Dentomaxillofacial Radiology (2004) 33, 340—341 © 2004 The British Institute of RadioloB’

SHORT COMMUNICATION

Lingual vascular canals of the interforaminal region of the

mandible: evaluation with conventional tomography
H Liang*, NL Frederiksen and BW Benson

Department of Diagnostic Sciences, Division of Oral and Maxillofacial Radiology, Baylor College of Dentistry, Texas A&M
Universily System Health Science Center, Dallas, Texas, USA

The presence of lingual vascular foramina and canals in the interforaminal region may increase the risk of surgical complications
during implant placement, bone grafting procedures and osteodistraction. Oral and maxillofacial radiologists should recognize this
anatomical variant and include a description in their interpretative report to inform the referring clinician of the potential for
surgical complications. Dentomaxillofacial Radiology (2004) 33, 340—34 1. doi: 10. 1259/dmfr133787240

Keywords: lingual vascular canals; interforaminal region; conventional tomography

Endosseous implants are becoming a routine restorative dental procedure. The placement of dental
implants in the interforaminal region (the anterior region between the mental foramina) of the mandible
has been considered to be relatively safe because anatomical structures including the inferior alveolar
canal and submandibular fossa are located posterior to this region. However, clinicians should be aware
that even in this region there are anatomical structures that might compromise the placement of implants.
These include an anterior extension of the inferior alveolar canal, a pronounced lingual concavity, a
severe concavity of the lingual cortex and lingual vascular canals.

Perforation of the lingual plate and inferior border of the mandible have previously been considered to be
benign occurrences. This is often intentional in the presence of a severely atrophic ridge to gain maximum
bone-implant surface area retention.1 However, several studies have reported the occurrence of life-
threatening conditions caused by bleeding secondary to the placement of dental implants into the lingual
cortex of the interforaminal region because of the presence of accessory vascular canals.” 2 In a recent
review article, Kalpidis and Setayesh3 reported that 12 cases of severe haernorrhage in the floor of mouth
with subsequent life-threatening upper airway obstruction associated with implant placement in the
anterior portion of the mandible were found in the literature from 1986 to 2003. In addition, newer
augmentative techniques undertaken to gain bone volume, such as osteodistraction of the
anterior region of the mandible and orthognathic surgical procedures have a potential for vascular injury
and subsequent bleeding in the interforaminal region.4

The sublingual branch of the lingual artery and the submental branch of the facial artery are among the
primary nutrient vessels to the floor of the mouth. Anastomoses are formed between these vessels prior to
passage through accessory lingual foramina in the mandible into lingual vascular canals and anastomosis
with incisive branches of the inferior alveolar artery.3 Anatomical studies have demonstrated two common
locations for accessory lingual foramina: the lingual midline of the mandible and close to the lingual
midline of the mandible. These have been referred to as median lingual foramina and lateral lingual
foramina, respectively.4’5 McDonnell et alti reported median lingual foramina to be present in 311 of 314
dried mandibles (99%). They also reported that 49% of an adult population (100 patients) demonstrated
median lingual foramina on periapical radiographs of the mandibular incisor region. Tepper et a1 7 who
studied computed tomography (CT) images of 70 patients found that all showed at least one median or
lateral lingual accessory canal in the interforaminal region.

The incidence of lingual vascular canals in the interforaminal region has not yet been assessed using
conventional tomography. This might be attributed to the limitation of coverage by the image to a specific
area, the thickness of the image layer, or the orientation of the X-ray beam relative to the long axis of the
mandible.4 By comparison, CT normally scans the whole jaw, reformats thinner cross sectional sections,
and has the ability to reformat images using multiple angulations relative to the long axis of the mandible.
Recognition of the possibility for the presence of lingual vascular canals in conventional tomography is
important for both oral and maxillofacial radiologists and dentists who perform the implant procedures.
Reported here are two examples of lingual vascular canals in the interforaminal region. One is oriented
parallel to the plane of the cortical bone plate (Figure 1) and the other is perpendicular to this plane
(Figure 2). Although smaller canals with a diameter of less than 1 mm are unlikely to cause a problem,
larger canals should be described in the radiological report to alert the dentist to potential surgical
complications. In neither of these cases was there evidence of lingual vascular canals inthe panoramic
image. Both images are octospiral conventional tomograms acquired on a Scanora imaging unit
(Soredex/General Electric, Milwaukee, WI). Layer thickness was 4 mm.

The presence of lingual vascular foramina and canals in the interforaminal region may increase the risk of
surgical complications during implant placement, bone grafting procedures, and osteodistraction. Oral and
maxillofacial radiologists should recognize this anatomical variant and include a description in their
interpretative report to inform the referring clinician of the potential for surgical complications.
 Figure 1 Cross-sectional image located in the right second premolar area showing a lingual vascular canal parallel
with the cortical plate (arrowhead) slightly anterior to the mental foramen (arrow)

Figure 2 Cross-sectional image located in the left edentulous premolar area showing a lingual vascular canal
perpendicular to the cortical plate (arrow)

References
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http://dmfr.birjournals.org
*Col.respondence to: Dr Hui Liang, Department of Diagnostic Sciences, Baylor College of Dentistry/TAMUSHSC, P.O. Box 660677,
Dallas, TX 75266-0677, USA; E-mail: hliang@bcd.tamhsc.edu
Received 8 April 2004; accepted 12 August 2004