Localization of Mental

foramen
With CBCT imaging

Introduction
Mental foramen

:
An opening in the lateral surface of mandible :
mental N. and vessels.
Procedures that might be harmful to mental foramen

Surgical endodontic procedures : periapical endodontic

surgery
Vertical incision for ease of reflection of a full-thickness
mucoperiosteal flap
Incision and drainage procedure
Administration of local anesthetic via infiltration
Sagittal split ramus osteotomy
Dental implant surgery
Orthodontic miniscrew for anchorage

Techniques to determine the

location of MF
1. Palpation
Palpation to feel for a raised area of the
mucosal tissues covering the MF in the
area adjacent to the apices of the
premolars.
Risk : Not precise

Techniques to determine the

location of MF
2. Periapical
Radiographs
Use of multiple
periapical radiographic
images.
Vertical and horizontal
periapical film.
Risk : Magnification,
failure to detect MF if it
is located below the
apical edge of the film

Techniques to determine the

location of MF
3. Direct Visualization
The accurate location of the MF has been
determined with dry human mandible

Techniques to determine the

location of MF
4. Panoramic Radiographs
Locating the MF with a panoramic radiograph is
not always possible. reported detection of the MF
with panoramic radiographs in 94% of the samples
(Jacobs et al2004)
Panoramic radiographs, w and w/o periapical
radiographs, have been used to determine the
location of the MF.

Techniques to determine the

location of MF
4. Panoramic Radiographs
Aging affect on the visibility of the MF.
Nonvisibility of the foramen was greatly
increased in patients aged 50 years and
older (Ngeow et al 2003)
Risk : Large degree of
magnification(20%36%) and failure to
detect MF when it is not clearly visible
(Choi et al. 2004)

Techniques to determine the

location of MF
5. Cone-beam Computed Tomography
The location of the MF was detected in 100% of
the cases using CBCT scanning (Parnia et al
2012).
Using CBCT imaging, the anatomic location and
position of the MF was accurately determined.
CBCT imaging allowed for
greater detectability of MF
than panoramic radiography.
(Naitoh et al 2009)

Techniques to determine the

location of MF
5. Cone-beam Computed Tomography
The risk of using CT imaging is patient
exposure to ionizing radiation.
Radiation dose : spiral multislice CT >
conventional spiral CT > CBCT imaging.
(Chau and Fung 2009)
Potential risks of exposure to x-rays and
CBCT imaging

A total of 180 CBCT images, analyzed by two

examiners
All CBCT images were taken by Sirona Orthophos,
Galileos (Sirona, Germany)
Exposure time was 14 seconds, effective
exposure time was 26 seconds, and voxel size
was 0.3x0.3x0.3 mm.
Inclusion criteria : patients older than 18 years
(skeletal growth completed; partial or full
edentulous and dentate patients).
Exclusion criteria : patients below 18 years old
and patients with pathologic lesions in mandible.
Sheikhi et al,

Method

CBCT projections were analyzed in

different planes (tangential, crosssectional, and axial).
Mental foramen was identified in crosssectional and axial views.
The shape and diameter of MF was
determined from tangential projection.

Sheikhi et al,

Method
The vertical position
of MF image in
relation to the root
Position 1: coronal to
apex Position 2: at
the apex Position 3:
apical to the apex

1
2
3

Method
The horizontal position of
mental foramen image
Position 1: ant to 1st premolar.
Position 2: in line with 1st
premolar.
Position 3: between
1st&2ndpremolar.
Position 4: in line with
2ndpremolar.
Position 5: between 2nd
premolar
&1st molar.
Position 6: in line with 1st molar.

4 3 2 1

Results
1.

Mental Foramen Shape.

Right side, 69.4% oval and 30.6% round.
Left side, 67.8% oval and 32.2% round.
82.8% of mental foramen shape in
images was round or oval in both sides
(22.8% round and 60% oval in the both
right and left sides).
MF shape and gender No significant
difference

Result
2. Mental Foramen Size.
The mean diameter of MF was 3.59mm in
the right side and 3.59 mm in the left side.

Result

3. Vertical Location of Mental Foramen

Result

3. Vertical Location of Mental Foramen

Low agreement in vertical location of MF in Rt
and Lt.
No statistically significant differences between
different vertical locations of MF and gender

4. Horizontal Location of MF
1
2
3

Dentate cases :

22.7% located
between
1st&2ndpremolar
18.2% were in line
with 2ndpremolar
6.8% between 2nd
premolar1st molar

2 1

4. Horizontal Location of MF

No agreement between the horizontal

locations of MF in the Rt&Lt
No statistically significant differences
between different horizontal locations of
MF and gender

Discussion
Mental Foramen Shape.
Oval and round
Differences between races (Fabian 2007, Juboori et
al 2014)

Indians : round mental foramen

Malawians have mostly oval one.
Tanzanian and Zimbabwean : oval = round

In this study

Oval shape was twice greater than round shape

The shape of mental foramen was the same in both
sides in many of our cases (82.8%).
MF shapes and sex Not Sig
Mental foramen shape did not change with age
increase.

Discussion
Mental Foramen Size.
Mental foramen size in this study was
similar to those reported by Neiva et al.
2004 among Caucasians

Discussion

Horizontal location of
MF was more
posterior in blacks
than in whites and the
most common
horizontal locations in
Caucasian population
were Positions 3 and 4
(Juboori et al, 2014)
Positions 1, 2, 5, and
6 have been reported
to have low incidence
in other studies

4 3 2 1

Discussion
Limitations for locate mental foramen w/
premolars

Partially or fully edentulous patients lost

their molars and premolars
Further studies

Invariable

landmarks : inferior border of mandible

Conclusions

Most common variation of MF in Iranian population

was oval, apical to the apex, and in between 1st &
2nd premolar.
CBCT imaging is the best current available
imaging technology, but it has some shortcomings
such as radiation, cost, and not being real time.
In the future, MRI and US might become more
promising
Non-invasive techniques
Capturing 3D images in real time
No radiation risk to the patient.

The majority of the reviewed studies used

large field of view volumes for their analysis.
The CS 9000 CBCT unit

High resolution
Limited field of view (LFOV)

Carruth et

Method

106 patients (must be 18 y or older)

Tangential, axial, and coronal CBCT
images
To determine the size and position of the
MF with respect to the lower 2nd
premolar apex & the CEJ.
Distinguishing characteristics of sex,
age, and race were evaluated.

Carruth et

Method

The vertical height and horizontal width

of the MF were measured as well as its
position in relationship to the apex and
CEJ of lower 2nd premolar.
Inclusion criteria
1. Lower 1st premolar, 2nd premolar, and 1st
molar teeth must be present.
2. Teeth are in a normal position and
alignment.
3. Patient must be 18 years or older.

Method

Exclusion criteria
1.
2.

a significant malocclusion
Rotation > 45 or overlap of teeth > 2 mm

Measurements were obtained and

recorded by a single viewer.
To analyze intraobserver agreement, 2
measurements were repeated at 2
different time points for each scanned
volume.

Method
Axial view
The maximum width of
the MF
This curve served as a
reproducible landmark
to reference for
measurements across
all scanned volumes

Method
Tangential view
The maximum
height and width of
the MF

Method
Coronal view
the maximum
height of the MF
was measured

Tangential view
A center point of
the MF was
marked with the
axial and coronal
marking lines.
The coordinates
(a, b) at this
location were
recorded

Tangential view
Axial and coronal
marking lines were
then moved until
they centered over
the apex of the
lower 2nd premolar.
The coordinates
(c, d) at this
location were
recorded

results

Location of the MFs

53.7% mesial
45.3% distal
1% apex of the lower 2nd premolar.

results

results

results

Result

Result

The size and position of the MF can be reliably

measured using LFOV CBCT technology.
The MFs size

3.5 mm in height, 4.1 mm in width

2.8 mm inferior, 0.01 mm mesial to the apex of
the lower 2nd premolar.

MFs in males had greater heights than

females.
Black patients had MFs located significantly
more distal in relationship to the CEJ of the
lower 2nd premolar than white patients.

69 adult mandibles (45 male, 24 female)

of Thai dry skulls
To determine the size and the location of
the MF related to gender and side.

Apinhasmit et al,

2
1

The mean distances

from the MF to
symphysis (A) =
28.83 mm
The mean distances
from the MF to the
post. border of
ramus (P) = 68.85
mm

The mean distances

from the MF to the
lower border of the
mandible (mb)
=14.88 mm
The mean distances
from the MF to to
the buccal cusp tip
of the 2nd Premolar =
24.27 mm

Tooth loss, proximal caries or proximal

attrition may cause mesial tooth drift.
Using an accurate method for recording
the MF position : anatomical landmarks
on the mandible.
symphysis menti
posterior border of the ramus
alveolar bone crest
lower border of the mandible.

CONCLUSIONS
1. The most common position of the MF is
in line with the longitudinal axis of the
lower 2nd premolar regardless of race.
2. The average position of the MF is
anterior (mesial) to the longitudinal axis of
the second premolar in Caucasoids and
more posterior (distal) in Mongoloids and
Negroids.

Green 1987

CONCLUSIONS
3. Clinician should expect to find the mental foramen
in line with the second premolar. If the foramen
cannot be located in this position, the racial
variations should be taken into consideration.
4. The textbook notion that the most common position
of the foramen is between the 1st and 2ndpremolars
is incorrect and seems to have arisen from early
studies of a limited sample of Europeans.

Green 1987