Sir, having undergone successful treatment for a squamous cell carcinoma of the anterior mandible and lower lip, a patient was now ready for the restorative phase of treatment. The surgery left her edentulous in the lower jaw and in need of some form of prosthesis. She was given a number of options for her treatment and upon discussion with the team, decided to have an implant retained lower complete denture.

Subsequently, she had three implant fixtures placed into her lower jaw under general anaesthetic and this was completed without complications. Having returned for a follow up appointment, a dental pantomogram (DPT) was taken to review the position of the implant fixtures (Fig. 1). The image shows the presence of only two implant fixtures, with the central fixture missing, which led to questions as to what had happened to it. The patient explained that she was completely oblivious to it all and had not noticed anything drop out of her mouth. One month later, she returned for a further follow up to review her implant fixtures, as well as her oral candidiasis. A new DPT was taken (Fig. 2) now with the middle implant fixture clearly visible!

Figure 1
figure 1

Only two implant fixtures are seen

Figure 2
figure 2

The third implant magically reappears

This acts as a reminder of a number of key areas with regards to dental radiography. Firstly, ensuring the radiograph is taken appropriately, including the preparation of the patient and the machine and the appropriate positioning of the patient. Secondly, taking care when combining what is known clinically with what can be seen radiographically to form an overall impression. Finally, it raises the question as to whether periapical views should be taken in addition to DPTs in such instances.

(With thanks to Mr Neil Macmillan and Mr Nick Lewis.)