[Downloaded free from http://www.ijdr.in on Wednesday, February 27, 2019, IP: 157.50.83.

28]

Original Research

Lingual vascular canal assessment by dental computed

tomography: A retrospective study

Prashant Jaju, Sushma Jaju1

Departments of Oral Medicine

Diagnosis and Radiology,
ABSTRACT
MGV KBH Dental College and
Hospital, Panchavati, Private
Practioner, Nashik, India
Received : 27-06-10
Review completed : 16-09-10
Accepted : 10-11-10
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.
Key words: Dental CT, lingual vascular canal, sublingual hematoma

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. [1-3] 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[4-12] [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.
MATERIALS AND METHODS
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

Address for correspondence:

Dr. Prashant Jaju
E-mail: docprashant_jaju@yahoo.com

Access this article online

Quick Response Code: Website:
www.ijdr.in

PMID:
***

DOI:
10.4103/0970-9290.84293 Figure 1: Post operative dental CT, with implant placed precariously
closed to lingual canal

Indian Journal of Dental Research, 22(2), 2011 232

[Downloaded free from http://www.ijdr.in on Wednesday, February 27, 2019, IP: 157.50.83.28]

Lingual vascular canal assessment by dental CT Jaju and Jaju

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, Figure 2: Post operative dental CT, with implant placed precariously
a dental radiologist, and a dentist in different sessions. closed to lingual canal
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 [Figures
3 and 4]. Statistical analysis was performed using SPSS
software to determine the frequency, size, and number of
the canal.

RESULTS
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 Figure 3: Measurement of canal distance and diameter on paraxial
was 43.8 years. The canal was visible clearly in the axial image
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 [Tables 1 and 2]. The
direction of canal wall was progressing anteriorly and
caudally.
Figure 4: Paraxial image showing lingual canal
Table 2 shows distribution of canals with respect to age
groups in male and female patients. DISCUSSION
Maximum patients in males belong to age group of 51−60 Mandibular anterior region is used for surgical procedures
years with canal present in 88.2% patients, while in females such as treatment of the edentulous jaw with oral implants
75% patients showed canals in same age groups. or as a donor site for grafting procedures. Whenever a true
233 Indian Journal of Dental Research, 22(2), 2011
[Downloaded free from http://www.ijdr.in on Wednesday, February 27, 2019, IP: 157.50.83.28]

Lingual vascular canal assessment by dental CT Jaju and Jaju

neurovascular bundle is identified in the anterior mandible patients, one canal was detected, while in one patient two
and considered to be functional, surgery in the mental canals were detected (48 year female).[9] CT is important tool
interforaminal area is not without risk.[13] With the increase for visualizing accurate anatomical structure and position,
in complications associated with the trauma to the vascular bone topography, osseous pathology associated with dental
channel, this study was undertaken to assess the role DCT implantology.[21] Few studies have been done confirming
can play in preventing such complications. The anatomical the role of CT in identifying the lingual canal. Jacobs
landmarks of particular interest in the interforaminal region et al., confirmed the presence of lingual foramen (82%),
of the mandible are not only the mental foramina, forming incisive canal (93%), in their examination of patients by
the boundaries of this area, the mental nerve, the incisive CT.[20] Multiplanar reformation (MPR) provide excellent
canal and its neurovascular bundle, but also the midline visualization of midline mandibular structure clearly
foramina. depicting the lingual canal and size of the lingual canals
correlate well with the results of anatomic studies. The small
A number of researchers have recommended that blood difference in the size values of the canals can probably be
vessels and nerves could enter the lingual foramen. Ennis, attributed to the fact that the smallest canals were too small
Suzuki and Sakai, McDonnell et al., Darriba and Mendonca– to be visible because of the limited resolution capability of
Cardad and Givol et al., assumed a vascular content being CT.[22-24]
an anastomosis of the sublingual branch of right and left
lingual arteries.[13-17] The artery could be of sufficient size to Liang et al., characterized the superior as well as the
provoke a hemorrhage intraosseously or in the connective inferior genial spinal foramen and their bony canal using
soft tissue, which might be difficult to control. Sutton a large CT data sample. On spiral CT scans, the superior
described the structures associated with the foramen as a and inferior genial spinal foramina were detected in 448
neurovascular bundle.[18] Goaz and White stated that the CT scans (81%). In 29% of the mandibular CTs, two or
foramen and canal were the termination of the incisive more midline canals were noted.[25] Liang et al., assessed
branch of the mandibular canal.[19] According to Yoshida histologically the true content of the superior genial spinal
et al., lingual artery visualization on radiography was foramen and to match these findings to the microanatomical
difficult and CT provides an adequate visualization of the canal the content was observed by using high-resolution
vascular canal. They found low frequency of occurrence magnetic resonance images of the same region.[13] It can be
(45.7%) of lingual foramen on internal surface of mandible assumed that the diameter of the lingual vascular channel
on dry cadavers.[20] According to McDonnell et al., lingual is proportional to the diameter of the entering artery and
foramen was present in 99% in midline of mandible.[15] to the potentially increased risk of hemorrhage of the floor
In the present study, it was detected in 73.3% (55 patients) of the mouth when injured. This injury probably occurs
of patients. The most common location found for this during drilling of the implantation site.[24] Mason et al.,
vascular canal was in midline of the mandible (75%). In most have summarized several reports on major hemorrhage in
the floor of the mouth caused by bleeding from different
Table 1: Distribution of canals gender wise sex of the surgical procedures and implant placement in the mental
patients region. They, therefore, recommend that appreciation of
Number of Canal Lingual Mean Mean the sublingual artery anatomy with the divisions in the
patients seen in vascular distance diameter floor of the mouth is mandatory for those performing
patients canal from of the
present inferior canal
mandibular implantation. In this study, the mean distance
border of (mm) of the canal measured from the inferior border of mandible
(%)
mandible was 0.56 mm. The mean distance in males was 0.64 mm
(mm) while for females it was 0.45 mm. The longest canal
Male 43 34 45.3 0.64 0.36 distance was 16.9 mm while the shortest distance was
Female 32 21 28 0.45 0.36 1.5 mm. The largest diameter of vessel noted was 1.6 mm
Table 2: Age wise distribution of canals
Age groups Male Female
(years) No. of Present Frequency Mean Mean No. of Present Frequency Mean length Mean
patients (%) length of diameter of patients (%) of canal diameter
canal canal (mm) of canal
(mm) (mm) (mm)
10−20 2 2 100 0.62 0.39 2 1 50 0.25 0.02
21−30 1 0 0 0 0 8 4 40 0.84 0.64
31−40 7 5 71.4 0.98 0.3 4 4 100 0.78 0.6
41−50 7 4 57.1 0.64 0.38 4 2 50 0.49 0.7
51−60 17 15 88.2 0.86 0.38 8 6 75 0.45 0.35
61−70 7 5 71.4 0.62 0.35 4 2 50 0.25 0.26
71−80 2 2 100 0.72 0.75 2 2 100 0.9 0.2

Indian Journal of Dental Research, 22(2), 2011 234

[Downloaded free from http://www.ijdr.in on Wednesday, February 27, 2019, IP: 157.50.83.28]
Lingual vascular canal assessment by dental CT Jaju and Jaju
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
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.
235
REFERENCES
1. Wyatt CC, Pharoah MJ. Imaging techniques and image interpretation
for dental implant treatment. Int J Prosthodont 1998;11:442-52.
2. Abrahams JJ. Dental CT imaging: A look at the jaw. Radiology
2001;219:334-45.
3. Misch CE. Contemporary implant dentistry. 2nd edition. Mosby:
Elsevier; 1999. p. 73-87.
4. Tepper G, Hofschneider UB, Gahleitner A, Ulm C. Computed
tomographic diagnosis and localization of bone canals in the
mandibular interforaminal region for prevention of bleeding
complications during implant surgery. Int J Oral Maxillofac Implants
2001;16:68-72.
5. Kattan B, Snyder HS. Lingual artery hematoma resulting in upper airway
obstruction. J Emerg Med 1991;9:421-4.
6. Krenkel C, Holzner K, Poisel S. Hematoma of the mouth floor following
oral surgeryand its anatomical characteristics. Dtsch Z Mund Kiefer
Gesichtschir 1985;9:448-51.
7. Krenkel C, Holzner K. Lingual bone perforation as causal factor in
a threatening hemorrhage of the mouth floor due to a single tooth
implant in the canine region. Quintessenz 1986;37:1003-8.
8. Laboda G. Life-threatening hemorrhage after placement of an
endosseous implant: Report of case. J Am Dent Assoc 1990;121:
599-600.
9. Mason ME, Triplett RG, Alfonso WF. Life - threatening hemorrhage
from placement of a dental implant. J Oral Maxillofac Surg 1990;48:
201-4.
10. Chase CR, Hebert JC, Farnham JE. Post-traumatic upper airway
obstruction secondary to a lingual artery hematoma. J Trauma
1987;27:953-4.
11. Hofschneider U, Tepper G, Gahleitner A, Ulm C. Assessment of
the blood supply to the mental region for reduction of bleeding
complications during implant surgery in the interforaminal region.
Int J Oral Maxillofac Implants 1999;14:379-83.
12. Pigadas N, Simoes P, Tuffin JR. Massive sublingual haematoma following
osseo-integrated implant placement in the anterior mandible. Br Dent
J 2009;206:67-8
13. Liang X, Jacobs R, Lambrichts I, Vandewalle G, van Oostveldt D,
Schepers E, et al. Microanatomical and histological assessment of
the content of superior genial spinal foramen and its bony canal.
Dentomaxillofac Radiol 2005;34:362-8.
14. Suzuki M, Sakai T. The foramina on the lingual surface of the mandible
in the Japanese. Med J Shinahu Univ 1957;2:1-10.
15. Mc Donnell D, Reza Nouri M, Todd ME. The mandibular lingual foramen:
A consistent arterial foramen in the middle of the mandible. J Anat
1994;184:363-9.
16. Ennis LM. Roentengraphic variations of the maxillary sinus and the
nutrient canals of the maxilla and mandible. Int J Orthod Oral Surg
1937;23:173-93.
17. Darriba MA, Mendonca-Cardad JJ. Profuse bleeding and lifethreatening
airway obstruction after placement of mandibular dental implants. Int
J Oral Maxillofac Surg 1997;55:1328-30.
18. Sutton RN. The practical significance of mandibular accessory foramina.
Aust Dent J 1974;19:167-73.
19. White SC, Pharoah MJ. Oral radiology: Principles and interpretation.
5th ed. Toronto: CV Mosby: Year Book Inc; 2004. p. 181-2.
20. Yoshida S, Kawai T, Okustu K, Yosue T, Takamori H, Sunohara M, et al.
The appearance of foramen in the internal aspect of mental region of
mandible from Japanese cadavers and dry skulls under macroscopic
observation and three dimensional CT images. Okajimas Folia Anat
Jpn 2005;82:83-7.
21. Rothmall SL, Chafetz N, Rhodes ML, Schwartz MS. CT in the
preoperative assessment of the mandible and maxilla for endosseous
implant surgery. Radiology 1988;168:171-5.
22. DuBrul EL. Sicher’s oral anatomy. 7th ed. St Louis: Mosby; 1980. p.
427-47.
23. Schiller W, Wiswell O. Lingual foramina of the mandible. Anat Rec
1954;119:387-90.
24. Andre G, Ursula H, Gabor T, Michael P, Susanne S, Konstantin Z, et al.
Indian Journal of Dental Research, 22(2), 2011
[Downloaded free from http://www.ijdr.in on Wednesday, February 27, 2019, IP: 157.50.83.28]

Lingual vascular canal assessment by dental CT Jaju and Jaju

Lingual Vascular Canals of the Mandible: Evaluation with Dental CT.
Radiology 2001;220:186-9.
25. Liang X, Jacobs ER, Lambrichts EI. An assessment on spiral CT scan
of the superior and inferior genial spinal foramina and canals. Surg
Radiol Anat 2006;28:98-104.
26. Gultekin S, Araç M, Celik H, Karaosmaoglu AD, Işik S. Assessment
of mandibular vascular canals by dental CT. Tani Girisim Radyol
2003;9:188-91.
27. Cova M, Ukmar M, Bole T, Morra A, Lubin E, Pozzi Mucelli R. Evaluation
of lingual vascular canals of the mandible with computed tomography.
Radiol Med 2003;106:391-8.
28. Scaravilli MS, Mariniello M, Sammartino G. Mandibular lingual vascular
canals (MLVC): Evaluation on dental CTs of a case series. Eur J Radiol
2010;76:173-6.
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.
Source of Support: Nil, Conflict of Interest: None declared.

“Quick Response Code” link for full text articles

The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has
a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full
text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/
yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can
also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free
applications.

Indian Journal of Dental Research, 22(2), 2011 236