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121]

Original Article

Comparison between Conventional Radiograph and 3D

Volumetric Radiograph for Determining the Morphology and
Morphometry of Mental Foramen
Rakashree Chakraborty, Sourav Sen1, Arati Panchbhai2, Rahul R. Bhowate2, Aditya Dupare3
Department of Oral Medicine and Radiology, Maharishi Markandeshwar College of Dental Sciences and Research (Deemed to be University), 1Department of Public
Health Dentistry, Maharishi Markandeshwar College of Dental Sciences and Research (Deemed to be University), Haryana, 2Department of Oral Medicine and
Radiology, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences, 3Department of Oral Medicine and Radiology, Yogita Dental College and Hospital,
Dental School in Vetalwadi, Maharashtra, India

Abstract
Objective: Mental foramen is a vital anatomical structure in human mandible as they are important for dental surgeons for extraction, implant
placement, osteotomy procedures, anesthetists in nerve block, and surgical procedures to avoid injury to neurovascular bundle in mental foramen
area. The aim of this study was to compare the position, shape, size, and distinctness of mental foramen using orthopantomogram (OPG) and
digitalized volumetric tomography (DVT). Materials and Method: This study was conducted on 25 individuals for both the genders. Position,
shape, size, and distinctness of mental foramen were compared using OPG and DVT and were evaluated by Expert three‑dimensional (3D)
software in DVT and Annotation software in OPG. Results: Mental foramen was found to be on the vicinity of the second premolar region
with respect to apices of premolars and molars and was more common in the middle third region of the jaw bone with respect to superoinferior
cortex of the mandible in vertical plane. There was no significant difference in the position of the mental foramen using OPG and DVT. The
commonest shape of mental foramen was found to be oval and was better defined in DVT. The size of the mental foramen was observed to
be 0.49 ± 0.05 and 0.51 ± 0.06 cm in OPG and DVT, respectively, and more distinctly visible in DVT. There was no significant difference in
the position, shape, size, and distinctness of the mental foramen among genders. Conclusion: Conventional radiography can be initially done
for the position of the mental foramen but the details must be confirmed using 3D volumetric radiography to avoid any kind of procedural
complications.

Keywords: Digitalized volumetric tomography, 3D volumetric radiograph, mental foramen, orthopantomography

Introduction postoperative complications. The size of the mental foramen

Mental foramen is an anatomical landmark located on the
anterolateral surface of the body of the mandible.[1] It transmits
the mental nerves and vessels.[2] The mental foramen varies
in position with race and age.[3] The superoinferior position
varies with age.[4] It lies at the lower border of the mandible
at infancy, at the midway between the alveolar crest and
lower border of the mandible at the middle age, and near
the alveolar crest at old age.[4] Hence, the most common
noninvasive method for assessing the mental foramen is
radiography which will lead to minimal postprocedural
complications. The shape of the mental foramen varies from
being oval, round, or even irregular.[5] The exact shape of the
mental foramen should be properly analyzed for minimal
Access this article online
varies according to various races, and hence its accurate
identification leads to effective nerve blocks and prevention
of postoperative neurovascular complications in the mental
region such as neurosensory disturbances, paralysis,
hemorrhage, altered sensation, orofacial pain, and atypical
Address for correspondence: Dr. Rakashree Chakraborty,
Department of Oral Medicine and Radiology, Maharishi Markandeshwar
College of Dental Sciences and Research (Deemed to be University),
Mullana, Amabala - 133 207, Haryana, India.
E‑mail: drrakashreesen@gmail.com
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How to cite this article: Chakraborty R, Sen S, Panchbhai A, Bhowate RR,
Dupare A. Comparison between conventional radiograph and 3D volumetric
radiograph for determining the morphology and morphometry of mental
DOI:
10.4103/jiaomr.jiaomr_169_18
foramen. J Indian Acad Oral Med Radiol 2019;31:17-23.
Received: 04-10-2018   Accepted: 22-12-2018   Published: 23‑04‑2019

© 2019 Journal of Indian Academy of Oral Medicine & Radiology | Published by Wolters Kluwer - Medknow 17
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Chakraborty, et al.: OPG versus DVT for determining the morphology and morphometry of mental foramen
neuralgia. Appropriate distinctness of the mental foramen
facilitates better morphometry. There are various general
dental surgeries which are performed on patients with poor
socioeconomic status. Hence, ideal radiographic techniques
with accurate exposure parameters can give a basic idea of the
position of the mental foramen. Extensive procedures such as
implant placement and osteotomy need accurate morphometry,
and therefore three‑dimensional (3D) volumetric imaging
is preferred over conventional radiographs. This research
on living human beings aims to elucidate the normal
morphology of the mental foramen and its position, shape,
size, and distinctness with a view to facilitate the accurate
identification using orthopantomogram (OPG) and digitalized
volumetric tomography (DVT) and comparing between the
two radiographic methods during invasive procedures of the
lower face, thereby limiting postprocedural complications.
Materials and Methods
This was a cross‑sectional in vivo study. The Institutional
Ethical Committee–approved study included 25 subjects
recruited from patients attending the outpatient department in
the Department of Oral Medicine and Radiology.
The inclusion criteria were as follows:
• Age group of patients between 15 and 65 years
• Patients with edentulous areas in the posterior region of
the mandible.
The exclusion criteria were as follows:
• Patients with systemic disease  (rheumatoid arthritis,
osteomalacia, osteogenesis imperfecta, osteoporosis)
which can affect bone integrity
• Patients suffering from bleeding disorders (hemorrhagic
diathesis, drug‑induced
• Anticoagulation
• Patients with pathologies in the upper and lower jaws and
oral mucous membrane
• Immunocompromised patients (HIV, immunosuppressive
medications)
• Drug abusers, alcohol consumers, and heavy smokers
• Psychological and mental disorders
• Noncompliant patients
• Patients who underwent radiotherapy
• Patients with habit of bruxism
• Patients on IV bisphosphonates.
For examination of the patients, the things used were
physiological dental chair with illumination, mouth mask,
sterile gloves, plain mouth mirror, straight probe, explorer,
kidney tray, cotton, gauze, 0.2% chlorhexidine gluconate
solution, and cheek retractor.
OPG was taken using orthopantomogram machine
(Planmeca Proline CC Panoramic X‑ray; Planmeca OY,
Helsinki, Finland). For 3D volumetric imaging, Philips Allura
Xper FD20  3D RA, digital subtraction angiography unit
(The Netherlands) was used.
18 Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 1  ¦  January‑March 2019
Methodology
After attaining a written consent from all the participants, a
thorough case history and general and oral examination of
participants were carried out and findings were noted. For the
purpose of radiographic evaluation of mental foramen in the jaw
bone, OPG and DVT were done for the mandibular posterior
region. The position, shape, size, and distinctness of the mental
foramen were evaluated using Expert 3D software in DVT and
Annotation software in OPG. The radiographic image was
analyzed and then the findings were noted. Further comparison
was made between the readings of the two radiographic
techniques. Statistical analysis was done using SPSS software
version 16, and Chi‑square test and unpaired t‑test were used.
Statistical significance level was set at P > 0.05.
Position of the mental foramen
The position of the mental foramen was analyzed by Expert
3D software in DVT and Annotation software in OPG.[4]
i. Position with respect to apices of premolars and molars
• Position 1: situated anterior to first premolar
• Position 2: situated at the apex of first premolar
• Position 3: situated in between first and second
premolar
• Position 4: situated at the apex of second premolar
• Position 5: situated in between second premolar and
first molar
• Position 6: situated apex in the of first molar
ii. Position with respect to superoinferior cortex of mandible
in vertical plane
• Position 0: at the superior third of the jaw
• Position 1: at the middle third of the jaw
• Position 2: at the inferior third of the jaw.
Shape of the mental foramen
The shape of the mental foramen was then analyzed using
Expert 3D software in DVT and Annotation software in OPG.
The shapes considered were round, oval, or irregular.[5]
Size of the mental foramen
The size of the mental foramen was then measured using Expert
3D software in DVT and Annotation software in OPG.[6] A
horizontal diameter was measured from the mesial aspect of
the mental foramen to the distal aspect of the mental foramen.
Distinctness of the mental foramen
The distinctness of the mental foramen was analyzed using
Expert 3D software in DVT and Annotation software in OPG.[7]
• Position 0: indistinct
• Position 1: distinct.
Results
This study was conducted to determine the location shape, size,
and distinctness of the mental foramen by conventional and
digitalized radiography. After following strict inclusion and
exclusion criteria, a total of 25 subjects were included having
edentulous areas in the mandibular posterior region of the jaw.
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Chakraborty, et al.: OPG versus DVT for determining the morphology and morphometry of mental foramen

Of the total 25 patients, 9 were males and 16 were females

Table 1: Position of the mental foramen (with respect to
who were clinically not significant. The age of patients ranged
apices of premolar and molar)
from 15 to 65 years with a mean age of 35.48 ± 12.69 years.
In this study, it was observed that comparing OPG and DVT With respect to apices of OPG DVT χ2 P
for the position of the mental foramen in the anteroposterior premolar and molar
n % n %
dimension of jaw bone, it was observed that there was no Anterior to 1st premolar 00 00 00 00 1.100 0.777
mental foramen observed anterior to the first premolar and in In line with the 1st premolar 02 08 03 12
line with the first molar in OPG and DVT. The most common In between 1st and 2nd premolar 06 24 05 20
position of the mental foramen was in line with the second In line with 2nd premolar 13 52 15 60
premolar in OPG and DVT [Table 1, Graph 1 and Figure 1]. In between 2nd premolar and 04 16 02 08
Comparing OPG and DVT for the position of the mental 1st molar
foramen in the superoinferior dimension of the jaw bone, it was In line with the 1st molar 00 00 00 00
OPG: Orthopantomogram; DVT: Digitalized Volumetric Tomography
observed that the most common position of the mental foramen
in the mandibular cortex was in the middle third region of the
jaw [Table 2, Graph 2 and Figure 2]. There was no significant Table 2: Position of the mental foramen (with respect to
difference for the position of the mental between OPG and superoinferior cortex of mandible in vertical plane)
DVT. Gender‑wise comparisons revealed that there was no
With respect to OPG DVT χ2 P
significant difference for the position of the mental foramen. superoinferior
n % n %
The most common shape of the mental foramen was oval cortex of mandible
for both OPG and DVT. There was a significant difference Superior third 00 00 00 00 0.222 0.637
between OPG and DVT for the shape of the mental foramen Middle third 22 88 23 92
[Table 3 and Graph 3]. Gender‑wise comparisons revealed Inferior third 03 12 02 08
OPG: Orthopantomogram; DVT: Digitalized Volumetric Tomography
that there was no significant difference for the shape of the
mental foramen.
The mean size of the mental foramen using OPG was Table 3: Shape of the mental foramen
0.49 ± 0.05 cm. The mean size of the mental foramen using Shape of OPG DVT χ2 P
DVT was 0.51  ±  0.06 cm  [Figure  3]. Hence, there was no mental foramen
n % n %
significant difference between OPG and DVT for the size Round 05 20 10 40 6.204 0.045*
of the mental foramen [Table 4 and Graph 4]. Gender‑wise Oval 13 52 14 56
comparisons revealed that there was no significant difference Irregular 07 28 01 04
for the size of the mental foramen. OPG: Orthopantomogram; DVT: Digitalized Volumetric Tomography

The mental foramen was distinctly visible in DVT compared

with OPG [Table 5 and Graph 5]. Gender‑wise comparisons Table 4: Size of the mental foramen
revealed that there was no significant difference for the
Parameters OPG DVT t P
distinctness of the mental foramen.
Mean ±SD Mean ±SD
Size of mental 0.49 0.05 0.51 0.06 ‑0.771 0.444
Discussion foramen
Position, shape, size, and distinctness of mental foramen OPG: Orthopantomogram; DVT: Digitalized Volumetric Tomography;
SD: standard deviation
Mental foramen was found on the anterolateral aspect of the
mandible in the vicinity of the second premolar region and
transmits mental nerves and vessels. It is an important anatomical Table 5: Distinctness of mental foramen
landmark to facilitate surgeries, local anesthesia, and other
Distinctness of OPG DVT χ2 P
invasive procedures in the periapical region of the mandible.[1] The mental foramen
location of the mental foramen is important both as a diagnostic n % n %
procedure and any surgical procedure of the mandible. Since Indistinct 16 64 00 00 23.529 0.000*
paresthesia, bleeding, and inadvertent nerve damages are common Distinct 9 36 25 100
OPG: Orthopantomogram; DVT: Digitalized Volumetric Tomography
in case of positional misjudgments of mental foramen, it is
therefore recommended to accurately localize the mental foramen
radiographically prior to any attempt of administration of routine both OPG and DVT. There was no significant difference
mental nerve blocks or other interventions at its location.[2] between these two radiographic analyses for the position of the
mental foramen [Table 1 and Graph 1]. This was in agreement
Position of the mental foramen with the study conducted by Juodzbalys et al.,[7] Afkhami
In our study, the most common position of the mental foramen et al.,[8] Ngeow and Yuzawati,[9] Greenstein and Tarnow,[10]
was in line with the second premolar in the mandibular using YeÕilyurt et al.,[4] Al‑Jasser and Nwoku,[11] Shankland,[12] Wang

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Chakraborty, et al.: OPG versus DVT for determining the morphology and morphometry of mental foramen

92%
70% 100%

88%
60%
90%

52%
60%

50%
80%
70%
40%
60%

24%
30%

20%
50%

16%
12%
20% 40%
8%

8%
10% 30%
0%
0%

0%
0%

12%
0% 20%

8%
Anterior to In line with In between In line with In between In line with 10%

0%

0%
1st premolar the 1st 1st and 2nd 2nd 2nd the 1st molar
premolar premolar premolar premolar and
0%
1st molar
Superior third Middle third Inferior third

OPG DVT OPG DVT

Graph 1: Position of the mental foramen (with respect to apices of Graph 2: Position of the mental foramen (with respect to superoinferior
premolar and molar) cortex of mandible)
56%

60% 0.6
52%

0.5
50%
40%

0.4
40%
0.3
28%

0.49 0.51
30% 0.2
20%

0.1
20%
0
10% OPG DVT
4%

Size of Mental Foramen

0% Size of Mental Foramen OPG Size of Mental Foramen DVT
Round Oval Irregular
OPG DVT
Graph 4: Size of the mental foramen
Graph 3: Shape of the mental foramen

Indistinct Distinct
100%

100%
90%
80%
64%

70%
60%
50%
36%

40%
30%
20%
10%
0%

0%
OPG DVT

Graph 5: Distinctness of mental foramen

et al.,[13] Kekere‑Ekun TA,[14] Kay LW,[15] Oliveira et al.,[16] and
Gungor et al.[17]
The study conducted by Singh and Srivastav [6] on dry
mandibles evaluated that the most common position of the
mental foramen was below the apex of second premolar
tooth in 68.8% of cases. Similar results on dried mandible
were obtained by Agarwal and Gupta,[1] Gupta and Soni,[18]
Hasan T,[3] Pokhrel and Bhatnagar,[19] Bhandari et al.,[20]
Figure 1: OPG showing location, shape, size, and distinctness of mental
foramen
Budhiraja et al.,[21] Roy et al.,[22] Nimje et al.,[23] and Vimala
et al.[24]
Studies by Babshet et al.,[25] Fishel et al.,[26] Olasoji et al.,[27]
Dehghani and Ghanea,[28] Al‑Khateeb et al.,[29] and Neiva
et al.[30] were in disagreement where they observed that the
mental foramen was located between the first and second

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Chakraborty, et al.: OPG versus DVT for determining the morphology and morphometry of mental foramen
Figure 2: DVT image showing location, shape, and distinctness of mental
foramen
premolars. Dissimilar results were obtained by Rai et al.[31]
where the mental foramen was located between the second
premolar and first molar on the right side and between first
and second premolars on the left side. Kjaer[32] reported that
during the early prenatal life, mental foramen is located in
the alveolar bone between the primary canine and first molar.
On gender‑wise comparison, our study showed that there was
no difference in the position of the mental foramen between
males and females. Similar results were obtained by Pokhrel
and Bhatnagar[19] and Jamdade et al.[33]
Assessing the position of mental foramen with respect to
superoinferior dimension of the mandible in vertical plane,
it was observed that the mental foramen was located in the
middle third of the mandibular jaw in most of the cases
[Table 2 and Graph 2]. Ngeow et al.[9] reported in their study that
the position of the mental foramen changed with age, alveolar bone
loss, and loss of teeth. Gupta and Soni[18] reported, in adults with
the advancement of age, that mental foramen moves toward the
superior border of the mandible. This was mainly because of the
loss of teeth and alveolar bone resorption. There was a significant
variation in the position of mental foramen seen with age.
Studies performed by Fishel et al.[26] classified the mental
foramen according to the periapex, apical, and coronal to
periapex of tooth. For second premolar, mental foramen was
coronal to the apex in 24.5% of cases, 13.9% at the apex, and
61.6% apical to the apex.
Budhiraja et al.[21] reported that variability in mental foramen
position may be related to different feeding habits subsequently
affecting mandibular development. Green[34] reported a clear
racial trend in the anteroposterior position of the mental
foramen, it being more anterior in the Caucasoid groups.
Seema et al.[35] reported that at birth, mental foramen lies close
to the lower border; in adults, it lies midway between the upper
and lower borders after eruption of permanent teeth. In old
age, resorption of alveolar margin after loss of teeth brought
the mental foramen nearer to the upper border.
Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 1  ¦  January‑March 2019
Figure 3: DVT image showing size of mental foramen
Shape of the mental foramen
In our study, it was observed that the most prominent shape
of the mental foramen was oval in both OPG and DVT. But
there was a significant difference between the analysis obtained
from OPG and DVT although the shape was evident to be oval
in both the techniques [Table 3 and Graph 3]. Similar results
were obtained by Juodzbalys et al.[7] and Agarwal and Gupta.[1]
Greenstein and Tarnow[10] in their study reported that the
mental foramen may be round or oval in shape. Similarly,
studies on dried mandibles by Hasan T,[3] Bhandari et al.,[20]
Udhaya et al.,[36] Roy et al.,[22] Nimje et al.,[23] and Vimala
et al.[24] reported that the most predominant shape was oval.
While the studies by Singh and Srivastav,[6] Gupta and Soni,[18]
and Rai et al.[31] on dried mandibles mentioned that the most
common shape of the mental foramen was round.
In our study, there was no difference in the shape of the mental
foramen between males and females. On reviewing literatures,
there has been no study performed on the gender‑wise
comparison for the shape of the mental foramen using OPG
and DVT.
Size of the mental foramen
In our study, the size of the mental foramen was measured to be
0.49 ± 0.05 cm using OPG and 0.51 ± 0.06 cm using DVT. There
was no significant difference between OPG and DVT for the
analysis of the size of the mental foramen [Table 4 and Graph 4].
Similar results were obtained by Juodzbalys et al.[7]
Singh and Srivastav[6] reported that the dimension of mental
foramen was 2.8 mm on dried mandibles. Oguz and Bozkir[37]
evaluated the size of the mental foramen to be 2.93–3.14 mm,
Hasan T[3] reported the mean width of the mental foramen to
be approximately 3.6 mm, and Roy et al.[22] reported the mean
width of the mental foramen to be approximately 3.01 mm.
Rai et al.,[31] on dried mandibles, reported the mean diameter
of the mental foramen to be 2.63 ± 0.85 mm.
In our study, there was no difference between males and
females for the size of the mental foramen using OPG and DVT.
21
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Chakraborty, et al.: OPG versus DVT for determining the morphology and morphometry of mental foramen
To the best of our knowledge, none of the studies included the
gender‑wise comparison for the size of the mental foramen.
Distinctness of the mental foramen
In this study, it was observed that the mental foramen was more
distinct when observed in DVT compared with OPG [Table 5,
Graph 5]. There has hardly been any study conducted for
the distinctness of the mental foramen using 3D volumetric
imaging. Greenstein and Tarnow[10] in their study reported
24% of the mental foramen as observed in OPG with indistinct
borders. Yosue and Brooks[38] conducted similar studies to
assess the distinctness of the mental foramen in panoramic
radiographs where they detected mental foramen in 87.5% of
panoramic radiographs, and it was distinct in 64% of cases.
Studies conducted by Jacobs et al.[39] detected the mental
foramen in 94% of cases on OPG, but a clear visibility was
attained only in 49% of cases.
In this study, there was no difference between males and
females for the distinctness of the mental foramen using OPG
and DVT. Again none of the previous studies included the
gender‑wise comparison to best of our knowledge.
The mental foramen being a vital anatomic structure in
the posterior region of the mandible, this study has also
analyzed the mental foramen with respect to position, shape,
size, and distinctness using OPG and DVT. For the position
of the mental foramen, there has been very less studies
conducted in India using radiographs where most of the
studies had been conducted on dried mandibles. But in our
study we have evaluated the foramen initially on OPG, and
for more accurate results DVT had been used, so that this
can be used in living human beings. We had also evaluated
the position of the mental foramen in the superoinferior
dimension of the jaw bone. This is because the position of
the mental foramen varies with age. This study has provided
insight into the precise location of mental foramen which
will be of great help in planning the implant, osteotomy
procedures, and other interventions in mandibular posterior
region without affecting the neurovascular bundle in the
mental region.
Conclusion
The most common position of the mental foramen in OPG and
DVT was along the line of the second premolar with respect
to apices of premolars and molars and was more common
in the middle third region of the jaw bone with respect to
superoinferior cortex of mandible in vertical plane, and there
was no significant difference in the position of the foramen
between males and females.
The most common shape of the mental foramen was found to
be oval and was better defined in DVT compared with OPG.
There was no significant difference in the shape of the foramen
between males and females.
The size of the mental foramen was observed to be
0.49 ± 0.05 cm in OPG and 0.51 ± 0.06 cm in DVT. There was
22 Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 1  ¦  January‑March 2019
no significant difference in the size of the foramen between
males and females.
The mental foramen was more distinctly visible with DVT
rather than OPG and there was no significant difference in
gender.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 31  ¦  Issue 1  ¦  January‑March 2019 23