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A morphological study of retromolar foramen and canal in Indian dried mandibles.

INTRODUCTION: The retromolar fossa, a triangular area present posterolateral to the 3rd lower molar contains retromolar foramen (RMF) and retromolar canal (RMC), as an anatomical variation in the mandible. [1] The boundary of retromolar fossa is formed medially by temporal crest & laterally by the anterior border of ramus. [2] The cribose triangular surface just posterior to lower 3rd molar is known as retromolar triangle. The retromolar canal normally arises from the mandibular canal, behind the third molar tooth.

Neurovascular structures passes through this canal gives additional supply to mandibular molars and buccal area. Extraction of lower 3rd molar, which is commonly known as Wisdom teeth, is a common dental procedure. A complete knowledge of the region around 3rd molar is necessary to minimize complications like unexpected bleeding, hematoma formation etc. The neurovascular bundles may get damage during placement of osteointegrated implant, endodontic treatment, sagittal split osteotomy & bone harvesting as a donor site for bone graft surgery. [3]

Since most of the anatomical textbooks and dental literatures do not mention about this foramen or canal and very few studies have been conducted on Indian populations. Hence, we study the possible variations in position of retromolar foranen (or canal) i.e. distance of RMF (or RMC) from the posterior border of 3rd molar socket, anterior border of the ramus & lingula and document its incidence in Indian population.

MATERIALS AND METHODS: The present study has been carried out on 224 dried fully ossified adult human mandibles, which are obtained from Department of Anatomy of Indira Gandhi Institute of Medical Sciences (Patna, Bihar, India), Maitri College of Dentistry & Research Centre (Durg, Chattishgarh, India), Lord Buddha Koshi Medical College (Saharsa, Bihar, India), F. I. Maulana Ali Mian Medical College (Unnao, Uttar Pradesh, India) & Patna Medical College (Patna, Bihar, India) by the consents and permission from heads of the institutes and anatomy department. These 224 mandibles are segregated into male and female mandibles on the basis of following criteria:

1. In males: The angle of mandible is everted.

2. In females: The angle of mandible is inverted.

Finally, these are segregated as 134 male and 90 female mandibles. Mandibles having marked deformities and fractured mandibles are excluded from the study. Each mandible are observed carefully for presence of retromolar foramen and retromolar canal. Wherever foramina are noticed, the distance of foramina from posterior border of 3rdmolar socket, anterior border of the ramus and lingula are measured, using a vernier caliper. The mean, range and standard deviation of all the measurement are statistically analyzed.

RESULT: The retromolar foramen and canal (Fig. 2 & 3) are found in 33 among 224 mandibles (14.7%) of which 11 on the right side (4.9%), 7 on the left side (3.1%) and 15 bilaterally (6.7%) (Table 1 & Figure 1). It is seen that the distance of RMF from posterior border of 3rd molar socket, anterior border of the ramus, and lingula (Fig. 4, 5 & 6) varies between 3 to 10 mm, 4 to 11 mm & 3 to 9 mm respectively in right side and 5 to 12 mm, 3 to 11 mm, & 2 to 8 mm respectively in left side (Table-2 & 3).

From the above observations, it is found that the occurrence of RMF is more common in females as compared to males. It is more common in right side of mandible. The bilateral occurrence of RMF is found to be also higher in females. The position of RMF is nearer to third molar in right side in comparison to left side.

DISCUSSION: The incidence of RMF, located in the retromolar triangle, in our study is 14.7%, which is lesser than incidence of Park MK et al [4] (93.5%), followed by incidence of Schejtman et al [5] (72%), Kawai et al [6] (52%), Rossi et al [7] (26.6%), Von Arx et al [8] (25.6%), Bilecenoglu and Tuncer [9] (25%), Kodera and Hashimoto [10] (20%) followed by Lagrana et al [11] (18%). The highest incidence of retromolar foramen is found in Korean population. [4] An our incidence (14.7%) is greater than incidence of Sawyer and Kiely [12] (7.7%), Pyle et al [13] (7.8%), Ossenberg [14] (8.2%) followed by Suazo et al [15] (12.9%).

The incidence of the RMF in our study is also compared with the studies of different authors on different races of world (Table-4). Percentage presence of RMF in our study falls somewhere within the range reported from study of Athavale et al [16] (14.1%) and Gupta et al [17] (18%), which were done on Indian population. The incidences reported from Indian population [16-19] are varying from 7.8 to 21.9%. The differences in the incidence of the RMF in these studies may be due to differential origins in Indian population.

Our findings show that the distance between the third molar and RMF is within the short range of 3 to 10 mm in right side and 5 to 12 mm in left side which is comparable with the recent study published in the literature. [16,18,19] This close relation of RMF with 3rd molar may damage the structures passing through RMF during 3rd molar extraction and causes postoperative hematomas due to rupturing of the blood vessels.

Pinsolle et al [20] found in his study that the RMF contain blood vessels, so this may be a cause of the spread of infection and metastasis from oral cavity to the blood circulation. Ossenberg NS [14] did not found any difference in incidence of RMF in male and female. But in our study, incidence is more common in female. He also found a positive intertrait relationship between presence of RMF and presence of accessory mandibular foramen & mental foramen.

Sawyer DR & Kiely ML [12] also did not found any difference in incidence of RMF between right and left side & between sexes. In our study, it is more common in female and right side of mandible. Park MK et al [4] classified the retromolar triangle according to its shape into three types: triangular, drop and tapering shape, in which triangular was most common. On Japanese cadavers, Kodera & Hashimoto [10] studied during dissection that a branch from the inferior alveolar artery originated and passed through RMC.

When this branch ran forward get joined with branches of buccal and facial artery. They also found that the nerve in RMC originated from inferior alveolar nerve. Anderson et al [21] studied the components of RMF & RMC and found that these contained nerve fibres, which supplied the 3rd molar pulp, retromolar area, temporalis and buccinator. So, damage of nerve fibres in RMC leads to alteration in function of temporalis and buccinator. Carter et al [22] also found in his study that nerve fibres which supplied the lower molar, arises from the inferior alveolar nerve or from the retromolar branch that passes through the RMC.

The course of neurovascular structures originating from the retromolar foramen was also studied by Schejtman et al [4] during dissection. He found that after leaving the foramen, these fibres were distributed mostly to temporalis tendon, buccinator, most posterior part of alveolar process and lower 3rd molar. They also studied under microscope & observed that the most constant element in RMC was a myelinated nerve. The branches of mandibular division of inferior alveolar nerve may arise high in the infratemporal fossa as explained by Ikeda et al [23] in his study.

These fibres extend to the base of coronoid process & enter the mandible in retromolar fossa and innervates the lower molar. Sutton [24] first of all explained additional sensory nerve fibres in RMF. He explained the relationship between the presence of this foramen and the failure of obtaining analgesia using classical anesthetic techniques. The bone surrounding the retromolar triangle is heavier as compared to cortical plate over triangle & cortical plate is more cancellous. [25] During routine anesthetic, surgical and implantation procedure of mandible, its cancellous nature always kept in mind to prevent damage of neurovascular bundles in RMF.

CONCLUSION: In this study, we report the incidence of retromolar foramen and its distance from the posterior border of 3rd molar socket, anterior border of the ramus, and lingula in Indian population, it is helpful in better understanding of clinical and surgical practice in this region. There is still possibility to study of this canal in living subjects by introducing the dye into the inferior alveolar artery. This may provide more information about this canal. It remains unknown, how the retromolar canal develops in the mandible, so there is need of further studies on large population across the world to understand its origin and evolutionary importance.

DOI: 10.14260/jemds/2014/3747

REFERENCES:

[1.] Patil S, Matsuda Y, Nakajima K, Araki K, Okano T. Retromolar canals as observed on cone-beam computed tomography: Their incidence, course, and characteristics. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 115: 692-699.

[2.] Susan Standring, "Infratemporal and pterygopalatine fossae and temporomandibular joint" in Grays Anatomy: The Anatomical Basis of Clinical Practices, S. Standring, H. Ellis, J. C. Healy, D. Jhonson and A. Williams, Eds., Churchill Livingtone, New York, NY, USA, 40th ed, 2008. pp. 532.

[3.] Naitoh M, Hiraiwa Y, Aimiya H, Ariji E. Observation of bifid mandibular canal using cone-beam computerized tomography. Int J Oral Maxillofacial Implants. 2009; 24: 155-159.

[4.] Park MK, Ryu SJ, Kim SH, Kwak HH. Morphometric Study of the Retromolar triangle and foramen in Korean Mandibles. Korean J Phys Antropol Korean, 2014; Jun 27 (2): 65-70.

[5.] R Scejtman, PC H Devoto, N H Arias. The origin and distribution of the elements of the human mandibular retromolar canal. Archives of Oral Biology.1967; 12 (11): 1261-1267.

[6.] T Kawai, R Asaumi, I Sato, Y Kumazawa, T Yosue. Observation of the retromolar foramen and canal of the mandibles: a CBCT and macroscopic study. Oral Radiology. 2012; 28 (1): 10-14.

[7.] A C Rossi, A R Freire, G B Prado, F B Prado, P R Botacin, P H Ferreira Caria. Incidence of retromolar foramen in human mandibles: Ethnic and clinical aspects. International Journal of Morphology. 2012; 30 (3): 1074-1078.

[8.] T Von Arx, A Hanni, P Sendi, D Buser, M M Bornstein. Radiographic study of the mandibular retromolar canal: an anatomic structure with clinical importance. Journal of Endodontics. 2011; 37 (12): 1630-1635.

[9.] B Bilecenoglu, N Tuncer. Clinical and Anatomical Study of Retromolar Foramen and Canal. Journal of Oral and Maxillofacial Surgery. 2006; 64 (10): 1493-1497.

[10.] Kodera H, Hashimoto I. A case of mandibular retromolar canal: elements of nerves and arteries in this canal. Kaibogaku Zasshi. 1995; 70 (1): 23-30.

[11.] R Lagrana, M Frank, M Camacho, F Gauna, M Abalo. Foramenes Accesorios del Hueso Mandibular Humano, Catedra de Anatomia General. Facultad de Odontologia Universidad Nacional del Nordeste, 2006.

[12.] D R Sawyer, M L Kiely. Retromolar foramen: a mandibular variant important to dentistry. Annals of Dentistry. 1991; 50 (1): 16-18.

[13.] M A Pyle, T R Jasinevicius, J A Lalumandier, K J Kohrs, D R Sawyer Prevalence and implications of accessory retromolar foramina in clinical dentistry. General Dentistry. 1999; 47 (5): 500-504.

[14.] N S Ossenberg Retromolar foramen of the human mandible. American Journal of Physical Anthropology. 1987; 73 (1): 119-128.

[15.] G Suazo, M Zavando, L Cant'in. Retromolar canal and foramen prevalence in dried mandibles and clinical implications. International Journal of Odontostomat. 2008; 2 (2): 183-187.

[16.] S A Athavale, M Vijaywargia, R Deopujari, S Kotgirwar. Bony and cadaveric study of retromolar region. People's Journal of Scientific Research. 2013; 6 (2): 14-18.

[17.] Gupta S, Soni A, Singh P. Indian journal of oral sciences. 2013; 4 (1): jan-apr, 12-16.

[18.] K Narayana, U A Nayak, W N Ahmed, J G Bhat, B A Devaiah. The retromolar foramen and canal in South Indian dry mandibles. European Journal of Anatomy. 2002; 6 (3): 141-146.

[19.] R Priya, K Y Manjunath. Retromolar foramen. Indian Journal of Dental Research: Official Publication of Indian Society for Dental Research. 2005; 16 (1): 15-16.

[20.] V Pinsolle, Y Truilhe, C Majoufre, V Michelet, J Pinsolle. Posterior marginal mandibulectomy for cancer of the oral cavity and oropharynx. An experience of 14 clinical cases. Annales de Chirurgie Plastique et Esthetique. 1997; 42 (3): 223-227.

[21.] L C Anderson, T F Kosinski, P J Mentag. A review of the intraosseous course of the nerves of the mandible. The Journal of oral Implantology. 1991; 17 (4): 394-403.

[22.] Carter RB, Keen EN. The intramandibular course of the inferior alveolar nerve. J Anat. 1971; 108: 433-40.

[23.] Ikeda K, Ho KC, Nowicki BH, Haughton VM. Multiplanar MR and anatomic study of the mandibular canal. AJNR Am J Neuroradiol. 1996; 17: 579-84.

[24.] R N Sutton The practical significance of mandibular accessory foramina. Australian Dental Journal. 1974; 19 (3): 167-173.

[25.] Ash M, Nelson S J. Wheelers dental anatomy, physiology and occlusion, 8th Ed, Elsevier, St Louis, MO. 2003; pp. 398.

[26.] A I Orhan, K Orhan, S Aksoy et al. Evaluation of perimandibular neurovascularization with accessory mental foramina using cone-beam computed tomography in children. Journal of Craniofacial Surgery. 2013; 24 (4): e365-e369.

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AUTHORS:

(1.) Md. Jawed Akhtar

(2.) Sufia Parveen

(3.) Premjeet Kumar Madhukar

(4.) Nafees Fatima

(5.) Avanish Kumar

(6.) Binod Kumar

(7.) Rajiv Ranjan Sinha

(8.) Vinod Kumar

PARTICULARS OF CONTRIBUTORS:

(1.) Senior Resident, Department of Anatomy, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India.

(2.) Lecturer, Department of Prosthodontics, Maitri College of Dentistry and Research Centre, Anjora, Durg, Chattishgarh, India.

(3.) Assistant Professor, Department of Anatomy, Lord Buddha Koshi Medical College & Hospital, Saharsa, Bihar, India.

(4.) Assistant Professor, Department of Anatomy, F. I. Maulana Ali Mian Institute of Medical Sciences, Unnao, U.P. India.

(5.) Associate Professor, Department of Anatomy, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India.

(6.) Assistant Professor, Department of Anatomy, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India.

(7.) Assistant Professor, Department of Anatomy, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India.

(8.) Professor & HOD, Department of Anatomy, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, Bihar, India.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Md. Jawed Akhtar, Senior Resident, Department of Anatomy, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-800014, Bihar, India.

Email: drjawedakhtarpmch@gmail.com

Date of Submission: 15/10/2014.

Date of Peer Review: 16/10/2014.

Date of Acceptance: 30/10/2014.

Date of Publishing: 01/11/2014.
Table 1: Distribution of Retromolar foramen

Sex      Right side   Left side   Bilateral     Total
            (%)          (%)         (%)         (%)

Male      5(2.2%)      3(1.3%)     6(2.7%)    14(6.2%)
Female    6(2.7%)      4(1.8%)      9(4%)     19(8.5%)
Total     11(4.9%)     7(3.1%)    15(6.7%)    33(14.7%)

Table 2: Distance of retromolar foramen from posterior border
of socket for third molar, anterior border of the ramus, and
lingual respectively of Right side

                   Distance between the retromolar
                            foramen and
Mandible   Side
Number     in      3rd molar   Ant. Border   Lingula
           which    socket      of ramus       (mm)
           RMF       (mm)         (mm)
           found

7          Right       3           11           7

11         Right       4            4           8

21         Right       6            8           7

25         Right       3            9           6

32         Right       4            4           4

37         Right       7            8           7

39         Right       3            9           6

43         Right       9            4           4

57         Right       8            5           8

63         Right       3            7           6

71         Right       7            6           9

75         Right       5            7           7

79         Right       3            5           5

81         Right       8            6           5

84         Right       4           10           6

109        Right       5            8           4

135        Right       8            5           7

147        Right       3            9           8

150        Right       9            4           4

172        Right       7            4           8

189        Right      10            9           4

192        Right       8           10           6

203        Right       5            9           8

217        Right       7            8           6

221        Right       8            4           3

224        Right       6            6           5

Mean[+ or -]SD       5.88         6.88         6.08
                   [+ or -]     [+ or -]     [+ or -]
                     2.25         2.25         1.62

Min-Max              3-10         4-11         3-9

Table 3: Distance of retromolar foramen from posterior
border of socket for third molar, anterior border of the
ramus, and lingual respectively of Left side

                     Distance between the retromolar
                             foramen and
Mandible    Side
Number       in       3rd        Ant.      Lingula
           which      molar      Border      (mm)
            RMF      socket     of ramus
            found      (mm)       (mm)

11          Left        6          7          5

17          Left        8          5          4

21          Left        7          7          6

32          Left        9          6          8

39          Left        5          10         6

41          left        11         5          2

43          Left        9          3          4

63          Left        11         9          5

75          Left        5          4          3

81          Left        5          9          2

95          Left        7          7          6

109         Left        9          9          3

143         Left        8          7          2

147         Left        9          11         5

167         Left        11         9          7

172         Left        6          11         6

192         Left        12         6          8

197         Left        8          4          4

203         Left        11         7          8

213         Left        9          6          6

217         Left        7          5          2

224         Left        10         8          8

Mean[+ or -]SD         8.32       7.04        5
                     [+ or -]   [+ or -]   [+ or -]
                       2.15       2.26       2.09

Min-Max     5-12       3-11       2-8

Table 4: Incidence of retromolar foramen and canal in different
population studied by different authors

Sr.   Population          Author              No. of      Incidence
No.                       (year of study)     mandible       (%)
                                              studied

1.    Argentine           Schejtman et           18       13 (72%)
      aborigines          al.[5] (1967)

2.    Eskimos             Ossenberg[14]         485       40(8.2%)
                          (1987)

3.    American            Sawyer and            234       18(7.7%)
                          Kiely[12] (1991)

4.    Japanese            Kodera and             41        8 (20%)
                          Hashimoto[10]
                          (1991)

5.    Caucasian (n=226)   Pyle et al.[13]       475       37 (7.8%)
      Afro-American       (1999)
      (n=249)

6.    Argentinean         Lagrana et             50        9 (18%)
                          al.[11](2006)

7.    Turkish             Bilecenoglu and        40       10 (25%)
                          Tuncer[9](2006)

8.    Brazilian           Suazo et              294      38 (12.9%)
                          al.[15](2008)

9.    Swiss               Von Arx et al.[8]     121      31 (25.6%)
                          (2011)

10.   Japanese            Kawai et               46       24 (52%)
                          al.[6](2012)

11.   Brazilian           Rossi et              222      59 (26.6%)
                          al.[7](2012)

12.   Turkish             Orphan et al.[26]     126      14 (11.1%)
                          (2013)

13.   Korean              Park MK et al.[4]     154      144 (93.5%)
                          (2014)

14.   Indian              Narayana et           242      53 (21.9%)
                          al.[18] (2002)

                          Priya et al.[19]      475       37 (7.8%)
                          (1999)

                          Athavale et            71      10 (14.1%)
                          al.[16] (2013)

                          Gupta et al.[17]       50        9 (18%)
                          (2013)

15.   Indian              OUR STUDY (2014)      224       33(14.7%)

Fig. 1: Distribution of Retromolar foramen in
male and female

               Right   Left    Bilateral

Males(6.2%)    2.20%   1.30%     2.70%
Female(8.5%)   2.70%   1.80%      4%

Note: Table made from bar graph.
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Title Annotation:ORIGINAL ARTICLE
Author:Akhtar, Md. Jawed; Parveen, Sufia; Madhukar, Premjeet Kumar; Fatima, Nafees; Kumar, Avanish; Kumar,
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Nov 3, 2014
Words:3084
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