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67]

Case Report

Imaging of accessory mental foramen before

implant therapy
Selin Aykol, Fikriye Orduyılmaz, Mustafa Gumusok1, Nurdan Ozmeric, Meryem Toraman Alkurt1
Departments of Periodontology and 1Dentomaxillofacial Radiology, Faculty of Dentistry, Gazi University, Ankara, Turkey

A B S T R A C T

It is critical to determine the location and variation of mental foramen (MF) during the implant treatment. Multiple numbers of MF can be
seen in the mandible, and they are called as accessory MF (AMF). Detecting the anatomic variations including AMFs with radiological
examinations before surgical applications are important to prevent neurovascular complications. Cone-beam computed tomography
(CBCT) is a beneficial method to determine the anatomical structures such as MF and its anatomical variations. The aim of this case
report was to present the diagnosis of AMF localized at the left side of the mandible of a 44-year-old woman patient who was applied
for implant therapy. Treatment planning and postoperative evaluation were performed with CBCT.

Key words: Accessory mental foramen, cone-beam computed tomography, implant

Introduction Case Report

The mental nerve is a terminal branch of the inferior alveolar
nerve. It emerges from mental foramen (MF), divides into
three branches beneath the anguli oris muscle and provides
for the innervation of the skin and mucous membrane of
the lower lip and chin, and vestibular gum of the mandibular
incisors.[1,2] MF is generally localized under the second
premolar or between two premolars.[2] Multiple MFs can rarely
be seen in the mandible. In such situations, one of them is
considered as MF, and the others as accessory mental foramen
(AMF) which can be presented as a result of branching of
MF.[3] Detecting the anatomic variations including AMFs
with radiological examinations before surgical applications
are important to prevent neurovascular complications.[4,5]
Cone-beam computed tomography (CBCT) is a beneficial
method that provides three-dimensional (3D) imaging with
low ionized radiation for imaging AMFs.[6]
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A 44-year-old female patient with no systemic diseases
applied for implant therapy. CBCT was used to diagnose
the height and thickness of the edentulous alveolar
bone. CBCT images were acquired with ProMax 3D®
(Planmeca, Helsinki, Finland) with exposure settings of
90 kVp, 12 mA, and 13.8 s. A thickness of radiographic
slices was 1 mm. After the examination of CBCT images,
AMF was observed at the left side of the mandible,
superior to MF. AMF’s relation with canalis mandibularis
was determined at cross-sectional and coronal section
images [Figures 1 and 2].
Anatomic variations should be considered during
the planning of dental implant placement to
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DOI: Cite this article as: Aykol S, Orduyilmaz F, Gumusok M, Ozmeric N, Alkurt
10.4103/2321-3841.170626 MT. Imaging of accessory mental foramen before implant therapy. J Oral
Maxillofac Radiol 2015;3:105-7.

Address for correspondence: Prof. Nurdan Ozmeric, Department of Periodontology, Faculty of Dentistry, Gazi University, Ankara, Turkey.
E-mail: nurdan@gazi.edu.tr

© 2015 Journal of Oral and Maxillofacial Radiology | Published by Wolters Kluwer - Medknow 105
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Aykol, et al.: Accessory mental foramen

prevent neurovascular bundle damage. The area of

mandibular second left premolar was measured about
8.25 mm in height and 5.34 mm in width. The area
of mandibular first left molar was measured about
12.03 mm in height and 4.02 mm in width to place
dental implants. Regarding to the measurements, for b
area of mandibular second left premolar 4.1-8 mm,
for mandibular first left molar 4.1-10 mm, (Institut
Straumann AG, CH-4002 Basel, Switzerland) regular
neck Sand Blasted Large Grid Acid-Etched implants
were applied. Considering that, it was hard to diagnose
the MF, AMF, and intraosseous relationships with
conventional methods such as intraoral and panoramic
radiography, postoperative CBCT images were obtained. Figure 1: Accessory mental foramen located on cone-beam computed
On the CBCT cross-sectional image of the related tomography cross-sectional image in the upper part of the mental foramen
by arrow (a), accessory mental foramen progresses as intraosseous canal after
area, no relation was detected between implants and starting on mandibular surface (b), the anastomosis of canalis mandibularis
neurovascular canals [Figure 3]. and intraosseous canal (c)

During 1 year of postoperative follow-up, no neurosensory

disturbance was observed.

Discussion

The location of inferior alveolar nerve or mental

nerve should be detected to prevent neurosensory
disturbances and hemorrhage at the anterior side of
the mandible. If the presence of AMF (part of MF
region), is missed, complications such as hemorrhage,
paralysis, and paresthesia may occur after the surgical
procedures in mental and cheek regions. [7,8] In this
Figure 2: Three-dimensional image of accessory mental foramen (a), accessory
patient, before implant surgery AMF was detected mental foramen on cone-beam computed tomography coronal image (b), the
during radiographic examination, so shorter implant was anastomosis of canalis mandibularis and accessory mental foramen (c)
planned to use to avoid nerve damage. Knowledge of
anatomic structures and localizations plays an important
role for a successful surgery.

Buccal foramina with no connection with mandibular

canal are called nutrient foramina. AMFs are buccal
foramina that have connection with the mandibular
canal.[6] It has been reported that AMFs are commonly
located at inferior region to MFs, with smaller sizes as
compared to the MFs.[3] In our patient, AMF located
at premolar area superior to MF. The measurement of
MF and AMF were 3, 69 and 1, 13 mm in diameter,
respectively. This measurement performed on cross-
sectional images for each foramen.
Figure 3: No relation was detected between implants and neurovascular
AMFs were showed in several studies.[6-10] It was mentioned canals on the cone- beam computed tomography cross-sectional image
that incidence of AMF is 2-10%.[11] Furthermore, the
prevalence of AMF has been reported to range from 6.3% The panoramic radiography, which is popular in dental
to 6.5% in a Turkish population.[9,10] practice, is an inexpensive, quick, easy, and low dose

106 Journal of Oral and Maxillofacial Radiology / September-December 2015 / Vol 3 | Issue 3
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Aykol, et al.: Accessory mental foramen
diagnostic tool.[12] However, offering only two-dimensional
(2D) images, inability to measure the bone width, distortions
in the horizontal plane, and magnifications in the vertical
plane are the limitations of this method. In addition, the
accuracy of the image depends largely on the experience
of the technician; accurate positioning of the patient is
also important.[13]
CBCT is a more effective tool for presurgical 2D
assessment of the neurovascular structures (such as MF
and its variations), than panoramic radiography.[6] CBCT is
specifically designed for 3D imaging of the maxillofacial
region. CBCT has better resolution with lower dose
radiation than CT. Clinicians can have an opinion about
anatomical volume acquisition with CBCT.[14] Implants
position and anatomical structures can be checked with
CBCT analysis. It gives exact linear measurements with
isotropic pixels, and metallic artifacts are significantly
reduced. It is commended tool in implantology due
to its 2D and 3D reconstruction possibilities. CBCT
is considered to be a gold standard for dental and
maxillofacial imaging.[15]
Conclusion
Detecting the variations of MF is important to avoid
complications such as paresthesia and hemorrhage before
implant surgery although AMF is a rare anatomical variation
of MF. Therefore, 3D imaging with CBCT is essential to
determine the anatomical structures anatomical variations.
Radiographic examination particularly 3D images can be
useful and help the clinicians for the treatment and surgical
plan.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Journal of Oral and Maxillofacial Radiology / September-December 2015 / Vol 3 | Issue 3
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