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MENTAL FORAMEN AND INFERIOR ALVEOLAR CANAL--A BEACON FOR SEX DETERMINATION BY DIGITAL RADIOGRAPH IN NORTH INDIAN POPULATION OF PUNJAB REGION.

BACKGROUND

An imperative eminent landmark, the mental foramen (MF) and inferior alveolar canal shares their significance in various fields of dentistry. The mental foramen morphology, in terms of position, varies not only according to age, sex and ethnicity but even within the same race, in different geographic regions and within the inhabitants of the same geographic area. [1] In conjunction with forensic medicine, identification is a devoir of further interpretation.

The need arises in mass fatalities and disasters when expertise is required for age and gender determination. Forensic dentists and anthropologists consider morphological characteristics of mandible as an important feature that can be used for the determination of sex. Among various anatomical landmarks in the human skull, the mental foramen is regarded as a stable landmark on the mandible. [2] Moreover, the confirmation of anatomical location of the MF is critical to preclude potential injuries to mental nerve during procedures such as periapical endodontic surgery, [3] drainage procedures or reflection of a full-thickness mucoperiosteal flaps. (4) In addition, precautionary measures are essential during the administration of local anaesthetic via infiltration in this area, [5] performing a sagittal split ramus osteotomy [6] and dental implants insertion. [7] The nerve injury can cause temporary or permanent paraesthesia or anaesthesia in the sensory distribution of the mental nerve leading to an adverse outcome and disappointment for the patient. Frequently, the mental foramen is difficult to locate. Generally, it cannot be visualized or palpated by clinical examination. [8]

Likewise, the inferior alveolar canal is a benchmark for performing procedures on the posterior mandible. It shows variations in shapes in both sexes and in both the sides (Left, right). It is mandatory to have a thorough knowledge on position and course of MC and its relationship to posterior teeth in the mandible for Oral and Maxillofacial surgeons to obtain the desired surgical outcome of the procedures which are carried out at different levels of mandible. [9]

The study of these two features in both genders would be a turning point and would pave a way for the surgeons, anthropologists and forensic experts.

A number of non-invasive techniques such as Radiography [10,11] and cone beam computed tomography [12] have been advocated to identify various anatomical landmarks. The radiographic assessment methods (panoramic and periapical radiographs) are non-invasive, convenient for the patients and have been used to determine the location of the MF. [13] Also the contrast and brightness enhancement and enlargement of images provide an accurate and reproducible method of measuring the chosen points. [14,15]

For this purpose, the retrospective radiographic data of patients selected randomly, have been analysed. Though 3-D modalities like Cone Beam Computed Tomography have an upper edge than OPGs, but they are expensive and require higher radiation. Hence, the study was performed using digital panoramic radiograph, which is cheaper, easy, giving a bird's eye view and with less radiation exposure for the patient.

Objectives of The Study

1. To evaluate and compare the superior border of mental foramen to the lower border of mandible (S-L) and the inferior border of mental foramen to lower border of mandible(I-L) values in males and females.

2. To compare the S-L and I-L between right and left side in males and females.

3. To compare the shape of the inferior alveolar canal in both the genders.

4. To study the location of mental foramen in both genders.

5. To compare Inter mental foramen distance in both genders.

The selected OPGs were digitalized, mental foramen was identified clearly and marked. The tangents were drawn through the superior and inferior borders of the foramen and perpendicular lines were drawn from tangents to the lower border of the mandible. Adobe Acrobat Reader was used to measure various parameters.

The measurements were tabulated on an excel sheet and analysed for mean value in males and females on both the right and left sides. Confidence interval, t-test between group comparison and p values were calculated.

METHODS

A retrospective study consisting of 150 patients in the age group between 18 and 50 years undergoing conventional OPG for diagnostic or surgical purposes recruited from the department of Oral Surgery from BJS Dental College & hospital, Ludhiana were selected for the study.

The following Inclusion Criteria were used

1. Adult patients who were 18 years to 50 years with permanent dentition.

2. Ethnicity--North-Indian Punjabi Population

3. Diagnostic quality images with acceptable density & contrast.

4. Images with minimal positioning errors and none or minimal superimposition of structures.

Exclusion Criteria

1. Patients younger than 18 years.

2. Any pathology or congenital anomaly which might affect X-ray interpretation.

3. Blurred vision or distorted radiographs.

4. Non-visualization or absent mental foramen.

5. X-rays of patients with imperfect positioned teeth in the relation between the MF.

The total number of 150 X-Rays were evaluated by Orthopantomograph (OPG) by machine Villa India and set at 60-65, 8 mA with 14 seconds exposure. The effects caused by the horse shape of dental arches were fixed by this panoramic machine.

RESULTS

Out of the 150 panoramic radiographs, 75 were of male patients and 75 were of female patients. Total 300 mental foramen and inferior alveolar canals were studied. Descriptive statistics of the male and female subjects are presented in the following tables.

The results showed distance between superior border of Mental Foramen and lower border of mandible in males- 0.80 inches (20.32 mm) on right side and 0.78 inches (19.81 mm) on left side. The inferior border of mental foramen and lower border of mandible in males showed 0.66 inches (16.74 mm) on right side and 0.63 inches (16.00 mm) on left side. Correspondingly, for females, distance between superior border of Mental Foramen and lower border of mandible on right side showed 0.70 inches (17.78 mm) and 0.68 inches (17.27 mm) on left side. The inferior border of mental foramen and lower border of mandible in females showed 0.54 inches (13.71 mm) on right side and 0.54 inches (13.71 mm) on left side.

Distance between inter mental foramen in males showed 3.03 inches (76.96 mm) and for females it is 2.90 inches (73.66 mm).

Location of Mental Foramen in males was observed maximum at the longitudinal axis of 2 Premolar, 81.33% on right side and 76% on left side. The site for location of mental foramen was observed minimum between 2 Premolar and 1 Molar, 5.33% on right side and 6.66% on left side.

Location of Mental Foramen in females was observed maximum at the longitudinal axis of 2 Premolar, 68% on right side and 70% on left side. The site for location of mental foramen was observed minimum between 2 Premolar and 1 Molar, 9.33% on right side and 4.0% on left side.

The location of mental foramen in our study for both sides, showed at longitudinal axis of 2 Premolar (Males-78.66%, Females-69.23%), between 1, 2 premolars (Males 15.33%, Females -20.66%) and between 2 Premolar and 1 Molar (Males 6%, Females 6.66%).

Shape of inferior alveolar canal for males on right side showed Elliptical (82.66%), Linear (5.25%), Turning (5.33%), Spoon (6.66%). On the left side, Elliptical (95.83%), Linear (1.33%), Turning (2.21%), Spoon (6.66%).

Shape of inferior alveolar canal for females on right side showed Elliptical (88%), Linear (1.33%), Turning (4.33%), Spoon (5.33%). On left side, Elliptical (89.33%), Linear (0), Turning (2.66%), Spoon (8.0%).

The study showed the confidence interval is 95% and level of significance is 5%.

Likewise, shape of the inferior alveolar canal corresponds with the study of Liu et al (2009), and Yun-Hoa Jung et al (2014). The most common course found in our study was Elliptical (males- 87.33%, Females- 88.66%), followed by Spoon (Males and females 6.66%), Turning (Males-2.66%, Females 4.0%) and Linear (Males-2.33%, Females 0.66%)

DISCUSSION

In 1974, Wical and Swoope described that despite the alveolar bone resorption above the mental foramen, the distance from the foramen to the inferior border of the mandible remains relatively constant throughout life. In the present study, the mean values of SMF to LBM and IMF to LBM were significantly higher in males as compared to females, which were in accordance with Chandra et al.'s study conducted in North Indian population. Other authors supporting the study are Mahima et al.'s study conducted in South Indian population, Thomas et al. and Catovie et al.'s studies conducted in different parts of the world. On the contrary, Vodanovic et al. found that the mean value of IMF to LBM does not exhibit sexual dimorphism. (17) The differences observed in our study may be due to racial differences in study population.

CONCLUSIONS

Recent advancements in clinical dentistry have increased the possibility of procedures in the mental region and a detailed knowledge of the mental foramen anatomy may not only aid in the prevention of post-surgical neurovascular complications and morbidity, but also hold the potential of contributing as an identifying maxillofacial anthropologic characteristic feature for different populations. Awareness of its typical morphological features in different ethnicities is pivotal for anatomists, ortho-dentists, surgeons and paleoanthropologists. [20]

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[1] Pokhrel R, Bhatnagar R. Position and number of mental foramen in dry human mandibles: comparison with respect to sides and sexes. OA Anatomy 2013;1(4):31.

[2] Naroor N, Shenai P, Chatra L, et al. Gender determination using the mental foramen. J Cranio Max Dis 2015;4(2):144-7.

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[4] Moiseiwitsch JR. Position of the mental foramen in a North American, white population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85(4):457-60.

[5] Hashiba Y, Ueki K, Marukawa K, et al. Relationship between recovery period of lower lip hypoesthesia and sagittal split area or plate screw position after sagittal split ramus osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105(1):11-5.

[6] Greenstein G, Tarnow D. The mental foramen and nerve: clinical and anatomical factors related to dental implant placement: a literature review. J Periodontol 2006;77(12):1933-43.

[7] Aminoshariae A, Su A, Kulild JC. Determination of the location of the mental foramen: a critical review. J Endod 2014;40(4):471-5.

[8] Maloth S, Shrinivas TR, Padmashree S, et al. Study on the position and symmetry of the mental foramen on panoramic radiographs in Indian population. Journal of International Medicine and Dentistry 2015;2(3):147-55.

[9] Kumari KB, Satya Bhushan NVV, Siva Kalyan U, et al. Evaluation of average distance from mandibular canal to the root apices, cement-enamel junction & alveolar crest of mandibular molars in coastal Andhra Population. International Journal of Advanced Research 2016;4(12):2384-92.

[10] Sadeghi SH, Esmi F. Clinical comparison between extra oral radiography technique with conventional periapical film and intra oral method on working length estimation in molars teeth in endodontics. J Guilan Univ Med Sci 2007;16(61):15-21.

[11] Zafar MS, Javed E. Extraoral radiography: an alternative to intraoral radiography for endodontic (root canal system) length determination. Eur Sci J 2013;9(15):51-61.

[12] von Arx T, Friedli M, Sendi P, et al. Location and dimensions of the mental foramen: a radiographic analysis by using cone-beam computed tomography. J Endod 2013;39(12):1522-8.

[13] Chkoura A, El Wady W. Position of the mental foramen in a Moroccan population: a radiographic study. Imaging Sci Dent 2013;43(2):71-5.

[14] Fabian FM. Position, shape and direction of opening of the mental foramen in dry mandibles of Tanzanian adult black males. Ital J Anat Embryol 2007;112(3):169-77.

[15] Paul P. Murder under the microscope: the story of Scotland Yard's Forensic Science Laboratory. London: MacDonald Publishing 1990.

[16] Chandra A, Singh A, Badni M, et al. Determination of sex by radiographic analysis of mental foramen in North Indian population. J Forensic Dent Sci 2013;5(1):52-5.

[17] Sahni P, Patel RJ, Shylaja, et al. Gender determination by pantomographic (OPG) analysis of mental foramen in North-Gujarat population- a retrospective study. Medico Research Chronicles 2015;2(5):701-6.

[18] Suragimath G, Ashwinirani SR, Christopher V, et al. Gender determination by radiographic analysis of mental foramen in the Maharashtra population of India. J Forensic Dent Sci 2016;8(3):176.

[19] Al-Juboori MJ, Saini R, Al-Wakeel HA, et al. Evaluation of the intermental foramina distance among Malaysian population by using orthopantomogram radiograph. Int J Experiment Dent Sci 2016;5(2):118-22.

[20] Fishel D, Buchner A, Hershkowith A, et al. Roentgenologic study of the mental foramen. Oral Surg Oral Med Oral Pathol 1976;41(5):682-6.

[21] Maloth S, Shrinivas TR, Padmashree S, et al. Study on the position and symmetry of the mental foramen on panoramic radiographs in Indian population. Journal of International Medicine and Dentistry 2015;2(3):147-55.

[22] Babshet M, Sandeep R, Burde K, et al. Evaluation of the position of mental foramen and its correlation with age in selected Indian population, using digital panoramic radiograph. International Journal of Dental Sciences and Research 2015;3(4):87-91.

[23] Hasan T. Characteristics of the mental foramen in different populations. The Internet Journal of Biological Anthropology 2011;4(2).

[24] Punjabi SK, ur Rehman H, Ahmed S, et al. Radiographic position of mental foramen in selected Pakistani population. Journal of Pakistan Dental Association 2010;19(2):105-9.

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[27] Laher AE, Motara F, Moolla M. The ultrasonographic determination of the position of the mental foramen and its relation to the mandibular premolar teeth. J Clin Diagn Res 2016;10(6):OC23-7.

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Daizy Singh (1), Sameer Kaura (2), Sumit Kaur (3), Sandeep Singh (4), Ritu Singh (5), Jasleen Kaur (6)

(1) Professor and HOD, Department of Anatomy, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India.

(2) Professor and HOD, Department of Oral & Maxillofacial Surgery, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India.

(3) Intern, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India.

(4) Assistant Professor, Department of Radiology, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India.

(5) Doctor MBBS, Lady Hardinge Medical College, New Delhi, India.

(6) Assistant Professor, Department of Pharmacology, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India.

'Financial or Other Competing Interest': None.

Submission 30-03-2019, Peer Review 05-05-2019, Acceptance 11-05-2019, Published 20-05-2019.

Corresponding Author:

Dr. Daizy Singh, 111 -New Lajpat Nagar, Pakhowal Road, Ludhiana-141002, Punjab, India.

E-mail: singh.daizy@yahoo.com

DOI: 10.14260/jemds/2019/358

Caption: Picture 1. OPG of a Male Showing Readings

Caption: Picture 2. OPG of a Female Showing Readings

Caption: Picture 3. Shape of The inferior alveolar Canal

(Courtesy: inferior alveolar Canal course: a radiographic study; Tie Liu, Zhi Yuan Gu, Bin Xia28)
Table 1. Comparison of Superior Border of Mental Foramen (SMF)-
Lower Border of Mandible (LBM) & inferior Border of Mental
Foramen (IMF)-Lower Border of Mandible (LBM) in Males

                              Males                   p-Value

                 Right (Inches)     Left (Inches)

Mean (SMF-LBM)   0.80 (20.32 mm)    0.78 (19.81)      0.001
Mean (IMF-LBM)   0.66 (16.76 mm)   0.63 (16.00 mm)    0.001

p < 0.05 = Significant

Table 2. Comparison of Superior Border of Mental Foramen
(SMF)--Lower Border of Mandible (LBM) & Comparison of inferior
Border of Mental foramen (IMF)-Lower Border of Mandible
(LBM) in Females

                                   Females                 p-Value

                      Right (Inches)     Left (Inches)

Mean (SMF-LBM)        0.70 (17.78 mm)   0.68 (17.27 mm)    0.001
Mean (IMF-LBM)        0.54 (13.71 mm)   0.54 (13.71 mm)    0.001

p < 0.05 = Significant

Table 3. Distance of Inter Mental Foramen (Male and Female)

Inter Mental Foramen    Male (Inches)    Female (Inches)      p-Value

Mean                   3.03 (76.96 mm)   2.90 (73.66 mm)      0.054

p value - Not significant

Table 4. Percentage of Location of Mental Foramen for Males &
Females (Rt/Lt)

Location              Males (Right)   Females (Right)   Males (Left)

2 Premolar               81.33%             68%           76.0%
1, 2 Premolar            13.33%            22.66%         17.33%
2 Premolar, 1 Molar       5.33%             9.33%          6.66%

Location               Females (Left)    Total (Males, Females)

2 Premolar                   70%            78%, 69.23%,
1, 2 Premolar              18.66%         15.33%, 20.66%
2 Premolar, 1 Molar         4.0%            6.0%. 6.6%

Table 5. Percentage of Shape of inferior alveolar Canal in Males
(Rt/Lt)

Inferior alveolar             Elliptical         Linear
Canal

                      Males      Females   Males    Females

Right                 82.66%      88.0%    5.25%     1.33%
Left                  95.83%     89.33%    1.33%       0

Inferior alveolar          Turning           Spoon
Canal

                     Males    Females   Males   Females

Right                5.33%     4.33%    6.66%    5.33%
Left                 2.21%     2.66%    6.66%    8.0%

Table 6. Comparison of Present Study with Previous Literature
(Distance from The Superior Border of Mental Foramen SMF, to
inferior Border of Mandible IBM; Distance from The inferior
Border of Mental Foramen IMF to inferior Border of Mandible IBM

Author         Year          SMF-IBM (mean)

Chandra A.                Males          Females
et al (16)     2013    R- 17.65 mm     R- 16.15 mm

                       L- 17.47 mm     L- 15.78 mm

Sahni P.                  Males          Females
et al (17)     2015    R- 16.86 mm     R-14.43 mm

                        L-15.23 mm     L-12.96 mm

Sugarimath G              Males          Females
et al (18)     2016    R- 17.19 mm     R-15.61 mm

                        L-17.31 mm     L-15.25 mm

Our study                 Males          Females
               2019    R- 20.32 mm     R-17.78 mm
                        L-19.81 mm     L-17.27 mm

Author                 IMF-IBM (mean)

Chandra A.         Males          Females
et al (16)      R- 12.67 mm     R- 11.46 mm

                L- 12.58 mm     L- 11.25 mm

Sahni P.           Males          Females
et al (17)      R- 13.35 mm     R- 11.29 mm

                L- 11.81 mm     L- 10.05 mm

Sugarimath G       Males          Females
et al (18)      R- 11.79 mm     R- 11.40 mm

                L- 11.89 mm     L- 11.39 mm

Our study          Males          Females
                R- 16.76 mm     R- 13.71 mm
                L- 16.00 mm     L- 13.71 mm

Table 7. Comparison of Present Study with Previous Literature
(Distance Between Inter Mental Foramina)

Author                  Year               Results
                                 Indian Population- 53.49 mm
Al-Juboori (19) et al   2016      Malay Population- 54.16 mm
                                 Chinese population-55.61 mm
Our study               2019    Males- 3.03 inches (76.96 mm)
                               Females-2.90 inches (73.66 mm)

Table 8. Comparison of Present Study with Previous Literature
(Position of Mental Foramen)

Author                  Year                   Results

Fischel et al (20)      1976      Most common location between two
                                 premolars (1, 2PM) Contrary to our
                                                study

Maloth S et al (21)     2015      Most common location between two
                                 premolars (1, 2PM) Contrary to our
                                                study

Babshet M, et al (22)   2015   At 1, 2 PM-43% At 2PM- 39% Contrary to
                                              our study

T. Hasan (23)           2011    Most Common position for Tanzanians,
                                 Mongoloids, Blacks, Srilankans- 2PM
                                        Similar to our study

Punjabi SK et al (24)   2011   Most common position is 2PM (47.2%), 1,
                                2PM (40.4%) 2PM, 1M (7.1%) Similar to
                                              our study

Ashaq Ali et al (25)    2016    At 2PM- 44%, 1, 2 PM-26% 2PM, 1M-9.9%
                                        Similar to our study

Shweta et al (26)       2016   Most common position is 2PM Similar to
                                              our study

Abdullah Ebrahim        2016   Most common position is 2PM Similar to
Laher et al. (27)                             our study

Our Study               2019     At longitudinal axis of 2 Premolar
                               (Males-78.66%, Females-69.23%), between
                               1, 2 premolars (Males 15.33%, Females -
                                20.66%) and between 2 Premolar and 1
                                  Molar (Males 6%, Females 6.66%).

Table 9. Comparison of Present Study with Previous Literature
(Shape of inferior alveolar Canal)

Name                Year                    Results

Liu et al (28)      2009    Describes linear, spoon, elliptical and
                               turning curve of mandibular canal.
                              Elliptical curve is the most common
                                            (48.50%)

Yun-Hoa Jung and    2014     Elliptical curves were most frequently
Bong-Hae Cho (29)            observed, lowest among were the linear
                                            curves.

Rai et al (30)      2018    Describes linear, spoon, elliptical and
                           turning curve of Mandibular canal. Linear
                           type of curve is the most common. Contrary
                                         to our study.

Our study           2019       Elliptical is the most common type
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Title Annotation:Original Research Article
Author:Singh, Daizy; Kaura, Sameer; Kaur, Sumit; Singh, Sandeep; Singh, Ritu; Kaur, Jasleen
Publication:Journal of Evolution of Medical and Dental Sciences
Geographic Code:9INDI
Date:May 20, 2019
Words:3509
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