Imaging-Based Clinical Management of Mandibular Canal Variants: PR-CBCT-Selective MRI

Background: Mandibular canal (MC) variants are common and clinically relevant for anesthesia, implant placement, third-molar surgery, and osteotomies. Reported prevalences vary widely because they depend on imaging modality, acquisition parameters, and operational definitions. Methods: This was a focused narrative review with structured methods (PubMed/MEDLINE and Scopus, 2000-6 October 2025; last search 6 October 2025), predefined eligibility criteria and dual independent screening; no meta-analysis was conducted. Study-selection counts are reported in the text. Prevalence statements are contextualized by modality, imaging parameters (e.g., cone-beam computed tomography (CBCT) voxel size magnetic resonance imaging (MRI) field strength/sequences), and diagnostic thresholds (e.g., anterior loop (AL) criteria). Results: Compared with panoramic radiography (PR), CBCT consistently reveals more variant pathways. Typical CBCT estimates for bifid MC fall in the single-digit to low double-digit range, contingent on voxel size and definitions, whereas PR detects far fewer. Trifid canals are uncommon (≈1-2% in CBCT series). Reported retromolar canal frequencies vary broadly across populations and protocols, and AL length and prevalence are threshold-dependent. Selective MRI may complement CBCT by depicting soft-tissue branches not accompanied by a bony canal. We synthesize a variant-aware, imaging-led workflow: PR for screening; CBCT when predefined criteria are met and results are reasonably expected to change management; MRI reserved for targeted soft-tissue questions, in line with As Low as Reasonably Achievable (ALARA)/and As Low As Diagnostically Acceptable (ALADA) principles. We apply the Landfald Clinical Framework (LCF) as a hypothesis-generating, clinical synthesis tool linking variant patterns to procedural modifications and risk mitigation. Conclusions: A narrowed, clinically oriented approach-contextualizing prevalence by modality and definitions and applying an imaging-led, variant-aware workflow-can improve planning and safety in the posterior mandible. The LCF is used pragmatically within this workflow and does not constitute a new anatomical taxonomy; formal reliability and validity testing remain necessary.