RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL 432

IN PANORAMIC RADIOGRAPHS

MANDIBULAR CANAL RADIOGRAPHIC

INTERPRETATION IN
PANORAMIC RADIOGRAPHS *

INTERPRETAÇÃO RADIOGRÁFICA DO CANAL

MANDIBULAR EM RADIOGRAFIAS
PANORÂMICAS

Tiago Palloni VALARELLI **

Ana Lúcia ÁLVARES-CAPELOZZA ***
Clóvis MARZOLA ****
João Lopes TOLEDO-FILHO ****
Márcia Juliani VILELA-SILVA *****

____________________________________________
* Work presented as monograph for conclusion of the Course of Residence in Surgery and
Traummatology Buco maxillofacial, promoted for the Brazilian College of Surgery and
Traummatology Buco maxillofacial and Base Hospital of the Hospital Association of
Bauru.
** Former Resident in Surgery and Traummatology Buco maxillofacial, promoted for the Brazilian
College of Surgery and Traummatology Buco maxillofacial and Base Hospital of the
Hospital Association of Bauru. Author of the monograph.
*** Associate Teacher of the College of Dentistry of Bauru of the USP and person who orientates of
the monograph.
***** Titular Professor of Buco maxillofacial Surgery and Traummatology of the College of
Dentistry of Bauru of the USP, pensioner, professor of the Course and collaborator of the
work.
**** Titular Professor of Anatomy of the College of Dentistry of Bauru of the USP, professor of the
Course and co-person who orientates of the work.
***** Collaborating of the work.
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ABSTRACT
The purpose of the present study was to assess the prevalence of bifurcations
and the positioning of the mandibular canal in panoramic radiographs. The study
was accomplished starting from the interpretation of four hundred panoramic
radiographs using the classifications (NORTJÉ et al., 1977 and LANGLAIS et al.,
1985). The results show that in 12,75% of the observed images, there was some
bifurcation type in the mandibular canal. Regarding the position of the mandibular
canal in relation to the mandibular base and the radicular apices of the lower teeth,
we found high bilateral canal in 32,5% of the images, 28,25% of intermediate canal,
0,25% of low bilateral canal and 27,25% with some variation. The panoramic
radiograph is an important auxiliary resource in diagnosis and treatment plan of the
dental anomalies and pathologies involving the mandibular canal, because it allows
the evaluation of its anatomy and anatomical variations, reducing the failure risk in
invasive o non-invasive interventions in the mandibular bone.

RESUMO
Nosso trabalho tem como objetivo avaliar a prevalência de bifurcações
e o posicionamento do canal mandibular em radiografias panorâmicas. O estudo foi
realizado a partir da interpretação de quatrocentas radiografias panorâmicas
utilizando classificações já descritas (NORTJÉ et al., 1977 e LANGLAIS et al.,
1985). Os resultados mostraram que em 12,75% das imagens observadas, havia
algum tipo de divisão no canal mandibular. Quanto à posição do canal mandibular
em relação à base mandibular e aos ápices radiculares dos dentes inferiores, foram
encontrados em 32,5% das imagens canais bilaterais altos, 28,25% de canais
intermediários, 0,25% de canais bilaterais baixos e, 27,25% com alguma variação. A
radiografia panorâmica é um recurso auxiliar importante no diagnóstico e plano de
tratamento das anomalias dentárias e patologias que envolvam o canal mandibular,
pois permite a avaliação da anatomia e das variações anatômicas do canal
mandibular, diminuindo o risco de insucesso nas em intervenções, invasivas ou não,
no osso mandibular.

Uniterms: Mandibular canal; Panoramic radiograph; Lower alveolar nerve.

Unitermos: Canal mandibular; Radiografia panorâmica; Nervo alveolar inferior.

INTRODUCTION
The mandibular canal is located inside the jaw and transmits the lower
alveolar artery and lower alveolar nerve, a branch of the third division of the
trigeminal nerve, from the mandibular foramen to the mentual foramen (BERBERI
et al., 1994 and MADEIRA, 1995). This plexus emits branches that supply the
lower teeth and the adjacent bone tissue, interdentally papilla, periodontium, lower
lip, anterior buccal mucosa to the mentual foramen and vestibular gingival of the
anterior lower teeth (HEASMAN, 1988 and MADEIRA, 1995).
The radiographic appearance of the mandibular canal is characterized
by a radiolucent line delimited by two radiopac lines (WORTH, 1975), usually as a
single and bilaterally symmetrical structure, it can assume different positions inside
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the body of the mandible, both super inferiorly and mediolaterally (STELLA;
THARANON, 1990).
Moreover, it can present duplications or bifurcations in its course
(NORTJÉ et al., 1977) and in some cases is possible to find a trifid mandibular
canal (AULUCK; KEERTHILATHA, 2005).
The knowledge of the mandible anatomy as well the lower alveolar
nerve course through the mandible canal is of great importance for the dental
surgeons, especially those planning to perform orthognatic surgeries, mandibular
reconstructions, lower third molar exodontics or the placement of dental implants
(TOLEDO-FILHO; MARZOLA; TOLEDO-NETO, 1998 and SANCHIS;
PEÑARROCHA; SOLER, 2003).
The non knowledge of the anatomical variations of the mandibular
canal can result in local anesthesia failure and even limit the use of some surgical
techniques.
The intention of this work is:
1. To evaluate the passage of the lower alveolar nerve in the interior of
the mandibular bone through panoramic x-ray.
2. To observe the prevalence of its variations in patients of the city of
Bauru as classifications proposal (NORTJÉ; FARMAN; GROTEPASS, 1977 and
LANGLAIS; BROADUS; GLASS, 1985).

LITERATURE REVIEW
It was dissected 18 mandible corpse had found a canal that if it
originates from the mandibular canal finishing in the retromolar foramen or
surrounding foramina, called of canal to retromolar in 72% of these. The authors had
observed that this canal gives ticket to a mielinizaded nerve and to one or more
arterioles and venues. They had concluded thus, that the great prevalence of
retromolar canal must it the crossed marriage of Argentine Europeans with
aborigines (SCHEITMANN; WORSHIPPER; ARIAS, 1967).
With the objective to determine the passage covered for the lower
alveolar nerve in the interior of the mandibular body, eight mandibles with the
muscles of the chew had been dissected still adhered. Three types of passage had
been described: Type 1 (6 of 8; 75%), where the lower alveolar nerve passes very
next to the dental apexes that if they inside project for of the mandible canal; Type 2
(1 of 8; 12,5%), where the lower alveolar nerve has its next passage the mandibular
base, of this form the main branch of the nerve emit small beams that penetrate the
radicular apexes and; Type 3 (1 of 8; 12,5%), where they had observed a ramification
of the main branch that innerve the posterior region of the mandible while a more
lower branch covers the mandibular body reaching the anterior region. The only
mandibular canal was observed in 49 (61,25%) of the 80 x-rays, with the well next
dental apexes exactly (Type 1). In 11 (13,75%) of the 80 x-rays, the canal met
moved away from the dental apexes, however with the posterior wall of the
corticalized canal more less; in 20 (25%) x-rays it did not have definition of the
mandibular canal (CARTER; KEEN, 1971).
It was observed and described a mandible with multiple accessory
foramens to the mandibular foramen in bilateral mandibular branch. The authors had
used radiopacs straps to evaluate in radiographic taking, the passage of each
foramen, being noticed that to leave of these intra-bones canals were initiated that
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some times presented bifurcations in its passage, being able to offer then to
enervation to teeth and underlying structures (BARCKER; LOCKETT, 1972).
Imperfection in the regional blockade of the lower alveolar, buccal
and lingual nerves to three factors was attributes to the deposition of the lower
anesthetically solution to the mandibular foramen; of supplemental enervation for the
nerves myloioydeus and, possibly of the cutaneous insufficient deposition and
auricular temporal, presence nerve the neck, finally, of anesthetic. The author
developed one alternative technique for mandibular anesthesia, using extra-buccal
points of reference, searching the deposition of the anesthetically solution in the
neighborhoods of the oval foramen, where the mandibular nerve emerges (GOW-
GATES, 1973).
A report of case illustrated with the radiographic image of the
duplication of the mandibular canal was presented and the authors had stranded out
that anatomical variations of this type can cause problems in anesthesia for regional
blockade of the lower alveolar nerve, questioning still the possibility of the presence
of a ridge myloioydeus deep to confer such image (KIERSCH; JORDAN, 1973).
By the comment of the panoramic x-ray of a patient, white of thirty
years of age, was noticed the presence of two distinct mandibular canals, breaking of
mandibular foramen right and, having its passage for the branch and mandibular
body, finishing in two separate mentuals foramens. The authors had not observed
alterations of left side (PATTERSON; FUNKE, 1973).
It was examined 300 human corpse mandibles consisting the presence
of accessory foramina for where they can came to pass sensitive staple fibers you
add. The author relates the presence of such foramina with the imperfection in the
attainment of the analgesia from the job of classic anesthetically techniques and,
moreover, proves the clinical importance of this comment through the study of
anesthetically techniques in 130 patients, suggesting some variations for the same
ones (SUTTON, 1974).
The interruption of the sanguineous circulation through the lower
alveolar nerve quickly is supplied by the establishment of a retrograde circulation,
mainly for the mental artery and mandibular branch of the sublingual artery was
noted. The authors had not observed any microscopically change for the interruption
of the sanguineous flow, noticing, however, temporary regressive changes in the
dental pulp of the molar ones of the affected side (CASTELLI; NASJLETI; DIAS-
PÉRES, 1975).
With the objective to determine the prevalence of accessory
foramina’s in mandible, as well as its diameter and localization, 150 corpse
mandibles had been evaluated of adult human beings, in the region of molar, being
identified 5332 foramina’s (average of 36 foramina for mandible) that, they had been
attributed to the vascular and/or nervous supplement of mandible (HAVEMAN;
TEBO, 1976).
To evaluate the success in the anesthesia of lower teeth through the
regional blockade of the lower alveolar, buccal and lingual nerves, was made a study
of 331 cases and observed imperfection in the analgesia in 79 (23,87%), being
necessary the extra infiltration of anesthetic in 72 (21,75%) of these cases, persisting
the imperfection in 7 cases (2,1%). With this study the author concluded that the
basic concept of that the pulpar enervation of mandibular teeth proved only of staple
fibers of the lower alveolar nerve must be coats, suggesting that nervous staple fibers
happened of all the divisions of the mandibular nerve and still cervical myloioydeus
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nerve and plexus can contribute for the sensitivity of the mandibular dental elements
(ROOD, 1976).
Based in a study with 3612 panoramic x-rays without mandibular
traumas or pathological conditions that could affect the normal passage of the lower
alveolar nerve, the passage in 4 types was classified, using as reference the lower
edge of the mandible and the dental apexes, in: Type 1 (46,7%), single channels and
high bilateral; Type 2 (3,3%), single channels and intermediate bilateral; Type 3
(48,9%), single channels and low bilateral; Type 4 (0,9%), other variations, as
duplications or divisions of mandibular canal (NORTJÉ; FARMAN;
GROTEPASS, 1977).
A technique of regional blockade of the lower alveolar, buccal and
lingual nerves, faster in the aesthetical induction, less painful, being able to be
carried through in patients presenting limitation of buccal opening was developed
(AKINOSI, 1977).
After the interpretation of 3612 panoramic x-rays, had concluded that
normally the mandibular canal is only symmetrical and bilaterally. However, three
variations of normality can be observed, thus considering a classification: Type 1,
two canals if originating from the same foramen; Type 2, a small additional canal if
extending until the region of second or third molar and; Type 3, two mandibular
canals originating from two distinct foramina’s and joining themselves in region of
molar, mandibular body, to form an only canal (NORTJÉ; FARMAN; JOUBERT,
1977).
A study from gotten histological material in the archives of the Oral
Department of Pathology of the University of Stellenbosch and, of panoramic x-rays,
observing the pathological conditions that affected the radiographic appearance of
the mandibular canal was made. The authors had concluded that benign cysts and
neoplasias generally cause displacement of the canal, but its cortical they remain
unbroken, while that in the severe infections or the cases of malignant tumors occurs
an irregular erosion of the bone with disappearance of the radiographic aspect of the
sclerotic lines of the canal (FARMAN; NORTJÉ; GROTEPASS, 1977).
It was attributed imperfections in the mandibular blockade to the
crossed enervation of the mandible, contribution of the enervation especially for
lingual, milohyoideo and buccal nerves and, still, to the insufficient deposition of
aesthetical solution (ROOD, 1977).
The mandibles of a Caucasian adult corpse, of approximately 30
years, probably of the feminine sort, observed an accessory foramen in the
retromolar region, immediately behind the third molar and bilateral one was
examining. The author suggested the possibility of the emergency nervous staple
fibers for this foramen that would previously sensitize the region and some teeth
made use to its emergency (CASEY, 1978).
To demonstrate that the presence of multiple mandibular canals is not
a rare situation, but yes unknown 1024 panoramic x-rays had been interpreted
finding in 85 (8,3%) occurrences of this anatomical variation. The authors point out
the importance of the knowledge of the double mandibular canals related to the
forensic dentistry, especially in the identification of bodies of people edentulous
(DURST; SNOW, 1980).
It was observed 122 corpse mandibles finding a foramen in the lingual
region in the premolar area in 68,9% of these. The authors attribute to this foramen,
the enervation made for the myloioydeus nerve or the cutaneous nerve of the neck,
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considering still the hypothesis of that this repair can be only one great nutritional
canal (CHAPNICK, 1980).
SINGH (1981) was come across during the extraction of one lower
third molar, with a nervous branch that left the mandible, through a small foramen in
retromolar fosse distant 5 mm of the distal face of the tooth. Through the
histological confirmation the author concluded to be about a nerve, having the patient
presented later, paresthesia of mandibular the deep mucosa and of ridge, since the
retromolar region until the region of tooth of the operated side. Tests of vitality of
inferior teeth had not shown to alterations, leading the authors to the conclusion that
if dealt with a ramification of the buccal nerve.
In a panoramic x-ray of a man of 29 years of age, carrier of syndrome
of Down, a bending radiolucid structure, in form of canal, ramified upper to the left
mandibular canal to the height of the distal crest of as the molar one was observed.
After the accomplishment of other radiographic taking, using different techniques,
and detailed physical examination, the authors had concluded that cited variation was
about a ramification of the lower alveolar nerve and mandibular canal (MADER;
KONZELMAN, 1981).
The interpretation of 5000 panoramic x-rays of conscripts of the army
of the United States was carried through, observing it prevalence of 0,08% of bifid
mandibular canals (4 cases). The authors point such anatomical variation as a
possible cause of the imperfection in the regional blockade of lower alveolar nerve
(GROVER; LORTON, 1983).
Clinical case of a patient of the masculine sort, caucasian, 54 years of
age, presenting bifurcation of the bilateral lower alveolar nerve was publish
(BYERS; RATCLIFF, 1983).
A study with 6000 panoramic x-rays evidencing the bifurcation of the
mandibular canal in 57 (0,95%) of these, had carried through. The authors had in
accordance with classified such occurrences in 4 types the anatomical localization
and configuration of the canal, being: Type 1 (0,367%), bifurcation I joined or
bilateral extending itself for region of third molar or adjacencies; Type 2 (0,517%),
bifurcation I joined or bilateral extending the long one to it of the main canal and if
they again join in branch or mandibular body; Type 3 (0,0333%), a combination of
the two first categories, being Type 1 of a side of the mandible and Type 2 of the
other side; Type 4 (0,0333%), two canals originating of two distinct foramens, if
joining to follow to form an only wide and mandibular canal (LANGLAIS;
BROADUS; GLASS, 1985).
A study involving 2391 jaws and noticed the occurrence of 40 cases
with a canal in the retromolar region which called canal of the temporal crest was
presented. The author standees out the possibility of these staple fibers to contribute
for the sensitive enervation of the molars and adjacent region being able to result in
imperfection in local anesthesia attainment through of the usual technique of the
lower alveolar, buccal and lingual blockade nerves (OSSENBER, 1986).
With the objective to evaluate the relation radiculars of the first one
enters the apexes and lowers second molar and the upper edge of the mandibular
canal, besides establishing the localization of the canal in the direction vestibule-
lingual and vertical line in relation, had been radiographed 46 mandibles. The
authors had especially stranded out the importance of the work for the professionals
who carry through endodontics and surgical procedures, due to great amount of
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accidents involving the mandibular canal in these treatments (LITTNER et al.,

1986).
A radiographic study with 96 mandibles using classification proposal
(NORTJÉ; FARMAN; GROTEPASS, 1977) for determination of the height of the
mandibular canal, having the dental apexes and the lower mandibular edge as control
points, observed a prevalence of 67,7% of the samples as being of type 3
(intermediate), 15.6% of type 1 (high), and 5.2% of type 2 (low). The classified
samples as type 4 (variations) were gifts in 11,5% of the total (HEASMAN, 1988).
A study comparing the information gotten between radiographic,
tomography and macroscopic images were carried through in four specimens of
mandibles. The authors had concluded that the image most trustworthy for the
planning of procedures involving the next area to the mandibular canal was that one
gotten by Computerized Cat scan (KLINGE; PETERSSON; MALY, 1989).
The panoramic x-ray with the computerized cat scan of 15 patients in
the localization of the mandibular canal had compared. The authors had concluded
that the Computerized Cat scan better got performance in the localization of the
mental foramen and the mandibular canal in the distant region 1 cm in the posterior
direction to exactly, however, significant differences between the techniques studied
in the mensurations carried through in the 2 cm posterior to the mental foramen had
not been observed (LINDH; PETERSSON, 1989).
Bifurcation in mandibular canal due to suggestive image in panoramic
x-ray and had confirmed this finding through the image gotten for Computerized Cat
scan ha suspected (QUATRONE; FURLINI; BIANCIOTTO, 1989).
The radiographic image of a unilateral bifurcation of the distal
mandibular canal the area of the third molar one was noted. The author stranded out
the necessity of the planning adjusted, for the localization of the mandibular canal,
which had preoperative to such variations (DRISCOLL, 1990).
A study to determine the incidence of the some mandibular channel
types and its relation with the sort of the patients, had carried through, being used
700 panoramic. In the present study only three cases of bifid mandibular canal had
been found and significance was not observed statistics between sorts, beyond the
mandibular channel type (ZOGRAFOS; KOLOKOUDIAS; PAPADAKIS, 1990).
A necessary method for localization of the mandibular canal was
developed. For the authors they had in such a way used eight jaws edentulous of
adult corpses, of which images for Computerized Cat scan had been gotten and after
the analysis of the results, had concluded that the mandibular canal exclusively
assumes lingualized position the 1 and 2 cm in posterior direction to the mental
foramen, predominantly lingualized to 3 cm posterior to exactly and 0 variable in the
height of the foramen and 4 cm posterior to this (STELLA; THARANON, 1990).
GRÖNDAHL et al., (1991) had in the distance evaluated the
trustworthiness of the gotten images of hypocycloidal cat scans, measuring vertical
between the alveolar crest and the superior edge of the mandibular canal. For 40 cat
scans of patients had been in such a way used, and the measures made for six
appraisers (three radiologists and three buco maxillofacial surgeons). The study it
showed a great variation in the mensurations between observers. The authors had
suggested that, in clinical environment, the images are interpreted for more than a
professional or that the gotten values are compared with the finding supplied for the
radiology services, in order to minimize the probability of errors due to the
mensuration imperfections.
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An anatomical study of neurovascular plexus of the lower alveolar

nerve using 3 human corpse parts had carried through. The authors had observed
that plexus, also called "trunk" are not individual and, yes a system of mesh of
nerves, some very fine, branching off inside of its course in the mandibular canal.
They had still observed the existence of as "plexus" between the mandibular and the
dental roots, composed canal of micron-filaments that penetrate the same ones
through its lateral face or its apexes (ZOUD; DORAN, 1993).
It was evidenced an anatomical variation of the mandibular canal in
one of its patients through the evaluation of panoramic x-rays and cat scan
computerized with axial and coronal cuts. The authors had noticed the presence of
two mandibular canals separate and overlapped of the right side of the mandible,
originating from an only foramen (BERBERI; MANI; NASSEHY, 1994).
A study comparing the precision of the x-rays: Periapical, Panoramic
and Cat scan Computerized in the localization of the mandibular canal, had carried
through. For in such a way, the authors had used an acrylic resin plate with markers
of guta percha and a human corpse jaw, and had gotten an average distortion of 1.9
mm (14%), 3,0 mm (23,5%) and 0,2 mm (1,8%) respectively (SONICK;
ABRAHAMS; FAIELLA, 1994).
The presence of a canal to retromolar bilateral in a patient with 47
years of age had described. The authors had presented a quarrel on the nature and
distribution of the elements of the canal of the left side and had pointed out the risks
and consequences of injuries to such structure (KODERA; HASHIMOTO, 1995).
The bilateral duplication of the mandibular canal in a panoramic x-ray
of a patient, edentulous, of 33 years of age had observed. The authors affirm that the
patient told to relate of unsatisfactory anesthesia during surgical procedure in both
the sides of the mandible (FREDEKIND; SCHIFF, 1995).
Four possibilities for the failure of the anesthesia of the mandible,
amongst them was publish in a article telling: contribution of sensitive enervation for
the milohioideus nerve; bifid mandibular nerve; retromolar foramen and;
contralateral enervation of anterior teeth. The authors present, still, the solutions to
skirt the cited variations and warn that the surgeon-dentists must know all the
anatomical variations of the area to be worked as well as different aesthetical
techniques for attainment of mandibular blockade (DESANTIS; LIEBOW, 1996).
A pioneering study with the objective to describe the prenatal
formation of the human mandibular canal had developed. The authors suggest the
hypothesis of that the lower alveolar nerve this gift probably in the jaw as three
different nervous pursuing originating in different periods of training of embryonic
development and that fast prenatal growth and, the remodeling of the region of the
branch results in a gradual coalescence of the entrances of the canals, what he is
obvious to the birth (CHÁVEZ-LOMELÍV et al., 1996).
With the objective to alert to the surgeon-dentists for the possible
existence of accessory mandibular canals and its implications, told the case of a
patient of 23 years of age, masculine sort, black race, that showed, in its panoramic
x-ray, the image of a similar structure to a canal, superior to the mandibular canal.
This canal if extended of the mandibular branch until the molar distal face of the
impacted third molar, to the height of the junction cement has enameled of the cited
dental element. The patient was submitted the surgical procedure for removal of the
impacted tooth, and told a brief period of postoperative paresthesia in the region
(WYATT, 1996).
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A morfometric study of the mandible human being using itself 60

hemi mandibles, carried through, parting them in 9 fragments of 7 mm from the
mental foramen, observing the thicknesses of the mandibular bone boards external
intern and, alveolar ridge, internal and external basal ridge, diameters of the
mandibular canal as well as the distances and thicknesses related to this (TOLEDO-
FILHO; MARZOLA; TOLEDO-NETO, 1998).
A clinical case of accessory canal mandibular bilateral, observed from
images gotten in Panoramic x-ray and Computerized Cat scan, followed for a
revision of excellent literature, had published. The authors conclude that the
Computerized Cat scan presents advantages in the detention of anatomical variations
in the mandible when compared the panoramic x-ray (KAUFMAN; SERMAN;
WANG, 2000).
The occurrence of the bifurcations and the positioning of the
mandibular canal had been described in 650 panoramic x-rays. Using the
classification the proposal (NORTJÉ; FARMAN; GROTEPASS, 1977 and
LANGLAIS; BROADUS; GLASS, 1985) the authors had observed 41.83% of high
bilateral canals, 32.09% of intermediate bilateral canals, 3.44% of low bilateral
canals and 22.64% presenting other variations. Between these last ones, 17.72%
showed bilateral asymmetries, 30.38% presented bifid canals in dentate, 34.18%
edentate bifid canals in and 17.72% partial absence of the image of the canal
(DEVITO; TAMBURÚS, 2001).
Alert for the possibility of bifurcation of the mandibular canal and the
importance of a planning preoperative detailed in the surgeries for installation of
bone integrated implantations was made. In the initial surgical planning, made from
a panoramic x-ray, the installation of two implantations measuring 13 mm in the
posterior region of mandible, being modified the length of the implantation for 10
mm would be carried through after the accomplishment of the Computerized Cat
scan (DARIO, 2002).
It was analyzed 2012 panoramic x-rays in the determination of the
incidence and the characteristics of the bifid mandibular canals. 7 (0,35%) images
suggestive of bifid canal had been found, all in women. In tomography examination
bifid canals in 2 of the 3 studied cases had been confirmed (SANCHIS et al., 2003).
The presence of trifid mandibular canal, unilateral, of the left side,
observed from a panoramic x-ray of a patient with 48 years of age was verified. The
authors affirm that they do not exist you evidence of similar cases in world-wide
literature (AULUCK; KEERTHILATHA, 2005).
The clinical case of a patient of 19 years of age, presenting two
mandibular canals of the right side originating from distinct mandibular foramens
and finishing in separate foramens was verified. Justified for the fact not to have
similar stories in literature, the authors suggest the classification of this variation in a
new subdivision (CLAEYS; WACKENS, 2005).

MATERIAL AND METHODS

Four hundred panoramic radiographs of consecutive patients, ranging
from 8 to 75 years of age, were used in this study. The panoramic radiographs were
drawn manually on a translucent paper aided by an illuminator supplied with two
fluorescent lamps of 15 watts each and a black mask around the radiographs in an
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environment with appropriate luminosity. The draws included the condyles, lower
molars, mandibular and mental foramens, mandibular canal and mandibular base.
All draws were analyzed by two observers and the classification
proposed (NORTJÉ et al., 1977) was used, regarding the permanent lower second
molar and, in its absence, the inferior first molar.
The mandibular canal was then classified in 4 types:
Type 1: Bilateral single high mandibular canals - single canals either
touching or within 2 mm of the apices first and second permanent molars.
Type 2: Bilateral single intermediate mandibular canals – single canals
not fulfilling the criteria for either high or low canals.
Type 3: Bilateral single low mandibular canals, single canals either
touching or within 2 mm of the cortical plate of the lower border of the mandible.
Type 4: Variations including: asymmetry, duplications and absence of
mandibular canal.
In radiographs where bifurcated canals were found, and the
classification proposed (LANGLAIS et al., 1985) was used (Figure 1).

Figure 1 – The classification proposed (LANGLAIS et al., 1985).

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RESULTS
Of the 400 interpreted panoramic radiographs, 150 (37,50%) belonged
to male patients and 250 (62,50%) to female patients.
Bifid mandibular canals were found in 51 radiographs, a prevalence of
12,75%. Of this total, 13 (25,50%) in men and 38 (74,50%) in women.
During the canal height canal analysis 47 (11,75%) radiographs were
excluded due to uni or bi-lateral absence of teeth.
There were 130 (32,5%) radiographs classified as Type 1, 113
(28,25%) as Type 2, and only 1 (0,25%) as Type 3.
In the cases where asymmetry in the height of canals or bifurcations
were observed, it was classified as Type 4, totalizing 109 (27,25%) radiographs
(Graphic 1).
The data were analyzed in a descriptive way.

400 353
350
300
250
Number of
200 130
cases 113 109
150
100
50 1
0
Type 1 Type 2 Type 3 Type 4 Total
Classification

Graphic 1 - Height variation of the mandibular canal.

The Type 1 bifurcations were present in 21 radiographs which 3 of

them belonged to men and 18 to women. The larger number of bifurcations was
verified on the right side of the mandible (17 radiographs) against 2 occurrences on
the left side and 2 occurrences bilaterally.
The radiographs presenting Type 1 bifurcations represented 5,25% of
the total number of studied radiographs and 41,17% of the bifid mandibular canal
cases.
The Type 2 bifurcations were observed in 24 radiographs being 8 in
men and 16 in women, occurring 17 times on the right side and 5 on the left side. In
the 2 remaining radiographs the bifurcations happened bilaterally and represented
6,0% of the total number studied and 47,05% of the cases presenting bifid
mandibular canals.
No Type 3 bifurcation was found in this study.
The Type 4 bifurcations were observed in 6 radiographs from women
(3 on the right side, 1 on the left side and 2 bilaterally).
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IN PANORAMIC RADIOGRAPHS

The radiographs containing bifurcations of the Type 4 totaled 1,50%

of the cases and 11,76% of the cases presenting bifid mandibular canals.
The Graphic 2 illustrates the results observed for the bifurcation of
the mandibular canals according to the classification of LANGLAIS et al., (1985).
No significant difference in the prevalence of mandibular canal
bifurcation related to the age group was seen in this study (Table 1).

Type 1 unilateral 19

Type 1 bilateral 2

Type 2 unilateral 22

Type 2 bilateral 2

Type 4 unilateral 4

Type 4 bilateral 2

Total 51

0 10 20 30 40 50 60
Number of cases

Graphic - 2. Bifurcation of the mandibular canal.

Tabela 1 - Canal mandibular bifid prevalence.

Age N % bifid canals %

0a9 01 0,25 0 0,00
10 a 19 101 25,25 14 13,86
20 a 29 167 41,75 22 13,18
30 a 39 55 13,75 7 12,73
40 a 49 50 12,50 5 10,00
50 a 59 18 4,50 2 11,11
60 a 69 06 1,50 1 16,67
70 a 79 02 0,50 0 0,00
Total 400 100,00

DISCUSSION

The mandibular chanals are usually, but not invariably, bilaterally

symmetrical, and the majority of hemi mandibles contain only one major canal.
Supplemental mandibular canals large enough to be seen on panoramic radiographs
are occasionally present (NORTJÉ et al., 1977).
The term "bifid" is derived from the Latin word meaning a cleft in two
parts or branches. Bifid mandibular canals can originate at mandibular foramen and
to contain a neurovascular bundle (LANGLAIS et al., 1985).
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For de height variation of the mandibular canal, it was observed

smaller indexes related to the percentage of Type 1 canals when compared our finds
with NORTJÉ et al., (1977) and DEVITO; TAMBURUS (2001) that evidenced
46,7% and 41,83% of occurrence, respectively, against 32,5% of this research. All
this data are in disagreement with the 15,6% observed (HEASMAN, 1988).
Low mandibular canals (Type 3) were little found in this research,
what is in agreement with the observations described in the literature, however, for
the intermediate channels (Type 2), we observed a prevalence of 28,25%, in
agreement to the 32,09% (DEVITO; TAMBURUS, 2001) and different from the
values related (NORTJÉ et al., 1977 and HEASMAN, 1988) that observed 3,3%
and 67,7% respectively.
The canals classified as Type 4 were observed in 27,25% of our
sample in agreement with the 22,64% observed (DEVITO; TAMBURÚS, 2001),
however, it is almost twice the number of cases observed (HEASMAN, 1988), who
found 11,5% of occurrence and much larger than the 1,1% found (NORTJÉ et al.,
1977).
We are in agreement with HEASMAN (1988) who admitted that the
discrepancy in the results can be related to the morphologic differences among racial
groups.
The Graphic 3 shows the results of the four researches above
mentioned.

80
67,7
70
60
46,7 48,9 Type 1
50
41,83
Type 2
40 32,5 32,09 Type 3
28,25 27,25
30 22,64 Type 4
20 15,6
11,5
10 3,44 3,3 5,2
0,25 1,1
0
VALARELLI DEVITO; NORTJÉ et al HEASMAN
TAMBURÚS

Graphic - 3. Comparison of the results of height variation of the mandibular canal.

In the present study we found a prevalence of 12,75% of mandibular

canal bifurcation, different from the 1% observed (DARIO, 2002). The author
emphasizes that such condition can happen in inferior-superior or medium-lateral
plans, being sometimes hard to be identified in panoramic or periapical radiographs.
The author reinforces the idea that the non detection of this variation can harm the
planning and the success of the surgical procedures in the patients.
SANCHIS et al. (2003) suggest that one possible cause for a wrong
interpretation of the mandibular canal bifurcation is the imprint of the milohyoid
nerve on the internal mandibular surface, where it separates from the lower alveolar
 RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL 445
IN PANORAMIC RADIOGRAPHS

nerve and travels to the floor of the mouth. Another explanation is related to the
image formed by the bony condensation produced by the insertion of the milohyoid
muscle into the internal mandibular surface, identified as a parallel image to the
canal.
Comparing the results of this research with the results obtained by
LANGLAIS et al., (1985), a disagreement is observed. They found a prevalence of
0,367%, 0,517%, 0,033%, 0,033% of bifurcations Types 1, 2, 3 and 4, respectively,
against 4,45%, 6,00%, 0,0% and 1,50% found in our study. Among the bifurcate
canals the Type 2 was the most seen, in agreement with the results described
(DEVITO; TAMBURÚS, 2001).
The Graphic 4 illustrates the comparison of our results with the
results obtained by other authors, expressed in percentage of the total of found
bifurcations.

%
60
56,86

50

54,5
Type 1
47,05

40 Type 2
41,17

37,26

Type 3
38,6

30
Type 4
11,75

20
3,92

3,5
3,5
1,96

10
0

0
VALARELLI DEVITO; LANGLAIS et al.
TAMBURÚS

Graphic 4 - Comparison of the results related to the types of bifid canals.

Adequate levels of local anesthesia can be difficulties by the

supplementary enervation and foramina’s of the mandible. The nerves more
commonly associated these fail are: the anterior cutaneous colli, the lingual,
auriculotemporal, the buccal and mylohyoid (HAVEMAN; TEBO, 1976;
KAUFMAN et al., 2000).
The contralateral enervation (DESANTIS; LIEBOW, 1996),
inadequate deposition of anesthetic solution (ROOD, 1977) and the incorrect employ
of the anesthetic technique should be considered in case of failure.
The identification of bifid mandibular canals is of great importance in
the success of a surgery. The failure in the anesthesia of the inferior alveolar nerve
can be attributed to some kind of bifurcation, especially the Type 4 that includes two
mandibular foramens.
To compensate such anatomical variations, alternative anesthetic
techniques can be used. The most promising is the technique proposed by GOW-
GATES (1973) where the anesthetic solution is deposited around the mandibular
 RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL 446
IN PANORAMIC RADIOGRAPHS

nerve trunk when it emerges from the oval foramen. This technique allows the
anesthesia of the inferior alveolar, buccal and lingual nerves and any other smaller
branch or division of the inferior alveolar nerve (MARZOLA, 1993 and 2005).
However, this technique requests maximum mouth opening and, in
patients presenting temporomandibular dysfunction, trismus, ankylosys of
temporomandibular joint and other alterations that difficult great buccal opening, it
cannot be possible. In these cases, the tuberosity approach suggested by AKINOSI
(1977) can be useful. This technique is based on knowledge of the anatomy of the
pterygo-mandibular space and the anesthetic solution is liberated in a posterior
position, comparing with the standard technique, anesthetizing mainly the inferior
alveolar, buccal and lingual nerves.
Extreme care is necessary during an inferior third molar exodontics,
especially when the variations Type 1 or 3 are present.
The tooth can damage the mandibular canal or even be positioned
inside of this (MARZOLA et al., 1997). Considering that a second branch of the
lower alveolar nerve can exist, complications as traumatic neuroma, paresthesia or
excessive bleeding can happen in case of fail in detection of this variation (WYATT,
1996).
In surgical procedures involving mandibular osteotomies, the surgery
becomes more complex with the addition of a second neuro-vascular bundle.
EPKER (1984) emphasized the necessity of the protection of the
blood supply during those procedures. In the cases of trauma, all mandibular
fractures should be manipulated carefully to guarantee the correct positioning of the
neuro-vascular bundle and to avoid interference in the reduction of the fracture.
The alignment becomes harder in case of a second neuro-vascular
bundle in a second plan. The interpretation of the panoramic radiographic is of great
importance in its location and on surgical planning. The clinician should recognize
the anatomical variations and modify the surgical technique if necessary. These
variations are of great importance on osteointegrated implant surgery. In case of the
indirection of this variation, the surgeon can false estimate the useful space for the
implant installation, leading to unfavorable consequences as the mandibular canal
violation.
When the alveolar bone is reabsorbed in the proximities of the mental
foramen, the patient it can relate discomfort in this area with the use of total
prostheses due to the compression of the neuro-vascular bundle. This can also be a
problem in the area of third molars in the presence of variations Type 1 or 3, making
necessary the identification of the variation and those subsequent modifications in
the prosthesis.
Anatomical variations as accessory foramina’s and bifid mandibular
canal can result in surgical complications not correctly identified.
If harmed, these structures can cause bleeding, hindering the surgeon's
vision and increasing the potential of formation of fibrous tissue in contact with the
surface of osteointegrated implants.
Most of the studies published in pertinent literature agree that the
foramina’s are located preferentially in the internal aspect of the posterior part of the
mandible (SUTTON, 1974; CARTER; KEEN, 1971 and HAVEMAN; TEBO,
1976). Furthermore, an association has been observed between the location of these
foramina’s and the area of insertion of masticator muscles.
 RADIOGRAPHIC INTERPRETATION OF THE MANDIBULAR CANAL 447
IN PANORAMIC RADIOGRAPHS

A question also exists regarding the contents of the accessory

foramina’s and the most probable is a vascular-nervous bundle (KAUFMAN et al.,
2000).
A possible explanation for the presence of accessory foramina’s and
duplication of the mandibular canal is that during the embryonic development, the
formation of three separated canals occur in each hemi mandible. These canals are
directed from the lingual surface of the mandibular ramus to different tooth groups.
It is believed that the fast prenatal growth and local remodeling result
in a gradual fusion of these segments (CHÁVEZ-LOMELÍ et al., 1996), confirming
the hypothesis.

CONCLUSIONS
The clinician should know the anatomy and the radiographic anatomy
the mandibular canal and its variations, making possible the correct planning of
surgical procedures, avoiding harmful results to the patient and solving the problem
in case of its occurrence.
The mandibular canals are usually, but not invariably, single and
bilaterally symmetrical, however supplemental canals are observed across the
mandibular body.
At the end of the analysis of the 400 panoramic radiographs,
considering the mandibular canal height, a prevalence of 32,5% of mandibular
canals Type 1, 28,25% of the Type 2, 0,25% of the Type 3 and 27,25% of the Type 4
was observed.
Regarding the bifurcation of the mandibular canal a prevalence of
12,75% of bifurcations was observed, being 5,25% bifurcations Type 1, 6,0% of the
Type 2 and 1,5% of the Type 4.
Bifurcations Type 3 was not observed.
The anatomical variations seem to be related to the genetic variation
and to the racial mixtures, varying in prevalence from one region to another.

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