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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 13-16

Relative position of mandibular foramen in 4–9-year-old children: A retrospective study


Department of Pediatric and Preventive Dentistry, Kannur Dental College, Kannur, Kerala, India

Date of Submission24-Aug-2020
Date of Decision21-Jan-2021
Date of Acceptance11-Feb-2021
Date of Web Publication30-Mar-2021

Correspondence Address:
Dr. Sruthi Chandran
Department of Pediatric and Preventive Dentistry, Kannur Dental College, Kannur, Kerala
India
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DOI: 10.4103/srmjrds.srmjrds_81_20

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  Abstract 

Introduction: Most common nerve block used in children is the inferior alveolar nerve block (IANB) for anesthetizing mandibular teeth. Therefore, knowledge of the location of the mandibular foramen is necessary for a successful IANB anesthesia. Aim: The study aimed to correlate the position of mandibular foramen in relation to the mandibular occlusal plane and the deepest point of the coronoid notch as a clinical guide for IANB injection in 4–9-year-old children. Materials and Methods: One-hundred orthopantamographs were analyzed and divided into two groups; Group 1 (4–6 years) and Group 2 (7–9 years). The orthopantamographs were traced on the acetate paper using a radiograph viewer and measurements were taken from mandibular lingula (ML) to the occlusal plane and to the deepest point of the coronoid notch. Results: Statistical analysis of the data revealed that there was a significant difference in mean distance between the two groups on both sides by measuring the position of ML to the mandibular occlusal plane and to the deepest point of the coronoid notch. Intergroup comparison of the distance from ML to the deepest point of the coronoid notch on the right and left sides shows a statistically significant difference (P < 0.001). Conclusion: There is a significant difference in both the distance and position of mandibular foramen in the considered age groups.

Keywords: Inferior alveolar nerve, mandibular foramen, mandibular lingula


How to cite this article:
Chandran S, Peedikayil FC, Chandru T P, Kottayi S, John S. Relative position of mandibular foramen in 4–9-year-old children: A retrospective study. SRM J Res Dent Sci 2021;12:13-6

How to cite this URL:
Chandran S, Peedikayil FC, Chandru T P, Kottayi S, John S. Relative position of mandibular foramen in 4–9-year-old children: A retrospective study. SRM J Res Dent Sci [serial online] 2021 [cited 2021 Jun 15];12:13-6. Available from: https://www.srmjrds.in/text.asp?2021/12/1/13/312477


  Introduction Top


Pain control is an important aspect in the behavior management of pediatric dental patients.[1] Therefore, any unpleasant experience during restoration or surgical procedure in children may lead to uncooperative child and develop apprehension for future dental treatment.[2] Various pain control modalities and treatment methods are available in pediatric dentistry.

Local anesthesia is a widely used technique in controlling the pain. The most common nerve block used in children is the inferior alveolar nerve block (IANB) for anesthetizing mandibular teeth. Therefore, knowledge of the location of the mandibular foramen is necessary for a successful IANB anesthesia. The landmarks considered for IANB are the external oblique ridge, coronoid notch, pterygomandibular raphe, and the occlusal plane on the ipsilateral side. The mandibular foramen present on the medial aspect of the mandibular ramus is protected anteriorly by a bony tongue-like protrusion known as mandibular lingula (ML). By following these landmarks, the anesthetic solution is delivered as close as possible to the mandibular foramen. However, various studies show that the mandibular foramen location varies among people of different ethnicity, age, and even within the same individual on two sides.[1],[3]

IANB is effective when the needle is inserted in close proximity to the mandibular foramen in order to deposit a solution of the anesthetic agent near the nerve. Despite the technique being commonly used in the daily routine dental procedure, the failure rate is high.[4] Two major factors are involved in the failure of IANB: The first is accessory innervations and the second, and most common, is improper placement of needle because of improper evaluation of landmarks.[5] The main complications during this technique are hemorrhage, injury to the neurovascular bundle, fractures, and necrosis of the mandibular ramus.[6] Hence, thorough knowledge of the anatomy of the mandible is very essential. Basically, in order to have a rapid, deep, and safe local anesthesia, the location of mandibular foramen in relation to the occlusal plane should be acquired. As the child grows up, the position of the mandibular foramen changes. Hence, for a successful mandibular local anesthesia, consideration to such changes is imperative.[7]

Radiography is the available noninvasive method for determining the exact position of the mandibular foramen. Panoramic radiography (orthopantomographs [OPG]) is a curved plane tomographic radiographic technique in which the mandibular canal appears as a radiolucent line delimited by two outer radiopaque lines which begin at mandibular foramen and extends up to the mental foramen. Although the panoramic radiograph is often magnified with loss of definition and there is anatomical structure superimposition, it has the advantage of being simple to acquire, requires a minimum amount of time for its execution, and is cost-effective when compared to the latest imaging techniques. Hence, a panoramic radiograph is commonly used for screening, diagnosis, and for selecting the best possible surgical approach.[8] Therefore, the study was planned to assess, the position of the mandibular foramen on 100 panoramic radiographs in two different age groups belonging to patients from Kannur District in Kerala.


  Materials and Methods Top


This retrospective study was performed on hundred OPG of children within the age group of 4–9 years, who had come for treatment to the Department of Paediatric and Preventive dentistry, Kannur Dental College, Anjarakandy, Kerala, India.



Z1−α/2 = Is standard normal variate

SD = standard deviation of variable. The value of standard deviation can be taken from a previously done study or through a pilot study.

d = Absolute error or precision



Based on the age criteria, the orthopantomographs of the children were allocated into two groups. Group 1: (4–6 years), Group 2: (7–9 years) with a sample size of fifty in each group.

Only radiographs without any gross anatomical abnormalities and with an acceptable mandibular occlusal plane were included in the study. Children with the previous history of craniofacial trauma, temporomandibular disorder, undergoing orthodontic treatment, and for whom occlusal plane cannot be established because of lack of posterior teeth were excluded from the study.

All the OPGs were recorded by a single orthopantamogram machine (Planmeca Proline EC Panoramic X-ray). In the present study, we have considered two age groups of 4–6 years and 7–9 years and observed difference in the vertical distance of mandibular foramen to the occlusal plane and horizontal distance from the deepest point of the coronoid notch to the mandibular foramen in both the sides of the groups. The orthopantamographs were traced on matte acetate paper using a radiograph viewer, followed by marking of anatomic points. [Figure 1] shows the reference points which include: the highest point on ML (A1), the distal most point on the crown of the fully erupted distal molar (A2), and the deepest point on the coronoid notch (A3). Using the reference points following lines were drawn; a horizontal line passing through the point (A1) and parallel to the orbit plane, a vertical line passing through the point (A2), and the occlusal plane passing through the cusp tip of the fully erupted molar and that of the canine. The vertical line was measured to obtain the relative position of ML (A1) to the mandibular occlusal plane (A2) and the horizontal line was measured to get the linear measurement of the relative position of ML (A1) from the deepest point of the coronoid notch (A3). Then, we compared:
Figure 1: An example of a traced orthopantomograph with three anatomic points marked and the planes drawn

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  1. Mean linear measurement of the relative position of ML (A1) to mandibular occlusal plane (A2) between the groups
  2. Mean linear measurement of the relative position of ML (A1) from the deepest point of the coronoid notch (A3) between the groups
  3. The age group difference between 4–6 years and 7–9 years old children.


All the points and lines were drawn on both sides and measurement of quantities was obtained in millimeters and by a single examiner.


  Results Top


This study was conducted to find the relative position of mandibular foramen in children of age groups 4–6 years and 7–9 years.

Data were analyzed using the software statistical package for the social sciences version 22.0(IBM corporation, Chicago, IL, USA) and expressed in terms of mean and standard deviation. Independent t-test was used to compare the mean linear measurement of the relative position of ML from the mandibular occlusal plane and the deepest point of the coronoid notch on either side between the age groups. Student paired t-test was used to compare the relative position of the ML of both sides from the occlusal plane and the deepest point of the coronoid notch in each group. P < 0.05 was considered significant.

[Table 1] shows the comparison of the mean linear measurement of the relative position of ML (A1) to mandibular occlusal plane (A2) between the groups. There is a significant difference in mean distance between the two groups on both the sides with the mean value of 5.470 ± 1.7214 in 4–6 year group and 6.840 ± 2.5504 in 7–9 year group on the right side and mean value of 6.970 ± 1.5597 in 4–6 year group and 8.040 ± 2.8353 in 7–9 year group on the left side. Higher the age group, higher the distance from ML to the mandibular occlusal plane.
Table 1: Comparison of distance from mandibular lingula (A1) to mandibular occlusal plane (A2)

Click here to view


[Table 2] shows the comparison of the mean linear measurement of the relative position of ML (A1) from the deepest point of the coronoid notch (A3) between the groups. There is a significant difference in mean distance between the two groups on both the sides with a mean value of 4.950 ± 0.9049 in 4–6 year and 6.080 ± 1.2752 in 7–9 year on the right side and a mean value of 4.920 ± 1.2950 in 4–6 year group and 5.780 ± 1.4748 in 7–9 year group on the left side. Higher the age group, higher the distance from ML to the deepest point of the coronoid notch.
Table 2: Comparison of distance from mandibular lingual (A1) to the deepest point of the coronoid notch (A3) between the groups

Click here to view


[Table 3] shows the comparison of the age group difference between 4–6 year and 7–9-year-old children. The distance from the relative position of ML (A1) to the mandibular occlusal plane (A2) is 2.4 mm and the distance from the relative position of ML (A1) to the coronoid notch (A3) is1.9 mm.
Table 3: Comparison between right and left side between age groups

Click here to view


While comparing the right side and left side variation in 4–6 year and 7–9-year-old children, there is a significant difference in mean distance from ML (A1) to mandibular occlusal plane (A2) between the sides in both groups. There is a significant difference in mean distance from ML (A1) to the coronoid notch (A3) between the sides in Group 2 (7–9 year), but there is no significant difference in mean distance from ML (A1) to the coronoid notch (A3) in Group 1 (4–6 years) between the sides.


  Discussion Top


The mandible is in a constant phase of remodeling as the child grows. It shows a differential growth pattern and remodeling at different areas. The eruption and shedding process of the teeth plays an important role in bone remodeling, particularly at the anterior border of the ramus and the alveolar crestal plane, which may influence the position of the mandibular foramen and hence, the IANB procedure.

Pain prevention in pediatric dentistry is crucial for a child in achieving a positive experience during the dental visit, building trust and cooperation, and making future visits enjoyable.[9] During the procedures of block anesthesia of the inferior alveolar nerve, it is important to locate the ML and mandibular foramen accurately in order to avoid the failure of anesthesia.[10] In the present study, a significant difference was found between the right side and left side in measuring the vertical distance between the mandibular foramen and the occlusal plane in both age groups and also in horizontal distance from the deepest point of the coronoid notch to the mandibular foramen in 7–9 years and in significant difference was seen in 4–6 years children. This finding was similar to the study conducted by Kanno et al., on 7–10-year-old Brazilian children where there was a gradual increase with age in the linear distance between ML and the occlusal plane.[11] Krishnamurthy et al. conducted a study on 7–12-year-old children of the Indian population, concluded that the distance from the ML to the occlusal plane shows a gradual increase with age, which was statistically significant, and also the position of the mandibular foramen is not bilaterally symmetrical for any of the considered age groups.[1] Poonacha et al. in a study done on the Indian population concluded a good success rate of IANB by placing the needle at the level of the occlusal plane in children of the age group of 3–13 years.[5] A study conducted by Ashkenazi et al. on age-associated changes of mandibular foramen position in AP dimension suggests that MF is located in the three-quarter of the ramus in the AP dimension and move anteriorly with age. These changes occur during the growth spurts at stages 2 and 3 of dentition development.[12] Contrary to our study, Feuerstein D et al. concluded that the location of MF was considered to be similar in all patients of 4–23 years old regardless of age.[13]

The present study sample consists of South Indian population from Kerala state; however, various other parameters may play a role, such as the nutritional status, general health of the child, ethnic and racial variations in the jaw growth patterns, the accuracy of the radiographic machine, the magnification factors, proper patient positioning, identification of the landmarks on radiographs, and finally, identification of the landmarks intraorally during IANB, which are highly individualistic. Therefore, similar studies may have to be conducted on large population groups with proper calibration of the examiners before arriving at any final conclusion.


  Conclusion Top


From our study, it can be concluded that there is a significant difference in distance from mandibular foramen to occlusal plane and coronoid notch on both the sides of age groups 4–6 and 7–9-year-old children. The position of the mandibular foramen is not bilaterally symmetrical in any of the considered age groups. This study suggests that during the IANB technique, the needle should be placed at the occlusal level below the coronoid notch in all age groups studied, and the point of insertion for the needle should be at posterior to the midpoint of the ramus of the mandible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krishnamurthy NH, Unnikrishnan S, Ramachandra JA, Arali V. Evaluation of relative position of mandibular foramen in children as a reference for inferior alveolar nerve block using orthopantamograph. J Clin Diagn Res 2017;11:ZC71-4.  Back to cited text no. 1
    
2.
Shukla RH, Tiku A. Correlation of mandibular foramen to occlusal plane as a clinical guide for inferior alveolar nerve block in children: A digital panoramic radiographic study. Contemp Clin Dent 2018;9:372-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Epars JF, Mavropoulos A, Kiliaridis S. Changes in the location of the human mandibular foramen as a function of growth and vertical facial type. Acta Odontol Scand 2015;73:375-9.  Back to cited text no. 3
    
4.
Phukan AH. Relative changes in Position of Mandibular Foramen In 3-13 year olds in Realtion to Inferior Alveolar Nerve Block. Int J Ane Rel 2018;2:1.  Back to cited text no. 4
    
5.
Poonacha KS, Shigli AL, Indushekar KR. Relative position of the mandibular foramen in different age groups of children: A radiographic study. J Indian Soc Pedod Prev Dent 2010;28:173-8.  Back to cited text no. 5
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Shalini R, RaviVarman C, Manoranjitham R, Veeramuthu M. Morphometric study on mandibular foramen and incidence of accessory mandibular foramen in mandibles of south Indian population and its clinical implications in inferior alveolar nerve block. Anat Cell Biol 2016;49:241-8.  Back to cited text no. 6
    
7.
Movahhed T, Makarem A, Imanimoghaddam M, Anbiaee N, Sarrafshirazi AR, Shakeri MT. Locating the mandibular foramen relative to the occlusal plane using panoramic radiography. J Appl Sci 2011;11:573-8.  Back to cited text no. 7
    
8.
Kapoor S, Sandhu A, Singla A, Sandhu S. Topographic anatomy of mandibular foramen in different age groups using panoramic radiographs. Eur J Anat 2018;22:27-35.  Back to cited text no. 8
    
9.
Jayakaran TG, Vignesh R, Shankar P. Local anesthetics in pediatric dental practice. Res J Pharm Technol 2019;12:4066-70.  Back to cited text no. 9
    
10.
Zhou C, Jeon TH, Jun SH, Kwon JJ. Evaluation of mandibular lingula and foramen location using 3-dimensional mandible models reconstructed by cone-beam computed tomography. Maxillofac Plast Reconstr Surg 2017;39:30.  Back to cited text no. 10
    
11.
Kanno CM, de Oliveira JA, Cannon M, Carvalho AA. The mandibular lingula's position in children as a reference to inferior alveolar nerve block. J Dent Child (Chic) 2005;72:56-60.  Back to cited text no. 11
    
12.
Ashkenazi M, Taubman L, Gavish A. Age-associated changes of the mandibular foramen position in anteroposterior dimension and of the mandibular angle in dry human mandibles. Anat Rec 2011;294:1319-25.  Back to cited text no. 12
    
13.
Feuerstein D, Costa-Mendes L, Esclassan R, Marty M, Vaysse F, Noirrit E. The mandibular plane: a stable reference to localize the mandibular foramen, even during growth. Oral radiology. 2020 Jan;36:69-79.  Back to cited text no. 13
    


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  [Table 1], [Table 2], [Table 3]



 

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