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      Predictive factors of the dimensions and location of mental foramen using cone beam computed tomography

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          Abstract

          Objective

          The mental foramen (MF) hosts main neurovascular structures, making it of crucial importance for surgical procedures. This study aimed to analyze the factors influencing the dimensions and location of the MF.

          Materials and methods

          Cone beam computed tomography (CBCT) scans of 344 patients were examined for MF dimensions, as well as for the distances from the MF to the alveolar crest (MF-MSB), and to the inferior mandibular border (MF-MIB).

          Results

          Gender, mandibular side and presence of accessory mental foramina (AMF) significantly influence MF area. Males, left hemimandibles, and hemimandibles with no AMF had a higher rate of large MF areas (B = − 0.60; p = 0.003, females; B = 0.55; p = 0.005; B = 0.85; p = 0.038). Age, gender and dental status significantly influence MF-MSB distance. The distance decreased as age increased (B = −0.054; p = 0.001), females showed a lower rate of long MF-MSB distances (B = −0.94, p = 0.001), and dentate patients showed a higher rate of long MF-MSB distances (B = 2.27; p = 0.001). Age, gender and emerging angle significantly influenced MF-MIB distance. The distance decreased as age and emerging angle increased (B = −0.01; p = 0.001; B = −0.03; p = 0.001), and females had a lower rate of long MF-MIB distances (B = −1.94, p = 0.001).

          Conclusions

          General and local factors influence the dimensions and location of MF. MF dimensions are influenced by gender, mandibular side, anteroposterior position, and the presence of AMF. Distance from MF to alveolar crest is influenced by gender, age and dental status, while the relative MF position is influenced by age and dental status. CBCT images make it possible to analyze the MF in order to avoid complications during surgical procedures.

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          Most cited references49

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          The mental foramen and nerve: clinical and anatomical factors related to dental implant placement: a literature review.

          The mental foramen is a strategically important landmark during osteotomy procedures. Its location and the possibility that an anterior loop of the mental nerve may be present mesial to the mental foramen needs to be considered before implant surgery to avoid mental nerve injury. Articles that addressed the position, number, and size of the mental foramen, mental nerve anatomy, and consequences of nerve damage were evaluated for information pertinent to clinicians performing implant dentistry. The mental foramen may be oval or round and is usually located apical to the second mandibular premolar or between apices of the premolars. However, its location can vary from the mandibular canine to the first molar. The foramen may not appear on conventional radiographs, and linear measurements need to be adjusted to account for radiographic distortion. Computerized tomography (CT) scans are more accurate for detecting the mental foramen than conventional radiographs. There are discrepancies between studies regarding the prevalence and length of the loop of the mental nerve mesial to the mental foramen. Furthermore, investigations that compared radiographic and cadaveric dissection data with respect to identifying the anterior loop reported that radiographic assessments result in a high percentage of false-positive and -negatives findings. Sensory dysfunction due to nerve damage in the foraminal area can occur if the inferior alveolar or mental nerve is damaged during preparation of an osteotomy. To avoid nerve injury during surgery in the foraminal area, guidelines were developed based on the literature with respect to verifying the position of the mental foramen and validating the presence of an anterior loop of the mental nerve. These guidelines included leaving a 2 mm zone of safety between an implant and the coronal aspect of the nerve; observation of the inferior alveolar nerve and mental foramen on panoramic and periapical films prior to implant placement; use of CT scans when these techniques do not provide clarity with respect to the position of the nerve; surgical corroboration of the mental foramen's position when an anterior loop of the mental foramen is suspected of being present or if it is unclear how much bone is present coronal to the foramen to establish a zone of safety (in millimeters) for implant placement; once a safety zone is identified, implants can be placed anterior to, posterior to, or above the mental foramen; and prior to placing an implant anterior to the mental foramen that is deeper than the safety zone, the foramen must be probed to exclude the possibility that an anterior loop is present. In general, altered lip sensations are preventable if the mental foramen is located and this knowledge is employed when performing surgical procedures in the foraminal area.
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            Morphometric analysis of implant-related anatomy in Caucasian skulls.

            Sequelae related to implant placement/advanced bone grafting procedures are a result of injury to surrounding anatomic structures. Damage may not necessarily lead to implant failure; however, it is the most common cause of legal action against the practitioner. This study aimed to describe morphological aspects and variations of the anatomy directly related to implant treatment. Morphometric analyses were performed in 22 Caucasian skulls. Measurements of the mental foramen (MF) included height (MF-H), width (MF-W), and location in relation to other known anatomical landmarks. Presence or absence of anterior loops (AL) of the inferior alveolar nerve (IAN) was determined, and the mesial extent of the loop was measured. Additional measurements included height (G-H), width (G-W), thickness (G-T), and volume (G-V) of monocortical onlay grafts harvested from the mandibular symphysis area, and thickness of the lateral wall (T-LW) of the maxillary sinus. The independent samples t test, and a two-tailed t test with equal variance were utilized to determine statistical significance to a level of P < 0.05. Multiple regression analyses were performed to determine if each one of these measurements was affected by age and gender. The most common location of the MF in relation to teeth was found to be below the apices of mandibular premolars. The mean MF-H was 3.47 +/- 0.71 mm and the mean MF-W was 3.59 +/- 0.8 mm. The mean distance from the MF to other anatomical landmarks were: MF-CEJ = 15.52 +/- 2.37 mm, MF to the most apical portion of the lower cortex of the mandible = 12.0 +/- 1.67 mm, MF to the midline = 27.61+/- 2.29 mm, and MF-MF = 55.23 +/- 5.34 mm. A high prevalence of AL was found (88%); symmetric occurrence was a common finding (76.2%), with a mean length of 4.13 +/- 2.04 mm. The mean size of symphyseal grafts was: G-H = 9.45 +/- 1.08 mm, G-W = 14.5 +/- 3.0 mm, and G-T = 6.15 +/- 1.04 mm, with an average G-V of 857.55 +/- 283.97 mm3 (range: 352 to 1,200 mm3). The mean T-LW of the maxillary sinus was 0.91 +/- 0.43 mm. Implant-related anatomy must be carefully evaluated before treatment due to considerable variations among individuals, in order to prevent injury to surrounding anatomical structures and possible damage.
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              Morphological variation in great ape and modern human mandibles.

              Adult mandibles of 317 modern humans and 91 great apes were selected that showed no pathology. Adult mandibles of Pan troglodytes troglodytes, Pongo pygmaeus pygmaeus and Gorilla gorilla gorilla and from 2 modern human populations (Zulu and Europeans from Spitalfields) were reliably sexed. Thirteen measurements were defined and included mandibular height, length and breadth in representative positions. Univariate statistical techniques and multivariate (principal component analysis and discriminant analysis) statistical techniques were used to investigate interspecific variability and sexual dimorphism in human and great ape mandibles, and intraspecific variability among the modern human mandibles. Analysis of interspecific differences revealed some pairs of variables with a tight linear relationship and others where Homo and the great apes pulled apart from one another due to shape differences. Homo and Pan are least sexually dimorphic in the mandible, Pan less so than Homo sapiens, but both the magnitude of sexual dimorphism and the distribution of sexually dimorphic measurements varied both among and between modern humans and great apes. Intraspecific variation among the 10 populations of modern humans was less than that generally reported in studies of crania (74.3% of mandibles were correctly classified into 1 of 10 populations using discriminant functions based on 13 variables as compared with 93% of crania from 17 populations based on 70 variables in one extensive study of crania). A subrecent European population (Poundbury) emerged as more different from a recent European population (Spitalfields) than other more diverse modern populations were from each other, suggesting considerable morphological plasticity in the mandible through time. This study forms a sound basis on which to explore mandibular variation in Neanderthals, early Homo sapiens and other more ancient fossil hominids.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ResourcesRole: Writing – original draftRole: Writing – review & editing
                Role: MethodologyRole: Validation
                Role: Project administrationRole: ResourcesRole: SupervisionRole: Visualization
                Role: Formal analysisRole: Validation
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                17 August 2017
                2017
                : 12
                : 8
                : e0179704
                Affiliations
                [1 ] Department of Surgery and Surgical Medical Specialties, Santiago de Compostela University, Santiago de Compostela, A Coruña, Spain
                [2 ] Department of Psychiatry, Radiology and Public Health, Santiago de Compostela University, Santiago de Compostela, A Coruña, Spain
                [3 ] Department of Morphological Sciences, Santiago de Compostela University, Santiago de Compostela, A Coruña, Spain
                [4 ] Department of Organizational Psychology, Forensic Law, and Methodology of Behavioral Sciences, Santiago de Compostela University, Santiago de Compostela, A Coruña, Spain
                [5 ] Department of Surgery and Medical Surgical Specialties, Medicine and Dentistry School, University of Santiago de Compostela, Spain, Health Research Institute of Santiago (IDIS), Santiago de Compostela, Spain
                Medical University of South Carolina, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist

                [¤]

                Current address: Medicine and Dentistry School, Santiago de Compostela University, Rúa Entrerríos, Santiago de Compostela, A Coruña, Spain

                ‡ These authors also contributed equally to this work.

                Article
                PONE-D-16-29246
                10.1371/journal.pone.0179704
                5560523
                28817595
                db07769f-4df7-4ca4-9be9-8abdf2f777a3
                © 2017 Muinelo-Lorenzo et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 21 July 2016
                : 8 May 2017
                Page count
                Figures: 5, Tables: 4, Pages: 16
                Funding
                The authors have no support or funding to report
                Categories
                Research Article
                Biology and Life Sciences
                Anatomy
                Digestive System
                Teeth
                Molars
                Medicine and Health Sciences
                Anatomy
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                Teeth
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                Surgical and Invasive Medical Procedures
                Biology and Life Sciences
                Anatomy
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                Medicine and Health Sciences
                Anatomy
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                Research and Analysis Methods
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                Dental Implant Surgery
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