Journal of Critical Reviews

ISSN- 2394-5125 Vol 7, Issue 14, 2020 A REVIEW ON VARIATIONS IN LINGUAL FORAMINA OF THE MIDLINE

1Jones Jayabalan, 2M.R.Muthusekhar

1Post Graduate Student Department of Oral and Maxillofacial Surgery Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India. 2Program Director Department of Oral and Maxillofacial Surgery Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.

Corresponding Author: Jones Jayabalan Post Graduate Student Department of Oral and Maxillofacial Surgery Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-600077Tamil Nadu, India. Email id: [email protected]

Received:16.04.2020 Revised: 21.05.2020 Accepted: 20.06.2020

Abstract The sublingual, submental arteries or their anastomosis perforate the lingual cortical plate through the . Both the arteries are branch of facial and lingual arteries respectively which either arises independently from the external carotid artery or arises from a common lingual facial trunk. The anterior mandibular midline at which the lingual foramen is frequently present is subjected to various procedure like dental implants, genioplasty, tori removal, block graft harvesting, screwing with or without plating following trauma or osteotomy. There is a wide range of anatomical variations of lingual foramen among individuals. Cone-beam computed tomography (CBCT) has been shown to be superior to panoramic radiographs in displaying mandibular lingual foramen and its variations. Numerous studies have been carried out to examine the frequency, diameter, and other anatomical features of the lingual foramen and its canals. There is a paucity of the data which compares the different group of the population based on the position and the occurrence of the lingual canal and very few studies compared the gender and population. The main purpose of the review is to examine the anatomical variations of the lingual foramen.

Keywords Lingual foramen , Lingual canal , Accessory foramen , Anatomy , Cone beam computed tomography ,Sublingual artery , Submental artery

© 2020 by Advance Scientific Research. This is an open-access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/) DOI: http://dx.doi.org/10.31838/jcr.07.14.169

INTRODUCTION lingual canal and very few studies compared the gender and The use of implants and the grafting procedures were population [15]. The main purpose of the review is to examine increasing specifically in the anterior results in the the anatomical variations of the lingual foramen. raising reports of postoperative complaints [1]. Many dental anatomy books or reports have failed to report the existence of Clinical Considerations the lingual foramen. Perhaps the lingual foramen is a well- The lingual is a special anatomical defined through oral radiographs [2]. The awareness of lingual variation on the inferior jaw bone. It consists of both vascular foramen plays a major role in pre-surgical consideration before and nervous anastomosis which is derived from the branches the installation of midline mandible implants. Anterior of the submental and lingual artery and mylohyoid nerve. mandible includes many anatomical structures which include Various studies reported that during implant interventions, mandibular incisive canal (MIC) and lingual foramen[3-5]. The the intraoperative massive bleeding occurs in this area [16-19] lingual foramen is situated in the midline of the mandible and . Bernardi. [20] reviewed the frequency and anatomical features at the equal level, inferior or superior to the mental spines[6]. of the mandibular lingual foramina on the midline of the inferior These anatomical structures in the anterior jaw plays major jaw. The finding highlighted that there exist high frequency of role in optimizing the plans for dental surgeries and also to variation with a quite important diameter, a sign of significant avoid further complications[7]. calibre of the related vessels. If the variation is underestimated in the modern textbooks of oral anatomy, the radiological The structure of the lingual foramen, dimension and the screening is necessary during preoperative planning. Further location of the bony canals have to be considered with greater appropriate risk management is mandatory to minimize injury importance during any anterior dental surgeries such as in the anterior floor of the oral cavity. grafting procedures, implant placement and genioplasty so as to avoid the major complications. Some of the complications In the current scenario, dental implants are considered as the involved in these kinds of dental surgeries include pulp canal standard options for the prosthetic rehabilitation for obliteration, intraoperative bleeding, neuropraxia of the edentulous patients. In many cases, the placement of the mandibular incisive nerve, and nerve injury. The short term and implants is a routine and predictable technique [21]. Certain long term disturbances involve alteration or loss of pulp situations leads to hemorrhagic episodes in lingual cortex, this sensitivity in the lower front teeth[8,9]. is perhaps due to dental implants in the anterior mandibular region. Previous studies showed that rupturing of lingual Many studies assume the vascular content, an anastomosis of periosteum leads to hematoma in this region and resulted in the the sublingual branch of the right lingual arteries and left swelling of the floor of the mouth and cause upper airway lingual arteries[10,11]. The size of the artery should be obstruction[22-24]. Hence, pre-operative planning should sufficient enough to aggravate the haemorrhage in the soft include radiological imaging to avoid complications[7]. connective tissues or intraosseously which may be very crucial to control[11]. Numerous studies have been carried out to Oettlé. [25], determined the exact location and the occurrence examine the frequency, diameter, and other anatomical of the midline (MLC) in the different age features of the lingual foramen and its canals[12,14]. There is a groups in both gender and dentition groups. There exists a paucity of the data which compares the different group of the significant difference in dentition pattern among gender shows population based on the position and the occurrence of the

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that edentulous females were at higher risk of vessel injury in 40% of the communicated with other anatomic structures, most the MLC in the process of implantation. frequently with the incisive canal. In a retrospective study to improve the safety of the mandibular Liang [7], in a cadaveric study, assessed the anatomic of the surgical procedure, Wang et al. [26] evaluated the occurrence, anterior mandible and its relative hemorrhage risk during location, and the diameter of the mandibular lingual canals implant dentistry. The finding highlighted that all the 118 using CBCT. The study finding emphasized the presence of detected had at least one lingual foramen above the mandibular lingual canals and lateral lingual canals, among genial spines. The single foramen was most frequently observed which MLC is common, detected using CBCT. Majority of the and the patients with a single lingual foramen will benefit from samples showed at least on lingual perforation (97.0%) and all the inferior location of this foramen, which facilitates deeper the samples showed at least one lingual perforation in the flap surgery and implant placement that reduces the risk of mandible. The further significant difference was observed damage to the canal. Therefore, the cautious preoperative among the gender in both MLC and LLC. planning is required for the implant positioning at mandibular midline, wisely choosing an even number of implants in the In the face mandible is the strongest, lowest and strongest bone interforaminal region, which avoids the risk of surgical in the face. In newborn the two halves of the mandibles are complications. Thus CBCT imaging can be recommended as a joined together by fibrous symphysis in the median plane and it preoperative evaluation before dental implants. has been replaced by the bone after a year. Natekar [27], showed that posterior symphysial surface shows a small The average diameter of the artery was measured at 1.41mm elevation and divided intoupper and lower part in the mental and 0.31 mm with the largest diameter of 1.6mm, this indicates spines. Mandibles having the lingual foramen open into the that the size of the artery entering [13,14] the lingual foramen canal which crosses the bone with the branch of the lingual is sufficient enough to cause hemorrhage in the floor of the artery. The location and the variations in the lingual foramen mouth when the lingual cortex is perforated. The bleeding may help in the pre-operative decision during mandibular surgeries. increase the risk of obstructing the air way[12]. Bilaterally on the lingual surface of the mandible the genial The trauma to the artery in MLC leads to the serious tubercle a group of four bony extensions are situated between haemorrhage, if the artery size increased. Airway obstruction is the superior and inferior borders of the mandible[28]. Although considered as the major complication due to hematoma its development is uncertain, it forms a useful radiological formation on the floor of the mouth which leads to swelling and landmark. In 28% of mandibles, radiographically lingual pushes the against the palate[24]. Further, the risk of foramen was observed, however, 49% was observed through hemorrhage may also result in the edentulous patients who periapical radiographs. Earlier studies emphasized that the were having atrophic mandibles with resorption of the alveolar superior canal is derived from the lingual artery and nerve end ridge. and for arterial origin, it was submental or sublingual, however, the innervations is branched from the mylohyoid nerve. Though The placement of the implant in the thin ridges is often the midline pit was observed on the lingual surface[29] a unrestricted as the implant strength where the surface area for persistent foramen has been seen radio graphically. In general load distribution is greatly reduced. Whereas when reducing the frontal part of the mandible is considered asafe place for the thin alveolar ride obtain a width of 6mm, in such cases surgical intervention; however, it has to be given more decreased the vertical dimension of the implant site. Thus, the attention in the aspect of vital structures which is passing vertical reduction might also be required to create the sufficient through the lingual foramen. vertical restorative space. The decrease in the alveolar bone might pose a major risk when the midline implant is considered, In the treatment of fracture, the genial tubercles are highly as it will encroach on the MLC position. controversial, as many believe in the conservative treatment[30,31], while some believe in the fracture bone The examination of the mandibular lingual region is frequently fragment removal and the muscles inserted into them[28,32].A done by using gross anatomical dissections through cadavers, single foramen on each side was observed by Nagar et al.[33]. CT, radiographic imaging, and CBCT. The CBCT is more superior No anatomical books have shown mentioned the intermediate to other radiographic techniques in visualizing the lingual and the paramedian foramen on the lingual surface of the foramina and its canal[37] Kawai [38] investigated the mandible. frequency, location, and angulations of the lingual foramina along with the bony canals in the median region of the mandible Sheikhi.[34], assessed the anatomical variations in the lingual using CBCT in the Japanese population. Most frequently foramen of 102 patients along with the bony canals with Cone- observed was the MLF and the arteries which pass through the Beam Computed Tomography (CBCT). The finding highlighted canal. Since midline superior to the was the most that the around 52% of the study population had at least one frequent and consist of the artery and located superior to the foramen and shows that there is an increased prevalence of the other MLFs, clinicians have to identify such foramina during anatomical lingual foramen. Further, the finding showed that preoperative images. upto four lingual foramen has been detected. A similar finding was observed by Katakami [35]. In a retrospective study, using In the description of the surgical procedures which involves the CBCT imaging, Katakam [35] examined the regional frequency anterior mandible, the occurrences of lingual foramina along along with the anatomical properties of lateral lingual with its afferent neurovascular bundles are frequently mandibular foramina. The study reported a higher regional neglected and it is associated with a negligible clinical and frequency of lingual foramina in the premolar area. Hundred surgical risk. The surgical procedure in foramina were and fifty-fourlingual foramina from 181 patients, among which generally considered as free from major neurovascular 31 of the 154 lingual foramina exhibits anastomoses to the complications, this might be due to the absence of the major mandibular canals in the premolar area through well-defined neurovascular structures. Perhaps the interforaminal implant lingual canals. intervention is a routine procedure which is free from vascular compilations due to the decent bone density in the median Von [36] evaluated the location and dimensions of lingual mandibular region and devoid of life-threatening endosseous foramina by using limited CBCT, and 217 were detected among vessels. 1054 sites. The high frequency (96.2%), of foramina was observed in the midline of symphysis followed by the right first Loukas [12] showed the anatomical variation of sublingual premolar area (27.5%). The sizes of the midline and posterior artery in relation to the mandible, and provide preoperative foramina differ significantly. The lingual foramina present information to avoid hemorrhagic complications of implant along with the bony canal originate from the lingual surface, placement. The lingual artery branched into sub lingual artery and provides vascular supply to the anterior mandibles.

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Specifically, 73% of the sublingual artery is originated from the and the increasing report of the complications during such lingual artery and 27 % from the submental artery. These data procedures. Secondary to the implant treatment, life suggested that single midline lingual foramen (24.5%) is widely threatening hemorrhage and hematoma formation in the floor seen above the genial spine. From a clinical perspective, the of the mouth were recorded in many earlier reports[11,22,40,44]. In location of the foramen is important rather than the number humans, three major subdivisions namely superior, inferior and and the midline lingual foramina have to be focused to avoid the middle sublingual alveolar branches have been identified. complications. In general facial artery is the fourth successive and third anterior branches of the external carotid artery, except it The clinical relevance of this anatomic feature is underlined by originates along with the lingual artery through the common the growing diffusion of implant treatments at the mandibular linguofacial trunk. midline and by reports of complications deriving from such procedures. Inter foraminal section is the best choice for the This anatomical attention lays the basic foundation for the role placement of the implant which supports the fixed partial of the submental artery is either a major vessel or a dentures or overdentures. One of the autologous areas in the supplementary vessel in this region and deserving the oral cavity is the symphysis which required excessive ridge consideration so as to understand the nature of hemorrhages augmentations. Lingual artery supplies the arteries from the descending from the perforation of the mandibular lingual submental branch and the sublingual branch which includes cortical during implant surgery. The mechanical injury in the muscles, geniohyoid, sublingual gland, mylohyoid, branches of the arterial plexus might possibly lead to the lingual gingiva and mucous membranes in the floor of the dangerous hemorrhage. The elaborate knowledge of the mouth floor. anatomy of the fine arterial structures is necessary for the implant surgeries. From the level of the hyoid bone, the lingual The inferior alveolar artery gives rises to the complex branches artery is the third sequential and second anterior branch of the and then separated into the mental artery and incisive external carotid artery. This lingual artery provides the body branches, which communicates with the sublingual artery in and the top of the tongue through the terminating deep dorsal the region of the internal mandible [39]. Even though the branches along with lingual artery. At the frontal border of the interforaminal is comparatively a safe region to place the hyoglossus muscle, the lingual artery leads to the sublingual implants, the perforation in the lingual cortex can lead to the artery. severe haemorrhage during the placement of the implant. Further, if drilling ruptures lingual periosteum, the bleeding Recommendations might be enhanced due to damage to the anatomical structures Clinically attention has to be given to recognize the situation in the sublingual spaces, these results in the hematoma in the where this risk might occur. Subsequently, following mouth floor. Apart from the interforaminal region, the lingual recommendations has to be followed. An appropriate [40] foramen present in the molar area is also well reported . The preoperative planning is mandatory before any surgical cadaveric studies showed that the sublingual and submental procedures concerning the median mandible, bearing in mind arteries both were perforated through the lingual foramina in that the degree of osseous atrophy along with the mandibular the mandible [41] inclination. If necessary radiographic examination of these Subsequent to the tooth extraction, the horizontal bone loss is endoosseous canals through computed tomography can be primarily on the labial side. This pattern of resorption leads to considered. An accurate knowledge of the anatomy of the the lingually angulated trajectory of the mandible. If the region is necessary. The positioning of implants in the atrophying mandible is not noticed prior to the implant mandibular midline has to be given most priority. A wise opting placement, the lingual perforation complication will increase. of an even number of implants in the interforaminal region can The bony architecture and its surrounding anatomical avoid the risk of trauma to the lingual cortical plate of the structures were well depicted by the CT which is frequently mandibular midline. used imaging technique. The 3D imaging of the particular area is extremely suggested to achieve favourable prosthetic CONCLUSION angulations which also excludes the complications[42]. The present review showed that the variations in the anatomical landmarks and the measurements of lingual The recent studies emphasize that the structures which foramen vary in every individual, thus it is important to think increase the risk of complications include the anterior dilation about the lingual foramen during the planning session for of inferior alveolar neural tubes, the concavity of lingual , surgery and particularly during the placement of anterior lingual foramina, and lingual tubes. However, there are cases mandibular implants, to avoid post-operative related were atypical hemorrhage have been caused due to lingual plate complications. The clinicians have to note the position of the perforation [22]. The mucosal branches are present along with midline mandibular lingual canal and should approach with the lingual side of the mandible requires special care pre precautions, specifically if the alveolar ridge has to be surgical period, as they are known to deposit lingual cortical decreased prior to the placement of the implant. bone into the mandible [43]. To conclude there are various kinds of lingual foramen has been The bleeding along with severe edema, in the process of the identified based on their position and their neurovascular implant surgery due to the direct damage of the sublingual contents. Future studies should focus on the micro-dissections, arteries followed by lingual cortical bone perforation. If the which in light on the neurovascularisation of the anterior bleeding is delayed the possibility of the bleeding in sublingual mandible, during surgical interventions. This kind of the artery branch has to be considered. However, the risk of knowledge on the anatomical variations is necessary during the bleeding should be assessed in patients with surgical process involves all potential risk which is related to hypertension/patients who were on anticoagulation drugs. The the anatomical variations in the lingual foramen. Further, it also pre surgical assessment is mandatory if foramen’s diameter is helps in planning the oral implants in terms of both aesthetic higher than 1mm in CT scan. The increased risk is prevalent point and also to avoid neurovascular complications. The among the elderly patients who are in the need of alveoloplasty current review provides the immense contribution to clinical (for dental procedures) and patients with severe alveolar bone and surgical understanding. atrophy. As in these patients, lingual foramina are closer to alveolar ridge and the frequency of appearance of lingual Conflicts of interest Nil foramina is higher. Funding Self funding Anatomical Considerations The anatomical feature and its clinical relevance underpinned by the increasing implant treatments in the mandibular midline

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