Oral Radiol (2012) 28:10–14
DOI 10.1007/s11282-011-0074-9
ORIGINAL ARTICLE
Observation of the retromolar foramen and canal of the mandible:
a CBCT and macroscopic study
Taisuke Kawai • Rieko Asaumi • Iwao Sato •
Yasuo Kumazawa • Takashi Yosue
Received: 6 September 2011 / Accepted: 21 September 2011 / Published online: 21 October 2011
Ó Japanese Society for Oral and Maxillofacial Radiology and Springer 2011
Abstract
Objectives The retromolar foramen (RMF) is an ana-
tomical structure on the alveolar surface of the retromolar
area. This foramen runs consecutive to the retromolar canal
(RMC), which diverges from the mandibular canal. It is
important to confirm the RMF and canal locations prior to
surgical procedures, such as extraction of an impacted
molar and bone harvesting as a donor site for bone graft
surgery. This aim of this study was to investigate the RMF
in Japanese cadaver mandibles using cone-beam computed
tomography (CBCT) images and anatomical observations.
Methods Ninety sides of 46 cadaver mandibles were
investigated in this study. CBCT images around the ret-
romolar region were acquired for all of the mandibles. The
frequency and anteroposterior and buccolingual locations
of the RMF were examined on these images. Subsequently,
four sides of three mandibles were dissected to confirm the
contents of the RMC/RMF.
Results In 24 of 46 (52%) mandibles and 34 of 90 (37%)
sides, at least one RMF was observed in the images. In 26
dentate mandibles, 12 (48%) mandibles and 14 (33%) sides
presented at least one RMF. The average location of the
RMF was 14.4 mm posterior from the distal edge of the
T. Kawai (&)
R. Asaumi
T. Yosue
Department of Oral and Maxillofacial Radiology, School of Life
Dentistry at Tokyo, Nippon Dental University, 1-9-20 Fujimi,
Chiyoda-ku, Tokyo 102-8159, Japan
e-mail: t-kawai@tky.ndu.ac.jp
I. Sato
Department of Anatomy, School of Life Dentistry at Tokyo,
Nippon Dental University, Tokyo, Japan
Y. Kumazawa
Oral and Maxillofacial Surgery, Nippon Dental University
Hospital, Tokyo, Japan
123
second molar. The buccolingual location was 3.0 mm lin-
gual from the mandibular canal. Observations made during
the cadaver dissections confirmed that the vessels and
nerves diverged from the mandibular canal.
Conclusions The findings suggest that the RMF is not a
rare anatomical structure and that practitioners should take
this foramen into account in all anesthetic and surgical
procedures involving the retromolar area.
Keywords Cone beam CT
Anatomy
Retromolar
foramen
Retromolar triangle
Mandible
Introduction
In recent years, the use of three-dimensional imaging
techniques, such as computed tomography (CT) and cone-
beam CT (CBCT), has been increasing in the dental field,
including oral surgery. These techniques can produce
three-dimensional high-resolution images that contribute
significantly to the diagnosis based on images and treat-
ment planning. In addition, it is now possible to confirm
mandibular structures, such as the double mental foramen,
bifid mandibular canal, and lingual foramina, which can
not be confirmed by conventional imaging [1–6].
The retromolar foramen (RMF) is an anatomical struc-
ture on the alveolar surface of the retromolar triangle. This
foramen run consecutive to the retromolar canal (RMC),
which diverges from the mandibular canal. Previous
reports based on anatomical studies suggest that the fre-
quency of the RMF ranges from 12 to 72% [7–12]. The
RMF is an orifice on the alveolar surface of the RMC. The
contents of the RMC have been reported to consist of
branches of inferior alveolar vessels and nerves [9, 13].
Since this area is related to surgical procedures, such as
Oral Radiol (2012) 28:10–14 11

Fig. 1 Sample cone-beam computed tomography (CBCT) images of a retromolar canal and foramen (arrow)

extraction of an impacted third molar, bone harvesting as a Table 1 Frequency of retromolar foramen
donor site for bone graft surgery, and sagittal split osteot- Retromolar foramen Number Frequency
omy, unexpected bleeding or parasthesia may occur via of RMFs of RMFs (%)
damage to the vessels and nerves through the RMC/RMF.
90 sides of 46 mandibles
It is therefore important to confirm the location of the RMF
In 46 mandibles 24 52
and the course of the RMC prior to these surgical
In 90 sides 34 37
procedures.
43 sides of 26 dentate mandibles
The aim of this study was to investigate the occurrence,
In 26 mandibles 12 48
location, and contents of the RMC/RMF of Japanese
cadaver mandibles using high-resolution CBCT images In 43 sides 14 33
prior to dissection and macroscopic observation. RMF, Retromolar foramen

Materials and methods anteroposterior and buccolingual locations of the RMF

Ninety sides of 46 cadaver mandibles were evaluated in
this study. Among these, detailed measurements were
made of 43 sides of 26 cadaver mandibles in which the first
and/or second molar were considered to be dentate. The
age and sex distributions of the mandibles were unknown.
CBCT images along the mandibular plane of all the man-
dibles were acquired as the reference plane around the
retromolar region (Alioth; Asahi Roentgen Industry Co.,
Kyoto, Japan). The cone-beam scans were operated around
the retromolar region, with a tube potential of 80 kV and a
tube current of 4 mA; high-resolution images
(u51 9 51 mm) of the cylindrical areas were acquired
(voxel size 0.1 mm) (Fig. 1).
One observer specialized in oral and maxillofacial
radiology evaluated the RMF using the CBCT images. The
longitudinal plane along with the mandibular canal on the
retromolar area and perpendicular plane were reconstructed
from volumetric CBCT data using image analysis software
(Asahi Vision; Asahi Roentgen Industry Co.). The observer
moved this plane buccolingually and mesiodistally to
detect and confirm the RMFs and RMCs. The mesiodistal
distance from the distal edge of the first or second molar to
the RMF and the horizontal distance from the mandibular
canal to the RMF were measured. The frequency and
were inspected.
Thereafter, to confirm the contents of the RMC/RMF,
four sides of three cadaver mandibles were dissected.
Results
At least one RMF was observed on the CBCT images in 24
of 46 (52%) mandibles and 34 of 90 (37%) sides (Table 1).
Among 26 dentate mandibles, at least one RMF was
observed on the CBCT images of 12 (48%) mandibles and
14 (33%) sides. A total of 16 RMFs were observed in
dentate mandibles The majority of the RMC courses were
forward near the bifurcation, although they were crooked
before the bifucation, with upward courses reaching the
foramen on the surface of the alveolar crest.
The average location of the RMF was 14.4 (range
8.1–21.6) mm posterior from the distal edge of the second
molar (12 sides) and 23.0 (range 18.3–27.6) mm from the
first molar (two sides). The average buccolingual location
was 3.0 (range 0–6.3) mm lingual from the mandibular
canal (Table 2; Fig. 2).
Dissection of the three cadaver mandibles confirmed
that neurovascular-like structures diverged from the man-
dibular canal in two sides of two mandibles. However, a

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few structures that could not be confirmed on the CBCT
images were confirmed by the cadaver dissections. Nerves
and vessels were confirmed in the histopathological eval-
uations of the two dissected mandibles (Figs. 3, 4).
Discussion
Frequency of the RMF
Previous reports have revealed that the frequency of RMF
evaluated anatomically range from 12 to 72% per mandible
[7–12]. The frequency of RMF in our study was relatively
higher than those previously reported, although there is
variation among the previous reports. One possibility is
that differences in the observation methods influenced
these results. Ossenberg [14] reported that the occurrence
rates of RMF differ between populations, with the rate in
the North American population being relatively lower than
those in other populations, such as those of Northeast Asia,
Europe, and Africa.
In an evaluation using radiographic images, Naitoh et al.
[2] investigated the RMC as a subtype of the bifid man-
dibular canal using clinical CBCT images (voxel size
0.155 mm) and observed the RMC at a frequency of 25.4%
per mandible and 13.5% per side. Since the CBCT images
used in our study were at a high resolution (voxel size
0.1 mm) and there was no movement of objects during
imaging, it is thought that these aspects led to the higher
frequency of RMC/RMF in our study compared with that
of Naitoh et al. [2].

Table 2 Location of the RMF Location of the RMF

Location of the RMF Distance (mm) Range (mm)
Bilecenoglu et al. [8] reported that the average location of
First molar (two sides) 23.0 18.3–27.6
the RMF from the distal edges of the second and third
Second molar (12 sides) 14.4 ± 4.3 8.1–21.6 molars was 11.91 and 4.23 mm, respectively. Löfgren [7]
Mandibular canal 3.0 ± 1.7 (lingually) 0–6.3 evaluated a Swedish population and found that the RMF
was located 8.3 mm distal from the third molar. Kodera
et al. [9] reported a location of 13 mm distal from the third
molar. In our study, the average location of the RMF was
14.4 mm posterior from the distal edge of the second
molar.
Considering that the mesiodistal diameter of the
crown of the mandibular third molar is about 10 mm
[15], our finding is similar to that of Bilecenoglu et al.
[8]. The differences in the results for the location of the
RMF between these reports are thought to be influenced
by the inclination and the eruption position of the third
molar.
In our study, the RMF was located lingually from the
mandibular canal, at a location ranging from 0 to 6.3 mm.
This finding suggests that the RMC generally runs upward
Fig. 2 Schematic images of the location of the retromolar foramen to the lingual portion of the mandibular canal.

Fig. 3 a CBCT image of a retromolar canal and foramen (arrow). b The retromolar canal observed in the CBCT image was also confirmed
macroscopically. c An hematoxylin-eosin (H&E)-stained image suggests a nerve structure

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Fig. 4 a, b Some structures that cannot be observed in the CBCT image can be confirmed macroscopically. c H&E-stained images suggest the
presence of the nerve structure and vessels, respectively (arrow)
Content of the RMF
Schejtman et al. [12] reported that the most frequently
found components were a myelinated nerve, one or more
arterioles, and one or more venules. After leaving the body
of the mandible, these elements are distributed mostly
along the temporal tendon, the buccinator muscle, the most
posterior zone of the alveolar process and the third man-
dibular molar.
Kodera [9] reported that within the RMC, the artery that
branched from the inferior alveolar artery ran forward
through the canal, joined with the branches of the buccal
artery and facial artery, and finally gave off the superior
and inferior labial arteries. The nerve in the RMC is
derived from the inferior alveolar nerve trunk and branches
13
off to the third molar, the mucosa of the retromolar trian-
gle, the buccal mucosa, and the buccal gingiva of the
mandibular premolar and molar regions.
The results of our study clearly show that the blood
vessels and the nerve in the RMC that diverged from the
mandibular canal had an orifice from the mandible through
the RMF. Unfortunately, the cadaver mandibles that we
evaluated did not have the surrounding structures (only the
mandibular bone with the gingiva). Therefore, we were
unable to evaluate the communication and distribution of
the blood vessels and the nerve in detail.
There were some RMCs that could not be observed in
the CBCT images prior to dissection. In these cases, we
believe that the diameter was very narrow with no sur-
rounding cortex, making it difficult to observe the nerve on
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the CBCT images. Further studies are needed to clarify the
clinical significance of these structures.
Clinical significance of the RMF
The RMC is often treated as a subtype of the bifid mandibular
canal, and a number of studies have evaluated the bifid
mandibular canal using panoramic radiographs. The occur-
rence of bifurcated mandibular canals has been reported to
range from 0.08 to 8.3% [16–20]. On the other hand, Naitoh
et al. [2] and Kuribayashi et al. [3] examined the frequency of
bifid mandibular canals using CBCT images and reported a
frequency of 15.6–43.0% of sides, which is higher that those
obtained based on panoramic radiography.
Since the RMC is generally very narrow, it is difficult to
detect smaller sized RMCs on panoramic radiographs. In
addition, because the images in the retromolar region overlap
the shadow of the opposite mandible, such as the soft palate,
the detailed status of the RMC may be difficult to depict on
panoramic radiographs. We believe that the high-resolution
CBCT images used in this study were very effective for
confirming the small structures in the maxillofacial region
that could not be described by panoramic radiographs.
When there is damage to the RMC during a surgical
procedure, it is easy to suggest that bleeding will arise from
the vessels and that this bleeding will restrict the sight of
the operator. Postoperative discomfort may also occur for
the patient.
Regarding damage to the nerve in this area, Misch [21]
reported that no soft tissue sensory deficits were noted in
19 ramus-grafted patients. On the other hand, Silva et al.
[22] reported that three of 36 (8.3%) patients complained
of numbness of the lower lip and the mental area associated
with bone harvesting from the ramus area. Therefore,
practitioners should still take care to avoid damage to the
RMC as much as possible through careful observation of
the preoperative images.
In conclusion, we observed the RMC/RMF in 52% of all
mandibles, suggesting that it is not a rare anatomical
structure. Since we clearly observed the RMC to run
uniquely after bifurcating from the mandibular canal, it
would be desirable to confirm the course of this canal and
the location of this foramen on three-dimensional images
when practitioners plan anesthetic/surgical procedures in
the retromolar area.
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