You are on page 1of 11

Configuration of the inferior alveolar canal as detected by cone

beam computed tomography


Umadevi P Nair, Mehran H Yazdi, [...], and Madhu K Nair
Additional article information

Abstract
Aims:
The aim of this study is to evaluate the course of the inferior alveolar canal
(IAC) including its frequently seen variations in relation to root apices and the
cortices of the mandible at fixed pre-determined anatomic reference points
using cone beam volumetric computed tomography (CBVCT).

Material and Methods:


This retrospective study utilized CBVCT images from 44 patients to obtain
quantifiable data to localize the IAC. Measurements to the IAC were made from
the buccal and lingual cortical plates (BCP/LCP), inferior border of the
mandible and the root apices of the mandibular posterior teeth and canine.
Descriptive analysis was used to map out the course of the IAC.

Results:
IACs were noted to course superiorly toward the root apices from the second
molar to the first premolar and closer to the buccal cortical plate anteriorly. The
canal was closest to the LCP at the level of the second molar. In 32.95% of the
cases, the canal was seen at the level of the canine.

Conclusions:
This study indicates that caution needs to be exercised during endodontic
surgical procedures in the mandible even at the level of the canine. CBVCT
seems to provide an optimal, low-dose, 3D imaging modality to help address
the complexities in canal configuration.
Keywords: Anterior loop, cone beam volumetric computed tomography,
mandibular canal, mental foramen, radiograph.

INTRODUCTION
Appropriate osteotomy and root-end resection are considered critical elements
of apicoectomy of mandibular posterior teeth. Caution should be exercised
during these procedures in order to prevent injury to the inferior alveolar
neurovascular bundle. The nerve along with the inferior alveolar artery and vein
sends branches to innervate posterior teeth through the inferior alveolar canal
(IAC) before splitting into incisive and mental components that innervate
mandibular anterior teeth, the lower lip and gingiva.[1] Injury to the nerve
during endodontic surgery is known to cause post-operative paresthesia or
anesthesia.[1]
The continuation of the IAC anteriorly as the incisive canal has been reported
in the literature.[1] The anterior loop refers to the extension of the inferior
alveolar nerve, anterior to the mental foramen prior to exiting the canal.[2] It
has also been described as the mental neurovascular bundle, which loops back
to exit through the mental foramen as it traverses anteriorly and inferiorly.
Paresthesia of the mental nerve from periapical infection of the canine has been
reported in the literature.[3] Data in the literature has been used to develop
guidelines for implant placement. These dictate that the most distal aspect of
the implant is located at least 2 mm anterior to the mental foramen.[4] Applying
similar guidelines to endodontic surgical treatment planning would imply that
the anterior loop of the neurovascular canal is located in the area of the
mandibular first premolar and the canine and injury to the nerve should be
considered a risk while treatment planning for an endodontic surgical procedure
in this area.[5]
Two-dimensional, conventional imaging techniques such as periapical and
panoramic radiography have been used for evaluation of surgical sites.
Localization of critical anatomic structures at the surgical site including an
estimation of the location, size and configuration of the inferior alveolar nerve
during mandibular surgery is usually difficult using conventional images.[6]
Superimposition of overlying anatomy, distortion and magnification, presence
of acquisition and processing artifacts and lack of information in the third
dimension are some of the known drawbacks of this type of imaging.[7]
Three-dimensional (3D) imaging circumvents most of these drawbacks
effectively; computed tomography (CT) has shown that the prevalence of the
anterior loop of the IAC is around 7%.[8] Cone beam volumetric computed
tomography (CBVCT), a relatively new imaging modality in dentistry,
produces high-resolution, superimposition-free, artifact-free, non-magnified
and undistorted 3D images of the maxillofacial anatomy that can be reformatted
in any desired plane for interactive viewing and image manipulation.[9] The
radiation dose is significantly less than that of conventional medical grade
CT.[9,10,11]
In this study, previously acquired CBVCT studies were used in plotting the
course of the inferior alveolar nerve and its anterior extensions, if any, to the
level of the mandibular canine.

MATERIAL AND METHODS


Institutional review board approval was sought to evaluate existing cone beam
computed tomography (CBCT) records of 44 patients in the age group of 18-70
years acquired using the iCAT, (Imaging Sciences International, Hatfield, PA,
USA). These were randomly selected for the study. The selected patients had
fully erupted mandibular posterior teeth and canines on both sides. CBCT
studies showing evidence of severe periodontal disease, osteoradionecrosis or
osteochemonecrosis, other hard tissue pathology, apical root resorption, and
previous endodontic surgery were excluded from the study. The images were
then reviewed by two examiners including a board certified oral and
maxillofacial Radiologist and an Endodontist, using InVivo (Anatomage, San
Jose, CA, USA) viewing software. Measurements from the IAC to the root
apices of the first molar, first and second premolar and the canine was obtained
from parasagittal reformatted images. Other measurements included the
distance from the IAC to the buccal and lingual cortical plates (LCP) from the
respective boundaries of the IAC, parallel to the X-axis on paracoronal slices at
the above locations, as well as to the superior and inferior borders of the
mandible, parallel to the Y-axis.
[Figure 1]. All measurements were repeated after a period of at least 2 weeks.
The average of both readings for each site was recorded for analyses.

Figure 1

RESULTS
The IAC was noted to be closest to the buccal cortical plate (BCP) in the region
of the premolars on both sides with a mean distance of 3.18 mm [Tables
[Tables11 and and2].2]. The canal courses toward the LCP and the inferior
border of the mandible (Inferior BM) as it moves posteriorly toward the distal
root of the second molars. Mean distance from the LCP to the canal at the level
of the molars was 2.2 mm and the distance to the Inferior BM was 6.68 mm.
Lateralization to the lingual varies to some degree. The canal was also closest
to the distal root of the second molar although the distance from the roots of
other teeth did not follow a set pattern. The roots of the second molar were in
direct contact with the IAC in 20.4% of the cases on the right side and 13.6%
of the cases on the left side. The presence of a canal in the region of the canine
was noted in 15 images of the right side and 14 of the left side [Figure 2]. When
present, the canal was centered in the body of the mandible, in the region of the
canine in most of the cases. It was 3-4 mm away from the root of the canine.
DISCUSSION
Previous researchers have examined the path of the inferior alveolar nerve in
cadaver studies.[2,12,13,14] Yet other studies have attempted to determine the
course of the inferior alveolar nerve through radiographic means instead of
purely relying on cadaver dissections.[15,16,17] Many of these studies,
however, suffer from a small sample sizes and the results may not be
generalized to the population at large.[14,18] On the other hand, most such
studies have noted that the canal and consequently the nerve do not maintain a
constant position in the mandible, specifically in relation to roots of the lower
teeth.[6] Such variability may then lead to unpredictable anatomic encounters
at the time of surgery. More recently, complex 3D imaging such as CT has been
utilized to establish the path of the IAC as well as other anatomic
landmarks.[6,8,18,19] This cross-sectional imaging technique offers more
detailed information to the clinician in 3D through interactive manipulation of
the volume, thus providing an effective tool for diagnosis and treatment
planning.[6] These studies have generally focused on the configuration of the
IAC with respect to anatomic landmarks other than the roots of teeth, such as
the buccal or LCPs or the canal path within the ramus as opposed to the body
of the mandible where the roots lie.[17,18] However, in endodontic
applications, the relationship of the IAC and its contents to the apices of teeth
is important to adequately plan for surgical procedures.
The results of the study indicated the general course of the IAC, in relation to
the buccal, lingual and Inferior BM, as it courses posteriorly from the canine to
the distal root of the mandibular second molar. Our results confirm the findings
of previous investigators who dissected cadaver jaws to study the course of the
canal.[14] The proximity of the canal to the BCP in the region of the first and
second premolar corresponds to the mental foramen. The canal was also found
to be closest to the BCP in the region of the canine in one case, possibly
indicating an anterior placement of the mental foramen. The canal was found to
be closer to the LCP and the Inferior BM in the region of the molars. The
measurement of the distance from the first molar root apices were in the range
reported recently in a study using CBVCT scans.[6] The canal was closest to
the second molar roots in 63.6% of the cases, on an average.
The significant finding in this study was the presence of the neurovascular
bundle at the level of the mandibular canine in approximately 50% of the
CBVCT scans that was studied. Various investigators using different techniques
have studied the prevalence of the anterior loop and its length. The detection of
anterior loops using panoramic radiographs reported incidence of 11-
12%.[4,20] The use of radiopaque markers in panoramic films detected an
anterior loop in 76% of dried skulls that were studied with the length ranging
from 4.17 to 4.64 mm.[21] However, panoramic radiographs are known to have
significant drawbacks that include variable distortion and magnification in the
X, Y and Z-axis, positioning errors and double and ghost artifacts.[22]
Measurements made from panoramic radiographs are not used for surgical
planning therefore. Dissection of skulls to detect the anterior loop showed
incidence ranging from 11% to 88%. The high percentage was reported by
Neiva et al., who identified the loop by probing the mesial cortical wall of the
mental canal.[23]
The use of periapical radiographs for detection of the anterior loop was
evaluated using dissection to confirm the findings.[24] This study reported a
significantly higher percentage detected in periapical radiographs (54%) when
compared with dissection findings (11%). The high percentage of false positives
was attributed to misinterpreting the incisive canal as part of the anterior loop.
Similar studies comparing CT and dissection have not been performed further
to validate these results.
Since the length of the anterior loop is reported to a range from 0 to 10 mm, it
is difficult to distinguish between an anterior loop and an incisive canal from
these studies.[25] The wide ranges of incidence reported by different
researchers have led to the following guidelines for detection of an anterior
extension of the IAC while treatment planning for an implant placement. After
reflecting a full thickness flap, the mental foramen is located and an explorer is
used to probe the configuration of the canal. If probing revealed a patent distal
aspect, it was assumed that the canal had an anterior loop.[4]
The present study did not differentiate between the anterior loop and the incisive
canal. From the surgeon's perspective, this differentiation is not significant. The
mere presence of the neurovascular bundle at the level of the mandibular canine
implies the need for caution during periapical surgery in the mandibular first
premolar and the canine area. Hence it is important to determine if such an
anatomic entity exists in patient at the time of surgery. With this study we hope
to demonstrate the value of CBCT imaging in apical surgery. We believe that
such 3-D image acquisition techniques will become the standard of care in the
pre-operative evaluation of endodontic surgical patients in the near future, in
select cases. Principles of as low as reasonably achievable when using radiation
should always be followed while treatment planning. Larger clinical studies
may be in order to establish the applications of CBCT in treatment planning in
endodontics.

Footnotes
Source of Support: Nil

Conflict of Interest: None declared

Article information
J Conserv Dent. 2013 Nov-Dec; 16(6): 518521.
doi: 10.4103/0972-0707.120964
PMCID: PMC3842719

Umadevi P Nair,1 Mehran H Yazdi,1 Gautam M Nayar,1 Heath Parry,1 Rujuta A


Katkar,1 andMadhu K Nair1
Department of Endodontics and Diagnostic Sciences, University of Florida, College of
1

Dentistry, Florida, USA


Address for correspondence: Dr. Umadevi P. Nair, P.O. Box 100436, Gainesville, FL: 32610-
0436, USA. E-mail: ude.lfu.latned@rianu
Received 2013 Jun 18; Revised 2013 Aug 15; Accepted 2013 Sep 13.
Copyright : Journal of Conservative Dentistry
This is an open-access article distributed under the terms of the Creative Commons Attribution-
Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC.
Articles from Journal of Conservative Dentistry : JCD are provided here courtesy of Wolters
Kluwer -- Medknow Publications

REFERENCES
1. Mraiwa N, Jacobs R, Moerman P, Lambrichts I, van Steenberghe D, Quirynen M.
Presence and course of the incisive canal in the human mandibular interforaminal
region: Two-dimensional imaging versus anatomical observations. Surg Radiol
Anat. 2003;25:41623. [PubMed]
2. Moiseiwitsch JR. Avoiding the mental foramen during periapical surgery. J
Endod. 1995;21:3402. [PubMed]
3. Ozkan BT, Celik S, Durmus E. Paresthesia of the mental nerve stem from periapical
infection of mandibular canine tooth: A case report. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2008;105:e2831. [PubMed]
4. Misch CE, Crawford EA. Predictable mandibular nerve location A clinical zone
of safety. Int J Oral Implantol. 1990;7:3740. [PubMed]
5. Kuzmanovic DV, Payne AG, Kieser JA, Dias GJ. Anterior loo
5. Kuzmanovic DV, Payne AG, Kieser JA, Dias GJ. Anterior loop of the mental nerve:
A morphological and radiographic study. Clin Oral Implants Res. 2003;14:464
71. [PubMed]
6. Simonton JD, Azevedo B, Schindler WG, Hargreaves KM. Age- and gender-related
differences in the position of the inferior alveolar nerve by using cone beam computed
tomography. J Endod. 2009;35:9449. [PubMed]
7. Huumonen S, Kvist T, Grndahl K, Molander A. Diagnostic value of computed
tomography in re-treatment of root fillings in maxillary molars. Int Endod
J. 2006;39:82733. [PubMed]
8. Jacobs R, Mraiwa N, vanSteenberghe D, Gijbels F, Quirynen M. Appearance,
location, course, and morphology of the mandibular incisive canal: An assessment on
spiral CT scan. Dentomaxillofac Radiol. 2002;31:3227. [PubMed]
9. Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam
computed tomography in the management of endodontic problems. Int Endod
J. 2007;40:81830. [PubMed]
10. Hamada Y, Kondoh T, Noguchi K, Iino M, Isono H, Ishii H, et al. Application of
limited cone beam computed tomography to clinical assessment of alveolar bone
grafting: A preliminary report. Cleft Palate Craniofac J. 2005;42:12837. [PubMed]
11. Nakagawa Y, Kobayashi K, Ishii H, Mishima A, Ishii H, Asada K, et al.
Preoperative application of limited cone beam computerized tomography as an
assessment tool before minor oral surgery. Int J Oral Maxillofac Surg. 2002;31:322
6. [PubMed]
12. Carter RB, Keen EN. The intramandibular course of the inferior alveolar nerve. J
Anat. 1971;108:43340. [PMC free article] [PubMed]
13. Narayana K, Vasudha S. Intraosseous course of the inferior alveolar (dental) nerve
and its relative position in the mandible. Indian J Dent Res. 2004;15:99
102.[PubMed]
14. Denio D, Torabinejad M, Bakland LK. Anatomical relationship of the mandibular
canal to its surrounding structures in mature mandibles. J Endod. 1992;18:161
5. [PubMed]
15. Littner MM, Kaffe I, Tamse A, Dicapua P. Relationship between the apices of the
lower molars and mandibular canal A radiographic study. Oral Surg Oral Med Oral
Pathol. 1986;62:595602. [PubMed]
16. Fox NA. The position of the inferior dental canal and its relation to the mandibular
second molar. Br Dent J. 1989;167:1921. [PubMed]
17. Wadu SG, Penhall B, Townsend GC. Morphological variability of the human
inferior alveolar nerve. Clin Anat. 1997;10:827. [PubMed]
18. Levine MH, Goddard AL, Dodson TB. Inferior alveolar nerve canal position: A
clinical and radiographic study. J Oral Maxillofac Surg. 2007;65:4704. [PubMed]
19. Sato I, Ueno R, Kawai T, Yosue T. Rare courses of the mandibular canal in the
molar regions of the human mandible: A cadaveric study. Okajimas Folia Anat
Jpn. 2005;82:95101. [PubMed]
20. Jacobs R, Mraiwa N, Van Steenberghe D, Sanderink G, Quirynen M. Appearance
of the mandibular incisive canal on panoramic radiographs. Surg Radiol
Anat. 2004;26:32933. [PubMed]
21. Arzouman MJ, Otis L, Kipnis V, Levine D. Observations of the anterior loop of
the inferior alveolar canal. Int J Oral Maxillofac Implants. 1993;8:295300.[PubMed]
22. Yeo DK, Freer TJ, Brockhurst PJ. Distortions in panoramic radiographs. Aust
Orthod J. 2002;18:928. [PubMed]
23. Neiva RF, Gapski R, Wang HL. Morphometric analysis of implant-related
anatomy in Caucasian skulls. J Periodontol. 2004;75:10617. [PubMed]
24. Bavitz JB, Harn SD, Hansen CA, Lang M. An anatomical study of mental
neurovascular bundle-implant relationships. Int J Oral Maxillofac
Implants. 1993;8:5637. [PubMed]
25. Greenstein G, Tarnow D. The mental foramen and nerve: Clinical and anatomical
factors related to dental implant placement: A literature review. J
Periodontol. 2006;77:193343. [PubMed]

You might also like