Oral Radiology

https://doi.org/10.1007/s11282-019-00414-0

ORIGINAL ARTICLE

Observation of retromolar canals on cone beam computed

tomography
Yunwen Hou1 · Guanying Feng1 · Wen Lin1 · Ruixia Wang1 · Hua Yuan1,2 

Received: 17 August 2019 / Accepted: 4 November 2019

© Japanese Society for Oral and Maxillofacial Radiology and Springer Nature Singapore Pte Ltd. 2019

Abstract
Objective  To evaluate the incidence and location of retromolar canal (RMC) in an eastern Chinese population using cone
beam computed tomography (CBCT) images.
Methods  Six hundred and fifty-seven patients (276 males and 381 females, 19–49 years old) from east China were enrolled.
Both right and left sides of the mandible were examined (n = 1314). Two-dimensional (2D) images of various planes in the
mandibular ramus region and reconstructed three-dimensional (3D) images were reviewed. The course of the RMC and the
location of the retromolar foramina (RMF) were observed.
Results  Retromolar canal (RMC) was observed in 25.9% (170/657) of patients and 15.7% of sides (206/1314). 20.4% patients
had unilateral RMC (134/657) and 5.5% had bilaterally RMC (36/657). Most RMC are horizontally curved course (Type
B, 45.6%), followed by vertically curved course (Type A, 44.2%). Type C RMC, which run independently from separate
foramina in the mandibular ramus, were relatively rare (10.2%). The distance from the middle of the RMF to the distal end
of the second molar ranged from 4.56 to 24.01 mm and the mean distance was 11.97 mm.
Conclusion  RMC is not a rare anatomical structure in the eastern Chinese population. CBCT should be applied as a diagnostic
tool to provide detailed information involving the retromolar area.

Keywords  Cone beam CT(CBCT) · Retromolar canal (RMC) · Retromolar foramina (RMF) · Incidence · Oral surgery

Introduction that inferior alveolar neurovascular bundles go through the

Abundant research achievements of morphology of the man-
dible and its anatomical variations have been described to
affect the development of clinical oral surgery plan. Ret-
romolar foramina (RMF), the aperture of the retromolar
canal (RMC), may be discovered on the bone surface in the
retromolar triangle region. Anatomical dissection found
Yunwen Hou and Guanying Feng contributed equally to this work.
* Ruixia Wang
riebett@sina.com
* Hua Yuan
yuanhua@njmu.edu.cn
1
Jiangsu Key Laboratory of Oral Diseases, Nanjing
Medical University, 140 Hanzhong Rd., Nanjing 210029,
People’s Republic of China
2
Department of Oral and Maxillofacial Surgery, Affiliated
Hospital of Stomatology, Nanjing Medical University,
Nanjing, China
RMC [1]. It makes the surgical procedures involving the
retromolar regions more complicated, such as dental implant
surgery, impacted third molar extraction and sagittal split
ramus osteotomy. RMC has been described as a subtype of
the bifid mandibular canal called the ‘retromolar type’ [2].
Chavez-Lomeli et al. suggested that bifid and trifid man-
dibular canals occurred as a result of the incomplete fusion
of three distinct inferior dental nerve (incisors, primary and
permanent molars) during embryonic development [3].
RMC is an anatomic structure that has often been
neglected in anatomic textbooks [4].The main reason is
that RMC is seldom visible in conventional radiographs,
such as panoramic radiograph. Innovative 3D imaging tech-
niques, particularly in CBCT, have facilitated the observa-
tion and diagnosis of the presence and course of RMC [5].
Cone beam computed tomography (CBCT) is a very good
imaging system for oral and maxillofacial application. The
advantages of CBCT include uniform magnification, three-
dimensional (3D) reconstructions, high geometric accuracy,
low radiation doses and a relatively low cost. For the study

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of teeth, spongy bone, and lamina dura, the accuracy of
CBCT has been judged to be equivalent to multi-slice com-
puted tomography [6].
In previous studies of retromolar canals on CBCT, some
scholars have reported the incidence of RMF respectively
[7-10]. But their results were inconsistent. The incidence of
RMC was distinct due to ethnic differences and the discrep-
ancy of scoring standards. Since there was little research
related to the RMF or RMC in China, the aim of this study
was to evaluate the occurrence, location, types and gender
differences of RMC on CBCT images. The results were ana-
lyzed to provide reference information for eastern Chinese
people.
Materials and methods
A total of 657 patients were retrospectively analyzed using
CBCT taken before possible impacted third molars surgery,
dental implant surgery or orthodontic treatment at the affili-
ated stomatological hospital to Nanjing Medical University,
Nanjing, China. Six hundred and fifty-seven patients includ-
ing 276 males and 381 females (ranging from 19 to 49 years
old) were all from east China. The patients had undergone
CBCT scans by a professional dental technologist following
a standardized protocol, with the same machine (New-Tom
VG 10048S; QR srl Inc., Verona, Italy, 18 s exposure time).
All study samples were collected according to the following
inclusion criteria: without pathologic lesions or prior sur-
gery in the mandible, patients with known sex and their age
ranging from 20 to 45 years, reformation CBCT images were
clear, symmetrical and not distorted or blurred. The imag-
ing data were stored in DICOM format and reconstructed
with the image analysis software Mimics 19.0 (Materialise,
Leuven, Belgium).
The typical RMC morphology were evaluated in the axial
and coronal views (Fig. 1) and types of RMC were identi-
fied in para-sagittal views (Fig. 2). The measurement accu-
racy was contrasted between 3D models and axial views.
Then locate the RMF and measure the distance between
RMF and the mandibular second molar with the reference
ruler (Fig. 3). In 3D models the RMF and the distal CEJ
of the mandibular second molar could be positioned more
precisely. All images were measured and evaluated by two
experienced oral and maxillofacial surgeons then averaged.
RMC was defined and classified into three types accord-
ing to the description of Ossenberg [11]. Type A was verti-
cally curved RMC that branches from the mandibular canal
to a single mandibular retromolar foramen. Type B RMC
branched from the mandibular canal and ran anteriorly to the
retromolar foramen. Type C RMC branched from a separated
fossa in the mandibular ramus and ran to open into the retro-
molar foramen [7]. Accessory canal in the mandibular ramus
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Oral Radiology
without a foramen in the retromolar areas and small RMCs
with a diameter less than 0.5 mm were excluded.
First, the observers evaluated the cross and axial sec-
tional slices by degrees to detect the typical RMC morphol-
ogy. Second, panoramic curves were created in the cross-
sectional slice to determine the types of RMC. Lastly, 3D
models were calculated to detect the RMFs and measure
the distance between the middle of the RMF and the distal
cementoenamel junction (CEJ) of the mandibular second
molar with the reference ruler included in the software. The
screenshots were edited using the image software Photoshop
CS6 (Adobe, San Jose, CA). The data was recorded in an
Excel table (MS Office Excel 2016) and analyzed by the × 2
test on SPSS® v. 18 (SPSS Inc., Chicago, IL). Statistical
significance was set at p < 0.05.
Results
Figure 1 presented typical RMC morphology. Figure 2 pre-
sented the classification of type A, B and C. Most RMC
had horizontally curved course (type B, 45.6%, 94/206), fol-
lowed by vertically curved course (type A, 44.2%, 91/206).
Type C RMC, which run independently from separate
foramina in the mandibular ramus, were infrequent (10.2%,
21/206). As is presented in Table 1, RMC were observed
in 25.9% (170/657) and absence in 74.1% (487/657) of
patients. About one case that RMC with RMF on the retro-
molar area occurs in 4 patients. Seventy-six cases of RMC
were observed in 276 males (76/276, 11.6%) and 94 cases
in 381 females (94/381, 14.3%). There was no significant
difference between genders (p > 0.05) through χ 2 test.
20.4% patients had unilateral RMC (134/657) and 5.5% had
bilaterally RMC (36/657). In total sides of all mandibles,
15.7% occurred RMCs (206/1314). 10.2% sides were uni-
lateral RMC (134/1314) and 5.5% were bilaterally RMCs
(72/1314). The location of RMF is presented in Fig. 3 and
Table 2. Among 206 sides, 197 sides were measured between
the middle of the RMF and the distal CEJ of the mandibular
second molar for there were nine sides without the second
molar. The distance ranged from 4.56 to 24.01 mm (mean:
11.97 mm).
Discussion
The incidence of RMC varied among ethnicities in previ-
ously studies (Table 3) and there was no research on the
east Chinese population. Schejtman et al. [12] reported 72%
incidence of RMC in 18 human skulls of Argentine, which
was a high frequency. However, in addition to small sam-
ple size, the criteria of RMC were not completely consist-
ent with the CBCT principles. By using CBCT images, Patil
Oral Radiology

Fig. 1  Typical RMC morphology in different views. a1–a4 Bifurcation of the mandibular canal in the axial views (white box). b1–b4 Bifurca-
tion of the mandibular canal in the coronal views (white box). c1 Bifurcation of the mandibular canal in the para-sagittal view

et al. [13] reported a high incidence of RMC (75.4%) in
Japanese, since the small-sized RMC that coursed between
the radicular portion of the third molar and retromolar
fossa were included. Percentages varied between 8.5 and
52% in other studies [7-10, 12-17]. Our research found a
25.9% incidence and was comparable moderate. In com-
pliance with the high incidence of RMC, Schejtman et al.
[12] and Patil et al. [13] observed 27% and 44.50% bilateral
RMC. Percentages varied between 1.6 and 22.8% in other
studies. In our study, bilateral RMC accounted for 5.5% of
total 1314 sides and 35% of total RMCs. The anatomical
structure exhibited a high incidence of symmetric. Type C
RMC were corresponded to the temporal crest canal (TCC)
based on the classifications of Ossenberg [11]. Our result
was comparable higher than most of the other studies. There
was not any difference in the incidence of RMC concerning
the gender (p > 0.05), which was consistent with the previ-
ous researches. According to von Arx et al. [10] and Han
et al. [7], the measurements of the average distance from the
RMF to the CEJ were 15.16 mm and 14.08 mm, comparably
longer than the distance of 11.97 mm in our study.
Previous anatomy studies demonstrated that RMC con-
tains small arteries, venules and a thin retromolar bundle
nerve [12]. The retromolar bundle was confirmed to be mye-
linated sensory nerve but the origin of this branched nerve
was variant. Hypothesis of the origin given by other authors
was inferior alveolar nerve (IAN) or buccal nerve (BN).
The histological studies showed the nerve contribute to the

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Fig. 2  Classification of RMC according to the course (white arrow).
Type A (a1–a2) is vertically curved RMC that branches from the
mandibular canal around the molars from a single mandibular fora-
men. Type B (b1–b2) is a horizontally curved RMC, which ran ante-
riorly and then turned poster-superiorly to open into the retromolar
fossa. Type C (c1–c2) is an RMC that branches from a separated fora-
men in the mandibular ramus
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Oral Radiology
sensory of the retromolar pad and continuing to the buccal
gingiva of up to two teeth anteriorly [12, 16]. Schejtman
et al. [12] reported that the branch extends to the temporal
tendon, buccinator muscle, posterior part of the mandible,
and the third molar. A nerve variation described by Turner
[18] was that the BN arising from the inferior alveolar nerve
within the mandible and passed through accessory foramina.
Kawai et al. [19] agreed with Ossenberg [20]’s hypothesis—
that the BN runs in the TCC. The BN was thought to arise in
the infratemporal fossa as a terminal branch of the anterior
trunk of the mandibular nerve. Kikuta et al. [21] reported
that postoperative hypoesthesia of the buccal gingiva in the
molar region was happened after impacted third molar sur-
gery in a 55-year-old male, whose RMC (2.9 mm in diam-
eter) and RMF (2.3 mm in diameter) were the largest in this
study and the patient still had hypoesthesia at the 12-month
follow-up.
The RMF is a common anatomical aberrance and the cli-
nician should take this foramen into consideration during
anesthetic and surgical procedures involve the retromolar
area. Clinically local anesthetic insufficiency may happen
after complete inferior alveolar nerve block (IANB). The
‘escape’ pain persisted after patients reporting successful
lip numbness [22]. The RMF and accessory mandibular
foramina may provide alternative (‘escape’) routes for pain
continue to be transmitted, even after the main trunk of the
IAN has been blocked at the mandibular foramen by the
injection of local anesthetic solution. Therefore, supple-
mentary infiltration of local anesthetic solution into the soft
tissues overlying the retromolar fossa is necessary in the
third molar extractions surgery. In the split sagittal ramus
osteotomy (SSRO), if the presence of the RMF is not taken
into consideration, damage to the neurovascular content of
RMC may be caused, including traumatic neuromas, intra-
canal hemorrhage, or postoperative numbness and pares-
thesia of the area innervated by the retromolar nerve. The
supplemental canal may also be a route for tumor spreading
or infection.
Conclusion
The incidence of RMC varied among ethnicities. This study
demonstrated the RMC is not a rare anatomic structure in
the eastern Chinese population. The canal contains a nerve
bundle highly possible to be the BN. Local anesthetic insuf-
ficiency of IANB may result from RMC. Supplementary
infiltration of local anesthetic solution in retromolar fossa is
necessary in the third molar extractions surgery. Since RMC
is generally very narrow, using CBCT images as a preopera-
tive examination in the anesthetic and surgical procedures
involving the retromolar area is necessary.
Oral Radiology

Fig. 3  The distance between the RMF and the mandibular second molar in 3D model and cross-sectional slices. d Schematic image of
molar in 3D models. a Identify the RMF in 3D model (white box). the distance from the middle of the retromolar foramen to the distal
b–c Measure the distance between the middle of the RMF and the end of the mandibular second molar
distal cemento-enamel junction (CEJ) of the mandibular second

Table 1  The incidence of RMC in different genders, sides and types

Presence incidence of RMC Absence Total of

incidence of patients
RMC
Unilaterally Male 76 Male 200 Male 276
134 (20.4%) (11.6%) (30.4%) (42%)
Bilaterally 36 Female 94 Female 287 Female 381
(5.5%) (14.3%) (43.7%) (58%)

Total 170 (25.9%) 487 (74.1%) 657 (100%)

Table 2  Location of RMF

N Average Minimum Maximum Standard

(mm) (mm) (mm) deviation(mm)

Second 197 11.97 4.56 24.01 4.08

molar

Table 3  Frequency of RMC in different population

Authors Population Sample size Year RMC (frequency) Bilateral (frequency) Type

Schejtman et al. Argentine 18 1967 13 (72%) 5 (27%) Human mandibles studies

Athavale et al. India 71 2013 10 (14.08%) 2 (2.81%) Human mandibles studies
Galdames et al. Brazil 294 2008 38 (12.9%) 11 (3.74%) Human mandibles studies
Patil et al. Japan 171 2013 129 (75.4%) 37/83 (44.50%) Cone Beam Computed Tomography studies
Kawai et al. Japan 46 2012 24 (52%) – CBCT and Human mandibles studies
von Arx T et al. Switzerland 121 2011 31 (25.4%) 4/21 (19%) CBCT and Human mandibles studies
Sang–Sun Han et al. Korean 446 2014 38 (8.5%) 7 (1.60%) Cone Beam Computed Tomography studies
Lizio et al. Italy 187 2013 30 (16%) 4/46 (8.70%) Cone Beam Computed Tomography studies
Sisman et al. Turkey 632 2015 253 (26.7%) 26 (8.25%) Cone Beam Computed Tomography studies
Motamedi et al. Iran 136 2015 55 (40.4%) 31 (22.8%) Human mandibles studies

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Acknowledgements  This work was supported in part by a project
funded by the Priority Academic Program Development of Jiangsu
Higher Education Institutions (PAPD, 2018–87). The Project of
Invigorating Health Care through Science, Technology and Education
(Jiangsu Provincial Medical Youth Talent QNRC2016852), Jiangsu
Provincial Medical Innovation Team (CXTDA2017036) and sponsored
by Qing Lan Project.
Compliance with ethical standards  Oral Biol. 1967;12(11):1261–8.
Conflict of interest  The authors declare that they have no conflicts of
interest.
Ethical approval  All procedures followed were in accordance with the
ethical standards of the responsible committee on human experimenta-
tion (institutional and national) and with the Helsinki Declaration of
1975, as revised in 2008.
Informed consent  Informed consent was obtained from all patients for
being included in the study.
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