RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS

432

MANDIBULAR CANAL RADIOGRAPHIC INTERPRETATION IN PANORAMIC RADIOGRAPHS * INTERPRETAÇÃO RADIOGRÁFICA DO CANAL MANDIBULAR EM RADIOGRAFIAS PANORÂMICAS

Tiago Palloni VALARELLI ** Ana Lúcia ÁLVARES-CAPELOZZA *** Clóvis MARZOLA **** João Lopes TOLEDO-FILHO **** Márcia Juliani VILELA-SILVA *****

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* Work presented as monograph for conclusion of the Course of Residence in Surgery and Traummatology Buco maxillofacial, promoted for the Brazilian College of Surgery and Traummatology Buco maxillofacial and Base Hospital of the Hospital Association of Bauru. ** Former Resident in Surgery and Traummatology Buco maxillofacial, promoted for the Brazilian College of Surgery and Traummatology Buco maxillofacial and Base Hospital of the Hospital Association of Bauru. Author of the monograph. *** Associate Teacher of the College of Dentistry of Bauru of the USP and person who orientates of the monograph. ***** Titular Professor of Buco maxillofacial Surgery and Traummatology of the College of Dentistry of Bauru of the USP, pensioner, professor of the Course and collaborator of the work. **** Titular Professor of Anatomy of the College of Dentistry of Bauru of the USP, professor of the Course and co-person who orientates of the work. ***** Collaborating of the work.

Panoramic radiograph. O estudo foi realizado a partir da interpretação de quatrocentas radiografias panorâmicas utilizando classificações já descritas (NORTJÉ et al..5% of the images. no osso mandibular. The results show that in 12. invasivas ou não. The radiographic appearance of the mandibular canal is characterized by a radiolucent line delimited by two radiopac lines (WORTH. Uniterms: Mandibular canal. because it allows the evaluation of its anatomy and anatomical variations. periodontium. The study was accomplished starting from the interpretation of four hundred panoramic radiographs using the classifications (NORTJÉ et al. Os resultados mostraram que em 12. A radiografia panorâmica é um recurso auxiliar importante no diagnóstico e plano de tratamento das anomalias dentárias e patologias que envolvam o canal mandibular. 1995). RESUMO Nosso trabalho tem como objetivo avaliar a prevalência de bifurcações e o posicionamento do canal mandibular em radiografias panorâmicas. it can assume different positions inside . diminuindo o risco de insucesso nas em intervenções.5% das imagens canais bilaterais altos. there was some bifurcation type in the mandibular canal. 28.25% with some variation.25% of low bilateral canal and 27. The panoramic radiograph is an important auxiliary resource in diagnosis and treatment plan of the dental anomalies and pathologies involving the mandibular canal. 1994 and MADEIRA. INTRODUCTION The mandibular canal is located inside the jaw and transmits the lower alveolar artery and lower alveolar nerve. Radiografia panorâmica.25% of intermediate canal. 1995).75% das imagens observadas. 1988 and MADEIRA. usually as a single and bilaterally symmetrical structure. This plexus emits branches that supply the lower teeth and the adjacent bone tissue. from the mandibular foramen to the mentual foramen (BERBERI et al. lower lip. pois permite a avaliação da anatomia e das variações anatômicas do canal mandibular. Quanto à posição do canal mandibular em relação à base mandibular e aos ápices radiculares dos dentes inferiores. we found high bilateral canal in 32.. 1985). anterior buccal mucosa to the mentual foramen and vestibular gingival of the anterior lower teeth (HEASMAN. 1977 and LANGLAIS et al.. foram encontrados em 32. 1975).RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 433 ABSTRACT The purpose of the present study was to assess the prevalence of bifurcations and the positioning of the mandibular canal in panoramic radiographs... interdentally papilla. 28. 1977 e LANGLAIS et al. a branch of the third division of the trigeminal nerve. 0.25% com alguma variação. Nervo alveolar inferior. 1985). Regarding the position of the mandibular canal in relation to the mandibular base and the radicular apices of the lower teeth. Lower alveolar nerve.25% de canais bilaterais baixos e. havia algum tipo de divisão no canal mandibular. reducing the failure risk in invasive o non-invasive interventions in the mandibular bone.25% de canais intermediários.75% of the observed images. 27. Unitermos: Canal mandibular. 0.

MARZOLA. 2005). The authors had used radiopacs straps to evaluate in radiographic taking. 1998 and SANCHIS. 2. mandibular reconstructions. 12. 75%).5%). THARANON. Type 3 (1 of 8. that the great prevalence of retromolar canal must it the crossed marriage of Argentine Europeans with aborigines (SCHEITMANN. where they had observed a ramification of the main branch that innerve the posterior region of the mandible while a more lower branch covers the mandibular body reaching the anterior region. the canal met moved away from the dental apexes. The non knowledge of the anatomical variations of the mandibular canal can result in local anesthesia failure and even limit the use of some surgical techniques. Three types of passage had been described: Type 1 (6 of 8. The intention of this work is: 1.25%) of the 80 x-rays. To evaluate the passage of the lower alveolar nerve in the interior of the mandibular bone through panoramic x-ray. LITERATURE REVIEW It was dissected 18 mandible corpse had found a canal that if it originates from the mandibular canal finishing in the retromolar foramen or surrounding foramina. BROADUS. it can present duplications or bifurcations in its course (NORTJÉ et al. GLASS. SOLER. ARIAS. 1971). both super inferiorly and mediolaterally (STELLA. They had concluded thus. The authors had observed that this canal gives ticket to a mielinizaded nerve and to one or more arterioles and venues. lower third molar exodontics or the placement of dental implants (TOLEDO-FILHO. 1990). Type 2 (1 of 8.. It was observed and described a mandible with multiple accessory foramens to the mandibular foramen in bilateral mandibular branch. however with the posterior wall of the corticalized canal more less. especially those planning to perform orthognatic surgeries. with the well next dental apexes exactly (Type 1). WORSHIPPER. With the objective to determine the passage covered for the lower alveolar nerve in the interior of the mandibular body. 1985). 1977) and in some cases is possible to find a trifid mandibular canal (AULUCK. the passage of each foramen. 2003).75%) of the 80 x-rays. FARMAN. being noticed that to leave of these intra-bones canals were initiated that . PEÑARROCHA. where the lower alveolar nerve passes very next to the dental apexes that if they inside project for of the mandible canal. 1967). The only mandibular canal was observed in 49 (61. 12. of this form the main branch of the nerve emit small beams that penetrate the radicular apexes and. where the lower alveolar nerve has its next passage the mandibular base. To observe the prevalence of its variations in patients of the city of Bauru as classifications proposal (NORTJÉ. KEEN. 1977 and LANGLAIS.5%). GROTEPASS. In 11 (13. eight mandibles with the muscles of the chew had been dissected still adhered. The knowledge of the mandible anatomy as well the lower alveolar nerve course through the mandible canal is of great importance for the dental surgeons. called of canal to retromolar in 72% of these. in 20 (25%) x-rays it did not have definition of the mandibular canal (CARTER.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 434 the body of the mandible. Moreover. KEERTHILATHA. TOLEDO-NETO.

By the comment of the panoramic x-ray of a patient. 1975). TEBO. NASJLETI. A report of case illustrated with the radiographic image of the duplication of the mandibular canal was presented and the authors had stranded out that anatomical variations of this type can cause problems in anesthesia for regional blockade of the lower alveolar nerve. as well as its diameter and localization. being able to offer then to enervation to teeth and underlying structures (BARCKER. FUNKE. DIASPÉRES. where the mandibular nerve emerges (GOWGATES. With the objective to determine the prevalence of accessory foramina’s in mandible. The interruption of the sanguineous circulation through the lower alveolar nerve quickly is supplied by the establishment of a retrograde circulation. persisting the imperfection in 7 cases (2. The authors had not observed alterations of left side (PATTERSON.75%) of these cases. 1972). finishing in two separate mentuals foramens. suggesting some variations for the same ones (SUTTON. 1973). 1974). temporary regressive changes in the dental pulp of the molar ones of the affected side (CASTELLI. 1973). The author developed one alternative technique for mandibular anesthesia. possibly of the cutaneous insufficient deposition and auricular temporal. buccal and lingual nerves.1%). LOCKETT. The author relates the presence of such foramina with the imperfection in the attainment of the analgesia from the job of classic anesthetically techniques and. using extra-buccal points of reference.87%). With this study the author concluded that the basic concept of that the pulpar enervation of mandibular teeth proved only of staple fibers of the lower alveolar nerve must be coats. of anesthetic.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 435 some times presented bifurcations in its passage. JORDAN. It was examined 300 human corpse mandibles consisting the presence of accessory foramina for where they can came to pass sensitive staple fibers you add. breaking of mandibular foramen right and. moreover. in the region of molar. buccal and lingual nerves to three factors was attributes to the deposition of the lower anesthetically solution to the mandibular foramen. presence nerve the neck. was noticed the presence of two distinct mandibular canals. 1973). Imperfection in the regional blockade of the lower alveolar. was made a study of 331 cases and observed imperfection in the analgesia in 79 (23. The authors had not observed any microscopically change for the interruption of the sanguineous flow. proves the clinical importance of this comment through the study of anesthetically techniques in 130 patients. they had been attributed to the vascular and/or nervous supplement of mandible (HAVEMAN. mainly for the mental artery and mandibular branch of the sublingual artery was noted. noticing. finally. 150 corpse mandibles had been evaluated of adult human beings. 1976). searching the deposition of the anesthetically solution in the neighborhoods of the oval foramen. having its passage for the branch and mandibular body. of supplemental enervation for the nerves myloioydeus and. suggesting that nervous staple fibers happened of all the divisions of the mandibular nerve and still cervical myloioydeus . white of thirty years of age. being necessary the extra infiltration of anesthetic in 72 (21. however. being identified 5332 foramina’s (average of 36 foramina for mandible) that. To evaluate the success in the anesthesia of lower teeth through the regional blockade of the lower alveolar. questioning still the possibility of the presence of a ridge myloioydeus deep to confer such image (KIERSCH.

observed an accessory foramen in the retromolar region. other variations. single channels and intermediate bilateral. to the insufficient deposition of aesthetical solution (ROOD. Type 4 (0. The authors attribute to this foramen. FARMAN. but yes unknown 1024 panoramic x-rays had been interpreted finding in 85 (8.7%). being able to be carried through in patients presenting limitation of buccal opening was developed (AKINOSI. using as reference the lower edge of the mandible and the dental apexes. The authors had concluded that benign cysts and neoplasias generally cause displacement of the canal. 1977). two canals if originating from the same foramen. while that in the severe infections or the cases of malignant tumors occurs an irregular erosion of the bone with disappearance of the radiographic aspect of the sclerotic lines of the canal (FARMAN. To demonstrate that the presence of multiple mandibular canals is not a rare situation. especially in the identification of bodies of people edentulous (DURST. FARMAN.9%). two mandibular canals originating from two distinct foramina’s and joining themselves in region of molar.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 436 nerve and plexus can contribute for the sensitivity of the mandibular dental elements (ROOD. Based in a study with 3612 panoramic x-rays without mandibular traumas or pathological conditions that could affect the normal passage of the lower alveolar nerve.3%) occurrences of this anatomical variation. in: Type 1 (46. thus considering a classification: Type 1. The author suggested the possibility of the emergency nervous staple fibers for this foramen that would previously sensitize the region and some teeth made use to its emergency (CASEY. It was attributed imperfections in the mandibular blockade to the crossed enervation of the mandible.3%). 1977). SNOW. It was observed 122 corpse mandibles finding a foramen in the lingual region in the premolar area in 68. Type 3 (48. The authors point out the importance of the knowledge of the double mandibular canals related to the forensic dentistry. After the interpretation of 3612 panoramic x-rays. JOUBERT. . but its cortical they remain unbroken. less painful. A technique of regional blockade of the lower alveolar. probably of the feminine sort. contribution of the enervation especially for lingual. of approximately 30 years. GROTEPASS. had concluded that normally the mandibular canal is only symmetrical and bilaterally. However. The mandibles of a Caucasian adult corpse.9%). 1977). to form an only canal (NORTJÉ. mandibular body. of panoramic x-rays. three variations of normality can be observed. a small additional canal if extending until the region of second or third molar and. GROTEPASS. as duplications or divisions of mandibular canal (NORTJÉ. Type 2 (3. observing the pathological conditions that affected the radiographic appearance of the mandibular canal was made. Type 3. A study from gotten histological material in the archives of the Oral Department of Pathology of the University of Stellenbosch and. 1978). buccal and lingual nerves. immediately behind the third molar and bilateral one was examining. single channels and high bilateral. the passage in 4 types was classified.9% of these. 1977). 1977). 1980). milohyoideo and buccal nerves and. Type 2. NORTJÉ. 1976). the enervation made for the myloioydeus nerve or the cutaneous nerve of the neck. faster in the aesthetical induction. still. single channels and low bilateral.

since the retromolar region until the region of tooth of the operated side. Type 4 (0. having the patient presented later. In a panoramic x-ray of a man of 29 years of age. Type 3 (0. the authors had concluded that cited variation was about a ramification of the lower alveolar nerve and mandibular canal (MADER.08% of bifid mandibular canals (4 cases). paresthesia of mandibular the deep mucosa and of ridge. observing it prevalence of 0. 1983). ramified upper to the left mandibular canal to the height of the distal crest of as the molar one was observed. using different techniques. A study with 6000 panoramic x-rays evidencing the bifurcation of the mandibular canal in 57 (0. Clinical case of a patient of the masculine sort. KONZELMAN. Through the histological confirmation the author concluded to be about a nerve. had been radiographed 46 mandibles. a bending radiolucid structure. With the objective to evaluate the relation radiculars of the first one enters the apexes and lowers second molar and the upper edge of the mandibular canal. with a nervous branch that left the mandible.367%). GLASS. The interpretation of 5000 panoramic x-rays of conscripts of the army of the United States was carried through. and detailed physical examination. 1981). two canals originating of two distinct foramens. A study involving 2391 jaws and noticed the occurrence of 40 cases with a canal in the retromolar region which called canal of the temporal crest was presented. Tests of vitality of inferior teeth had not shown to alterations. being: Type 1 (0. bifurcation I joined or bilateral extending the long one to it of the main canal and if they again join in branch or mandibular body. a combination of the two first categories. The authors had especially stranded out the importance of the work for the professionals who carry through endodontics and surgical procedures. in form of canal. bifurcation I joined or bilateral extending itself for region of third molar or adjacencies. BROADUS. leading the authors to the conclusion that if dealt with a ramification of the buccal nerve. SINGH (1981) was come across during the extraction of one lower third molar. 1980). The authors had in accordance with classified such occurrences in 4 types the anatomical localization and configuration of the canal. had carried through. RATCLIFF. if joining to follow to form an only wide and mandibular canal (LANGLAIS. 54 years of age.0333%). due to great amount of . carrier of syndrome of Down. through a small foramen in retromolar fosse distant 5 mm of the distal face of the tooth. being Type 1 of a side of the mandible and Type 2 of the other side. After the accomplishment of other radiographic taking. presenting bifurcation of the bilateral lower alveolar nerve was publish (BYERS.0333%). buccal and lingual blockade nerves (OSSENBER. The author standees out the possibility of these staple fibers to contribute for the sensitive enervation of the molars and adjacent region being able to result in imperfection in local anesthesia attainment through of the usual technique of the lower alveolar.517%).95%) of these. caucasian. LORTON. Type 2 (0. 1983). besides establishing the localization of the canal in the direction vestibulelingual and vertical line in relation. The authors point such anatomical variation as a possible cause of the imperfection in the regional blockade of lower alveolar nerve (GROVER. 1985).RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 437 considering still the hypothesis of that this repair can be only one great nutritional canal (CHAPNICK. 1986).

Bifurcation in mandibular canal due to suggestive image in panoramic x-ray and had confirmed this finding through the image gotten for Computerized Cat scan ha suspected (QUATRONE. 1986). 1989). having the dental apexes and the lower mandibular edge as control points. and 5. (1991) had in the distance evaluated the trustworthiness of the gotten images of hypocycloidal cat scans. for the localization of the mandibular canal. The radiographic image of a unilateral bifurcation of the distal mandibular canal the area of the third molar one was noted. 1990).2% of type 2 (low). BIANCIOTTO. 1989). 15. The authors had concluded that the image most trustworthy for the planning of procedures involving the next area to the mandibular canal was that one gotten by Computerized Cat scan (KLINGE. KOLOKOUDIAS. FARMAN. A study comparing the information gotten between radiographic. A study to determine the incidence of the some mandibular channel types and its relation with the sort of the patients. The panoramic x-ray with the computerized cat scan of 15 patients in the localization of the mandibular canal had compared. had carried through. 1989). GRÖNDAHL et al. The classified samples as type 4 (variations) were gifts in 11. PETERSSON. THARANON. measuring vertical between the alveolar crest and the superior edge of the mandibular canal. 1977) for determination of the height of the mandibular canal. .RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 438 accidents involving the mandibular canal in these treatments (LITTNER et al. and the measures made for six appraisers (three radiologists and three buco maxillofacial surgeons).. observed a prevalence of 67. MALY. PAPADAKIS. In the present study only three cases of bifid mandibular canal had been found and significance was not observed statistics between sorts. in order to minimize the probability of errors due to the mensuration imperfections.7% of the samples as being of type 3 (intermediate). A necessary method for localization of the mandibular canal was developed. GROTEPASS.6% of type 1 (high). For the authors they had in such a way used eight jaws edentulous of adult corpses.5% of the total (HEASMAN. The authors had suggested that. however. The authors had concluded that the Computerized Cat scan better got performance in the localization of the mental foramen and the mandibular canal in the distant region 1 cm in the posterior direction to exactly. beyond the mandibular channel type (ZOGRAFOS. PETERSSON. significant differences between the techniques studied in the mensurations carried through in the 2 cm posterior to the mental foramen had not been observed (LINDH. had concluded that the mandibular canal exclusively assumes lingualized position the 1 and 2 cm in posterior direction to the mental foramen. The author stranded out the necessity of the planning adjusted. predominantly lingualized to 3 cm posterior to exactly and 0 variable in the height of the foramen and 4 cm posterior to this (STELLA. 1990). The study it showed a great variation in the mensurations between observers. FURLINI. For 40 cat scans of patients had been in such a way used.. in clinical environment. of which images for Computerized Cat scan had been gotten and after the analysis of the results. the images are interpreted for more than a professional or that the gotten values are compared with the finding supplied for the radiology services. 1990). A radiographic study with 96 mandibles using classification proposal (NORTJÉ. 1988). which had preoperative to such variations (DRISCOLL. tomography and macroscopic images were carried through in four specimens of mandibles. being used 700 panoramic.

A study comparing the precision of the x-rays: Periapical. A pioneering study with the objective to describe the prenatal formation of the human mandibular canal had developed. The patient was submitted the surgical procedure for removal of the impacted tooth.0 mm (23. and told a brief period of postoperative paresthesia in the region (WYATT. what he is obvious to the birth (CHÁVEZ-LOMELÍV et al. yes a system of mesh of nerves. bifid mandibular nerve. and had gotten an average distortion of 1. also called "trunk" are not individual and. The authors had noticed the presence of two mandibular canals separate and overlapped of the right side of the mandible. For in such a way. The bilateral duplication of the mandibular canal in a panoramic x-ray of a patient. still. 3. The authors suggest the hypothesis of that the lower alveolar nerve this gift probably in the jaw as three different nervous pursuing originating in different periods of training of embryonic development and that fast prenatal growth and. 1996). some very fine. . HASHIMOTO.5%) and 0. 1994). 1996). the authors had used an acrylic resin plate with markers of guta percha and a human corpse jaw. The authors had observed that plexus. This canal if extended of the mandibular branch until the molar distal face of the impacted third molar. told the case of a patient of 23 years of age. Four possibilities for the failure of the anesthesia of the mandible. FAIELLA.. The authors affirm that the patient told to relate of unsatisfactory anesthesia during surgical procedure in both the sides of the mandible (FREDEKIND. Panoramic and Cat scan Computerized in the localization of the mandibular canal. masculine sort.8%) respectively (SONICK. of 33 years of age had observed. the solutions to skirt the cited variations and warn that the surgeon-dentists must know all the anatomical variations of the area to be worked as well as different aesthetical techniques for attainment of mandibular blockade (DESANTIS. LIEBOW. DORAN. ABRAHAMS. that showed. 1995). edentulous. retromolar foramen and. They had still observed the existence of as "plexus" between the mandibular and the dental roots. 1993). 1995). The authors had presented a quarrel on the nature and distribution of the elements of the canal of the left side and had pointed out the risks and consequences of injuries to such structure (KODERA. black race. the remodeling of the region of the branch results in a gradual coalescence of the entrances of the canals. It was evidenced an anatomical variation of the mandibular canal in one of its patients through the evaluation of panoramic x-rays and cat scan computerized with axial and coronal cuts. contralateral enervation of anterior teeth. With the objective to alert to the surgeon-dentists for the possible existence of accessory mandibular canals and its implications. MANI. had carried through. the image of a similar structure to a canal. NASSEHY. 1994). originating from an only foramen (BERBERI. The presence of a canal to retromolar bilateral in a patient with 47 years of age had described. 1996). to the height of the junction cement has enameled of the cited dental element. The authors present. composed canal of micron-filaments that penetrate the same ones through its lateral face or its apexes (ZOUD.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 439 An anatomical study of neurovascular plexus of the lower alveolar nerve using 3 human corpse parts had carried through. amongst them was publish in a article telling: contribution of sensitive enervation for the milohioideus nerve.9 mm (14%). in its panoramic x-ray. branching off inside of its course in the mandibular canal. superior to the mandibular canal.2 mm (1. SCHIFF.

30. The authors affirm that they do not exist you evidence of similar cases in world-wide literature (AULUCK. being modified the length of the implantation for 10 mm would be carried through after the accomplishment of the Computerized Cat scan (DARIO. A clinical case of accessory canal mandibular bilateral. 17. 2002).. 1977 and LANGLAIS. MATERIAL AND METHODS Four hundred panoramic radiographs of consecutive patients. 1985) the authors had observed 41. MARZOLA. TAMBURÚS. were used in this study. all in women. 2000). 34. Using the classification the proposal (NORTJÉ. parting them in 9 fragments of 7 mm from the mental foramen. The occurrence of the bifurcations and the positioning of the mandibular canal had been described in 650 panoramic x-rays.18% edentate bifid canals in and 17. 32.72% partial absence of the image of the canal (DEVITO. Justified for the fact not to have similar stories in literature. internal and external basal ridge. of the left side. 2005).44% of low bilateral canals and 22. 2001). diameters of the mandibular canal as well as the distances and thicknesses related to this (TOLEDOFILHO. followed for a revision of excellent literature. the authors suggest the classification of this variation in a new subdivision (CLAEYS. The clinical case of a patient of 19 years of age. observed from images gotten in Panoramic x-ray and Computerized Cat scan. Between these last ones. 7 (0.35%) images suggestive of bifid canal had been found. 2003). presenting two mandibular canals of the right side originating from distinct mandibular foramens and finishing in separate foramens was verified.72% showed bilateral asymmetries. alveolar ridge. WANG. observing the thicknesses of the mandibular bone boards external intern and. KEERTHILATHA. carried through. BROADUS. the installation of two implantations measuring 13 mm in the posterior region of mandible. It was analyzed 2012 panoramic x-rays in the determination of the incidence and the characteristics of the bifid mandibular canals. The presence of trifid mandibular canal.83% of high bilateral canals.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 440 A morfometric study of the mandible human being using itself 60 hemi mandibles. SERMAN. GROTEPASS. The authors conclude that the Computerized Cat scan presents advantages in the detention of anatomical variations in the mandible when compared the panoramic x-ray (KAUFMAN. observed from a panoramic x-ray of a patient with 48 years of age was verified. had published. FARMAN. 2005). 3.64% presenting other variations. unilateral. The panoramic radiographs were drawn manually on a translucent paper aided by an illuminator supplied with two fluorescent lamps of 15 watts each and a black mask around the radiographs in an .09% of intermediate bilateral canals. In the initial surgical planning. Alert for the possibility of bifurcation of the mandibular canal and the importance of a planning preoperative detailed in the surgeries for installation of bone integrated implantations was made. made from a panoramic x-ray. GLASS. ranging from 8 to 75 years of age. In tomography examination bifid canals in 2 of the 3 studied cases had been confirmed (SANCHIS et al. WACKENS.38% presented bifid canals in dentate. TOLEDO-NETO. 1998).

1985) was used (Figure 1).. the inferior first molar. regarding the permanent lower second molar and. in its absence. All draws were analyzed by two observers and the classification proposed (NORTJÉ et al. Type 4: Variations including: asymmetry. . duplications and absence of mandibular canal. In radiographs where bifurcated canals were found. mandibular canal and mandibular base. The mandibular canal was then classified in 4 types: Type 1: Bilateral single high mandibular canals . lower molars. 1985).RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 441 environment with appropriate luminosity. Type 2: Bilateral single intermediate mandibular canals – single canals not fulfilling the criteria for either high or low canals. The draws included the condyles. Type 3: Bilateral single low mandibular canals. Figure 1 – The classification proposed (LANGLAIS et al. single canals either touching or within 2 mm of the cortical plate of the lower border of the mandible.. and the classification proposed (LANGLAIS et al. 1977) was used.. mandibular and mental foramens.single canals either touching or within 2 mm of the apices first and second permanent molars.

and only 1 (0.50%) in men and 38 (74. In the cases where asymmetry in the height of canals or bifurcations were observed.75%) radiographs were excluded due to uni or bi-lateral absence of teeth.0% of the total number studied and 47.50%) in women. No Type 3 bifurcation was found in this study. occurring 17 times on the right side and 5 on the left side. The Type 1 bifurcations were present in 21 radiographs which 3 of them belonged to men and 18 to women.25%) as Type 2.05% of the cases presenting bifid mandibular canals. 400 350 300 250 Number of 200 cases 150 100 50 0 353 130 113 1 109 Type 1 Type 2 Type 3 Type 4 Total Classification Graphic 1 . The larger number of bifurcations was verified on the right side of the mandible (17 radiographs) against 2 occurrences on the left side and 2 occurrences bilaterally.25% of the total number of studied radiographs and 41.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 442 RESULTS Of the 400 interpreted panoramic radiographs.50%) belonged to male patients and 250 (62. The radiographs presenting Type 1 bifurcations represented 5.50%) to female patients.5%) radiographs classified as Type 1. it was classified as Type 4. totalizing 109 (27.25%) as Type 3.17% of the bifid mandibular canal cases.Height variation of the mandibular canal. The data were analyzed in a descriptive way. 113 (28. Bifid mandibular canals were found in 51 radiographs. Of this total.25%) radiographs (Graphic 1).75%. . The Type 4 bifurcations were observed in 6 radiographs from women (3 on the right side. During the canal height canal analysis 47 (11. 13 (25. a prevalence of 12. 1 on the left side and 2 bilaterally). In the 2 remaining radiographs the bifurcations happened bilaterally and represented 6. The Type 2 bifurcations were observed in 24 radiographs being 8 in men and 16 in women. 150 (37. There were 130 (32.

50 0.Canal mandibular bifid prevalence.76% of the cases presenting bifid mandibular canals.00 DISCUSSION The mandibular chanals are usually. Bifurcation of the mandibular canal. No significant difference in the prevalence of mandibular canal bifurcation related to the age group was seen in this study (Table 1).2. 1985).25 41. Supplemental mandibular canals large enough to be seen on panoramic radiographs are occasionally present (NORTJÉ et al.50 4..73 10.50 100. .86 13.00 bifid canals 0 14 22 7 5 2 1 0 % 0. bilaterally symmetrical. (1985).75 12.50 1.75 13..25 25.00 11. The term "bifid" is derived from the Latin word meaning a cleft in two parts or branches.11 16. Tabela 1 . Age 0a9 10 a 19 20 a 29 30 a 39 40 a 49 50 a 59 60 a 69 70 a 79 Total N 01 101 167 55 50 18 06 02 400 % 0. The Graphic 2 illustrates the results observed for the bifurcation of the mandibular canals according to the classification of LANGLAIS et al. and the majority of hemi mandibles contain only one major canal.18 12. 1977).50% of the cases and 11. Type 1 unilateral Type 1 bilateral Type 2 unilateral Type 2 bilateral Type 4 unilateral Type 4 bilateral Total 0 19 2 22 2 4 2 51 10 20 30 40 50 60 Number of cases Graphic .67 0.. but not invariably.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 443 The radiographs containing bifurcations of the Type 4 totaled 1.00 13. Bifid mandibular canals can originate at mandibular foramen and to contain a neurovascular bundle (LANGLAIS et al.

7 Type 1 Type 2 Type 3 Type 4 Graphic . 2001). for the intermediate channels (Type 2).25 3. Comparison of the results of height variation of the mandibular canal. different from the 1% observed (DARIO. All this data are in disagreement with the 15.83% of occurrence. we observed a prevalence of 28. who found 11. The author emphasizes that such condition can happen in inferior-superior or medium-lateral plans. 1988). We are in agreement with HEASMAN (1988) who admitted that the discrepancy in the results can be related to the morphologic differences among racial groups. In the present study we found a prevalence of 12.25% of our sample in agreement with the 22. 1977).3. The canals classified as Type 4 were observed in 27.5% of this research.6 5..25 27. 2002).64% observed (DEVITO.09 22. respectively. TAMBURUS. Low mandibular canals (Type 3) were little found in this research. TAMBURUS (2001) that evidenced 46. SANCHIS et al. what is in agreement with the observations described in the literature.25 46. in agreement to the 32. 1977 and HEASMAN.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 444 For de height variation of the mandibular canal.75% of mandibular canal bifurcation. 1988).. 80 70 60 50 40 30 20 10 0 VALARELLI DEVITO.83 32.7 41.25%.5% of occurrence and much larger than the 1.3 1.1% found (NORTJÉ et al. it was observed smaller indexes related to the percentage of Type 1 canals when compared our finds with NORTJÉ et al.. TAMBURÚS NORTJÉ et al HEASMAN 0.64 15.5 28.44 3.1 32. (2003) suggest that one possible cause for a wrong interpretation of the mandibular canal bifurcation is the imprint of the milohyoid nerve on the internal mandibular surface.09% (DEVITO.7% respectively. being sometimes hard to be identified in panoramic or periapical radiographs. however.6% observed (HEASMAN. however. it is almost twice the number of cases observed (HEASMAN. against 32.9 67. TAMBURÚS.5 48.3% and 67. The Graphic 3 shows the results of the four researches above mentioned. 1988) that observed 3. 2001) and different from the values related (NORTJÉ et al.7% and 41. (1977) and DEVITO. The author reinforces the idea that the non detection of this variation can harm the planning and the success of the surgical procedures in the patients. where it separates from the lower alveolar .2 11.

the buccal and mylohyoid (HAVEMAN. against 4. TAMBURÚS LANGLAIS et al.45%. The nerves more commonly associated these fail are: the anterior cutaneous colli. 0. (1985).0% and 1. The identification of bifid mandibular canals is of great importance in the success of a surgery. 2000). 0. LIEBOW.6 3. They found a prevalence of 0.50% found in our study. TEBO. Graphic 4 .033%.5 50 41.5 . especially the Type 4 that includes two mandibular foramens. 1976. % 60 54.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 445 nerve and travels to the floor of the mouth. 2001).5 0 VALARELLI DEVITO.367%.86 40 30 20 47. Comparing the results of this research with the results obtained by LANGLAIS et al.05 Type 1 Type 2 Type 3 Type 4 37. Adequate levels of local anesthesia can be difficulties by the supplementary enervation and foramina’s of the mandible. 3 and 4. inadequate deposition of anesthetic solution (ROOD. 2. 6.033% of bifurcations Types 1.75 3. auriculotemporal.96 38.26 11. KAUFMAN et al. the lingual. 1996). respectively.Comparison of the results related to the types of bifid canals. The most promising is the technique proposed by GOWGATES (1973) where the anesthetic solution is deposited around the mandibular 0 10 3. The Graphic 4 illustrates the comparison of our results with the results obtained by other authors. The failure in the anesthesia of the inferior alveolar nerve can be attributed to some kind of bifurcation. Among the bifurcate canals the Type 2 was the most seen. in agreement with the results described (DEVITO. expressed in percentage of the total of found bifurcations.. alternative anesthetic techniques can be used. 0. 1977) and the incorrect employ of the anesthetic technique should be considered in case of failure. TAMBURÚS. Another explanation is related to the image formed by the bony condensation produced by the insertion of the milohyoid muscle into the internal mandibular surface.00%. The contralateral enervation (DESANTIS.517%.17 56.92 1.. identified as a parallel image to the canal. To compensate such anatomical variations. 0. a disagreement is observed.

This can also be a problem in the area of third molars in the presence of variations Type 1 or 3. 1971 and HAVEMAN. all mandibular fractures should be manipulated carefully to guarantee the correct positioning of the neuro-vascular bundle and to avoid interference in the reduction of the fracture. leading to unfavorable consequences as the mandibular canal violation. these structures can cause bleeding. making necessary the identification of the variation and those subsequent modifications in the prosthesis. 1976). When the alveolar bone is reabsorbed in the proximities of the mental foramen. The clinician should recognize the anatomical variations and modify the surgical technique if necessary. In surgical procedures involving mandibular osteotomies. However. Furthermore. Extreme care is necessary during an inferior third molar exodontics. The interpretation of the panoramic radiographic is of great importance in its location and on surgical planning. In case of the indirection of this variation. the patient it can relate discomfort in this area with the use of total prostheses due to the compression of the neuro-vascular bundle. trismus. In these cases. in patients presenting temporomandibular dysfunction. comparing with the standard technique. buccal and lingual nerves and any other smaller branch or division of the inferior alveolar nerve (MARZOLA..RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 446 nerve trunk when it emerges from the oval foramen. This technique allows the anesthesia of the inferior alveolar. The alignment becomes harder in case of a second neuro-vascular bundle in a second plan. 1993 and 2005). the surgeon can false estimate the useful space for the implant installation. the tuberosity approach suggested by AKINOSI (1977) can be useful. Considering that a second branch of the lower alveolar nerve can exist. anesthetizing mainly the inferior alveolar. Anatomical variations as accessory foramina’s and bifid mandibular canal can result in surgical complications not correctly identified. this technique requests maximum mouth opening and. This technique is based on knowledge of the anatomy of the pterygo-mandibular space and the anesthetic solution is liberated in a posterior position. 1997). 1996). KEEN. ankylosys of temporomandibular joint and other alterations that difficult great buccal opening. it cannot be possible. 1974. In the cases of trauma. These variations are of great importance on osteointegrated implant surgery. If harmed. the surgery becomes more complex with the addition of a second neuro-vascular bundle. complications as traumatic neuroma. an association has been observed between the location of these foramina’s and the area of insertion of masticator muscles. . hindering the surgeon's vision and increasing the potential of formation of fibrous tissue in contact with the surface of osteointegrated implants. CARTER. paresthesia or excessive bleeding can happen in case of fail in detection of this variation (WYATT. Most of the studies published in pertinent literature agree that the foramina’s are located preferentially in the internal aspect of the posterior part of the mandible (SUTTON. buccal and lingual nerves. TEBO. especially when the variations Type 1 or 3 are present. EPKER (1984) emphasized the necessity of the protection of the blood supply during those procedures. The tooth can damage the mandibular canal or even be positioned inside of this (MARZOLA et al.

34. p. v. 15. Dentomaxillofac. Implant placement above a bifurcated mandibular canal: a case report. E. A.25% of the Type 3 and 27. The intramandibular course of the inferior alveolar nerve.. 259. The human mandibular canal arises from three separate canals innervating different tooth groups. At the end of the analysis of the 400 panoramic radiographs. Brit. J.. Int. 3. J. p. KEERTHILATHA. The anatomical variations seem to be related to the genetic variation and to the racial mixtures. L. MANI..RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 447 A question also exists regarding the contents of the accessory foramina’s and the most probable is a vascular-nervous bundle (KAUFMAN et al. AULUCK. Alexandria. n. n. single and bilaterally symmetrical. 108. confirming the hypothesis. dent. These canals are directed from the lingual surface of the mandibular ramus to different tooth groups. 2005.. Implant Dent. N. DARIO. 2000). p. 8. making possible the correct planning of surgical procedures.. Philadelphia. Oxford. KEEN.. I. Quintes. avoiding harmful results to the patient and solving the problem in case of its occurrence. CARTER. 1994..5% of mandibular canals Type 1. et al. 6. a prevalence of 32. 11. being 5. n. CHÁVEZ-LOMELÍ. P. 4. v. p..75% of bifurcations was observed. 83-7. . Res. Bifurcations Type 3 was not observed. J. M. 1996. 3. varying in prevalence from one region to another.. Regarding the bifurcation of the mandibular canal a prevalence of 12. 25. n. A possible explanation for the presence of accessory foramina’s and duplication of the mandibular canal is that during the embryonic development. considering the mandibular canal height. jul. A. REFERENCES * AKINOSI. B. It is believed that the fast prenatal growth and local remodeling result in a gradual fusion of these segments (CHÁVEZ-LOMELÍ et al. v. London. CONCLUSIONS The clinician should know the anatomy and the radiographic anatomy the mandibular canal and its variations. v. 28. R. 1977. ________________________________ * According the ABNT norms. 0. 1540-4. 75. J. p.25% of the Type 4 was observed. BERBERI. sep. however supplemental canals are observed across the mandibular body.. 4. 1996). 258-61. E. M.0% of the Type 2 and 1. Edinburgh. Trifid mandibular nerve canal.. 277-81. Anatomy.. A new approach to the mandibular nerve block. 433-40. 1971.25% of the Type 2.5% of the Type 4. NASSEH. J. v.25% bifurcations Type 1. Rad. p. the formation of three separated canals occur in each hemi mandible. The mandibular canals are usually. oral Surg. aug. O. n. but not invariably.. J. Duplicated mandibular canal: report of a case. v. Carol Stream.. 2002..

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v. Chicago: Year Book Medical. Accessory mandibular canal: literature review and presentation of an additional variant. WYATT. H. M.. 63-71. p. Principles and practice of oral radiologic interpretation. n. Carol Stream. W. Quintes.RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL IN PANORAMIC RADIOGRAPHS 449 WORTH. 1996. 1975. Int. o0o . 111-3. 27. 2. p. M.