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Morphologie (2013) xxx, xxx—xxx

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GENERAL REVIEW

Retromolar foramen and canal: A comprehensive

review on its anatomy and clinical applications
Foramen et canal rétromolaire : une revue complète de son anatomie et
ses applications cliniques

B. Kumar Potu a,∗, S. Jagadeesan a, K. MR Bhat b, S. Rao Sirasanagandla c

a
Faculty of medicine and health sciences, UCSI university school of medicine, Jalan Menara Gading, Cheras, Kuala Lumpur,
Malaysia
b
Department of anatomy, Kasturba medical college, Manipal university, Karnataka, India
c
Department of anatomy, Melaka Manipal medical college (Manipal Campus), Manipal university, Karnataka, India

KEYWORDS Summary The retromolar foramen (RMF) and retromolar canal (RMC) are the anatomical struc-
Retromolar foramen; tures of the mandible located in retromolar fossa behind the third molar tooth. This foramen
Retromolar canal; and canal contain neurovascular structures which provide accessory/additional innervation to
Variation; the mandibular molars and the buccal area. These neurovascular contents of the canal gain
Failed inferior more importance in medical and dental practice, because these elements are vulnerable to
alveolar nerve damage during placement of osteointegrated implants, endodontic treatment and sagittal split
blockage; osteotomy surgeries and a detailed knowledge of this anatomical variation would be vital in
Incidence; understanding failed inferior alveolar nerve blockage, spread of infection and also metasta-
Review of literature sis. Although few studies have been conducted in the past showing the incidence and types
in different population groups, a lacunae in comprehensive review of this structure is lacking.
Though this variation posed challenging situations for the practicing surgeons, it has been quite
neglected and the incidence of it is not well presented in all the textbooks. Hence, we made
an attempt to provide a consolidated review regarding variations and clinical applications of
the RMF and RMC.
© 2013 Elsevier Masson SAS. All rights reserved.

MOTS CLÉS
Foramen
rétromolaire ;
Canal rétromolaire ;
Variation ;
Échec du bloc du nerf
alvéolaire inférieur ;
∗ Corresponding author.
E-mail address: potu kumar2000@yahoo.co.in (B. Kumar Potu).
Résumé Le foramen rétromolaire (RMF) et le canal rétromolaire (RMC) sont des structures
anatomiques de la mandibule situées dans la fosse rétromolaire derrière la troisième dent
molaire. Ce foramen et ce canal contiennent des éléments neurovasculaires qui assurent
une innervation accessoire/additionnelle aux molaires mandibulaires et à la surface buccale.
L’importance des éléments neurovasculaires de ce canal s’est accrue en pratique médicale et
dentaire. En effet, ces structures sont sujettes à lésions lors de la mise en place d’implants
ostéo-intégrés, lors de traitements endodontiques et lors de chirurgies d’ostéotomie sagittale.
Une connaissance détaillée de leurs variations anatomiques est importante pour la compré-
hension des échecs de bloc du nerf alvéolaire inférieur, de la diffusion des infections et des

1286-0115/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.morpho.2013.04.004

Please cite this article in press as: Kumar Potu B, et al. Retromolar foramen and canal: A comprehensive review on its
anatomy and clinical applications. Morphologie (2013), http://dx.doi.org/10.1016/j.morpho.2013.04.004
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2 B. Kumar Potu et al.

métastases. Bien que quelques études aient été conduites par le passé pour montrer les varia-
Incidence ; tions anatomiques dans différents groupes de population, il n’existe pas de revue complète de
Revue de la cette structure. Alors que les variantes anatomiques posent des problèmes aigus aux chirurgiens
littérature praticiens, elles ont été négligées et leur incidence n’est pas bien explicitée dans les ouvrages
didactiques. C’est pourquoi nous avons réalisé une revue générale exhaustive concernant les
variations et les applications cliniques du RMF et du RMC.
© 2013 Elsevier Masson SAS. Tous droits réservés.

Introduction • type A2: vertical course of RMC with additional anterior

Knowledge of the normal morphology of human mandible
and its possible variations that occur have attracted spe-
cial interest in the recent years in the field of surgery [1].
One such anatomical variation which draws special atten-
tion in clinical dental practice is the retromolar foramen
(RMF). The RMF has generally been neglected in anatomi-
cal textbooks and this has been rarely studied or reviewed
in the dental literature. The frequency of presence of RMF
has been reported by a few authors in different populations
showing its increasing incidence [2—7,9—12]. Although, few
studies have been published in the recent past, yet there is
no systematic up-to-date review on the RMF and canal; fur-
thermore significance of its presence in failure of the inferior
alveolar nerve block, prompted us to review its anatomical
and clinical background.
Definition of retromolar foramen and canal
The RMF is an inconstant foramen situated in the central
portion of the retromolar fossa which is bounded by the
anterior border of ramus of the mandible and temporal crest
(Fig. 1). The foramen receives a canal of variable depth that
normally arises from the mandibular canal behind the lower
third molar, which is regarded as the retromolar canal (RMC)
[13,14].
horizontal branch;
• type B1: posterior curved course of RMC;
• type B2: posterior curved course of RMC with additional
anterior horizontal branch;
• type C: posterior horizontal course of RMC.
Review methodology
The existing up-to-date literature (till 2013) on the anatom-
ical variations of RMF was selected through a search of
Pubmed, Medline and Google Scholar databases. Addition-
ally, a manual search in the available text books of anatomy,
morphology and dentistry were also performed. The publica-
tions were searched and selected by including the keywords
‘‘anatomical, clinical and radiological studies of the RMF
and canal’’.
Incidence of the retromolar foramen and
canal reported so far
In a study, first attempted by Schejtman et al., found the
RMF and canal in cadavers during autopsy [2,19]. Histological

Contents of the retromolar canal

The content of the RMC has been evaluated in cadav-

ers and clinical biopsies [2,9,15,16] and also radiologically
[6,11,17,18]. Histological studies and gross examinations
conducted so far have revealed that the canal has a neu-
rovascular bundle which is found to contain predominantly
thin myelinated nerve fibers, numerous venules and arteri-
oles covered by collagen bundle fibres and a little amount
of adipose tissue. A recent study has mentioned that the
diameter of nerve bundles varied between 40 to 60 microns,
the larger ones ranged from 80 to 180 microns. The largest
arteriole had a diameter of a maximum of 600 microns [17].

Types of retromolar canals

The panoramic radiographical evaluations conducted so far
[3,6,11,17] classifies the RMC into five types according to
the course and morphology (Fig. 2):
• type A1: vertical course of RMC;
Figure 1 Showing the location of retromolar foramen (RMF)
on the mandible (superior view). Circle denotes the area of
retromolar fossa.
Montrant la localisation du foramen rétromolaire (RMF) sur la
mandibule (vue supérieure). Le cercle montre la région de la
fosse rétromolaire.

Please cite this article in press as: Kumar Potu B, et al. Retromolar foramen and canal: A comprehensive review on its
anatomy and clinical applications. Morphologie (2013), http://dx.doi.org/10.1016/j.morpho.2013.04.004
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Retromolar foramen and canal 3

Figure 2 Schematic diagram showing different types of retromolar canals.

Diagramme schématique montrant les différents types de canaux rétromolaires.

findings of the canal revealed that the neurovascular ele-
ments from the RMC and foramen are distributed mainly in
the tendon of the temporalis muscle, in buccinator mus-
cle, in the region of the alveolar process and in the lower
third molar tooth, at its distal portion. His studies reported
that the RMC emerging for the RMF was found to have a
thin myelinated nerve in eight of the nine cases that he
studied. His studies also found one or more arterioles (six
cases) and one or more venules (four cases). It has been
mentioned that the fibers found in RMC are probably sen-
sory for the molar teeth and posterior part of the alveolar
process of the mandible and also sometimes to the tem-
poralis muscle. His study was followed by the findings of
llić et al. on vasculature of the retromandibular foramen
[20]. After a long gap, in year 1987, Ossenberg collected
data from archaeological museum and his anthropological
studies included a large number of mandibles of different
human groups (n = 2500) [3]. His findings found that the RMF
can be found in diverse populations, being more common in
native populations of North America than other populations
of Africa, Europe, India and Northeast Asia. He also reported
that the RMF occurred unilaterally more often than bilater-
ally, with generally a higher ratio of bilateral to unilateral
occurrence in populations with a high frequency of the RMF.
With regard to gender, women tended to have RMC more
often than men and a greater incidence of RMF in male than
female, however no statistical difference was found.
Sawyer and Kiely in their study, RMF was found in 18
of 234 adult human mandibles studied (7.7%). No statisti-
cally significant difference was found between left and right
sides or between sexes. A statistical correlation was made
between the occurrence of the RMF and accessory mandibu-
lar foramina, accessory mental foramina, mandibular third
molars, and three-rooted mandibular first molars. Only the
accessory mandibular foramen showed a significant positive
correlation with RMF of the same side. That means when
an accessory mandibular foramen is present, there is a high
chance of having a horizontal bony canal leading to a fora-
men in the retromolar fossa. This bony canal could be the
temporal crest canal that was first described by Ossenberg
in 1986 [4].
Kodera and Hashimoto reported that the RMCs and foram-
ina were found in eight out of 41 Japanese skulls (19.5%).
They examined a left mandibular RMC which arises from the
bifurcation of the mandibular canal at 18 mm anterior to
the mandibular foramen and it opened on the surface of the

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anatomy and clinical applications. Morphologie (2013), http://dx.doi.org/10.1016/j.morpho.2013.04.004
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4 B. Kumar Potu et al.
retromolar fossa at 13 mm posterior to the third mandibular
molar tooth. The total length of the RMC from the bifur-
cation to the RMF was about 16 mm, and 2.5 to 2.6 mm in
diameter. They reported that the artery and nerve found in
the canal was given from inferior alveolar artery and nerve
respectively. The artery was in canal was found to join with
facial artery, buccal artery and then gave off superior and
inferior labial arteries [21].
A study in a sample of 475 dry cadaver skulls revealed
higher occurrence rate of the RMF in male skulls (9.6%)
than in female skulls (6.1%) [5]. His findings go side by side
with Ossenberg findings [3]. It was reported by Ossenberg
that the peak incidence of the RMF was seen in the adoles-
cent cohort. With the above findings, he hypothesized that
this might be due to increased neurovascular requirements
related to the adolescent growth spurt and eruption of the
wisdom teeth [3].
Radiological evaluation of 242 dry adult mandibles of
south Indian origin showed a bilateral occurrence of the RMF
in 4.1% and a unilateral occurrence in 17.8%, with no differ-
ence between left and right sides. They also reported the
width of the canal ranging from 1.5 to 4.35 mm for the RMC
and length of the RMC ranging from 8.7 to 20.3 mm [6].
A cadaveric study reported the occurrence of bilat-
eral retromolar foramina in 5.1% and a unilateral foramen
in 12.7% of cases studied with the mean length of 2 mm
(cadaver study) in 157 south Indian mandibles [7]. Bile-
cenoglu and Tuncer evaluated 40 mandibles and found the
presence of bilateral RMF in 5% and a unilateral foramen
in 20%. They also reported the mean distance of the RMF
from the distal aspect of the alveolar socket of the third
and second molars was 4.2 and 11.9 mm respectively [9].
The RMC and foramen was found in 38 of 294 mandibles
analyzed (12.9%) with more incidence of unilateral presence
(n = 27). This study was conducted with 294 mandibles of
known sex and age, 195 male and 99 female from the uni-
versidade Federal de São Paulo collection, between 20 and
100 years old [10].
López-Videla et al. evaluated for bifid mandibular canal
variables in a sample of 84 subjects (52 women, 32 men)
between 12 and 80 years of age [22]. It was a study
conducted between 2008 and 2009 at the Maxillo Facial
Radiology Systems Center of Santiago de Chile. They found
to have RMC variations for about 23.80% [22]. von Arx
et al. evaluated 121 sides in 100 patients (100 unilateral
and 21 bilateral cases). A total of 31 RMCs were identified
with cone beam computed tomography (CBCT) (25.6%). Only
seven of these canals were also seen on the correspond-
ing panoramic radiographs. The existence of a RMC was not
statistically related to gender or side. With regard to the lin-
ear measurements, the mean distance from the RMC to the
second molar was 15.16 mm, the mean height of the canal
was 11.34 mm, and the mean width was 0.99 mm (10). This
data is in accordance with the measurements of the study
by Narayana et al. [6]. von Arx et al. also reported that men
have longer RMCs than women. This difference is not neces-
sarily explained by the fact that men have an overall greater
height of the mandible in the retromolar area, because the
length of the canal was determined as the distance from the
mandibular canal to the RMF. Hence, the length of the RMC
is dependent on the location of the mandibular canal within
the mandible [11].
Please cite this article in press as: Kumar Potu B, et al. Retromolar foramen and canal: A comprehensive review on its
anatomy and clinical applications. Morphologie (2013), http://dx.doi.org/10.1016/j.morpho.2013.04.004
Motta-Junior et al. analyzed 35 mandibles for the pres-
ence of the RMF and its relationship with the third or last
molar tooth of the arch. In addition, the distance between
foramen and lingula was also evaluated. In all the mandibles
included in this study, the RMF was found in six (17%). In
two mandibles, the foramen was found to be present bilat-
erally, totaling eight RMF. The average distance reported
between the RMF and lingula was 15.24 mm and between
retromandibular foramen and third molar tooth was 8.99 mm
[23].
A recent study was conducted by Rossi et al. on
222 mandibles of Brazilian origin, independent of gender.
The evaluation revealed that 59 had at least one RMFs
resulting in an incidence of 26.58%. The RMF was present uni-
laterally in 41 mandibles and 18 bilaterally, with incidences
of 18.47% and 12.16% respectively. On the right side, the RMF
was present in incidences of 16.22% and 18.92% respectively.
The analysis of the right side of the mandibles revealed that
47.46%, 21.21% and 3.03% had one, two and three foramens
and the left side showed 55.93%, 16.22% and 8.11% of the
222 mandibles with one, two and three RMFs, respectively
[12].
Kawai et al. investigated ninety sides of 46 cadaver
mandibles in their study from Japan. CBCT images around
the retromolar region were acquired for all of the
mandibles. The frequency of the RMF was examined on these
images. Subsequently, four sides of three mandibles were
dissected to confirm the contents of the RMC/RMF. In 24 of
46 (52%) mandibles and 34 of 90 (37%) sides, at least one
RMF was observed in the images. In 26 dentate mandibles,
12 (48%) mandibles and 14 (33%) sides presented at least one
RMF. The average location of the RMF was 14.4 mm poste-
rior from the distal edge of the second molar and 23.0 mm
from the first molar. Observations made during the cadaver
dissections confirmed that the vessels and nerves diverged
from the mandibular canal to RMC. The findings also suggest
that the RMF is not a rare anatomical structure and that
practitioners should take this foramen into account in all
anesthetic and surgical procedures involving the retromolar
area. This recent study in a Japanese population warrants
that the incidence of the RMF is getting higher and this
can increase clinical burden for the surgeons [22]. A recent
study by Lizio et al. conducted a study on radiographs of
233 hemimandibles from year 2007—2010. Thirty-four RMCs
with a foramen were detected on 233 CBCT (14.6%). In the
46 patients who underwent CBCT bilaterally, the RMC was
found in nine subjects (19.6%) and was present bilaterally in
four subjects, for an incidence of 8.7% [18]. The incidence
of RMF reported till date in various populations is tabulated
in Table 1.
Clinical burden of the retromolar foramen and
canal reported so far
It has been observed that the neurovascular bundle of
foramen originated in the mandibular canal. They also
mentioned that the high incidence of RMC is due to
genetic crossbreeding of European individuals with Aborig-
inal Argentineans. They also stressed upon penetration of
the neurovascular bundle into distal lamina dura of the dis-
tal root of the third molar [2]. Clinician should be aware of
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Retromolar foramen and canal 5

Table 1 Showing the incidence of retromolar canal and foramen in different populations.
Montrant l’incidence du canal rétromolaire et du foramen dans différentes populations.

Author Year of Number of Presence of retromolar Population of the study

study mandibles studied foramen (%)

Schejtman et al. [2,19] 1967 18 13 (72) Argentine aborigines

Ossenberg 1987 86 7 (8.1) Italian
[3] 94 3 (3.2) Japanese
485 40 (8.2) Eskimos
11 1 (9.1) Canadians of European
descent
Sawyer and Kiely [21] 1991 234 18 (7.7) American
Kodera and Hashimoto [21] 1995 41 8 (20) Japanese
Pyle et al. [5] 1999 475 37 (7.8) Caucasian (n = 226)
Afro-American (n = 249)
Narayana et al. [6] 2002 242 53 (21.9) Indian
Priya et al. [7] 2005 157 20 (12.7) Indian
Lagrana et al. [8] 2006 50 9 (18) —
Bilecenoglu and Tuncer [9] 2006 40 10 (25) Turkish
Suazo et al. [10] 2008 294 38 (12.9) Brazilian
von Arx et al. [11] 2009 121 31 (25.6) Swiss
(published
in 2011)
Kawai et al. [24] 2011 46 24 (52) Japanese
Motta-Junior et al. [23] 2012 35 6 (17) Brazilian
Lizio et al. [18] 2012 233 (hemi 34 (14.6) Italian
mandibles)
Rossi et al. [12] 2012 222 59 (26.58) Brazilian

this accessory innervation provided by RMC in the endodon-
tic treatment [25]. Postoperative hematomas caused by
damage to the contents of canal and foramen during a sur-
gical procedure or implantation should be kept in mind as
described by authors [26—29].
The presence of RMF which was crossed by additional sen-
sory fibers reported. The author related the presence of this
foramen to the failure to obtain analgesia from the clas-
sical anesthetic techniques [30]. Thus, the studies of the
incidence of RMF are important in order to avoid failure
in regional anesthetic techniques for blocking the inferior
alveolar nerve and buccal nerve fibers [21,31].
Singh, during surgery of a third molar, injured a nerve
that crossed an unusual foramen located in the retromo-
lar fossa. After the surgery, it was found that the patient
presented paresthesia of the buccal mucosa from the retro-
molar region until the canine on the operated side. They
have conducted many tests and found out that the nerve
injured was a branch of the buccal nerve passing by fora-
men [16]. Anderson et al. confirmed that the components
in the RMF and canal are the nerves that provide innerva-
tion to the pulp of third molar, retromolar region and to the
fibers of the temporalis and buccinator muscles [32]. This
study also described that the damage to nerves of canal will
have huge impact on the functions of temporalis and buc-
cinator muscles. Pinsolle et al. suggested that because the
RMC also allow the passage of vascular components, may
facilitate the spread of infection and metastases from the
oropharynx [33].
During surgery of third molar extraction or sagittal
osteotomies of the mandible [28], neurovascular bundle
may get disturbed and cause bleeding if injured [21,31,34].
These neurovascular elements may be injured in the diere-
sis procedures, flap lifting, bone tissue for autologous
bone grafts, osteotomy for the surgical extraction of lower
third molars, placement of osseo integrated implants for
orthodontic or during the division of the mandibular ramus
in the sagittal split osteotomy surgery [35].
The lesion of the vascular component of the RMC dur-
ing insertion of surgical implants is reported [36]. Moreover,
in addition to becoming an element of risk should be con-
sidered as potential routes for the entry of additional
innervation to the lower third molar region. It has been
reported that this anatomical variation provides innervation
in retromolar area, causing failure in anesthetic mandibular
blocking [37]. An accidental finding of RMC during wis-
dom tooth extraction [17]. These authors have confirmed
the contents of the canal with histochemical staining’s,

Please cite this article in press as: Kumar Potu B, et al. Retromolar foramen and canal: A comprehensive review on its
anatomy and clinical applications. Morphologie (2013), http://dx.doi.org/10.1016/j.morpho.2013.04.004
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6 B. Kumar Potu et al.
histological quantifications and added their promising signif-
icant findings to the studies done on same line [2,9,16,38].
Conclusion
This review summarizes the incidence of RMF, RMC reported
in different populations concerning their anatomical vari-
ations to give detailed basis for a better understanding of
clinical and surgical practice related to oral area. The RMC
and RMF have great importance in the odontostomatological
practice due to the prevalence of the pathological processes
and complications related to the retro molar area involved
in the practice. This could be the reason why this area is
subject of a great number of surgical procedures. The knowl-
edge of the location and contents of RMC should be carefully
considered for choosing the best plan and consequently for
optimizing anesthetic and surgery procedure during oral and
maxillofacial procedures.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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Please cite this article in press as: Kumar Potu B, et al. Retromolar foramen and canal: A comprehensive review on its
anatomy and clinical applications. Morphologie (2013), http://dx.doi.org/10.1016/j.morpho.2013.04.004