Dusan V Kuzmanovic Alan GT Payne Jules A Kieser George J Dias

Anterior loop of the mental nerve: a morphological and radiographic study

Authors afliations: Dusan V Kuzmanovic, Alan GT Payne, Department of Oral Rehabilitation, School of Dentistry, University of Otago, New Zealand Jules A Kieser, Department of Oral Sciences, School of Dentistry, University of Otago, New Zealand George J Dias, Department of Anatomy and Structural Biology, Medical School, University of Otago, New Zealand Correspondence to: Dr Alan GT Payne Department of Oral Rehabilitation School of Dentistry PO Box 647 University of Otago Dunedin New Zealand Fax 64 3 479 5079 e-mail: alan.payne@stonebow.otago.ac.nz

Key words: anterior loop of mental nerve, implant treatment planning, anatomical dissection, radiography Abstract: Treatment planning for dental implant patients is often complicated by the unknown extent of the anterior loop of the mental neurovascular bundle. The aim of this study was to determine the correlation between the visual interpretation of the panoramic radiographs and the anatomical dissection ndings in a cadaveric sample. Panoramic radiographs of the 22 randomly selected coronally sectioned human head specimens were taken using the Scanoras (Soridex, Orinon Corporation Ltd, Helsinki, Finland) radiographic unit jaw panorama (Programme 001, magnication 1.3) and dental panorama (Programme 003, magnication 1.7) and interpreted by two calibrated observers. Bilateral anatomical dissection was then performed on all specimens. The anterior loop of the mental canal was only identied in six panoramic radiographs (27%) (range 0.53 mm). There was a signicant positive correlation between both observers of the radiographs and between the two radiographic programmes used. Anatomical measurements of the anterior loop of the mental neurovascular bundle revealed its presence in eight dissected specimens (range 0.11 3.31 mm; mean 1.20, 0.90). Fifty percent of the radiographically observed anterior loops of the mental canal were misinterpreted by observers with both radiographic programmes and 62% of the anatomically identied loops were not observed radiographically. Clinicians should not rely on panoramic radiographs for identifying the anterior loop of the mental nerve during implant treatment planning. However, a safe guideline of 4 mm, from the most anterior point of the mental foramen, is recommended for implant treatment planning, on the basis of our anatomical ndings.

Date: Accepted 24 June 2002 To cite this article: Kuzmanovic DV, Payne AGT, Kieser JA, Dias GJ. Anterior loop of the mental nerve: a morphological and radiographic study Clin. Oral Impl. Res. 14, 2003; 464471

Copyright r Blackwell Munksgaard 2003

ISSN 0905-7161

Treatment concepts for the edentulous mandible using removable implant overdentures or xed implant bridges identify surgical requests for two to ve interforaminal implants, regardless of superstructure design (Batenburg et al. 1998; Merickse-Stern et al. 2000). When two implants are used, for removable overdentures, there is lack of consensus on the inter-abutment distance (1235 mm) with variation within reports (Naert et al. 1997; Watson et al. 1997; Wright & Watson 1998; Naert et al. 1999; Payne & Solomons 2000). When three, four or ve implants are used for xed or removable prosthodontic

solutions, the crucial position of the distal two implants is determined by the essential surgical reference point of the mental foramina, and particularly the extent of the anterior loop of the mental neurovascular bundle (Solar et al. 1994; Rosenquist 1996; Misch 1998). The cantilever length of the xed implant bridge, distal to the last implant, is also dictated by, to a greater extent, the position of the distal implant closest to the mental foramen. Additionally, in partially dentate patients, who have lost mandibular premolar and molar teeth, the mental foramen and mental nerve or its anterior loop is also the critical surgical

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landmark and essential reference point during treatment planning. It is acknowledged that surgical trauma or injury to the mental nerve is possible during implant surgery in the interforaminal area of the mandible (Ellies 1992; Ellies & Hawker 1993). As a result, a number of studies have reported an incidence of transient altered sensation from 8.5% to 24% during periods of up to 316 months postoperatively following implant surgery (Wismeijer et al. 1997; Dao & Mellor 1998; Bartling et al. 1999; Walton 2000). There is considerable variation among researchers of the incidence and extent of the anterior loop of the mental neurovascular bundle. The reported length of the anterior loop ranged as little as 0.5 mm in some patients (Rosenquist 1996) and as much as 10 mm in others (Rothman 1998). Several methods and techniques for identifying the extent of the anterior loop of the mental neurovascular bundle have been proposed using panoramic radiographs, computed tomography, and determination of the anterior loop during surgery using a curved explorer (Rothman 1998; Misch 1999). While intraoral (periapical) radiographs have not been recommended for preoperative assessment of the extent of the anterior loop, there have been some attempts by researchers to correlate visualization of these radiographs with anatomic reality (Bavitz et al. 1993; Mardinger et al. 2000). Bavitz et al. (1993) investigated the path of the mental nerve in a cadaveric sample and compared its anatomy with this type of radiographic interpretation. They reported that the maximum length of the anterior loop based on anatomical measurements was 1 mm. In contrast, the average radiographic loop was 2.5 mm for a dentate group and 0.6 mm for an edentulous group. It was apparent that there was a tendency to overestimate the extent of the anterior loop during these radiographic examinations. Mardinger et al. (2000) concluded that there was no correlation between the anatomical intraosseous path of the mental nerve in 46 hemisected cadaveric mandibles and the radiographic interpretation of periapical radiographs. These authors reported the presence of the anterior loop in 28% of dissected specimens (range 0.4 2.19 mm), and concluded that the periapical radiographs of the anterior loop of the mental nerve in cadaver mandibles do not

disclose the true ramication of the inferior alveolar nerve to the mental and incisive nerve. Panoramic radiography has been suggested and used for diagnostic purposes in implantology (Lekholm & Zarb 1985; Schwartz et al. 1992; Truhlar et al. 1993; Misch 1999; Bartling et al. 1999; Walton 2000). However, there is paucity in documented research attempting to correlate anatomical dissection ndings with these radiographic views. The only study that has attempted to correlate anatomic measurements of the extent of the anterior loop of the mental neurovascular bundle with actual panoramic radiographic measurements was by Arzouman et al. (1993). The extent of the anterior loop was measured directly on 25 skulls, using polyethylene tubing that was placed into the anterior loop and the distance the tube extended beyond the anterior border of the mental foramen was recorded. An average length of the anterior loop was 6.95 mm identied on these anatomical measurements. On the other hand, in radiographic measurements, without radiographic markers, the average length of the loop was 2.69 mm (Panelipse) and 2.75 mm (Orthoralix). The mean anterior loop lengths, identied in radiographs with radiopaque markers, were 4.17 mm (Panelipse) and 4.64 mm (Orthoralix). There have been no reports published to date evaluating the predictability of panoramic views using Scanoras (Soridex, Orinon Corporation Ltd. Helsinki, Finland) jaw or dental panoramas for identifying the anterior loop of the mental neurovascular bundle. The aim of the present study was to determine if a correlation existed between the anatomically dissected path of the mental neurovascular bundle in a cadaver sample and the radiographically estimated path of the mental canal using a rotational, narrow-beam panoramic imaging Scanoras radiographic unit.

Materials and methods

Twenty-two coronally sectioned human head specimens, xed in formalin, were randomly selected from the collection of the Department of Anatomy and Structural Biology, University of Otago, Dunedin, New Zealand. The specimens were all from people of Caucasian descent. Characteristics of the study sample are shown in Table 1. The mandibular residual ridge morphology of the edentulous specimens was classied (Cawood & Howell 1988) during anatomical dissection.
Radiographic evaluation

The specimens were placed on a custommade plastic platform secured to the chin brace of the Scanoras machine. The specimens were accurately positioned with the guidance of light lines for the mid-sagittal, frontal, and horizontal planes, correctly placed relative to the anatomical landmarks. Jaw panorama using Scanora Imaging Programme 001 (1.3 magnication), and dental panorama using Scanora Imaging Programme 003 (1.7 magnication) were taken with the recommended technique. The specimens were exposed with Kodak T.Mat G/RA Panoramic (Eastman Kodak Company, Rochester, NY, USA) lms and with the use of a single Lanex Fine screen installed in the back of the cassette. The Scanoras X-ray machine was operated at 66 kVp, 10 mA, for 13 s. The lms were processed in the ALL PRO 100L (ALL PRO Imaging Corporation, New York, NY, USA) automatic processor. These radiographs were observed, prior to anatomical dissection, by two independent observers under standard viewing conditions. Observers classied the radiologic appearance of the mental foramina into four types (Yosue & Brooks 1989): Type I, a continuous type in which the mental canal was connected to the mandibular canal;

Table 1. Characteristics of the study sample

Number of specimens F Edentulous Partially edentulous Total 14 8 22 50 37.5 45.45 Gender (%) M 50 62.5 54.54 7193 6488 6493 80 (SD 7.79) 71 (SD 8.15) 77 (SD 8.86) Age range Mean age

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Type II, a separated type in which the mental canal does not show continuity with the mandibular canal; Type III, a diffuse type in which the foramina could be identied but with indistinct borders; Type IV, an unidentied type in which the mental foramina could not be identied on the panoramic radiographs. The extent of the anterior loop of the mental canal of each

radiograph was estimated by each observer by measuring the shortest distance from the two lines passing through the most anterior point of the mental foramen and the most anterior point of the mental canal to the nearest 0.5 mm (Fig. 1). A Scanoras Soredex-Finndent ruler with graduated measurements, according to the respective magnication, was used.

Anatomical evaluation

Fig. 1. Reference points of measurement for the anterior loop of the mental canal. a point of deepest anterior concavity of the mental foramen; b point of the most anterior point of the mental canal : x line and y drawn through point a and point b.

Fig. 2. Reference points of measurement for the anterior loop of the mental neurovascular bundle. a point of deepest anterior concavity of the mental foramen; x line and y drawn through point a; b point of the ramication between the incisive and mental branches; c nearest point on y line from the point b; d the mental neurovascular bundle; e the mental nerve; f the incisive nerve.

The mandibles of all specimens were excised from the specimen heads by sectioning the ramus. The canines and premolars were extracted in the partially edentulous specimens. The soft tissue of each mandible was dissected and the mental foramen and mental neurovascular bundle were identied. An osteotomy with a radius of 2 cm was made on each mandible. Firstly, using a round bur No. 1, holes were drilled through the cortex. Subsequently, these holes were connected with a ssure bur No. 2 and the cortex was removed en block. The osteotomy was extended 1 cm anteriorly, from 0.5 mm above the point of most anterior concavity of the mental foramen, parallel to the lower border of the mandible, and 1 cm posteriorly, from the point of deepest posterior concavity of the mental foramen. The cancellous bone was then curetted using a scaler and, in some difcult cases, a No. 2 round bur was used. The bone quality in the edentulous mandibles was classied during these procedures (Lekholm & Zarb 1985). After exposure of the incisive and the inferior neurovascular bundles, photographs with scales in place were taken with a Nikon E2S digital camera. The images were taken from the superior lingual side of the mandibles at a 451 angle. This orientation was maintained for imaging of every specimen. The rationale for the lingual approach was to maintain the accurate three-dimensional anatomical relationship between the neurovascular bundle and the bone. The Scion Image, Beta 4.0.2 (Scion Corporation, Frederick, Maryland, USA) programme was used to draw two lines, x and y line (Fig. 2). The x line was constructed through point a (point of deepest anterior concavity of the mental foramen), parallel to the outer cortex of the mandible. The y line was also drawn through point a. The value of the angle formed by the two lines (x and y) drawn through the a point was 90o. The length of the anterior loop of the mental neurovascular bundle was obtained by measuring the nearest distance from the reference point b (point of the ramication between the incisive and mental branches) to the line y (reference point c). The diameter of the incisive neurovascular bundle was measured as close to the ramication as

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possible also using the Scion Image, Beta 4.0.2 programme.

Data and statistical analysis

All calculations were performed with SPSS statistical software. The degree of agreement between the different examiners and programmes readings was examined using the Kappa statistics for categorical measures, and the Pearson correlation coefcient test for continuous measures.

Results
The most common radiographic appearance of the mental foramen (Yosue &

on both panoramic radiographs jaw panorama (Programme 001) and dental panorama (Programme 003) by the two observers, was continuous type (Type I) with an overall prevalence of 44%, followed by the separated type (Type II, 31%). The mental foramen was not able to be identied in 12% of radiographs, while the diffuse type (Type III) was found in 13% of radiographs (Table 2). Intraobserver agreement for each of the two observers using the two radiographic programmes (Programme 001 and Programme 003) showed almost perfect agreement (observer 1: 0.967 (P<0.01) and observer 2: 0.890 (P<0.01). Agreement between the two radiographic programmes was moderate to substantial

Table 2. Radiographic appearance of the mental foramina (classication according to Yosue & Brooks, 1989)
Observer 1 Programme 001 (%) Type I Type II Type III Type IV 32 43 14 11 Observer 1 Programme 003 (%) 32 40 14 14 Observer 2 Programme 001 (%) 57 23 11 9 Observer 2 Programme 003 (%) 54 18 14 14 Overall prevalence (%) 44 31 13 12

Brooks 1989 classication), as determined

(Programme 001 and 003, 0.575 and 0.650 respectively (P<0.01). A comparison of the extent of the anterior loops of the mental neurovascular bundle revealed by the radiographic measurements and anatomical dissection is presented in Fig. 3. The anterior loop of the mental canal was observed to be present in six radiographs (27%) by both observers and ranged from 0.5 to 3 mm in length (mean 1.50; 0.09). The length of the anterior loop of the mental canal was either over- or underestimated in all radiographs. A signicant positive correlation was found between the two observers and between the two radiographic programmes (Table 3). Following anatomical dissection of the cadaver specimens, measurements of the anterior loop of the mental neurovascular bundle revealed its presence on both the left and right sides in eight dissected specimens (37%) (Fig. 3). The extent of the anterior loop ranged from 0.11 to 3.31 mm (mean 1.20; 0.90). The Pearson correlation coefcient between the measurements of the left and right sides of the mandible indicated signicant agreement (0.954, P<0.01). The results of Kappa statistics

Fig. 3. The individual values (by specimen) of the extent of the anterior loop of the mental neurovascular bundle obtained from the panoramic measurements and anatomical dissection.

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Table 3. Inter - and intraobserver correlation of the radiographic measurements; (P001) Scanora Programme 001; (P 003) Scanora Programme 003
Observer 1P 001 Observer 1P 0 03 Radiographic interpretation of the anterior loop 0.991 (P<0.01) Observer 2P 001 Observer 2P 003 0.981 (P<0.01) Observer 1P 001 Observer 2P 001 0.943 (P<0.01) Observer 1P 003 Observer 2P 003 0.917 (P<0.01)

Table 4. Bone quality and bone quantity, with radiographic interpretation analysed using the Pearson correlation test; (P 001) Scanora programme 001; (P 003) Scanora programme 003
Observer Observer Observer Observer 1P 001 1P 003 2P 001 2P 003 Bone quality with radiographic interpretation of the anterior loop Bone quantity with radiographic interpretation of the anterior loop 0.416 0.303 0.416 0.307 0.416 0. 304 0.416 0.304

showed only slight agreement between radiographic interpretation of the anterior loop and measurements of the anatomical dissection (0.101). The most common bone quality with Lekholm & Zarb classication was Type III (36%), followed by type II (32%). Type I and Type IV were less common, 9% and 23%, respectively. With the Cawood & Howell classication bone quantity, Type 6 was observed in 16 specimens (57%), followed by Type 5 found in eight cadavers (29%) and Type 4 in four cadavers (14%). Pearson correlation analyses showed a negative correlation between both the bone quality and quantity and the radiographic extent of the anterior loop (Table 4). Anatomical dissection also revealed that the mean diameter of the incisive nerve was 1.80, 0.46 (range 0.92.53 mm).

Discussion
Our study has shown that the reliability of the panoramic radiographs, when planning for implant placement in the interforaminal region of the mandible, may be limited. The radiographic length of the anterior loop of the mental canal can only be measured in radiographs where the entire course of the mental canal is visualized, from the mandibular canal through the mental foramen (Type I, or continuous Type, Yosue & Brooks classication (1989)). The results of our study show that on respective panoramic radiographs, Type I was identied in average of 44% of the specimens (Table 2). These ndings conrm the

previous ones of Yosue & Brooks (1989). Furthermore, our ndings showed that the anterior loop of the mental canal was observed in six radiographs (27%), in which the mental foramen was identied as Type I, in both radiographic images (range 0.5 3 mm in length). It is of interest that the length of the anterior loop of the mental canal, when identied radiographically and conrmed anatomically, was either over- or underestimated. One of the disadvantages of panoramic images is its geometric distortion of the anatomical structures (Grondahl et al. 1996). Distortions of the panoramic images in the horizontal and vertical plane, especially in the anterior region, depend on the anatomical variations between arch curvatures and on accurate patient positioning in the radiographic machine (Schiff et al. 1986; Truhlar et al. 1993). Therefore, difculty with positioning the specimens accurately probably resulted in either overor underestimation of the length of the anterior loop of the mental canal. In contrast to our results, Arzouman et al. (1993) showed a clear tendency to underestimate the extent of the anterior loop in radiographic examinations without radiopaque markers. The differences may be explained by the fact that Arzouman et al. (1993) used dry human mandibles and radiopaque markers to determine the length of the anterior loop of the mental canal. Radiopaque markers could penetrate the mental canal or enter the incisive canal, resulting in overestimation of the length of the mental canal.

The true diagnostic accuracy of the jaw panorama and dental panorama was evaluated in our dissection of cadaveric specimens. The mean anatomical incidence of the anterior loop of the mental neurovascular bundle in our study was 37% (range 0.113.31 mm). This is similar to those of Mardinger et al. (2000), who reported the presence of the anterior loop in 28% of dissected specimens (length range 0.4 2.19 mm). Although a low incidence of the anterior loop reported by Bavitz et al. (1993) and Rosenquist (1996) was in accordance with our study, the results of the anatomical measurements were somewhat different. Bavitz et al. (1993) reported the maximum length of the anterior loop, based on anatomical measurements in a cadaveric sample, to be 1 mm. In a study performed unilaterally in 58 patients, Rosenquist (1996) reported the maximum length of the anterior loop to be 1 mm. Differences in the length of the anterior loop reported in these studies and the present study can be explained by different experimental techniques. The main advantage of our lingual-approach technique is that the three-dimensional anatomy of the mental neurovascular bundle and mental foramen is maintained and inaccuracies of anatomical measurements are minimized. Our results do however differ widely from those reported by Arzouman et al. (1993). A critical review of that work showed that the authors estimated that the average diameter of the incisive canal was 2 mm; hence they used radiopaque markers and exible tubing that were approximately 2 mm in diameter. They also suggested that the incisive canal was thinner than the inferior alveolar canal. Our study shows that the incisive neurovascular bundle, near the ramication, can in fact be as wide as 2.53 mm in diameter. Furthermore, our observation was that the walls of the mental canal can be very porous and thin in specimens with advanced bone resorption. Therefore, the marker inserted

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into the mental canal can easily penetrate the mental canal or enter the incisive canal. Consequently, other anatomical structures can be accidentally measured rather than the anterior loop of the mental canal. The signicance of their ndings may be questionable. There are undoubtedly clear differences between the anatomical and panoramic measurements of the anterior loop. Data analyses showed that 50% of the radiographically observed anterior loops of the mental canal were misinterpreted in both radiographic programmes and by both observers, and 62% of the anatomically identied loops was not observed radiographically. The same inaccuracy of radiographic measurements was found when using both jaw panorama (Scanora Programme 001) and dental panorama (Scanora Programme 003). Therefore, these ndings indicated low specicity and low sensitivity of both panoramic programmes regardless of their magnication. Poor bone quality and bone quantity in the edentulous specimens had negative correlation with both radiographic and anatomical extent of the mental canal or mental neurovascular bundle. Radiographic visualization of the anterior loop of the mental canal, especially in edentulous patients, may be adversely affected by poor bone quality. This is of signicance to clinicians during implant treatment planning. The negative correlation between the radiographic interpretations of the mental canal in specimens could be due to the decreased porosity of the mental canal walls due to poor bone quality. Furthermore, resorption of the residual alveolar ridges in edentulous patients may have progressed to such an extent causing resorption of the mental canal and exposure of the mental neurovascular bundle. This may explain the negative correlation between the poor bone quantity and anatomical presence of the mental nerve. Intraoral and panoramic radiographs of the area for edentulous and partially edentulous patients give two-dimensional views (Jacobs & van Steenberghe 1998; Serhal et al. 2001). It is acknowledged that there are proposals of advantages in the use of computerized tomography to clarify the mandibular canal and the anterior loop of the mental neurovascular bundle (Roth-

man 1998; Serhal et al. 2001). One surgical approach that has been proposed, aided by preoperative panoramic radiographs during treatment planning, can be the tilting of the posterior mandibular implants (Krekmanov et al. 2000). If the mandibular implants are tilted approximately 25351 in the area of the anterior loop of the mental nerve, then the prospective research has indicated, at least in edentulous patients that the patients, can gain a mean distance of 6.5 mm of prosthesis support (Krekmanov et al. 2000). This described surgical technique of his suggests that the implant can be placed close to the anterior wall of the mental neurovascular bundle and parallel to it, and then tilted mesially by 25351 to accommodate the anterior loop. The results of our study indicated that Scanoras panoramic radiographs may not be accurate in determining the tilt of the implants because of its low sensitivity and specicity. Therefore, tilting could only be determined clinically or with the aid of CT.

sume Re
sirant des Le plan de traitement pour les patients de connaisimplants est souvent complique par la me rieure du sance de lemplacement de la boucle ante rieur. Le but de cette e tude a e de te nerf dentaire infe terminer la relation entre linterpre tation visuelle de couvertes de radiographies panoramiques et les de es effectue par dissection anatomique sur cadavres. Des radiographies panoramiques de 22 humains ont choire te e prises par Scanoras, panoramique ma (programme 001, grandissement 1,3) et panoramique dentaire (programme 0,03, grandissement 1,7) et te s. La interpre es par deux observateurs calibre rale a ensuite e effecte dissection anatomique bilate e. rieure du canal na seulement e te tue La boucle ante e identie que dans six radiographies panoramiques ` (27%)(de 0,5 a 3 mm). Il y avait une relation positive signicative entre les deux observateurs des radiographies et entre les deux programmes de radioes. Les mesures anatomiques de la graphies utilise rieure ont montre leur pre sence dans six boucle ante ` cimens disse s ( de 0,11 a 3,31 mm; moyenne que spe rieures 1,200,90). Cinquante % des boucles ante es taient mal interpre observe radiographiquement e es te par les observateurs avec les deux programmes es de radiographies, et 62 % des boucles identie taient pas de celables radiograanatomiquement ne phiquement. Les cliniciens ne devraient pas trop se baser sur les radiographies panoramiques pour rieure du nerf mentonnier identier la boucle ante durant le plan de traitement implantaire. Cependant, ventive serait de une conduite raisonnable et pre ` rieure du laisser 4 mm a partir du point le plus ante foramen mentonnier lors du plan de traitement implantaire.

Conclusions
Clinicians should not rely on panoramic radiographs for identifying the anterior loop of the mental nerve during implant treatment planning. However, a safe guideline of 4 mm, from the most anterior point of the mental foramen, is recommended for implant treatment planning on the basis of our anatomical ndings.

Zusammenfassung
Die Schleife des Nervus mentalis: Eine morphologische und radiologische Studie. Die Behandlungsplanung mit Zahnimplantaten wird am Patienten wegen dem unbekannten Verlauf und der variablen Ausdehnung des Nervgefa nssbu dels vom Nervus mentalis oft erschwert. Das Ziel dieser Studie war, eine Korrelation zu nden zwischen der visuellen Interpretation des Panoramarontgenbildes und den effektiven anatomischen Verha ltnissen auf Schnitten von Leichenpra paraten. Man stellte mit dem Rontgengera Scanoras von 22 t zufa llig ausgewa hlten menschlichen Scha delpra paraten nach zwei verschiedenen Programmen (Programm 001, Vergrosserung 1.3 und Programm 003, Vergrosserung 1.7) Panoramaaufnahmen her und liess sie von zwei kalibrierten Untersuchern interpretieren. Anschliessend stellte man beidseits der Scha del ein anatomisches Schnittpra parat her. Die vordere Schleife des Mentalkanals konnte nur auf 6 Panoramarontgenbildern (27%) (Bandbreite 0.5 3mm) bestimmt werden. Man fand eine signikante positive Korrelation zwischen den beiden Untersuchern der Rontgenaufnahmen und auch zwischen den zwei verschiedenen verwendeten Rontgenpro grammen. Die anatomische Vermessung des vorderen Bogens des Gefa ssnervenbundels vom N. mentalis

Acknowledgements: The authors wish to acknowledge the assistance of the staff of the Clinical Overdenture Research Project (CORP), School of Dentistry, and the Department of Anatomy and Structural Biology, School of Medicine, University of Otago, Dunedin, New Zealand. Radiographic Supplies Ltd, Christchurch, New Zealand are thanked for their generous supply of radiographic lms for our study. We also thank Professor Brian Monteith for allowing the project to be conducted within the Department of Oral Rehabilitation, University of Otago, Dunedin, New Zealand, in partial fullment of a Master of Dental Surgery (Prosthodontics).

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gelang in 8 Pra paraten (Bandbreite 0.11-3.31mm; Mittelwert 1.20 0.90). 50% der radiologisch beobachteten vorderen Bogen des Mentalkanales wurden von den Untersuchern mit beiden Rontgenprogram men falsch interpretiert, und 62% der anatomisch freigelegten Bogen konnten rontgenologisch nicht nachgewiesen werden. Der Kliniker sollte sich also bei der Implantatplanung und der Identikation des vorderen Bogens des N. mentalis nicht auf Panoramarontgenbilder verlassen. Man empfahl jedoch fur die Implantatplanung auf Grund dieser anatomischen Erkenntnisse ein Sicherheitsabstand von 4mm vom vordersten Punkt des Foramen mentale.

Resumen
La planicacion de los pacientes de implantes dentales es a veces complicada por el desconoci miento de la extension de la curva del paquete neurovascular del nervio mentoniano. La intencion de este estudio fue determinar la correlacion entre la micas y los interpretacion de las radiografas panora hallazgos en la diseccion anatomica en muestras micas ricas. Se tomaron radiografas panora cadave

de los 22 especmenes seleccionados de cabezas humanas seccionadas coronalmente usando la uni dad radiograca Scanoras, panorama mandibular (Programa 001, magnicacion 1.3) y panorama dental (Programa 003, magnicacion 1.7) y se interpretaron por dos observadores calibrados. La curva anterior del canal mentoniano fue identicado micas (27%) (rango 0.5 solo en 6 radiografas panora 3 mm). Hubo una correlacion positiva entre los dos programas radiogracos usados. Las mediciones anatomicas de la curva anterior del paquete neurovascular mentoniano revelaron su presencia en 8 especmenes diseccionados (rango 0.11 3.31 mm; media 1.20 0.90). Se malinterpretaron por los observadores el 50% de las curvas anteriores observadas radiogracamente con ambos programas radiogracos y el 62% de las curvas identicadas anatomicamente no se observaron radiograca mente. Los clnicos no pueden conar en las micas para identicar la curva radiografas panora anterior del nervio mentoniano durante la planica cion del tratamiento de implantes. De todos modos, se recomienda un margen seguro de 4 mm, desde el s ndose en punto ma anterior del foramen dental, basa nuestros hallazgos anatomicos.

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