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Mandibular Canal Duplication

Mandibular Canal Duplication

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Mandibular Canal Duplication
Mandibular Canal Duplication

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Published by: andrada67 on May 06, 2013
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Allan G. Farman, BDS, PhD(odont.), DSc (odont.),Diplomate of theAmerican Board of Oraland MaxillofacialRadiology, Professor ofRadiology and ImagingSciences, Department ofSurgical and HospitalDentistry, The University ofLouisville School ofDentistry, Louisville, KY.
Dr. C.J. Nortjé, BChD, PhD, DSc,Professor and Chairman ofOral and MaxillofacialRadiology, Tygerberg, SouthAfrica, President-Elect of theInternational Association ofDentomaxillofacial Radiology.
Featured Article:
Panoramic radiographicappearance of themandibular canal in healthand in disease
Volume 2, Issue 2
US $6.00
Panoramic radiographic appearance of themandibular canal in health and in disease
The mandibular canal is ofparticular importance to thedentist and dental specialist as itcarries both the dental division ofthe trigeminal nerve and theinnervation for the lower lip. Thetrigeminal nerve enters the innersurface of the mandibular ramus atthe mandibular foramen, in thevicinity of a bony eminence, thelingula. This is a fact learned instudy of anatomy and reinforcedby the everyday necessity oflocating an inferior dental blockinjection for local analgesiarequired in many dentalprocedures. What is not so wellunderstood is that normal is arange and that variations do occurin which there may be more thanone nerve entry point – a factorthat might account for failedanesthesia in at least a smallpercentage of patients. Suchvariations have been describedboth during studies of maceratedmandibles from cadavers and alsofrom the study of panoramicradiographs. Panoramicradiographs may also help find theposition of the mental foramen,through which the nerve supply tothe lower lip passes. Failure toprotect the mental foramen canlead to permanent loss of normalsensation in the lower lip. Thepanoramic radiographicpositioning of the mental foramenand the mandibular canal hasbeen used as an indication of boneloss following dental extractions.A comprehensive study ofvariations in the mandibular canalin patients who had not sufferedmandibular pathoses or trauma
By Dr. Allan G. Farman incollaboration with Dr. C.J. Nortjé
found that the mandibular canalsare usually, but not invariably,bilaterally symmetrical, and thatthe majority of hemimandiblescontain only one major canal.
Theposition of the canal varies withrespect to the apices of the toothroots and the lower border of themandible. They can be classifiedas high (Type I – close to theapices of the teeth), intermediate(Type II) or low (Type III – close tothe lower cortex of the mandible)varieties.
The proportions of typesvaries with the investigationperhaps indicating a geographicor ethnic variability.
Neither studyshowed a gender difference withrespect to the positioning of thecanal. There were almost equalnumbers of high and low canals ina South African study with fewintermediate canals.
In a Greekstudy there were few high canalsand almost equal proportions ofintermediate and low canals.
TheGreek study also found asymmetryin canal positioning in almost onein five of those studies; whereasthe South African study found thisto occur in less than one in ahundred.
It can be concludedthat in a single panoramicradiograph the mandibular canalshould not be used as a setreference point for assessment ofbone loss following extractions. Tomake such an assessment requiressequential panoramic radiographson a given patient.Supplemental mandibularcanals large enough to be seen onpanoramic radiography are rarebut are occasionally present, themost common being duplicatecanals commencing from a singlemandibular foramen, and the least
Primary lesions developing within themandibular canal are frequently neural or vascular in origin.” 
common arising from two separateforamina [Fig. 1 & 2].
Suchduplicate canals are found in only0.5 to 1.0 % of studied adultpopulations.
They are sometimestermed “bifid canals.”
That suchbilateral canals are a reality ratherthan a projection artifact has beenproven both by anatomicaldissection (Carter and Keen 1971)
and also by computed tomography(Quattrone et al, 1989)
. Whether thecontents are neural, neurovascularor simply vascular is a contentiouspoint. If nerves were present in thetwo canals, this might account forsome failure to achieve localanesthesia when applying blockinjections.On occasion, appearance ofduplicated mental foramina is alsoobserved [Fig. 3]. Such trueduplication needs to bedistinguished from the separatedepictions of the mental canal atits origin from the mandibular canalcentral within bone, and at its exitfrom the facial cortex of themandible.It is possible that bifid canalsrepresent a minor expression ofstructural twinning. Very rarely, themandible may evidence augnathus,a variant of paragnathus.
Such acase, subsequently treatedsuccessfully by surgeons Davis andBreytenbach in Cape Town, SouthAfrica, is illustrated in Fig. 4. In thiscase, unilateral duplication of themandible was accompanied byduplication of the mandibularcanal – and also of the dentition forthat jaw quadrant.
Pathological conditions of the mandible 
The effects of pathologicalconditions of the mandible on thepanoramic appearance of themandibular canal was first reportedby the author of the present report,a quarter of a century ago.
It was found that variousdisease processes canaffect the panoramicradiographic appearanceof the mandibular canal in avariety of ways. Localizedloss of the canal corticalbone was found withchronic apicalperiodontitis, chronicpericorontitis, advancedchronic destructiveperiodontitis (in patientshaving a high mandibularcanal), and rarely also withvery large Stafne’s bonecavities. Generalized loss ofthe canal’s cortical bonewas usually indicative ofsevere infection oraggressive neoplasia, andwas found in associationwith rarefying osteomyelitis,invasive squamous cellcarcinoma, multiplemyeloma, osteogenicsarcoma and occasionallywith ameloblastoma.Displacement of the canalsuggested a benign cysticor neoplastic process, andwas found with largeradicular cysts, residualdental cysts, dentigerouscysts and the cemento-ossifying fibroma amongother benign conditions.
Benign lesions within the mandibular canal 
Primary lesions developingwithin the mandibular canalare frequently neural orvascular in origin. Benignneoplasm within the canalwill tend to widen the canaland cause superior andinferior displacement of thecanal as the lesion expands.Especially with slow growing
Fig. 1.
Examples of“bifid,” or “duplicate,”mandibular canals.Such canals have beenconfirmed in variousstudies both usinganatomical dissectionand by computedtomography.
Fig. 2.
Detailsfrom panoramicradiographsdemonstratingvarious“duplicate,” or“bifid”mandibularcanals.
Fig. 3.
Duplicatedmentalforamen(detail frompanoramicradiograph).
Fig. 4.
Augnathus (avariant of paragnathus)demonstrating anextreme form ofduplication of themandibular canal. (Casetreated by Professors D.Davis and M.Breytenbach, CapeTown, South Africa.)
lesions the cortical plate of thecanal will remain intact. Fig. 5illustrates a case of neurilemmomaarising within the mandibular canal.This is a homogeneously radiolucentlesion that has caused dilation of thecanal in the site of the tumor. Thenormal canal blends with the lesionboth mesially and distally with thecortical plate expanding toencompass the lesion. Certainly, notall neuilemmonas of the mandibleare associated with dilation of themandibular canal, especially if theyare situated in the premolar oranterior regions.
However, dilation ofthe mandibular canal, when present,does suggest a lesion epicenterwithin the canal.Shapiro et al (1984) investigatedthe maxillofacial radiographicmanifestations of neurofibromatosis(von Recklinghausen’s disease), acondition affecting one in 3000 livebirths in which those affected areprone to the development of benignneural tumors, neurofibromas.
Theyfound that 72 % of the 22 subjectsstudied had oral or maxillofacialradiological signs of the diseasesuch as widened mandibular canals(6 cases) or enlarged mandibularforamina (6 cases including two whoalso had widened canals). Lee et al.(1996) found that six of 10 patientswith neurofibromatosis showedenlargement of the mandibularforamen.
Malignant lesions within the mandibular canal 
Primary malignancies arising withinthe mandibular canal are extremelyrare.
When they do arise they willreflect a tissue of origin from the siteconcerned; i.e. neural, vascular,fibrous or smooth muscle. Fig. 6illustrates a case of primaryleiomyosarcoma arising in the leftmandibular body and causingdestruction of the canal outline. The
Fig. 5.
Neurilemmomawithin mandibularcanal. The canal isgreatly dilated bythis homogeneouslyradiolucent benignneoplasm.
Fig. 6.
Leiomyosarcoma(malignant neoplasm ofsmooth muscle),epicentered on themandibular canal, withdestruction of thecanal’s cortical outlines.
Fig. 7.
Radicular cyst arising from the grosslydecayed left mandibular first permanent molartooth. Pressure developing within the cyst due toan osmotic gradient causes growth of the lesionand displacement of adjacent structures includingthe mandibular canal.
Fig. 8.
Large dentigerous cyst associatedwith the crown of a horizontally positionedunerupted third molar tooth in the right sideof the mandible. The right mandibular canalis displaced downwards in comparison withthe ipsilateral canal.
Fig. 9.
Ameloblastomain the right mandibularbody. The lesionresulted in resorptionof the apices of thesuperjacent teeth –but in downwarddisplacement of theintact subjacentmandibular canal.
Fig. 10.
 odontodownwthe mapermashowscrownresembcyst. Thdisplacborder
Fig. 11.
Cementoblastoof the mandibular firsmolar tooth displacinthe roots of the secopremolar and permansecond molar teeth. Tmandibular canal hasalso been displaceddownwards.
Fig. 12.
Squamous cell-carcinoma invadingthe left mandibularbody and ramus –and eroding themandibular canalcortices. The lesionoriginated peripherallyto bone and hence is“saucer-shaped.”

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