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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 232-236
Lingual vascular canal assessment by dental computed tomography: A retrospective study


1 Department of Oral Medicine Diagnosis, MGV KBH Dental College and Hospital, Panchavati, Private Practioner, Nashik, India
2 Department of Radiology, MGV KBH Dental College and Hospital, Panchavati, Private Practioner, Nashik, India

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Date of Submission27-Jun-2010
Date of Decision16-Sep-2010
Date of Acceptance10-Nov-2010
Date of Web Publication27-Aug-2011
 

   Abstract 

Background: Lingual vascular canal (LVC) is an important anatomical structure in mandibular anterior region. Trauma to this structure during implant placement has been reported in this study. Dental computed tomography (DCT) provides a three-dimensional visualization of lingual vascular canal.
Aim: To assess the frequency, location, and size of LVC using dental CT.
Materials and Methods: A retrospective analysis of 75 mandibular DCT was done. Evaluation was done to detect the frequency, size, and number of lingual vascular canal using Seimens Somatom Sensation 64.
Results: About 73.3% patients (male=34, female=21) demonstrated presence of LVC with only one patient showing two canals. The mean distance from the inferior border of mandible was 0.5 mm, S.D.±0.70. The mean diameter of the canal was 0.31 mm, S.D.±0.70.
Conclusion:Dental CT provides adequate information regarding frequency, number, and size of lingual vascular canal, which is an important anatomical structure in mandibular anterior region.

Keywords: Dental CT, lingual vascular canal, sublingual hematoma

How to cite this article:
Jaju P, Jaju S. Lingual vascular canal assessment by dental computed tomography: A retrospective study. Indian J Dent Res 2011;22:232-6

How to cite this URL:
Jaju P, Jaju S. Lingual vascular canal assessment by dental computed tomography: A retrospective study. Indian J Dent Res [serial online] 2011 [cited 2019 Oct 14];22:232-6. Available from: http://www.ijdr.in/text.asp?2011/22/2/232/84293
Dental implants have emerged as the conservative method of replacing missing teeth and thus restoring the function of stomagnathic system, proprioception, and aesthetics. Dental computed tomography (DCT) has emerged as the imaging modality of choice for pre-evaluation of implant sites. DCT provides detailed view of jaw topography along with the proximity to critical anatomical structures like the maxillary sinus, mandibular canal, mental foramen, and incisive canal. [1],[2],[3] Mandibular anterior region has long being considered as a safe zone for implant placement, with implant length extending up to the inferior border of mandible. But recent literature suggests serious life-threatening complications such as sublingual hematoma formation, upper airway obstruction, and profuse bleeding in this region [4],[5],[6],[7],[8],[9],[10],[11],[12] [Figure 1]. Thus, a proper anatomical, radiological, and surgical considerations must be done prior to implant placement in interforaminal region of anterior mandible. Considering the importance of this region, the present study was conducted to assess the frequency, number, and size of canals using dental CT.
Figure 1: Post operative dental CT, with implant placed precariously closed to lingual canal

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   Materials and Methods Top


A retrospective study was conducted by selecting images from DCT examinations of 75 patients, who were supposed to undergo mandibular dental implant at Jupiter Heart Scan Centre, Mumbai between 2008 and 2009. Patients undergoing mandibular scan for other purposes were excluded from the study. The CT scan machine used was Seimens Somatom Sensation 64, which had multidetector technology and had 32 detectors and 64 data channels. Scan direction was caudocranial beginning with the mandible base and extending up to the alveolar crest. Slice thicknesses of the images were adjusted to 1 mm with slice interval of 2 mm. Axial images were acquired and then these images were processed with the DCT reformatting program [Figure 2]. Multiplanar reconstructions based on the DCT protocol were obtained in the orthoradial and panoramic plane by using a dental software package (Syngo Dental CT 2006 A-W VB20B-W) on a workstation. The images were evaluated separately by a general radiologist, a dental radiologist, and a dentist in different sessions. Agreement was reached by means of a majority decision (at least two of three observers agreed). The frequency, number, and size of the lingual vascular canals were evaluated. In addition, the exact location of each canal was obtained by measuring the distance to the canal from the inferior border of the mandible. The diameter of the canal was measured midway of the canal wall [Figure 3] and [Figure 4]. Statistical analysis was performed using SPSS software to determine the frequency, size, and number of the canal.
Figure 2: Post operative dental CT, with implant placed precariously closed to lingual canal

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Figure 3: Measurement of canal distance and diameter on paraxial image

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Figure 4: Paraxial image showing lingual canal

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   Results Top


This study included 43 males and 32 females patients. The mean age of the patient was 47.5 years. For male, the average age was 50 years while for female the average age was 43.8 years. The canal was visible clearly in the axial and paraxial images.

LVC was detected in 73.3% of patients (male=34, female =21). The most common location found for these vascular canals was in midline of the mandible with 75% of positive cases. The mean distance of the canal measured from the inferior border of mandible was 0.56 mm with a SD of ±0.7. The mean distance in males was 0.64 mm while for females it was 0.45 mm. The longest canal distance was 16.9 mm while the shortest distance was 1.5 mm. The largest diameter of vessel noted was 1.6 mm, while the smallest vessel diameter was 0.01 mm. The mean diameter of the vessel was 0.31 mm with a S.D. ±0.7. The mean diameter for males and females was 0.36 mm [Table 1] and [Table 2]. The direction of canal wall was progressing anteriorly and caudally.
Table 1: Distribution of canals gender wise sex of the patients


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Table 2: Age wise distribution of canals


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[Table 2] shows distribution of canals with respect to age groups in male and female patients.

Maximum patients in males belong to age group of 51?60 years with canal present in 88.2% patients, while in females 75% patients showed canals in same age groups.


   Discussion Top


Mandibular anterior region is used for surgical procedures such as treatment of the edentulous jaw with oral implants or as a donor site for grafting procedures. Whenever a true neurovascular bundle is identified in the anterior mandible and considered to be functional, surgery in the mental interforaminal area is not without risk. [13] With the increase in complications associated with the trauma to the vascular channel, this study was undertaken to assess the role DCT can play in preventing such complications. The anatomical landmarks of particular interest in the interforaminal region of the mandible are not only the mental foramina, forming the boundaries of this area, the mental nerve, the incisive canal and its neurovascular bundle, but also the midline foramina.

A number of researchers have recommended that blood vessels and nerves could enter the lingual foramen. Ennis, Suzuki and Sakai, McDonnell et al., Darriba and Mendonca-Cardad and Givol et al., assumed a vascular content being an anastomosis of the sublingual branch of right and left lingual arteries. [13],[14],[15],[16],[17] The artery could be of sufficient size to provoke a hemorrhage intraosseously or in the connective soft tissue, which might be difficult to control. Sutton described the structures associated with the foramen as a neurovascular bundle. [18] Goaz and White stated that the foramen and canal were the termination of the incisive branch of the mandibular canal. [19] According to Yoshida et al., lingual artery visualization on radiography was difficult and CT provides an adequate visualization of the vascular canal. They found low frequency of occurrence (45.7%) of lingual foramen on internal surface of mandible on dry cadavers. [20] According to McDonnell et al., lingual foramen was present in 99% in midline of mandible. [15] In the present study, it was detected in 73.3% (55 patients) of patients. The most common location found for this vascular canal was in midline of the mandible (75%). In most patients, one canal was detected, while in one patient two canals were detected (48 year female). [9] CT is important tool for visualizing accurate anatomical structure and position, bone topography, osseous pathology associated with dental implantology. [21] Few studies have been done confirming the role of CT in identifying the lingual canal. Jacobs et al., confirmed the presence of lingual foramen (82%), incisive canal (93%), in their examination of patients by CT. [20] Multiplanar reformation (MPR) provide excellent visualization of midline mandibular structure clearly depicting the lingual canal and size of the lingual canals correlate well with the results of anatomic studies. The small difference in the size values of the canals can probably be attributed to the fact that the smallest canals were too small to be visible because of the limited resolution capability of CT. [22],[23],[24]

Liang et al., characterized the superior as well as the inferior genial spinal foramen and their bony canal using a large CT data sample. On spiral CT scans, the superior and inferior genial spinal foramina were detected in 448 CT scans (81%). In 29% of the mandibular CTs, two or more midline canals were noted. [25] Liang et al., assessed histologically the true content of the superior genial spinal foramen and to match these findings to the microanatomical canal the content was observed by using high-resolution magnetic resonance images of the same region. [13] It can be assumed that the diameter of the lingual vascular channel is proportional to the diameter of the entering artery and to the potentially increased risk of hemorrhage of the floor of the mouth when injured. This injury probably occurs during drilling of the implantation site. [24] Mason et al., have summarized several reports on major hemorrhage in the floor of the mouth caused by bleeding from different surgical procedures and implant placement in the mental region. They, therefore, recommend that appreciation of the sublingual artery anatomy with the divisions in the floor of the mouth is mandatory for those performing mandibular implantation. In this study, the mean distance of the canal measured from the inferior border of mandible was 0.56 mm. The mean distance in males was 0.64 mm while for females it was 0.45 mm. The longest canal distance was 16.9 mm while the shortest distance was 1.5 mm. The largest diameter of vessel noted was 1.6 mm while the smallest vessel diameter was 0.01 mm. The mean diameter of the vessel was 0.31 mm. The mean diameter for males and females was 0.36 mm. Maximum number of patients belonged to age group 51?60 years in both the sexes [Table 2]. There was no significant corelation found between different age groups and sexes with respect to frequency, number, and size of the canal.

Gultekin et al, in their study revealed typical lingual canal locations were the middle of the mandible and the premolar regions. The mean diameter of the lingual canals was 0.8 mm±0.2 mm in the middle, 0.6 mm±0.1 mm in the premolar regions. The direction of median canal was anterior and slightly caudal. Lateral canals were directed in a medial manner. [26]

Cova et al., in their study found that 0?5 canals were found in each patient. The mean diameter of the entrance foramen was 0.85±0.28 mm located adjacent the symphysis menti and 11.3±2.6 mm from the inferior margin of the mandible. [27] Scaravilli et al., in their study found that the 90.3% had at least one lingual vascular canal and 45.6% had multiple (two or three) canals. The mean diameter of the lingual canals in the midline was 0.8 mm±0. [28]

With age related changes and osteoporotic factors, ossification surrounding the canal can decrease, thereby reducing the visibility of canal. In addition, visibility of structures such as these is heavily dependent upon image quality (resolution, contrast, etc.). The difference between studies in the literature and this study may be due to different scanners, different imaging protocols and observer detection variability. Radiographic report of DCT for pre-evaluation of implant sites should mention about the vascular channel present in mandibular anterior region before any surgical procedure is formulated. DCT offers the advantage of proper anatomic delineation of the jaw and depiction of the lingual vascular canals of the mandible, hence reducing the risk of implantation surgery in the preoperative phase. While CT images show lingual canals, we have less evidence that the hemorrhage is due to these rather than surgical error. Research should focus on looking at cases with hemorrhage problems and to see what clinical and radiological factors are associated with it, of which the presence of lingual canals may only be a small contributory factor.


   Conclusion Top


With the upward trend in the placement of Dental implants, there is a simultaneously upsurge in its postoperative complications. Damage to the lingual artery in the mandibular anterior region is one of such complication. With the advent of DCT, the visualization of jaw anatomy has improved tremendously and proper utilization of technology can prevent unnecessary complications that can result due to poor knowledge of jaw anatomy.

 
   References Top

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Correspondence Address:
Prashant Jaju
Department of Oral Medicine Diagnosis, MGV KBH Dental College and Hospital, Panchavati, Private Practioner, Nashik
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.84293

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    Figures

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