sectional dimensions and mor- (most data pertains to single
phology of the ridge are shown accurately in the mid- arch scans)
sagittal plane of the anterior maxilla and mandible. Magnetic resonance imaging 0 0
Rotational panoramic radiography (OPG) is an
incredibly popular form of radiography in dentistry  1990 guidelines for effective dose calculation do not apply an indi-
vidual tissue weighting to salivary glands and brain tissue.
generally. No other imaging modality gives as much   2005 draft guidelines apply an individual tissue weighting to sali-
information about the jaws with such a small radiation vary glands and brain tissue – increasing their relative weighting in the
dose. With rare earth intensifying screens the dose from effective dose calculation.
n ⁄ a: not available.
a single OPG is approximately 0.007 mSv using
analogue technology (Table 1). Panoramic radiographs
provide an excellent general overview of the dentition
and the jaws. However, OPGs have their limitations
when being used for pre- and post-implant assessment
of the jaws. There are inherent problems with OPGs
which include distortion in the horizontal plane,
magnification in the vertical plane, true relationships
are not demonstrated well and the image is only two-
dimensional. The accuracy of the image is largely
operator dependent and varies greatly with patient
positioning. Figure 2 shows an OPG in which the
patient’s head is rotated to the left, resulting in
horizontal magnification of the structures on the left

Fig 1. Lateral cephalometric radiograph of an edentulous patient

showing the available bone in the mid sagittal plane of the maxilla Fig 2. Panoramic radiograph showing horizontal enlargement of
and mandible (arrows) with the trial mandibular denture in place structures on the left side due to rotation of the head to the left during
(arrowhead). (Courtesy of Dr Gary Smith.) taking of the radiograph.
S12 ª 2008 Australian Dental Association

(a)
(b)
Fig 3. (a) Panoramic radiograph with the occlusal plane in
the incorrect position (chin up). (b) Same patient with the chin
down further.
and a reduction in the horizontal dimension of struc-
tures on the right. Figure 3 shows the effect on
horizontal dimension of having the patient positioned
with the chin up too high for an OPG. Figure 4 shows
the effect on horizontal dimension of the head being too
far forward and too far back in the OPG machine. The
inferior dental canal is not always well shown on
(a)
(b)
Fig 4. (a) Cropped panoramic radiograph with the anterior teeth
inside the focal trough, resulting in horizontal enlargement and
blurring of the anterior teeth. (b) Panoramic radiograph with the
anterior teeth in front of the focal trough, resulting in all structures
being compressed in the horizontal plane.
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Implant radiography and radiology
(a)
(b)
Fig 5. Cross-sectional diagram of the mandible showing that
structures that are more lingual are projected higher on the film than
structures that are more buccal. (a) shows the inferior dental canal
close to the buccal cortex and a relative indication of where the canal
is projected onto the film, (b) demonstrates that when the inferior
dental canal is more lingual, the canal is projected higher on the film.
The inferior line drawings depict the difference in appearance of the
canal when buccal or lingual, on the panoramic radiograph.
rotational panoramic radiographs and when it is
shown, its relationship to the crest of the ridge may
be distorted. For example, if the inferior dental canal
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 (Fig 5). Due to the mode of operation of OPG
machines and the shape of the alveolar ridge, the ridge
may appear to have adequate vertical dimension for an
implant, but the reality is very different (Fig 6). Also, as
the image on an OPG is only two-dimensional, it is
difficult to assess the available bone width (Fig 7).
Other problems with OPGs include superimposition of
airway shadows, soft tissue shadows and ghost images,
all of which can interfere with interpretation of the
radiograph. As a general rule if the inferior dental canal
is poorly visualized on a well-taken OPG it will be
difficult to localize, but not impossible, using other
imaging modalities.
Tomography
A number of multifunctional imaging machines are
currently available that are capable of performing
rotational panoramic, cephalometric and tomographic
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PA Monsour and R Dudhia
(a)
(b)
Fig 6. (a) Cropped panoramic radiograph demonstrating considerable
bone height in the left mandibular body. Three lines identified as 1, 2
and 3 have been drawn vertically across the left mandibular body.
(b) Reformatted cross-sectional CT images corresponding to each line
from (a), indicating there is far less usable bone height in the left
mandibular body than the panoramic radiograph suggests.
examinations. Cross-sectional images obtained using
specially designed panoramic radiographic units have
been shown to be acceptable for dental implant
planning.1 The tomography performed is usually linear,
spiral or hypocycloidal. These devices are capable of
producing thin (as small as 1 mm) cross-sectional slices
of the jaws that are suitable for pre- and post-implant
assessment. Figure 8 shows a series of cross-sectional
images of the mandible obtained using hypocycloidal
tomography to demonstrate the available bone and
the location of the inferior dental canal. The images
are produced at a constant known magnification and
therefore measurements may be taken directly from
the images using a special ruler provided with the
appropriate scale or in the case of digital images using a
measurement programme after calibration. The multi-
functional units are also capable of providing images
similar to intra-oral radiographs. Limitations of these
types of units are that the examination times can be
very long (up to 20 minutes) and the patient is required
to remain still for up to 20 seconds during tomographic
acquisition of each site. Additionally, image detail may
not be sharp due to slight patient movement or
superimposition of adjacent structures, tomographic
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(a)
(b)
Fig 7. (a) Cropped panoramic radiograph demonstrating excellent
bone height in the lower right molar region. (b) Reformatted
cross-sectional CT images showing reasonable bone height, but the
ridge is narrow bucco-lingually.
examinations are not widely available and the exam-
ination can be uncomfortable for the patient due to the
restraining devices and the length of the examination.
Trans-tomographic examinations when performed
with a radiographic reference guide during implant
surgery have been shown to provide accurate informa-
tion for implant placement.2 This form of navigation
surgery allows the surgeon to rectify the drill’s orien-
tation when needed. Trans-tomographic navigation
protocols may allow flapless surgical procedures to be
utilized in a greater range of cases.
Computed tomography (CT)
For a long period of time CT has been the gold standard
for pre-implant assessment of the jaws. Modern CT
units have extremely fast gantry speeds and generate
multiple fan-shaped x-ray beams. As a result multislice
CT units have very short examination times and
isotropic images can be reformatted in any plane. The
scan time using a 16-slice Toshiba CT unit is approx-
imately five seconds for one arch. With appropriate
software packages, reformatted images are generated in
the panoramic plane and cross-sectional images are
generated at right angles to the panoramic plane with
intervals of between 1 and 2 mm. The CT pre-implant
imaging software is designed to produce life-size images
ª 2008 Australian Dental Association

Fig 8. Cross-sectional and panoramic images of the 46 region produced using hypocycloidal tomography to demonstrate the inferior dental canal
(arrows) and the available bone.
that can be used to assess the available bone, the
location of vital structures and to present the images in
an easy-to-read format. Figure 9 shows pre-implant
images generated using Toshiba’s pre-implant imaging
package. The pre-implant imaging packages can be
used to assess the bone in both jaws for implants, the
available bone in the various bone donor sites prior
to harvesting for ridge augmentation procedures and to
assess the available bone in the malar bones prior
to implant placement. The limitations of CT include
a relatively high radiation dose compared to other
imaging modalities (Table 1), the appropriate software
is not always available, the cost of the examination is
relatively high and not always rebateable from Medi-
care, the inferior dental canal is not always shown well
and beam hardening artefact or scatter from metal
restorations can obscure the regions of interest. Low-
density structures such as osteoid are generally beyond
the resolution of CT units.
CT is also of value in assessing the quantity and
subjective quality of bone prior to harvesting for
a bone graft or ridge augmentation procedure. As
implants are not only placed in the jaws, CT is of
value in assessing other implant sites such as the
malar bones prior to surgery. It will be necessary to
liaise closely with medical radiology practices when
requesting CT images for pre-implant assessment. It
should be made clear to the CT radiographer in the
practice exactly what information is required and this
is especially true when the data is to be imported for
further manipulation using pre-implant planning soft-
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Implant radiography and radiology
ware. CT radiographers should be encouraged to scan
the patient in a way that optimizes the information
obtained and that means orientating the patient to
minimize artefact from metal restorations and avoid-
ing gantry tilt wherever possible. The presence of a
post in the tooth next to the region of interest or
close by may result in too much ‘‘beam hardening’’
artefact or scatter to make the scan worthwhile.
Computed tomography will not be of value in
assessing integration of implants as a radiolucent
band is usually present around the implant on CT
images (Fig 10), but the location of the implant can
be assessed in three dimensions using CT.
Cone beam volumetric tomography (CBVT)
Cone beam volumetric tomography was pioneered at
the Nihon University School of Dentistry during the
1990s, and the first machines became commercially
available during 2000.3,4 Since then, numerous ma-
chines have been marketed and much research assessing
the usefulness of the technology in dentistry has been
performed. As with any emergent technology, it can
sometimes be difficult to separate fact from fiction.
Cone-beam technology is progressing rapidly and
scanners are constantly being refined and upgraded.
Keeping abreast with the latest technologies and
upgrades presents a significant challenge. A reasonable
number of scanners have already been installed in
dental practices and radiology practices, and this
number is sure to grow in the future.
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PA Monsour and R Dudhia

(a)

(b)

(c)

Fig 9. (a) Scout axial CT image of the mandible identifying the location of each reformatted panoramic and cross-sectional image using
pre-implant software. (b) Three of the usual five Ôlife sizeÕ reformatted panoramic images demonstrating the ROI in the right mandibular body.
(c) Consecutive reformatted Ôlife sizeÕ cross-sectional images showing part of the ROI. The location of each cross-section is identified on the
panoramic provided with each series of cross-sectional images.

While CBVT permits three-dimensional visualization With the majority of cone-beam machines, the patient
of the dental hard tissues in a similar manner to is seated or standing rather than being supine. Cone
multislice CT,5 there are some fundamental differences. beam volumetric tomography utilizes a cone-shaped
S16 ª 2008 Australian Dental Association

Fig 10. Axial CT image of the maxilla showing implants (arrows) in
the 14 and 24 regions with the typical CT radiolucent halo artefact.
x-ray beam and either an image intensifier or flat panel
detector for volumetric image acquisition.6,7 During a
single rotation around the patient’s head, multiple basis
images are acquired at specific intervals. These are
subsequently reconstructed by a personal computer
running proprietary software supplied by the machine’s
manufacturer, and this enables the clinician to arbi-
trarily reformat the data in any plane.8 Standard axial,
coronal and sagittal views are available, as are pano-
ramic reformats, cross-sectional cuts of varying thick-
ness and 3D volume rendered images.6,8,9 Image
reformatting is identical to that available with multi-
slice CT. This enables the clinician to easily assess an
implant site in all three planes and perform accurate
measurements using in-built measuring tools. The
volumetric data can also be exported in DICOM 3
format and viewed with numerous third-party pro-
grammes including some that are freely available from
the internet.
Image acquisition times vary and are specific to
particular models, but typically range between 10 to
70 seconds.6–8,10–12 Acquisition time is also dependent
on the selected field of view (FOV) and voxel size,
which relates to the image resolution.11 Smaller voxel
sizes theoretically equate to increased resolution. Faster
scan times typically result in reduced resolution (larger
voxel sizes) and increased noise, but with a lower
radiation dose and decreased likelihood of motion
artefact.8,13 This is achieved by decreasing the number
of basis images acquired prior to volume reconstruc-
tion. Longer scan times utilizing an increased number of
basis images permit increased resolution or a decrease
in image noise but with a significantly higher radiation
dose and an increased risk of patient movement.8 There
are currently no clear guidelines for what scan param-
eters produce acceptable image quality with the lowest
radiation dose to the patient.
As cone-beam technology was built on the platform
of complex-motion tomography, the radiation dose is
ª 2008 Australian Dental Association
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Implant radiography and radiology
typically lower than a multislice CT scan of the
jaws.3,4,6,14 Exposure parameters, selected FOV and
acquisition times differ markedly from one model to
another, and as such radiation dose is highly specific to
each individual machine and varies widely. A conse-
quence of the low exposure parameters is that soft-
tissue contrast is markedly decreased compared with
the higher-dose multislice CT examination.15–18 Fur-
thermore, image noise is more intrusive in CBVT
images compared with multislice CT.15,17,19 Numerous
authors have written that the lack of soft tissue contrast
with CBVT is acceptable as these units are designed for
hard tissue imaging,4,6,20,21 but the inability to change
the exposure parameters has implications when imag-
ing larger patients.
The theoretical resolution of CBVT scanners is very
high; numerous manufacturers report a minimum
voxel size of between 0.1 and 0.2 mm3.9,19,22 All
scans are isotropic, with typical voxel sizes ranging
between 0.2 and 0.4 mm3.7,19 Smaller voxel sizes
necessitate longer scan times and increased radiation
dose to the patient. Isotropic multislice CT data
acquired with a 16-slice unit typically produces voxel
sizes of 0.5 mm3, although 0.35 mm3 is achievable
with modern machines.5,7 As multislice spiral-CT
acquisition is significantly faster than CBVT, move-
ment artefact is less of a problem, and this ensures
higher image sharpness. Generally, CBVT scans
performed with larger voxel sizes result in subjectively
better image quality due to decreased noise. Numerous
authors have reported that CBVT offers higher
resolution and better image quality compared with
CT, but these studies all utilized either radiographic
test-phantoms with soft-tissue simulation or cadav-
ers.14,17,21 There was no assessment of how patient
movement may affect resolution, sharpness and image
quality. At present no studies compare the quality of
patient images obtained from CBVT with high-quality,
low-dose multislice CT using either a 16- or 64-slice
CT unit.17
The geometric accuracy of multislice CT scans is
widely accepted,22 and recent research indicates that
CBVT images are also of sufficient accuracy to use for
pre-implant assessments.11,12,23–27 It was found that the
error in measurements obtained from CBVT scans was
less than 0.5 mm.26 Volume rendered images obtained
from CT data were found to be superior to those from
CBVT, but the difference was minimal and the CBVT
images were still of acceptable quality.28 One study has
suggested that soft-tissues may decrease the accuracy of
CBVT scans, but the authors did not feel that this was
significant.12 Cone beam volumetric tomography still
suffers the same volume-averaging effect as CT, and
this most likely accounts for the slight errors in
measurements.27 Theoretically, higher resolution scans
permit improved accuracy of measurements, but
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PA Monsour and R Dudhia
increased noise and patient movement12 may negate
any potential gains.
Cone beam verses multislice CT
Given that CBVT and multislice CT have similar
capabilities it is prudent to examine the differences
between the two modalities. Acquisition time with a
16-slice CT scanner is shorter than the fastest CBVT
scan, and newer 64-slice CT units reduce the scan time
even further. This effectively minimizes the risk of
patient movement. The theoretical resolution of CBVT
is higher than CT,20 but the difference may not be as
significant as once thought due to the impact of patient
movement resulting from the increased scan times.
Image quality has been the subject of much debate,
and there is no clear answer at present. Cadaver studies
demonstrate the capabilities of cone-beam technol-
ogy,14,21,29 but patient images have been less impres-
sive.30 The low exposure parameters of CBVT result in
poor soft-tissue contrast compared with CT,8,31 and the
inability to alter the exposure parameters in most
machines means that image quality suffers in larger
patients. Furthermore, CBVT suffers from the same
beam-hardening artefact that CT does; limiting the
usefulness of the exam in patients with metallic
restorations, posts or surgical plates.17 It has recently
been reported that dental implants produce a similar
artefact on CBVT images.32 Sample cross-sectional
images from CT, CBVT and hypocycloidal tomography
(a)
(c)
Fig 11. Comparison between cross-sectional images of the mandible obtained using hypocycloidal tomography (a), multislice CT (b) and CBVT (c).
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are shown in Fig 11 highlighting comparative image
quality.
While it is recognized that multislice CT is a higher-
dose examination than CBVT, reports indicate that
low-dose CT protocols result in significantly less
exposure than previously thought, without compromis-
ing image quality significantly.33 A consequence of the
lesser dose of the CBVT scan is reduced contrast and
therefore image quality. Image noise is also significant,
especially with larger patients or higher resolution
scans. It is important to note that while the radiation
dose from a CBVT scan may be less than from low-dose
CT, the dose is still significantly higher than other forms
of dental radiographic examination.8
Magnetic resonance imaging (MRI)
MRI has become accepted as a powerful imaging tool
in medicine. Using the magnetic properties of the
hydrogen atom, MRI units are capable of producing
images of the human body. As the technology is
dependent upon the presence of hydrogen atoms MRI
is particularly suited to imaging of soft tissues. Using
various radiofrequency pulse sequences and relaxation
times, images may be produced to better demonstrate
anatomy or pathology in the body. As MRI relies on the
use of a strong magnetic field, MRI examinations are
contraindicated in patients with metal foreign bodies
in the eyes, ferromagnetic intracranial aneurysm clips,
cardiac pacemakers, cochlear implants and patients in
(b)
ª 2008 Australian Dental Association

(a) (b)
Fig 12. Magnetic resonance imaging demonstrating the left inferior
dental canal as a low signal line (arrow heads) surrounded by high
signal cancellous bone in the ramus (a) and as a small black void
(arrow) in a cross-section of the left mandibular angle (b).
the first trimester of pregnancy. The presence of certain
metals such as amalgam and non-precious alloys will
result in considerable artefact on the images and often
render the examination useless.34,35 Pure titanium
implants show no artefact with MRI, but if there are
any impurities in the titanium there will be artefact.
Other considerations include the significant cost to the
patient for MRI examinations and claustrophobia is a
real concern as the examinations are generally per-
formed with the patient in a very confining tunnel.
Most studies using MRI for pre-implant imaging
have focused on the ability of MRI units to locate the
inferior dental canal.36–38 With MRI the inferior dental
canal appears as a black void within the high-signal
cancellous bone (Fig 12). If the inferior dental canal is
surrounded by sclerotic bone, visualization of the canal
is more difficult with MRI as the presence of sclerotic
bone results in a low bone marrow signal. The reverse is
true for CT, as the presence of sclerotic bone in the
mandibular body makes the inferior dental canal more
obvious. Magnetic resonance imaging has potential
for pre-implant imaging due to the lack of ionizing
radiation, but acquisition times can be as long as
30 minutes and there is limited bone information
available.
Radiographic interpretation
The primary role of any pre-implant imaging system is
to provide adequate information regarding bony mor-
phology and the location of structures that should be
avoided when placing implants in the jaws. To a lesser
extent pre-implant imaging may also give some mean-
ingful information on the quality of the bone. Super-
imposed over the above considerations is the need to
keep exposure of the patient to ionizing radiation as
low as possible in adherence with the ALARA principle
(as low as reasonably achievable).
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Implant radiography and radiology
Inferior dental canal
The inferior dental canal (IDC) carries the neurovas-
cular components that supply and innervate the teeth
and bone of the mandible. In 1992, Gowgiel49 studied
the position and arrangement of the IDC. He found
that the neurovascular bundle remained intact from
the mandibular foramen to the mental foramen.
Approaching the mental foramen the IDC turned
sharply from the lingual plate buccally toward the
mental foramen. Anterior to the mental foramen
the neurovascular bundle was smaller and close to
the labial cortical plate. In 1997, Wadu et al.50 showed
that in all cases they examined the inferior alveolar
nerve divided into its incisive and mental branches in
the molar region, well before the mental foramen was
reached. They also demonstrated that before dividing
into incisive and mental branches the inferior alveolar
nerve gives off a branch to supply the molars and in
two cases they found separate branches to the second
premolar.
As a general rule if the IDC is well demonstrated
on the OPG, it will usually be well demonstrated on
other imaging modalities. Conversely, if the IDC is
poorly demonstrated on the OPG and the OPG is of
reasonable quality, the canal will be difficult to
localize using other modalities. The IDC is identifiable
on radiographs as a narrow radiolucent ribbon
bordered by radio-opaque lines. Wadu et al.50 found
that in a reasonable number of cases the radio-opaque
border was disrupted in certain areas and in some
cases absent radiographically. The superior border
was more prone to disruption than the inferior
border. There are a number of software programmes
currently available that can be used to help locate the
IDC. Figure 13 shows a cropped OPG where the IDC
is difficult to localize and a reformatted CT image in
the sagittal plane of the same mandible, showing the
location of the canal. If the mandible is osteoporotic
or the cancellous bone has few or very thin trabec-
ulae, sometimes the only clue to the location of
the canal is scalloping of the cortical plate on the
endosteal surface. When in close relation to the
lingual cortical plate in particular, the IDC may lie
in a groove in the endosteal aspect of the cortical
bone (Fig 14a). On some occasions the IDC will not
appear as a circumscribed area of reduced density,
but as a circumscribed area of increased density
(Fig 14b).
Mental foramen
Typically the mental foramen is located in the buccal
cortex of the mandible in the premolar region. The
inferior dental canal usually rises quite sharply to the
foramen. In cases where the patient has been edentulous
S19

PA Monsour and R Dudhia
(a)
(b)
Fig 13. (a) Cropped panoramic radiograph with poor visualization of
the left inferior dental canal. (b) Reformatted, corrected sagittal CT
image demonstrating the inferior dental canal (arrow heads) not seen
on the panoramic radiograph shown at (a).
(a)
(b)
Fig 14. (a) Reformatted cross-sectional CT images demonstrating
grooving of the endosteal surface of the lingual cortical plate (arrows)
as a guide to the location of the inferior dental canal. (b) The inferior
dental canal may appear as a small circular opacity on reformatted
cross-sectional images of the mandible (arrow heads).
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40 45
(a)
(b)
Fig 15. Reformatted panoramic (a) and cross-sectional (b) CT images
of an edentulous and atrophic mandible showing the inferior dental
canal very close to the crest of the ridge (arrows) and the mental
foramen at the crest (arrow head).
for a considerable period of time and the ridge has
atrophied, the inferior dental canal may run very close
to the crest of the ridge and the mental foramen may
open onto the crest (Fig 15). The IDC may extend
anteriorly past the mental foramen and then loop back
to the foramen. The extent of this looping of the IDC is
very variable and not always visible on conventional
radiographs.51,52
Incisive branch of the inferior dental canal
The anterior region of the mandible is generally
considered to be a relatively safe area for implant
surgery due to little chance of significant damage to
neurovascular structures. Previous studies however,
have reported life-threatening complications caused by
profuse bleeding after implant placement between the
mental foramina.53–55 A number of other compli-
cations have been reported following placement of
implants in the inter-mental region and some of these
have been attributed to damage of the incisive canal
(IC).56,57 Kohavi and Bar-Ziv56 describe a case where
an implant was placed through a large lumen IC
resulting in pain.
The incisive branch of the IDC extends anteriorly
from the mental foramen to supply the lower anterior
teeth. The incisive branch is usually poorly demon-
strated on conventional radiographs.51,52 Generally, the
IC extends anteriorly and inferiorly from the mental
foramen. The IC has been shown to be located on
average 9.7 mm (SD 1.8 mm) from the lower border of
the mandible and continues toward the incisor region
in a slightly downward direction with a mean distance
to the lower border of 7.2 mm (SD 2.1 mm).58 The
diameter of the IC has been found to range from
0.48 mm to 2.90 mm.52 As the incisive canal is an
anterior extension of the IDC, it should be considered
to contain the same neurovascular elements.58
ª 2008 Australian Dental Association

(a) (b)
Fig 16. Reformatted cross-sectional CT images demonstrating the
superior (a) and inferior (b) genial foramina (arrows) and canals
(arrow heads).
Genial foramina
The anatomical structures worthy of note between the
mental foramina of the mandible include the midline
foramina. These foramina may be denoted as the
superior and inferior genial foramina with their asso-
ciated canals. The typical appearance of the genial
foramina on reformatted CT images is shown in Fig 16.
Liang et al.59 found that 98 per cent of the 50
mandibles assessed had at least one genial foramen.
Only one mandible lacked a genial foramen and in one
mandible there were three foramina. In those cases with
only one foramen, the superior genial foramen was
Fig 17. Cropped axial CT images demonstrating some of the variations found in the morphology of the incisive canals of the maxilla (arrows) in
cross-section.
ª 2008 Australian Dental Association
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Implant radiography and radiology
much more common (72 to 28 per cent). The canals had
a mean length of 6.5 mm (SD 2.4 mm). In most cases
the canal has a downward course toward the labial
plate, but in a reasonable number of cases the canal was
directed upwards toward the labial side. The genial
foramina and canals are not always shown on refor-
matted cross-sectional CT images.60 The superior and
inferior genial foramina have been shown to contain
neurovascular elements and this has obvious implica-
tions for pre-operative planning of surgical procedures
in the anterior mandible.59,60
Submandibular depression
Below the mylohyoid ridge on the lingual aspect of
the mandibular body is a concavity known as the
submandibular fossa or depression. There is consider-
able variation in length, height and depth of the
submandibular fossae. The submandibular fossae are
well demonstrated using tomography, CT and CBVT.
Incisive foramen and canal
The size and morphology of the incisive canal and the
incisive foramen is extremely variable (Fig 17).61 The
incisive foramen has been described as a funnel-shaped
hole between the two halves of the maxilla palatal to
the upper central incisors.62 The incisive canal contains
the nasopalatine nerve and the descending palatine
artery. It has been shown that the descending palatine
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PA Monsour and R Dudhia

(a) (b)

(c) (d)

Fig 18. (a) Reformatted CT image showing mucosal thickening on the floor of the right maxillary sinus. (b) Reformatted CBVT image showing
considerable mucous in the right maxillary sinus (coronal plane). (c) Reformatted CT image showing circumferential mucosal thickening in both
maxillary sinuses (axial plane). (d) Reformatted CT image showing fluid on the floor of the right maxillary sinus.

artery lies in an anterior canal and there are branches

sprouting from the left and right sides of the canal that
contain connective tissue and blood vessels.62

Maxillary sinuses
The maxillary sinuses are the first of the paranasal
sinuses to form and they usually develop symmetrically
with only minor variations. Unilateral hypoplasia of
the maxillary sinuses has been reported to occur in
1.7 per cent of people and bilateral hypoplasia in 7.2
per cent of people.63 The posterior superior alveolar
nerve enters the maxillary sinus through the posterior
wall, then runs forward and downwards in a small
canal to supply the molars. Usually the maxillary
sinuses do not extend anteriorly beyond the apex of
the upper canine, but the maxillary sinus may on occa-
sion extend almost to the midline of the maxilla. The
maxillary sinus is visualized as an air-filled space, as
the healthy mucosal lining is not visible on radiographs.
The most common pathology noted in the maxillary
sinus is thickening of the mucosal lining of the sinus. This
mucosal thickening may sometimes take the form of
Fig 19. Reformatted cross-sectional images of the mandibular body
polypoidal thickening or circumferential mucosal thick- showing marked resorption of the alveolar ridge resulting in a thin
ening. Often sinus changes on the floor of the maxillary plate of bone (arrows) on the lingual aspect of the ridge.
S22 ª 2008 Australian Dental Association

(a)
(b)
Fig 20. (a) Cropped panoramic radiograph showing double radio-
opaque lines at the crest of the ridge in the lower left molar region.
(b) Reformatted cross-sectional CT images of the mandible above
showing a concavity at the crest of the ridge.
sinus develop in response to adjacent pathology such as
periodontal disease or pulpal pathology. The radio-
graphs of choice for plain film evaluation of the maxillary
sinuses are the Waters view, Caldwell view and lateral
sinus view. Sinus pathology is best demonstrated on CT
images and some examples are shown in Fig 18.
Ridge form
Information obtained from intra-oral radiographs and
rotational panoramic radiographs typically give very
little information about the available bone width as
they are two-dimensional. The anterior alveolar ridge
may have excellent bone height but be extremely thin in
the labio-lingual dimension. Another common finding
in the edentulous arch is marked flattening of the ridge
in the lower premolar ⁄ molar region and the formation
of a thin plate of bone on the lingual aspect (Fig 19).
It is also not uncommon to find a concavity at the crest
of the ridge in the lower molar regions that can be
predicted from an OPG, but is best demonstrated with
three-dimensional imaging (Fig 20).
CONCLUSIONS
The decision on what pre-implant imaging is appropri-
ate for each case must be considered carefully due to the
radiation involved and the cost of each examination.
Although in the opinion of the authors, multislice CT is
ª 2008 Australian Dental Association
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Implant radiography and radiology
the gold standard, this type of examination cannot be
justified for every implant case. Cone beam volumetric
tomography has great potential with regard to pre-
implant imaging. In deciding on what imaging is
appropriate, the clinician should not be swayed entirely
by the dose of radiation the patient will receive. There is
very little to be gained by opting for pre-implant
imaging where the dose is very low, if the end result is
compromised because of a lack of reliable information.
The risk-to-benefit ratio should be determined on an
individual basis so as to maximize success.
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