Galore International Journal of Health Sciences and Research Vol.3; Issue: 3; July-Sept. 2018 Website: www.gijhsr.com Original Research Article P-ISSN: 2456-9321

An Anatomico-Radiological Study of Inter-Relationship between the and Accessory Mandibular Foramina in Population of Rajasthan State

Sakshi Mathur1, Puneet Joshi2

1,2Ph.D. Scholar, Department of Anatomy, Sawai Man Singh Medical College & Hospital, Jaipur

Corresponding Author: Sakshi Mathur ______

ABSTRACT ramus of the . [1] The Mf curves downwards and forwards into the body of The Mandibular foramen (Mf) is present on the the mandible to form the mandibular inner surface of the ramus of the mandible. It which exit opens into . The leads into the giving passage (IAN) and vessels to Inferior Alveolar Nerve (IAN) and vessels pass through it which supplies the which enter the roots of the teeth and the periodontal septa. Many unnamed accessory mandibular teeth, which runs further down foramina are present on the lingual side of the in the mandibular canal to emerge out from [2] mandible which are very variable in their the mental foramen. distribution but they are observed more often on Any other openings in the mandible the internal surface of the mandible in position other than Mf, sockets of teeth, mental above or below the MF. A dental surgeon foramen and are labelled as performing tooth extraction should be aware of Accessory Mandibular foramen (AMf). [3] Accessory Mandibular Foramina (AMf) for The incidence of AMf has been planning anaesthesia at an appropriate found to be greater on the medial surface anatomical site as the branches of the facial than on the lateral surface. [4,5] nerve, , buccal nerve and Many unnamed accessory foramina transverse cervical cutaneous nerve are known to pass through these foramina. Nerve block are present on the lingual side of the techniques by local anaesthetics might fail if any mandible which are very variable in their of these nerves or their branches pass through distribution but they are observed more these AMf and escape the nerve block. The often on the internal surface of the mandible present research paper reports the presence of in position above or below the mandibular AMf around Mf in 25 dry human out foramen. [6] of 100 mandibles studied and emphasizes the These foramina were studied inter-relationship between Mf and AMf in immuno histochemically and proved that certain cases studied radiologically. Precise their contents included an artery and a knowledge and awareness of such AMf would nerve. Injecting an anaesthetic solution into therefore be important for dental surgeons the pterygomandibular region, where the performing nerve block and also for oncologists in planning radiation therapy. IAN is found in the Mf, is an anaesthetic technique which is commonly employed in Key Words: Accessory mandibular foramina, the dental clinics. It was reported that the mandibular foramen, mandibular canal, nerve local anaesthesia which was given during block. dental extractions might fail, if the branches of IAN pass through these accessory INTRODUCTION foramina and thus escape the drug. [7-9] The Mandibular foramen (Mf) is an Awareness of the presence of AMf irregular foramen which is located just may be important in achieving successful above the centre of the medial surface of the IAN anaesthesia and so this is best

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 1 Vol.3; Issue: 3; July-September 2018 Sakshi Mathur et.al. An Anatomico-Radiological Study of Inter-Relationship between the Mandibular Foramen and Accessory Mandibular Foramina in Population of Rajasthan State performed at a higher level using the Procedure of OPG:- technique also known as the “Gow-Gates I. An OPG which stands for technique”. [10] “Orthopantomogram”, gives a This procedure involves the panoramic view of the mouth, giving administration of the anaesthetic solution at information on the teeth and the a higher level before the division of the of the upper and lower . . [11] II. An OPG machine (Fig. 2) is The presence of anatomical specifically designed to produce X- variations in human mandible such as the rays of the teeth, and AMf, presents clinical implications, if not temporomandibular joints. The previously identified, can cause image provides an overview of the complications to clinical dental practice. [12] state of the dentition, as well as Furthermore, failures in the information regarding the bones of anaesthesia by regional blockage of the IAN the jaw (the mandible and ), are reported due to the presence of these the air sinuses in the upper jaw and foramina. [13] the joints between the jaw and the Knowledge of the anatomical details (the temporomandibular of AMf may then be of significant clinical joints). interest to surgeons and oncologists in III. During the procedure, the patient’s clinical practice. is placed on a ‘chin rest’. The Therefore, the aim of present study jaws are held in place by biting was to radiologically analyse the inter- down on a small disposable plastic relationship between the Mandibular guide. Most OPGs are performed Foramen (Mf) and Accessory Mandibular with the patient standing. An OPG Foramina (AMf) in dry human mandibles of aims to view the jaw, while blurring Rajasthan State. out the other structures of the and skull. This is done using a MATERIALS AND METHODS technique called "tomography". The present study included 100 dry During the exposure, the X-ray tube human mandibles procured from the and film cassette rotate around the Department of Anatomy, Mahatma Gandhi jaws. As the X-ray tube moves Medical College & Hospital, Jaipur, the around the head, the x-ray film Department of Anatomy, SMS Medical moves in the opposite direction College & Hospital, Jaipur, the Department behind the head. of Anatomy, NIMS Medical College & IV. An exposure lasts a few seconds Hospital, Jaipur. during which time the patient must The mandibles were examined for remain still. The film cassette is then the presence of AMf around the Mf and 25 removed to allow development of out of 100 mandibles reported the presence the exposed X-ray film. of AMf. V. This generates an image where the Out of the 25 mandibles with AMf mandible and teeth are in focus, and incidences, 8 mandibles were selected for the other structures are blurred. detailed radiological analysis and VI. OPG procedures can take up to 15 interrelationship between Mf &AMf was minutes. studied after inserting probed wire in While performing OPGs for the respective canals/foramina (Fig. 1). purpose of present study, the dry mandibles For this purpose, OPG of mandibles with inserted probed wire in the with AMf incidences was undertaken. canals/foramina were fixed on the ‘chin rest’ (Fig. 3) one by one by using surgical tape for proper adhesion. After that, the

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 2 Vol.3; Issue: 3; July-September 2018 Sakshi Mathur et.al. An Anatomico-Radiological Study of Inter-Relationship between the Mandibular Foramen and Accessory Mandibular Foramina in Population of Rajasthan State above mentioned procedure of OPG (Fig. 4) was conducted repeatedly and images were thus obtained for studying the interrelationship between Mf and AMf.

Fig.4:- Picture showing the different positions of an OPG Fig.1:- Picture showing a mandible with inserted probed wires procedure being undertaken. in the Mf and AMf to study the interrelationship between them. RESULTS The details of mandibles with incidences of AMf which have undergone the procedure of OPG have been depicted in tabulated form in the Table 1:-

Table 1:- Details of radiologically analysed mandibles with AMf incidences. S.No. of No. of Accessory Mandibular Radiographically studied Foramina (AMf) Fig.2:-An OPG machine with mandible placed over the ‘chin Mandibles rest’. Right half Left half 1. 1 4. 2 7. 1 8. 1 16. 1 1 17. 1 18. 1 1 23.

Fig.3:- Picture showing the adhesion of mandible by using surgical tape on the ‘chin rest’ of the OPG machine.

Fig.5:-Mandibles with incidences of AMf. Probed wire has been inserted in the Mf &AMfs of the respective mandible.

After conduction of OPGs of the ray digital images were obtained for the above mentioned mandibles (Fig. 5) the X- purpose of studying the interrelationship

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 3 Vol.3; Issue: 3; July-September 2018 Sakshi Mathur et.al. An Anatomico-Radiological Study of Inter-Relationship between the Mandibular Foramen and Accessory Mandibular Foramina in Population of Rajasthan State between Mf and AMf and thus the following observations were made:-

I. Mandible No. 1:- Here, the AMf was single and present on the right half of the mandible. The probed wires had been inserted in the Mf and AMf of the right half. It was observed that the probed wires inserted in the

respective foramina traverses within Fig. 6(b):- The wire already present inside the mandible the mandible through same canal superimposes with the probed wire inserted through the Mf of and thus superimposes to form a left half.

single mandibular canal [Fig. 6(a)]. II. Mandible No. 4:-

Here, the AMf were double and present on the left half of the mandible. The probed wires had been inserted in the Mf and the two AMf (AMf 1 &AMf 2) of the left half. It was observed that the probed wires inserted in the Mf and AMf 2 traverses within the mandible through separate canals and do not superimpose to form a single mandibular canal whereas the Fig. 6(a):- The probed wires inserted in the respective foramina traverses within the mandible through same canal probed wire inserted in AMf 1 and thus superimpose to form a single mandibular canal. traverses within the mandible and superimposes with the probed wired  Special case study:-While performing inserted through the Mf, thus the OPG of this mandible, it was forming a single mandibular canal observed that a wire was already present [Fig. 7]. within the substance of the left half of the mandible. So, for the purpose of finding out the reason for the presence of a wire prior to inserting probed wires through the foramina, another OPG of the same mandible was conducted by inserting probed wire through the Mf of left half. It was observed that the wire already present inside the mandible superimposes with the probed wire inserted through the Mf of left half.

Thus, the reason for the presence of such Fig. 7:- The probed wires inserted in the Mf and AMf 2 wire might be due to accidental insertion traverses within the mandible through separate canals and do not superimposes whereas that in AMf superimposes with the of the wire without folded head of a probed wired inserted through the Mf forming a single probe into the Mf by the students during mandibular canal.

osteological study/practice of aforesaid III. Mandible No. 7:- sample in the medical college [Fig. Here, the AMf was single 6(b)]. and present on the right half of the

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mandible. The probed wires had the Mf and AMf of both the halves. been inserted in the Mf and AMf of It was observed that the probed the right half. It was observed that wires inserted in the respective the probed wires inserted in the foramina traverses within the respective foramina traverses within mandible through separate canals the mandible through separate canals and do not superimpose to form a and do not superimpose to form a single mandibular canal on either single mandibular canal [Fig. 8]. side [Fig. 10].

Fig. 8:-The probed wires inserted in the respective foramina traverses within the mandible through separate canals and do Fig. 10:-The probed wires inserted in the respective foramina not superimpose to form a single mandibular canal. traverses within the mandible through separate canals and do not superimpose to form a single mandibular canal on either side. IV. Mandible No. 8:- Here, the AMf was single VI. Mandible No. 17:- and present on the left half of the Here, the AMf was single mandible. The probed wires had and present on the left half of the been inserted in the Mf and AMf of mandible. The probed wires had the left half. It was observed that the been inserted in the Mf and AMf of probed wires inserted in the the left half. It was observed that the respective foramina traverses within probed wires inserted in the the mandible through same canal respective foramina traverses within and thus superimposes to form a the mandible through separate canals single mandibular canal [Fig. 9]. and do not superimpose to form a single mandibular canal [Fig. 11].

Fig. 9:-The probed wires inserted in the respective foramina traverses within the mandible through same canal and thus Fig. 11:-The probed wires inserted in the respective foramina superimpose to form a single mandibular canal. traverses within the mandible through separate canals and do not superimpose to form a single mandibular canal. V. Mandible No. 16:- Here, two AMf were VII. Mandible No. 18:- observed, one single AMf on the Here, the AMf was single right half and another single AMf on and present on the left half of the the left half of the mandible. The mandible. The probed wires had probed wires had been inserted in been inserted in the Mf and AMf of

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the left half. It was observed that the probed wires inserted in the respective foramina traverses within the mandible through same canal and thus superimposes to form a single mandibular canal [Fig. 12].

Fig. 14:-The probed wires have been inserted in the Mf and AMf of same side and another probed wire is inserted in the Mf of other side with no incidence of AMf.

DISCUSSION Literature evidences regarding

Fig. 12:-The probed wires inserted in the respective foramina radiological analysis of the inter- traverses within the mandible through same canal and thus relationship between Mf and AMf are very superimpose to form a single mandibular canal. few. VIII. Mandible No. 23:- Das and Suri et al (2004) passed a Here, the AMf was single metallic wire through an AMf and examined and present on the right half of the it radiologically and found that the neurovascular bundle passing through it mandible. The probed wires had [2] been inserted in the Mf and AMf of supplied the root of the third molar tooth. the right half. It was observed that o In the present study, the interrelationship the probed wires inserted in the between Mf & AMf was studied respective foramina traverses within radiologically by the procedure of OPG the mandible through separate canals after inserting probed wire in respective and do not superimpose to form a canals/foramina and it was observed that single mandibular canal [Fig. 13]. in certain mandibles, the probed wires inserted in the Mf and AMf traverses within the mandible through same canal and thus superimposes to form a single mandibular canal whereas in certain other mandibles, the probed wires inserted in the respective foramina traverses within the mandible through separate canals and do not superimpose to form a single mandibular canal. Thus the presence of Accessory Mandibular Fig. 13:-The probed wires inserted in the respective foramina traverses within the mandible through separate canals and do canal was observed. not superimpose to form a single mandibular canal. The reason for the presence of Accessory Mandibular canal can be In one of the mandibles, with explained by the branching pattern of IAN. incidence of AMf the probed wires were The branching pattern of the IAN may also inserted in the Mf and AMf of same side show several variations within the and another probed wire was inserted in the mandibular canal. It may either run as single Mf of other side with no incidence of AMf. trunk giving branches to molar and premolar The mandible was studied radiographically teeth or give a major and minor trunk near and X-ray digital image was obtained [Fig. the Mf, the major trunk after traversing 14]. through the mandibular canal comes out

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 6 Vol.3; Issue: 3; July-September 2018 Sakshi Mathur et.al. An Anatomico-Radiological Study of Inter-Relationship between the Mandibular Foramen and Accessory Mandibular Foramina in Population of Rajasthan State through mental foramen whereas, the minor 7. Browne JS, Browne RM (1995). Factors trunk after innervating molar and premolar influencing the pattern ofinvasion of the teeth becomes incisive nerve. The IAN may mandible by oral squamous cell carcinoma. also give branches for molar and premolar Intern J Oral Maxillofacial Surg, 24: 417– teeth, for canine and teeth and for 426. 8. Lavanya CV, Imtiazul H, Rajeshwari T mental foramen near the Mf. [14] (2011). Position of Mandibular Foramen in Developmentally, the presence of South Indian Mandibles. Anatomica double mandibular canals can be explained Karnataka; 5: 53-6. as the incomplete fusion of three IANs, that 9. Lukinmaa PL, Hietanen J, Soderholme AL, develop initially to innervate three groups of Lindqvist C (1992). The histologic pattern mandibular teeth and the inferior alveolar of invasion by squamous cell artery passes through the small-sized AMf carcinoma of the mandibular region. Br J located behind the Mf. [15,16] Oral MaxillofacSurg, 30: 2–7. 10. McGregor DA, Mac Donald DG (1987). CONCLUSION Routes of entry of squamous cell carcinoma The present research concludes that into the mandible. Head Neck Surg, 10: 294–301. the presence of AMf might be important for 11. Quattrone G, Furlini E, Bianciotto M orthognathic or reconstructive surgery of the (1989). Bilateral bifid mandibular canal: mandible and also during dental implants. In Presentation of a case. Minerva Stomatol, view of the clinical importance of AMf, 38: 1183-1185. prior anatomical knowledge of such 12. Christopher H, Avital M, Steven M, anomalies may be helpful for dental and Sheldon M (1993). Dimorphic study of maxillo-facial surgeons and oncologists surgical anatomic landmarks of the lateral performing irradiation in day to day ramus of the mandible. OralSurg. Oral Med. practice. Oral Pathol., 75(4): 436-8. 13. Quinn JH (1998). Inferior alveolar nerve REFERENCES block using the internal oblique ridge. J Am 1. Galdames IC, Matamala DA, Smith RL Dent Assoc; 129: 1147-8. (2009). Is the conduct of serres an 14. Raghavendra VP, Benjamin W (2015). anatomical variation in adults? Int J Position of mandibular foramen and Morphol, 27, 43-7. incidence of accessory mandibular foramen 2. Das S, Suri RK (2004). An anatomical- in dry mandibles. Int J Pharm Bio Sci; 6(1): radiological study of an accessory (B) 282 - 288. mandibular foramen on the medial surface 15. Chavez ME, Mansilla J, Pompa JA, Kjaer I of mandible. Folia Morphol; 63: 511-513. (1996). The human mandibular canal arises 3. Sicher H, Dubrul EL (1980). Oral Anatomy, from three separate canals innervating 7thed, St. Louis. The C.V. Mosby different tooth groups. J Dent Res, 75: Company: 468. 1540–1544. 4. Fabian FM (2006). Observation of the 16. Pastor-Vazquez JF, Gil-Verona JA, De Paz- position of the lingula in relation to the Fernandez FJ, Barbosa Cachorro M (2001). mandibular foramen and the mylohyoid Atlas de variacionesepigeneticascraneales. groove. It J AnatEmbryol; 111: 151-58. Universidad de Valladolid, Valladolid, pp 5. Gupta S, Soni A, Singh P (2013). 20-21 & 74-75.

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