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MANDIBULAR CANAL RADIOGRAPHIC INTERPRETATION IN PANORAMIC RADIOGRAPHS * INTERPRETAO RADIOGRFICA DO CANAL MANDIBULAR EM RADIOGRAFIAS PANORMICAS

Tiago Palloni VALARELLI ** Ana Lcia LVARES-CAPELOZZA *** Clvis MARZOLA **** Joo Lopes TOLEDO-FILHO **** Mrcia Juliani VILELA-SILVA *****

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* Work presented as monograph for conclusion of the Course of Residence in Surgery and Traummatology Buco maxillofacial, promoted for the Brazilian College of Surgery and Traummatology Buco maxillofacial and Base Hospital of the Hospital Association of Bauru. ** Former Resident in Surgery and Traummatology Buco maxillofacial, promoted for the Brazilian College of Surgery and Traummatology Buco maxillofacial and Base Hospital of the Hospital Association of Bauru. Author of the monograph. *** Associate Teacher of the College of Dentistry of Bauru of the USP and person who orientates of the monograph. ***** Titular Professor of Buco maxillofacial Surgery and Traummatology of the College of Dentistry of Bauru of the USP, pensioner, professor of the Course and collaborator of the work. **** Titular Professor of Anatomy of the College of Dentistry of Bauru of the USP, professor of the Course and co-person who orientates of the work. ***** Collaborating of the work.

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ABSTRACT
The purpose of the present study was to assess the prevalence of bifurcations and the positioning of the mandibular canal in panoramic radiographs. The study was accomplished starting from the interpretation of four hundred panoramic radiographs using the classifications (NORTJ et al., 1977 and LANGLAIS et al., 1985). The results show that in 12,75% of the observed images, there was some bifurcation type in the mandibular canal. Regarding the position of the mandibular canal in relation to the mandibular base and the radicular apices of the lower teeth, we found high bilateral canal in 32,5% of the images, 28,25% of intermediate canal, 0,25% of low bilateral canal and 27,25% with some variation. The panoramic radiograph is an important auxiliary resource in diagnosis and treatment plan of the dental anomalies and pathologies involving the mandibular canal, because it allows the evaluation of its anatomy and anatomical variations, reducing the failure risk in invasive o non-invasive interventions in the mandibular bone.

RESUMO
Nosso trabalho tem como objetivo avaliar a prevalncia de bifurcaes e o posicionamento do canal mandibular em radiografias panormicas. O estudo foi realizado a partir da interpretao de quatrocentas radiografias panormicas utilizando classificaes j descritas (NORTJ et al., 1977 e LANGLAIS et al., 1985). Os resultados mostraram que em 12,75% das imagens observadas, havia algum tipo de diviso no canal mandibular. Quanto posio do canal mandibular em relao base mandibular e aos pices radiculares dos dentes inferiores, foram encontrados em 32,5% das imagens canais bilaterais altos, 28,25% de canais intermedirios, 0,25% de canais bilaterais baixos e, 27,25% com alguma variao. A radiografia panormica um recurso auxiliar importante no diagnstico e plano de tratamento das anomalias dentrias e patologias que envolvam o canal mandibular, pois permite a avaliao da anatomia e das variaes anatmicas do canal mandibular, diminuindo o risco de insucesso nas em intervenes, invasivas ou no, no osso mandibular. Uniterms: Mandibular canal; Panoramic radiograph; Lower alveolar nerve. Unitermos: Canal mandibular; Radiografia panormica; Nervo alveolar inferior.

INTRODUCTION
The mandibular canal is located inside the jaw and transmits the lower alveolar artery and lower alveolar nerve, a branch of the third division of the trigeminal nerve, from the mandibular foramen to the mentual foramen (BERBERI et al., 1994 and MADEIRA, 1995). This plexus emits branches that supply the lower teeth and the adjacent bone tissue, interdentally papilla, periodontium, lower lip, anterior buccal mucosa to the mentual foramen and vestibular gingival of the anterior lower teeth (HEASMAN, 1988 and MADEIRA, 1995). The radiographic appearance of the mandibular canal is characterized by a radiolucent line delimited by two radiopac lines (WORTH, 1975), usually as a single and bilaterally symmetrical structure, it can assume different positions inside

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the body of the mandible, both super inferiorly and mediolaterally (STELLA; THARANON, 1990). Moreover, it can present duplications or bifurcations in its course (NORTJ et al., 1977) and in some cases is possible to find a trifid mandibular canal (AULUCK; KEERTHILATHA, 2005). The knowledge of the mandible anatomy as well the lower alveolar nerve course through the mandible canal is of great importance for the dental surgeons, especially those planning to perform orthognatic surgeries, mandibular reconstructions, lower third molar exodontics or the placement of dental implants (TOLEDO-FILHO; MARZOLA; TOLEDO-NETO, 1998 and SANCHIS; PEARROCHA; SOLER, 2003). The non knowledge of the anatomical variations of the mandibular canal can result in local anesthesia failure and even limit the use of some surgical techniques. The intention of this work is: 1. To evaluate the passage of the lower alveolar nerve in the interior of the mandibular bone through panoramic x-ray. 2. To observe the prevalence of its variations in patients of the city of Bauru as classifications proposal (NORTJ; FARMAN; GROTEPASS, 1977 and LANGLAIS; BROADUS; GLASS, 1985).

LITERATURE REVIEW
It was dissected 18 mandible corpse had found a canal that if it originates from the mandibular canal finishing in the retromolar foramen or surrounding foramina, called of canal to retromolar in 72% of these. The authors had observed that this canal gives ticket to a mielinizaded nerve and to one or more arterioles and venues. They had concluded thus, that the great prevalence of retromolar canal must it the crossed marriage of Argentine Europeans with aborigines (SCHEITMANN; WORSHIPPER; ARIAS, 1967). With the objective to determine the passage covered for the lower alveolar nerve in the interior of the mandibular body, eight mandibles with the muscles of the chew had been dissected still adhered. Three types of passage had been described: Type 1 (6 of 8; 75%), where the lower alveolar nerve passes very next to the dental apexes that if they inside project for of the mandible canal; Type 2 (1 of 8; 12,5%), where the lower alveolar nerve has its next passage the mandibular base, of this form the main branch of the nerve emit small beams that penetrate the radicular apexes and; Type 3 (1 of 8; 12,5%), where they had observed a ramification of the main branch that innerve the posterior region of the mandible while a more lower branch covers the mandibular body reaching the anterior region. The only mandibular canal was observed in 49 (61,25%) of the 80 x-rays, with the well next dental apexes exactly (Type 1). In 11 (13,75%) of the 80 x-rays, the canal met moved away from the dental apexes, however with the posterior wall of the corticalized canal more less; in 20 (25%) x-rays it did not have definition of the mandibular canal (CARTER; KEEN, 1971). It was observed and described a mandible with multiple accessory foramens to the mandibular foramen in bilateral mandibular branch. The authors had used radiopacs straps to evaluate in radiographic taking, the passage of each foramen, being noticed that to leave of these intra-bones canals were initiated that

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some times presented bifurcations in its passage, being able to offer then to enervation to teeth and underlying structures (BARCKER; LOCKETT, 1972). Imperfection in the regional blockade of the lower alveolar, buccal and lingual nerves to three factors was attributes to the deposition of the lower anesthetically solution to the mandibular foramen; of supplemental enervation for the nerves myloioydeus and, possibly of the cutaneous insufficient deposition and auricular temporal, presence nerve the neck, finally, of anesthetic. The author developed one alternative technique for mandibular anesthesia, using extra-buccal points of reference, searching the deposition of the anesthetically solution in the neighborhoods of the oval foramen, where the mandibular nerve emerges (GOWGATES, 1973). A report of case illustrated with the radiographic image of the duplication of the mandibular canal was presented and the authors had stranded out that anatomical variations of this type can cause problems in anesthesia for regional blockade of the lower alveolar nerve, questioning still the possibility of the presence of a ridge myloioydeus deep to confer such image (KIERSCH; JORDAN, 1973). By the comment of the panoramic x-ray of a patient, white of thirty years of age, was noticed the presence of two distinct mandibular canals, breaking of mandibular foramen right and, having its passage for the branch and mandibular body, finishing in two separate mentuals foramens. The authors had not observed alterations of left side (PATTERSON; FUNKE, 1973). It was examined 300 human corpse mandibles consisting the presence of accessory foramina for where they can came to pass sensitive staple fibers you add. The author relates the presence of such foramina with the imperfection in the attainment of the analgesia from the job of classic anesthetically techniques and, moreover, proves the clinical importance of this comment through the study of anesthetically techniques in 130 patients, suggesting some variations for the same ones (SUTTON, 1974). The interruption of the sanguineous circulation through the lower alveolar nerve quickly is supplied by the establishment of a retrograde circulation, mainly for the mental artery and mandibular branch of the sublingual artery was noted. The authors had not observed any microscopically change for the interruption of the sanguineous flow, noticing, however, temporary regressive changes in the dental pulp of the molar ones of the affected side (CASTELLI; NASJLETI; DIASPRES, 1975). With the objective to determine the prevalence of accessory foraminas in mandible, as well as its diameter and localization, 150 corpse mandibles had been evaluated of adult human beings, in the region of molar, being identified 5332 foraminas (average of 36 foramina for mandible) that, they had been attributed to the vascular and/or nervous supplement of mandible (HAVEMAN; TEBO, 1976). To evaluate the success in the anesthesia of lower teeth through the regional blockade of the lower alveolar, buccal and lingual nerves, was made a study of 331 cases and observed imperfection in the analgesia in 79 (23,87%), being necessary the extra infiltration of anesthetic in 72 (21,75%) of these cases, persisting the imperfection in 7 cases (2,1%). With this study the author concluded that the basic concept of that the pulpar enervation of mandibular teeth proved only of staple fibers of the lower alveolar nerve must be coats, suggesting that nervous staple fibers happened of all the divisions of the mandibular nerve and still cervical myloioydeus

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nerve and plexus can contribute for the sensitivity of the mandibular dental elements (ROOD, 1976). Based in a study with 3612 panoramic x-rays without mandibular traumas or pathological conditions that could affect the normal passage of the lower alveolar nerve, the passage in 4 types was classified, using as reference the lower edge of the mandible and the dental apexes, in: Type 1 (46,7%), single channels and high bilateral; Type 2 (3,3%), single channels and intermediate bilateral; Type 3 (48,9%), single channels and low bilateral; Type 4 (0,9%), other variations, as duplications or divisions of mandibular canal (NORTJ; FARMAN; GROTEPASS, 1977). A technique of regional blockade of the lower alveolar, buccal and lingual nerves, faster in the aesthetical induction, less painful, being able to be carried through in patients presenting limitation of buccal opening was developed (AKINOSI, 1977). After the interpretation of 3612 panoramic x-rays, had concluded that normally the mandibular canal is only symmetrical and bilaterally. However, three variations of normality can be observed, thus considering a classification: Type 1, two canals if originating from the same foramen; Type 2, a small additional canal if extending until the region of second or third molar and; Type 3, two mandibular canals originating from two distinct foraminas and joining themselves in region of molar, mandibular body, to form an only canal (NORTJ; FARMAN; JOUBERT, 1977). A study from gotten histological material in the archives of the Oral Department of Pathology of the University of Stellenbosch and, of panoramic x-rays, observing the pathological conditions that affected the radiographic appearance of the mandibular canal was made. The authors had concluded that benign cysts and neoplasias generally cause displacement of the canal, but its cortical they remain unbroken, while that in the severe infections or the cases of malignant tumors occurs an irregular erosion of the bone with disappearance of the radiographic aspect of the sclerotic lines of the canal (FARMAN; NORTJ; GROTEPASS, 1977). It was attributed imperfections in the mandibular blockade to the crossed enervation of the mandible, contribution of the enervation especially for lingual, milohyoideo and buccal nerves and, still, to the insufficient deposition of aesthetical solution (ROOD, 1977). The mandibles of a Caucasian adult corpse, of approximately 30 years, probably of the feminine sort, observed an accessory foramen in the retromolar region, immediately behind the third molar and bilateral one was examining. The author suggested the possibility of the emergency nervous staple fibers for this foramen that would previously sensitize the region and some teeth made use to its emergency (CASEY, 1978). To demonstrate that the presence of multiple mandibular canals is not a rare situation, but yes unknown 1024 panoramic x-rays had been interpreted finding in 85 (8,3%) occurrences of this anatomical variation. The authors point out the importance of the knowledge of the double mandibular canals related to the forensic dentistry, especially in the identification of bodies of people edentulous (DURST; SNOW, 1980). It was observed 122 corpse mandibles finding a foramen in the lingual region in the premolar area in 68,9% of these. The authors attribute to this foramen, the enervation made for the myloioydeus nerve or the cutaneous nerve of the neck,

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considering still the hypothesis of that this repair can be only one great nutritional canal (CHAPNICK, 1980). SINGH (1981) was come across during the extraction of one lower third molar, with a nervous branch that left the mandible, through a small foramen in retromolar fosse distant 5 mm of the distal face of the tooth. Through the histological confirmation the author concluded to be about a nerve, having the patient presented later, paresthesia of mandibular the deep mucosa and of ridge, since the retromolar region until the region of tooth of the operated side. Tests of vitality of inferior teeth had not shown to alterations, leading the authors to the conclusion that if dealt with a ramification of the buccal nerve. In a panoramic x-ray of a man of 29 years of age, carrier of syndrome of Down, a bending radiolucid structure, in form of canal, ramified upper to the left mandibular canal to the height of the distal crest of as the molar one was observed. After the accomplishment of other radiographic taking, using different techniques, and detailed physical examination, the authors had concluded that cited variation was about a ramification of the lower alveolar nerve and mandibular canal (MADER; KONZELMAN, 1981). The interpretation of 5000 panoramic x-rays of conscripts of the army of the United States was carried through, observing it prevalence of 0,08% of bifid mandibular canals (4 cases). The authors point such anatomical variation as a possible cause of the imperfection in the regional blockade of lower alveolar nerve (GROVER; LORTON, 1983). Clinical case of a patient of the masculine sort, caucasian, 54 years of age, presenting bifurcation of the bilateral lower alveolar nerve was publish (BYERS; RATCLIFF, 1983). A study with 6000 panoramic x-rays evidencing the bifurcation of the mandibular canal in 57 (0,95%) of these, had carried through. The authors had in accordance with classified such occurrences in 4 types the anatomical localization and configuration of the canal, being: Type 1 (0,367%), bifurcation I joined or bilateral extending itself for region of third molar or adjacencies; Type 2 (0,517%), bifurcation I joined or bilateral extending the long one to it of the main canal and if they again join in branch or mandibular body; Type 3 (0,0333%), a combination of the two first categories, being Type 1 of a side of the mandible and Type 2 of the other side; Type 4 (0,0333%), two canals originating of two distinct foramens, if joining to follow to form an only wide and mandibular canal (LANGLAIS; BROADUS; GLASS, 1985). A study involving 2391 jaws and noticed the occurrence of 40 cases with a canal in the retromolar region which called canal of the temporal crest was presented. The author standees out the possibility of these staple fibers to contribute for the sensitive enervation of the molars and adjacent region being able to result in imperfection in local anesthesia attainment through of the usual technique of the lower alveolar, buccal and lingual blockade nerves (OSSENBER, 1986). With the objective to evaluate the relation radiculars of the first one enters the apexes and lowers second molar and the upper edge of the mandibular canal, besides establishing the localization of the canal in the direction vestibulelingual and vertical line in relation, had been radiographed 46 mandibles. The authors had especially stranded out the importance of the work for the professionals who carry through endodontics and surgical procedures, due to great amount of

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accidents involving the mandibular canal in these treatments (LITTNER et al., 1986). A radiographic study with 96 mandibles using classification proposal (NORTJ; FARMAN; GROTEPASS, 1977) for determination of the height of the mandibular canal, having the dental apexes and the lower mandibular edge as control points, observed a prevalence of 67,7% of the samples as being of type 3 (intermediate), 15.6% of type 1 (high), and 5.2% of type 2 (low). The classified samples as type 4 (variations) were gifts in 11,5% of the total (HEASMAN, 1988). A study comparing the information gotten between radiographic, tomography and macroscopic images were carried through in four specimens of mandibles. The authors had concluded that the image most trustworthy for the planning of procedures involving the next area to the mandibular canal was that one gotten by Computerized Cat scan (KLINGE; PETERSSON; MALY, 1989). The panoramic x-ray with the computerized cat scan of 15 patients in the localization of the mandibular canal had compared. The authors had concluded that the Computerized Cat scan better got performance in the localization of the mental foramen and the mandibular canal in the distant region 1 cm in the posterior direction to exactly, however, significant differences between the techniques studied in the mensurations carried through in the 2 cm posterior to the mental foramen had not been observed (LINDH; PETERSSON, 1989). Bifurcation in mandibular canal due to suggestive image in panoramic x-ray and had confirmed this finding through the image gotten for Computerized Cat scan ha suspected (QUATRONE; FURLINI; BIANCIOTTO, 1989). The radiographic image of a unilateral bifurcation of the distal mandibular canal the area of the third molar one was noted. The author stranded out the necessity of the planning adjusted, for the localization of the mandibular canal, which had preoperative to such variations (DRISCOLL, 1990). A study to determine the incidence of the some mandibular channel types and its relation with the sort of the patients, had carried through, being used 700 panoramic. In the present study only three cases of bifid mandibular canal had been found and significance was not observed statistics between sorts, beyond the mandibular channel type (ZOGRAFOS; KOLOKOUDIAS; PAPADAKIS, 1990). A necessary method for localization of the mandibular canal was developed. For the authors they had in such a way used eight jaws edentulous of adult corpses, of which images for Computerized Cat scan had been gotten and after the analysis of the results, had concluded that the mandibular canal exclusively assumes lingualized position the 1 and 2 cm in posterior direction to the mental foramen, predominantly lingualized to 3 cm posterior to exactly and 0 variable in the height of the foramen and 4 cm posterior to this (STELLA; THARANON, 1990). GRNDAHL et al., (1991) had in the distance evaluated the trustworthiness of the gotten images of hypocycloidal cat scans, measuring vertical between the alveolar crest and the superior edge of the mandibular canal. For 40 cat scans of patients had been in such a way used, and the measures made for six appraisers (three radiologists and three buco maxillofacial surgeons). The study it showed a great variation in the mensurations between observers. The authors had suggested that, in clinical environment, the images are interpreted for more than a professional or that the gotten values are compared with the finding supplied for the radiology services, in order to minimize the probability of errors due to the mensuration imperfections.

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An anatomical study of neurovascular plexus of the lower alveolar nerve using 3 human corpse parts had carried through. The authors had observed that plexus, also called "trunk" are not individual and, yes a system of mesh of nerves, some very fine, branching off inside of its course in the mandibular canal. They had still observed the existence of as "plexus" between the mandibular and the dental roots, composed canal of micron-filaments that penetrate the same ones through its lateral face or its apexes (ZOUD; DORAN, 1993). It was evidenced an anatomical variation of the mandibular canal in one of its patients through the evaluation of panoramic x-rays and cat scan computerized with axial and coronal cuts. The authors had noticed the presence of two mandibular canals separate and overlapped of the right side of the mandible, originating from an only foramen (BERBERI; MANI; NASSEHY, 1994). A study comparing the precision of the x-rays: Periapical, Panoramic and Cat scan Computerized in the localization of the mandibular canal, had carried through. For in such a way, the authors had used an acrylic resin plate with markers of guta percha and a human corpse jaw, and had gotten an average distortion of 1.9 mm (14%), 3,0 mm (23,5%) and 0,2 mm (1,8%) respectively (SONICK; ABRAHAMS; FAIELLA, 1994). The presence of a canal to retromolar bilateral in a patient with 47 years of age had described. The authors had presented a quarrel on the nature and distribution of the elements of the canal of the left side and had pointed out the risks and consequences of injuries to such structure (KODERA; HASHIMOTO, 1995). The bilateral duplication of the mandibular canal in a panoramic x-ray of a patient, edentulous, of 33 years of age had observed. The authors affirm that the patient told to relate of unsatisfactory anesthesia during surgical procedure in both the sides of the mandible (FREDEKIND; SCHIFF, 1995). Four possibilities for the failure of the anesthesia of the mandible, amongst them was publish in a article telling: contribution of sensitive enervation for the milohioideus nerve; bifid mandibular nerve; retromolar foramen and; contralateral enervation of anterior teeth. The authors present, still, the solutions to skirt the cited variations and warn that the surgeon-dentists must know all the anatomical variations of the area to be worked as well as different aesthetical techniques for attainment of mandibular blockade (DESANTIS; LIEBOW, 1996). A pioneering study with the objective to describe the prenatal formation of the human mandibular canal had developed. The authors suggest the hypothesis of that the lower alveolar nerve this gift probably in the jaw as three different nervous pursuing originating in different periods of training of embryonic development and that fast prenatal growth and, the remodeling of the region of the branch results in a gradual coalescence of the entrances of the canals, what he is obvious to the birth (CHVEZ-LOMELV et al., 1996). With the objective to alert to the surgeon-dentists for the possible existence of accessory mandibular canals and its implications, told the case of a patient of 23 years of age, masculine sort, black race, that showed, in its panoramic x-ray, the image of a similar structure to a canal, superior to the mandibular canal. This canal if extended of the mandibular branch until the molar distal face of the impacted third molar, to the height of the junction cement has enameled of the cited dental element. The patient was submitted the surgical procedure for removal of the impacted tooth, and told a brief period of postoperative paresthesia in the region (WYATT, 1996).

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A morfometric study of the mandible human being using itself 60 hemi mandibles, carried through, parting them in 9 fragments of 7 mm from the mental foramen, observing the thicknesses of the mandibular bone boards external intern and, alveolar ridge, internal and external basal ridge, diameters of the mandibular canal as well as the distances and thicknesses related to this (TOLEDOFILHO; MARZOLA; TOLEDO-NETO, 1998). A clinical case of accessory canal mandibular bilateral, observed from images gotten in Panoramic x-ray and Computerized Cat scan, followed for a revision of excellent literature, had published. The authors conclude that the Computerized Cat scan presents advantages in the detention of anatomical variations in the mandible when compared the panoramic x-ray (KAUFMAN; SERMAN; WANG, 2000). The occurrence of the bifurcations and the positioning of the mandibular canal had been described in 650 panoramic x-rays. Using the classification the proposal (NORTJ; FARMAN; GROTEPASS, 1977 and LANGLAIS; BROADUS; GLASS, 1985) the authors had observed 41.83% of high bilateral canals, 32.09% of intermediate bilateral canals, 3.44% of low bilateral canals and 22.64% presenting other variations. Between these last ones, 17.72% showed bilateral asymmetries, 30.38% presented bifid canals in dentate, 34.18% edentate bifid canals in and 17.72% partial absence of the image of the canal (DEVITO; TAMBURS, 2001). Alert for the possibility of bifurcation of the mandibular canal and the importance of a planning preoperative detailed in the surgeries for installation of bone integrated implantations was made. In the initial surgical planning, made from a panoramic x-ray, the installation of two implantations measuring 13 mm in the posterior region of mandible, being modified the length of the implantation for 10 mm would be carried through after the accomplishment of the Computerized Cat scan (DARIO, 2002). It was analyzed 2012 panoramic x-rays in the determination of the incidence and the characteristics of the bifid mandibular canals. 7 (0,35%) images suggestive of bifid canal had been found, all in women. In tomography examination bifid canals in 2 of the 3 studied cases had been confirmed (SANCHIS et al., 2003). The presence of trifid mandibular canal, unilateral, of the left side, observed from a panoramic x-ray of a patient with 48 years of age was verified. The authors affirm that they do not exist you evidence of similar cases in world-wide literature (AULUCK; KEERTHILATHA, 2005). The clinical case of a patient of 19 years of age, presenting two mandibular canals of the right side originating from distinct mandibular foramens and finishing in separate foramens was verified. Justified for the fact not to have similar stories in literature, the authors suggest the classification of this variation in a new subdivision (CLAEYS; WACKENS, 2005).

MATERIAL AND METHODS

Four hundred panoramic radiographs of consecutive patients, ranging from 8 to 75 years of age, were used in this study. The panoramic radiographs were drawn manually on a translucent paper aided by an illuminator supplied with two fluorescent lamps of 15 watts each and a black mask around the radiographs in an

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environment with appropriate luminosity. The draws included the condyles, lower molars, mandibular and mental foramens, mandibular canal and mandibular base. All draws were analyzed by two observers and the classification proposed (NORTJ et al., 1977) was used, regarding the permanent lower second molar and, in its absence, the inferior first molar. The mandibular canal was then classified in 4 types: Type 1: Bilateral single high mandibular canals - single canals either touching or within 2 mm of the apices first and second permanent molars. Type 2: Bilateral single intermediate mandibular canals single canals not fulfilling the criteria for either high or low canals. Type 3: Bilateral single low mandibular canals, single canals either touching or within 2 mm of the cortical plate of the lower border of the mandible. Type 4: Variations including: asymmetry, duplications and absence of mandibular canal. In radiographs where bifurcated canals were found, and the classification proposed (LANGLAIS et al., 1985) was used (Figure 1).

Figure 1 The classification proposed (LANGLAIS et al., 1985).

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RESULTS
Of the 400 interpreted panoramic radiographs, 150 (37,50%) belonged to male patients and 250 (62,50%) to female patients. Bifid mandibular canals were found in 51 radiographs, a prevalence of 12,75%. Of this total, 13 (25,50%) in men and 38 (74,50%) in women. During the canal height canal analysis 47 (11,75%) radiographs were excluded due to uni or bi-lateral absence of teeth. There were 130 (32,5%) radiographs classified as Type 1, 113 (28,25%) as Type 2, and only 1 (0,25%) as Type 3. In the cases where asymmetry in the height of canals or bifurcations were observed, it was classified as Type 4, totalizing 109 (27,25%) radiographs (Graphic 1). The data were analyzed in a descriptive way.

400 350 300 250 Number of 200 cases 150 100 50 0

353

130

113 1

109

Type 1

Type 2

Type 3

Type 4

Total

Classification

Graphic 1 - Height variation of the mandibular canal.

The Type 1 bifurcations were present in 21 radiographs which 3 of them belonged to men and 18 to women. The larger number of bifurcations was verified on the right side of the mandible (17 radiographs) against 2 occurrences on the left side and 2 occurrences bilaterally. The radiographs presenting Type 1 bifurcations represented 5,25% of the total number of studied radiographs and 41,17% of the bifid mandibular canal cases. The Type 2 bifurcations were observed in 24 radiographs being 8 in men and 16 in women, occurring 17 times on the right side and 5 on the left side. In the 2 remaining radiographs the bifurcations happened bilaterally and represented 6,0% of the total number studied and 47,05% of the cases presenting bifid mandibular canals. No Type 3 bifurcation was found in this study. The Type 4 bifurcations were observed in 6 radiographs from women (3 on the right side, 1 on the left side and 2 bilaterally).

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The radiographs containing bifurcations of the Type 4 totaled 1,50% of the cases and 11,76% of the cases presenting bifid mandibular canals. The Graphic 2 illustrates the results observed for the bifurcation of the mandibular canals according to the classification of LANGLAIS et al., (1985). No significant difference in the prevalence of mandibular canal bifurcation related to the age group was seen in this study (Table 1).

Type 1 unilateral Type 1 bilateral Type 2 unilateral Type 2 bilateral Type 4 unilateral Type 4 bilateral Total 0

19 2 22 2 4 2 51

10

20

30

40

50

60

Number of cases

Graphic - 2. Bifurcation of the mandibular canal.

Tabela 1 - Canal mandibular bifid prevalence.

Age 0a9 10 a 19 20 a 29 30 a 39 40 a 49 50 a 59 60 a 69 70 a 79 Total

N 01 101 167 55 50 18 06 02 400

% 0,25 25,25 41,75 13,75 12,50 4,50 1,50 0,50 100,00

bifid canals 0 14 22 7 5 2 1 0

% 0,00 13,86 13,18 12,73 10,00 11,11 16,67 0,00

DISCUSSION
The mandibular chanals are usually, but not invariably, bilaterally symmetrical, and the majority of hemi mandibles contain only one major canal. Supplemental mandibular canals large enough to be seen on panoramic radiographs are occasionally present (NORTJ et al., 1977). The term "bifid" is derived from the Latin word meaning a cleft in two parts or branches. Bifid mandibular canals can originate at mandibular foramen and to contain a neurovascular bundle (LANGLAIS et al., 1985).

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For de height variation of the mandibular canal, it was observed smaller indexes related to the percentage of Type 1 canals when compared our finds with NORTJ et al., (1977) and DEVITO; TAMBURUS (2001) that evidenced 46,7% and 41,83% of occurrence, respectively, against 32,5% of this research. All this data are in disagreement with the 15,6% observed (HEASMAN, 1988). Low mandibular canals (Type 3) were little found in this research, what is in agreement with the observations described in the literature, however, for the intermediate channels (Type 2), we observed a prevalence of 28,25%, in agreement to the 32,09% (DEVITO; TAMBURUS, 2001) and different from the values related (NORTJ et al., 1977 and HEASMAN, 1988) that observed 3,3% and 67,7% respectively. The canals classified as Type 4 were observed in 27,25% of our sample in agreement with the 22,64% observed (DEVITO; TAMBURS, 2001), however, it is almost twice the number of cases observed (HEASMAN, 1988), who found 11,5% of occurrence and much larger than the 1,1% found (NORTJ et al., 1977). We are in agreement with HEASMAN (1988) who admitted that the discrepancy in the results can be related to the morphologic differences among racial groups. The Graphic 3 shows the results of the four researches above mentioned.

80 70 60 50 40 30 20 10 0 VALARELLI DEVITO; TAMBURS NORTJ et al HEASMAN

0,25 3,44 3,3 1,1 32,5 28,25 27,25 46,7 41,83 32,09 22,64 15,6 5,2 11,5 48,9 67,7

Type 1 Type 2 Type 3 Type 4

Graphic - 3. Comparison of the results of height variation of the mandibular canal.

In the present study we found a prevalence of 12,75% of mandibular canal bifurcation, different from the 1% observed (DARIO, 2002). The author emphasizes that such condition can happen in inferior-superior or medium-lateral plans, being sometimes hard to be identified in panoramic or periapical radiographs. The author reinforces the idea that the non detection of this variation can harm the planning and the success of the surgical procedures in the patients. SANCHIS et al. (2003) suggest that one possible cause for a wrong interpretation of the mandibular canal bifurcation is the imprint of the milohyoid nerve on the internal mandibular surface, where it separates from the lower alveolar

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nerve and travels to the floor of the mouth. Another explanation is related to the image formed by the bony condensation produced by the insertion of the milohyoid muscle into the internal mandibular surface, identified as a parallel image to the canal. Comparing the results of this research with the results obtained by LANGLAIS et al., (1985), a disagreement is observed. They found a prevalence of 0,367%, 0,517%, 0,033%, 0,033% of bifurcations Types 1, 2, 3 and 4, respectively, against 4,45%, 6,00%, 0,0% and 1,50% found in our study. Among the bifurcate canals the Type 2 was the most seen, in agreement with the results described (DEVITO; TAMBURS, 2001). The Graphic 4 illustrates the comparison of our results with the results obtained by other authors, expressed in percentage of the total of found bifurcations.
%
60
54,5

50
41,17

56,86

40 30 20

47,05

Type 1 Type 2 Type 3 Type 4

37,26

11,75

3,92 1,96

38,6

3,5

0 VALARELLI DEVITO; TAMBURS LANGLAIS et al.

Graphic 4 - Comparison of the results related to the types of bifid canals.

Adequate levels of local anesthesia can be difficulties by the supplementary enervation and foraminas of the mandible. The nerves more commonly associated these fail are: the anterior cutaneous colli, the lingual, auriculotemporal, the buccal and mylohyoid (HAVEMAN; TEBO, 1976; KAUFMAN et al., 2000). The contralateral enervation (DESANTIS; LIEBOW, 1996), inadequate deposition of anesthetic solution (ROOD, 1977) and the incorrect employ of the anesthetic technique should be considered in case of failure. The identification of bifid mandibular canals is of great importance in the success of a surgery. The failure in the anesthesia of the inferior alveolar nerve can be attributed to some kind of bifurcation, especially the Type 4 that includes two mandibular foramens. To compensate such anatomical variations, alternative anesthetic techniques can be used. The most promising is the technique proposed by GOWGATES (1973) where the anesthetic solution is deposited around the mandibular

10

3,5

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nerve trunk when it emerges from the oval foramen. This technique allows the anesthesia of the inferior alveolar, buccal and lingual nerves and any other smaller branch or division of the inferior alveolar nerve (MARZOLA, 1993 and 2005). However, this technique requests maximum mouth opening and, in patients presenting temporomandibular dysfunction, trismus, ankylosys of temporomandibular joint and other alterations that difficult great buccal opening, it cannot be possible. In these cases, the tuberosity approach suggested by AKINOSI (1977) can be useful. This technique is based on knowledge of the anatomy of the pterygo-mandibular space and the anesthetic solution is liberated in a posterior position, comparing with the standard technique, anesthetizing mainly the inferior alveolar, buccal and lingual nerves. Extreme care is necessary during an inferior third molar exodontics, especially when the variations Type 1 or 3 are present. The tooth can damage the mandibular canal or even be positioned inside of this (MARZOLA et al., 1997). Considering that a second branch of the lower alveolar nerve can exist, complications as traumatic neuroma, paresthesia or excessive bleeding can happen in case of fail in detection of this variation (WYATT, 1996). In surgical procedures involving mandibular osteotomies, the surgery becomes more complex with the addition of a second neuro-vascular bundle. EPKER (1984) emphasized the necessity of the protection of the blood supply during those procedures. In the cases of trauma, all mandibular fractures should be manipulated carefully to guarantee the correct positioning of the neuro-vascular bundle and to avoid interference in the reduction of the fracture. The alignment becomes harder in case of a second neuro-vascular bundle in a second plan. The interpretation of the panoramic radiographic is of great importance in its location and on surgical planning. The clinician should recognize the anatomical variations and modify the surgical technique if necessary. These variations are of great importance on osteointegrated implant surgery. In case of the indirection of this variation, the surgeon can false estimate the useful space for the implant installation, leading to unfavorable consequences as the mandibular canal violation. When the alveolar bone is reabsorbed in the proximities of the mental foramen, the patient it can relate discomfort in this area with the use of total prostheses due to the compression of the neuro-vascular bundle. This can also be a problem in the area of third molars in the presence of variations Type 1 or 3, making necessary the identification of the variation and those subsequent modifications in the prosthesis. Anatomical variations as accessory foraminas and bifid mandibular canal can result in surgical complications not correctly identified. If harmed, these structures can cause bleeding, hindering the surgeon's vision and increasing the potential of formation of fibrous tissue in contact with the surface of osteointegrated implants. Most of the studies published in pertinent literature agree that the foraminas are located preferentially in the internal aspect of the posterior part of the mandible (SUTTON, 1974; CARTER; KEEN, 1971 and HAVEMAN; TEBO, 1976). Furthermore, an association has been observed between the location of these foraminas and the area of insertion of masticator muscles.

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A question also exists regarding the contents of the accessory foraminas and the most probable is a vascular-nervous bundle (KAUFMAN et al., 2000). A possible explanation for the presence of accessory foraminas and duplication of the mandibular canal is that during the embryonic development, the formation of three separated canals occur in each hemi mandible. These canals are directed from the lingual surface of the mandibular ramus to different tooth groups. It is believed that the fast prenatal growth and local remodeling result in a gradual fusion of these segments (CHVEZ-LOMEL et al., 1996), confirming the hypothesis.

CONCLUSIONS
The clinician should know the anatomy and the radiographic anatomy the mandibular canal and its variations, making possible the correct planning of surgical procedures, avoiding harmful results to the patient and solving the problem in case of its occurrence. The mandibular canals are usually, but not invariably, single and bilaterally symmetrical, however supplemental canals are observed across the mandibular body. At the end of the analysis of the 400 panoramic radiographs, considering the mandibular canal height, a prevalence of 32,5% of mandibular canals Type 1, 28,25% of the Type 2, 0,25% of the Type 3 and 27,25% of the Type 4 was observed. Regarding the bifurcation of the mandibular canal a prevalence of 12,75% of bifurcations was observed, being 5,25% bifurcations Type 1, 6,0% of the Type 2 and 1,5% of the Type 4. Bifurcations Type 3 was not observed. The anatomical variations seem to be related to the genetic variation and to the racial mixtures, varying in prevalence from one region to another.

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