RESEARCH

DIAGNOSTIC AGREEMENT OF CONVENTIONAL

AND INVERTED SCANNED PANORAMIC
RADIOGRAPHS IN THE DETECTION
OF THE MANDIBULAR CANAL AND
THE MENTAL FORAMEN

Celso Eduardo Sakakura, DDS, MSc
Leonor de Castro Monteiro
Loffredo, PhD
Gulnara Scaf, DDS, MSc, PhD
KEY WORDS
Agreement
Panoramic radiography
Radiography image
enhancement
Mandibular canal
Mental foramen
Celso Eduardo Sakakura, DDS, MSc,
and Gulnara Scaf, DDS, MSc, PhD, are
associate professors in the Department of
Oral Diagnosis and Surgery, Araraquara
Dental School, State of São Paulo Univer-
sity, Unesp, Araraquara, São Paulo, Brazil.
Leonor de Castro Monteiro Loffredo,
PhD, is an associate professor in the
Department of Social Dentistry,
Araraquara Dental School, State of São
Paulo University, Unesp, Araraquara,
Rua Humaitá, 1680, 14801-903,
Araraquara, São Paulo, Brazil (e-mail:
scaf@foar.unesp.br). Correspondence should
be addressed to Dr Scaf.
The aim of this study was to evaluate the diagnostic agreement of
conventional panoramic radiographs and their inverted scanned
images in the detection of the mandibular canal and mental foramen.
A total of 77 panoramic radiographs obtained from the files of totally
edentulous patients were used. Digitization was done by means of
a scanner with brightness and contrast adjustment, as well as image
inversion. The extension of mandibular canal was divided into anterior,
middle, and posterior regions, and the presence of a radiopaque line
that characterized the mandibular canal was classified according to a 5-
point confidence scale. The mental foramen was classified in 4 types:
continuous, separated, diffuse, and unidentified. Both conventional
and inverted scanned panoramic radiographs were evaluated by 3
calibrated implantologists at 2 distinct moments with a minimum
interval of 10 days between them. Intraexaminer agreement was
evaluated by Kappa statistics by point and by 95% confidence interval.
Because the intraexaminer level of agreement was low, interexaminer
agreements could not be carried out. The results showed a substantial
(in 2 situations), moderate (in 16 situations), and fair (in 18 situations)
intraexaminer agreement for mandibular canal and a substantial (in 1
situation), fair (in 1 situation), and moderate (in 10 situations)
intraeaminer agreement for mental foramen. There were no statistically
significant differences in most instances. In conclusion, the diagnostic
agreement of conventional and inverted scanned panoramic radio-
graphs for detection of mandibular canal and mental foramen was low.

2 Vol. XXX /No. One /2004


INTRODUCTION
sseointegrated im-
O
plant treatment
has increased over
the past decade,
with functional 5-
year success rate
of 90% or higher.1 One of the
factors that contribute to this
successful therapy is the careful
surgical and prosthetic treatment
plan. The main components of
this plan are diagnostic waxing,
study of dental casts, and clinical
and radiographic examinations.2
The presurgical radiographic
examinations for the treatment
with osseointegrated implant
give detailed information on the
potential area for implantation.
The presence of lesions and ana-
tomical landmarks are conditions
and structures that may limit the
placement of osseous implant.
The radiographic examinations
should also provide evaluation
of morphology, angulations of the
alveolar ridge, and quantity and
quality of the available bone.1–4
Currently, around 95% of the
implantologists use panoramic
radiograph examination for the
surgical planning of osseointe-
grated implants,3 despite its lim-
itations related to distortion,
sharpness, and no information
about bone width.4–11 Taking into
account the limitation of pano-
ramic radiograph, the American
Academy of Oral Maxillofacial
Radiology has recommended it
as an initial diagnostic aid.4 On
the other hand, the large indica-
tion of this examination3 justifies
further studies to improve the
radiographic interpretation.
Some studies5–7,10,11 demon-
strated that the roof of the man-
dibular canal in the mandibular
posterior segment may not be
identified in 36% of panoramic
radiographs, and the linear mea-
surements may be overestimated
in 0.4 mm.11 Regarding the mental
foramen, the radiographic image
of this anatomic site presents
a different position when com-
pared with the dry mandible8;
thus, the use of panoramic radio-
graph is not indicated as a single
examination for the surgical plan-
ning of implants. The difficulty to
find the roof of the mandibular
canal and the mental foramen and
the inaccuracy of the measure-
ments provided by panoramic
radiograph have been related to
sensory alterations of the inferior
alveolar nerve.12–14 The preva-
lence of sensory alterations may
occur in 37% of the patients,
whereas permanent changes
may affect 13% of the patients
submitted to implant placement
in the mandibular posterior
segment.13,14
The development of computer
technology applied to radiology
has allowed the image ma-
nipulation such as to convert the
conventional radiographs into
scanned images that can be ex-
hibited on a monitor. The scanned
images can enhance interpreta-
tion, for resources such as bright-
ness and contrast control,
colorization, and inversion effects
may be applied to the radio-
graphic image.15–19
Studies concerning scanned
panoramic radiographs with a
view to improve the imaging of
the mandibular canal and mental
foramen are deficient in literature.
Therefore, this study was carried
out to explore this simple and
inexpensive procedure for analy-
sis of these anatomic sites in
panoramic radiographs, which
have been the diagnostic aid of
choice for many implantologists.3
In order to study the diagnos-
tic agreement of the radiographic
interpretation, 3 calibrated exam-
iners read the radiographs twice
on 2 different occasions, indepen-
dently and under blind condi-
Celso Eduardo Sakakura et al
tions, to verify intraexaminer
agreement. If the intraexaminer
agreement reached a good level,
interexaminer agreement could
be estimated. If the examiners
did not agree with themselves,
they could not agree with some-
one else.
The aim of this study was to
evaluate the diagnostic agreement
of conventional and inverted
scanned panoramic radiographs
in the detection of the mandibular
canal and mental foramen.
MATERIALS AND METHODS
A total of 77 panoramic radio-
graphs of edentulous patients
from the diagnostic department
files were used. The panoramic
radiographs were taken with
X-ray unit Panoramax AX-4CM
(Asahi, Kyoto, Japan), and the
images were acquired with
Kodak Lanex Regular screens
and T-Mat G film (Eastman
Kodak, Rochester, NY). The radio-
graphs were selected on the basis
of nonprobabilistic sampling with
the selection criteria of high-qual-
ity radiographs, which present
maximum sharpness, ideal con-
trast, and density.
The conventional film radio-
graphs were digitized with a flat-
bed scanner (Snapscan TPO, Agfa,
Taiwan, China.) with a transpar-
ency and radiograph adapter
(Snapscan 1236 s, Agfa, Taiwan,
China) used for transilluminating
the radiograph image.18 Digitiza-
tion was performed at 600 dpi and
in gray scale. The manipulation of
the scanned images was obtained
through the software Image Tool
2.0 (Image Tool, San Antonio, Tex)
by using image inversion, that is,
transformation of radiopaque
structures into radiolucent struc-
tures and vice versa.
Three calibrated implantolo-
gists viewed the conventional
Journal of Oral Implantology 3
DETECTION OF MANDIBULAR CANAL AND MENTAL FORAMEN WITH PANORAMICS
panoramic images with a stan-
dard view box under reduced
room lighting. Masks were used
to prevent extraneous light from
reaching their retinas. The
inverted scanned panoramic
images were displayed on a 15-
inch and 24-bit video monitor
S-VGA (Sync Master 500b, Sam-
sung, Serebran, Malaysia). The 3
examiners read the images under
reduced room lighting and at
a viewing distance between 50
and 70 cm from the screen.20
Brightness and contrast were ad-
justed in accordance with the
examiners’ individual demand.19
To minimize bias, the same ex-
aminer read the images twice on 2
different occasions, independent-
ly and under blind conditions.
The interval between the 2 read-
ings was 10 days.
The characteristics of the man-
dibular canal and mental foramen
were defined according to the
following criteria:

The roof of the mandibular
canal was characterized by the
presence of a radiopaque line
and was divided in 3 parts:
anterior region (premolar area),
middle region (first and second
molars), and posterior region
(between the third molar and
mandibular foramen). They
were classified according to
the criteria of a 5-point confi-
dence scale8: definitely present,
probably present, uncertain,
probably absent, and definitely
absent.

The mental foramen was clas-
sified according to the criteria
of Yosue and Brooks21: in con-
tinuity with the mandibular
canal, separated from the man-
dibular canal, diffuse, noniden-
tified, or absent.
STATISTICAL ANALYSIS
The intraexaminer agreement
considering the mandibular canal
4 Vol. XXX /No. One /2004
and mental foramen was evalu-
ated. Also, the interexaminer
agreement would be estimated if
it had reached a good level of
intraexaminer agreement, accord-
ing to Light22 and the classifica-
tion of Landis and Kock.23 As
a measure of agreement (intra/
inter), we suggest the statistics
type Kappa by point (j) and by
95% of confidence interval (CI)
with the statistical software
STATA.
RESULTS
Table 1 shows j and 95% CI for
diagnosis of the mandibular ca-
nal. The intraexaminer agreement
for diagnosis of the mandibular
canal showed that the examiner C
presented higher intraexaminer
agreement than did the examiner
B (statistically significant) for the
anterior region, right side of the
conventional radiograph. The ex-
aminer C presented a lower intra-
examiner agreement than did the
examiner A (statistically signifi-
cant) for the anterior region, right
side of the inverted scanned
radiograph.
Concerning the middle and
posterior regions, there were no
statistically significant differences
among the 3 intraexaminers’
agreement for conventional and
inverted scanned radiographs as
well as for the right and left sides.
Considering both types of
image, the examiner C presented
different intraexaminer agree-
ments (statistically significant)
related to the right side for the
anterior and middle regions of
the mandibular canal.
Table 2 shows j and 95% CI
for diagnosis of the mental fora-
men. There were no differences
among the 3 intraexaminers’
agreement for the conventional
image. The examiner C presented
a lower intraexaminer agreement
than did the examiner B (statisti-
cally significant) for the right side
of inverted scanned radiograph.
The intraexaminer agreement
values were similar in most in-
stances in relation to the CI for the
diagnosis of the mandibular canal
and mental foramen with con-
ventional and inverted scanned
panoramic radiographs. The clas-
sification by j was substantial in 2
situations, moderate in 16 situa-
tions, and fair in 18 situations
(Table 1) for mandibular canal
and was substantial in 1 situation,
fair in 1 situation, and moderate
in 10 situations (Table 2) for
mental foramen.
DISCUSSION
The 3 examiners presented low
agreement for both types of im-
ages and structures, but the exam-
iner C presented values with
statistically significant differences
in 2 situations for the mandibular
canal (Table 1) and 1 situation for
the mental foramen (Table 2).
These differences observed for
examiner C in relation to the other
examiners may be attributed to
the subjectivity of the method and
the intrinsic characteristics of
the examiner, such as emotional,
visual, and neurological features.
The difficulty to detect the roof
of the mandibular canal and the
mental foramen on the panoramic
radiographs might be explained
by the poor details presented by
such radiograph.4,6-8,10 Moreover,
anatomical descriptions showed
that the tubular shape of the canal
is lost in the molar area because of
the great amount of ramifications
of its contents.24 These findings
might explain the results achieved
by Lindh and Petersson7 and
Lindh et al,6 who observed a
higher prevalence of nonidenti-
fied canals.
The examiners’ behavior was
identical in the evaluation of the
posterior region of the mandibu-
 Celso Eduardo Sakakura et al

TABLE 1
Kappa values by point (j) and by 95% of confidence interval (CI) for the detection of mandibular canal at the anterior,
middle, and posterior regions, right and left sides on the conventional panoramic radiograph (CPR), and scanned inverted
panoramic radiograph (SIPR)
Anterior Middle Posterior
Left Right Left Right Left Right
Method Examiner j CI j CI j CI j CI j CI j CI
CPR A 0.35* 0.22–0.48 0.37* 0.24–0.50 0.31* 0.19–0.43 0.47y 0.35–0.59 0.47y 0.33–0.61 0.55y 0.38–0.72
B 0.36* 0.24–0.48 0.32* 0.20–0.44 0.47y 0.35–0.59 0.43y 0.30–0.56 0.53y 0.39–0.67 0.44y 0.29–0.59
C 0.56y 0.39–0.73 0.64à 0.49–0.79 0.48y 0.32–0.64 0.65à 0.49–0.81 0.42y 0.29–0.55 0.46y 0.32–0.60
SIPR A 0.44y 0.32–0.56 0.55y 0.42–0.68 0.45y 0.32–0.58 0.38* 0.26–0.50 0.45y 0.28–0.62 0.38* 0.21–0.56
B 0.27* 0.14–0.40 0.36* 0.23–0.49 0.26* 0.13–0.39 0.31* 0.19–0.43 0.27* 0.13–0.42 0.56y 0.41–0.71
C 0.34* 0.22–0.48 0.21* 0.03–0.39 0.31* 0.16–0.47 0.25* 0.11–0.39 0.26* 0.12–0.40 0.38* 0.33–0.53
*Fair ¼ 0.21–0.40.
yModerate ¼ 0.41–0.60.
àSubstantial ¼ 0.61–0.80.

lar canal on the conventional ent study, it was not possible to
radiograph. Even though this get the interexaminer agreement
area is not intended for implant because of the low intraexaminer
placement, this result may be agreement, which was scored as
explained by the image quality moderate and fair in most instan-
improvement of the canal. The ces. The interexaminer agreement
anatomical aspect may provide requires at least a substantial
such high quality because the intraexaminer reproducibility,
area’s length comprises just one- which was not achieved in the
third molar, probably with no present study.
ramifications for the tooth. The The low agreement might also
same anatomical features previ- be explained by the methods used
ously mentioned to explain the for radiographic interpretation
difficulty to detect the roof of the related to a 5-point confidence
mandibular canal might also be scale for the mandibular canal. A
applied to the mental foramen, confidence scale with fewer vari-
which may represent a projection ables might have yielded higher
of the mandibular canal on the agreement. The selection of such
radiograph.25 methods provided the reliability
Another aspect that must be about the real situations observed
considered is the level of intra- by clinicians to determine the roof
examiner agreement. In the pres- of the mandibular canal.
TABLE 2
Kappa values by point (j) and by 95% of confidence interval (CI) for detection of
mental foramen at right side (RS) and left side (LS) on conventional panoramic
radiograph (CPR) and scanned inverted panoramic radiograph (SIPR)
LS RS
Method Examiner j CI j CI
CPR A 0.43y 0.28–0.59 0.42y 0.28–0.56
B 0.66à 0.52–0.81 0.54y 0.40–0.68
C 0.58y 0.44–0.74 0.49y 0.35–0.63
SIPR A 0.50y 0.36–0.65 0.52y 0.36–0.67
B 0.56y 0.41–0.71 0.58y 0.44–0.73
C 0.42y 0.27–0.58 0.26* 0.12–0.40
*Fair ¼ 0.21–0.40.
yModerate ¼ 0.41–0.60.
àSubstantial ¼ 0.61–0.80.
The low agreement related to
mental foramen may be explained
by the classification used based on
the presence of the roof of the
mandibular canal. Thus, the diffi-
culty to classify the foramen may
be related to the difficulty to
identify the mandibular canal.
Considering the inverted
scanned radiograph, a possibility
to explain the low agreement is
the presence of noises generated
during the digitization process,
which may impair the identifica-
tion of the structures.15
One important aspect of this
research was to study the intra-
examiner agreement in the in-
terpretation of 2 types of
radiographic images. The results
can show the agreement level by
a single examiner during the
radiographic interpretation at 2
distinct occasions. Therefore, it
was not possible to state which
examiner interpretation was cor-
rect or to determine the best
radiographic method for diag-
nosis, because such evaluation
would require study of the va-
lidity of interpretations and
diagnosis, including the compar-
ison of the methods with a gold
standard. We concluded that the
diagnostic agreement of conven-
tional and inverted scanned
panoramic radiographs for detec-

Journal of Oral Implantology 5

DETECTION OF MANDIBULAR CANAL AND MENTAL FORAMEN WITH PANORAMICS
tion of mandibular canal and
mental foramen was low.
ACKNOWLEDGMENTS
This study was supported by
C A P E S ( C o o r d e n a ç ã o d e
Aperfeiçoamento de Pessoal de
Nı́vel Superior). The authors
greatly appreciate the assistance
of Dr Jamil Awad Shibli and
D r R o g é r i o M a r g o n a r i n
radiographic examination.
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