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Dentomaxillofacial Radiology (2004) 33, 340—341 © 2004 the British Institute

Dentomaxillofacial Radiology (2004) 33, 340—341 © 2004 the British Institute

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Dentomaxillofacial Radiology (2004) 33, 340—341 © 2004 The British Institute of RadioloB’
SHORT COMMUNICATION
Lingual vascular canals of the interforaminal region of themandible: evaluation with conventional tomography
H Liang*, NL Frederiksen and BW Benson
 Department of Diagnostic Sciences, Division of Oral and Maxillofacial Radiology, Baylor College of Dentistry, Texas A&M Universily System Health Science Center, Dallas, Texas, USA
The presence of lingual vascular foramina and canals in the interforaminal region may increase the risk of surgical complicationsduring implant placement, bone grafting procedures and osteodistraction. Oral and maxillofacial radiologists should recognize thisanatomical variant and include a description in their interpretative report to inform the referring clinician of the potential forsurgical complications. Dentomaxillofacial Radiology (2004) 33, 340—34 1. doi: 10. 1259/dmfr133787240
Keywords: lingual vascular canals; interforaminal region; conventional tomography
Endosseous implants are becoming a routine restorative dental procedure. The placement of dentalimplants in the interforaminal region (the anterior region between the mental foramina) of the mandiblehas been considered to be relatively safe because anatomical structures including the inferior alveolarcanal and submandibular fossa are located posterior to this region. However, clinicians should be awarethat even in this region there are anatomical structures that might compromise the placement of implants.These include an anterior extension of the inferior alveolar canal, a pronounced lingual concavity, asevere concavity of the lingual cortex and lingual vascular canals.Perforation of the lingual plate and inferior border of the mandible have previously been considered to bebenign occurrences. This is often intentional in the presence of a severely atrophic ridge to gain maximumbone-implant surface area retention.
1
However, several studies have reported the occurrence of life-threatening conditions caused by bleeding secondary to the placement of dental implants into the lingualcortex of the interforaminal region because of the presence of accessory vascular canals.”
2
In a recentreview article, Kalpidis and Setayesh
3
reported that 12 cases of severe haernorrhage in the floor of mouthwith subsequent life-threatening upper airway obstruction associated with implant placement in theanterior portion of the mandible were found in the literature from 1986 to 2003. In addition, neweraugmentative techniques undertaken to gain bone volume, such as osteodistraction of theanterior region of the mandible and orthognathic surgical procedures have a potential for vascular injuryand subsequent bleeding in the interforaminal region.
4
The sublingual branch of the lingual artery and the submental branch of the facial artery are among theprimary nutrient vessels to the floor of the mouth. Anastomoses are formed between these vessels prior topassage through accessory lingual foramina in the mandible into lingual vascular canals and anastomosiswith incisive branches of the inferior alveolar artery.
3
Anatomical studies have demonstrated two commonlocations for accessory lingual foramina: the lingual midline of the mandible and close to the lingual
 
midline of the mandible. These have been referred to as median lingual foramina and lateral lingualforamina, respectively.
4
5
McDonnell et al
ti
reported median lingual foramina to be present in 311 of 314dried mandibles (99%). They also reported that 49% of an adult population (100 patients) demonstratedmedian lingual foramina on periapical radiographs of the mandibular incisor region. Tepper et a1
7
whostudied computed tomography (CT) images of 70 patients found that all showed at least one median orlateral lingual accessory canal in the interforaminal region.The incidence of lingual vascular canals in the interforaminal region has not yet been assessed usingconventional tomography. This might be attributed to the limitation of coverage by the image to a specificarea, the thickness of the image layer, or the orientation of the X-ray beam relative to the long axis of themandible.
4
By comparison, CT normally scans the whole jaw, reformats thinner cross sectional sections,and has the ability to reformat images using multiple angulations relative to the long axis of the mandible.Recognition of the possibility for the presence of lingual vascular canals in conventional tomography isimportant for both oral and maxillofacial radiologists and dentists who perform the implant procedures.Reported here are two examples of lingual vascular canals in the interforaminal region. One is orientedparallel to the plane of the cortical bone plate (Figure 1) and the other is perpendicular to this plane(Figure 2). Although smaller canals with a diameter of less than 1 mm are unlikely to cause a problem,larger canals should be described in the radiological report to alert the dentist to potential surgicalcomplications. In neither of these cases was there evidence of lingual vascular canals inthe panoramicimage. Both images are octospiral conventional tomograms acquired on a Scanora imaging unit(Soredex/General Electric, Milwaukee, WI). Layer thickness was 4 mm.The presence of lingual vascular foramina and canals in the interforaminal region may increase the risk of surgical complications during implant placement, bone grafting procedures, and osteodistraction. Oral andmaxillofacial radiologists should recognize this anatomical variant and include a description in theirinterpretative report to inform the referring clinician of the potential for surgical complications.
 
Figure 1
Cross-sectional image located in the right second premolar area showing a lingual vascular canal parallelwith the cortical plate (arrowhead) slightly anterior to the mental foramen (arrow)
Figure 2
Cross-sectional image located in the left edentulous premolar area showing a lingual vascular canalperpendicular to the cortical plate (arrow)
References
1. Laboda G. Life-threatening hemorrhage after placement of an endosseous implant: report of case.
J Am Dent Assoc 
1990; 121:599—600.2. Mason ME, Triplett RG, Alfonso WF. Life-threatening hemorrhage from placement of a dental implant.
J Oral Maxillofac Surg 
1990;
48:
201—204.3. Kalpidis CD, Setayesh RIvI. Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review ofthe literature.
J Periodontol 
2004; 75:
631—645.
4. Gahleitner A, Hofschneider U, Tepper G, Pretterklieber M, Schick S, Zauza K. et al. Lingual vascular canals of the mandible:evaluation with dental CT.
Radiology 
2001; 220: 186—189.
5.
Shiller WR, Wiswell OB. Lingual foramina of the mandible.
Anat Rec 
1954;
119:
387—390.6. McDonnell D, Reza Noun M, Todd ME. The mandibular lingual foramen: a consistent arterial foramen in the middle of themandible.
JAnat 
1994;
184 (Pt
2): 363—369.7. Tepper G, Hofschneider UB, Gahleitner A, Ulm C. Computed tomographic diagnosis and localization of bone canals in themandibular interforaminal region for prevention of bleeding complications during implant surgery.
liv’ J Oral Maxillofac Implants 
2001;
16:
68—72.

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