J. Anat. (1989), 167, pp.

195-198 With 2 figures Printed in Great Britain

195

The mandibular incisive foramen

School of Dental and Oral Surgery, Columbia University, 630 West 168th Street, New York, N.Y. 10032, USA

(Accepted 2 May 1989)

Although no specific reference could be found in the literature, it is generally accepted that the inferior alveolar nerve runs an entirely intra-osseous course from its entry into the mandible at the mandibular foramen. The nerve is accompanied in the mandibular canal by the inferior alveolar artery, a branch of the maxillary artery. While in the canal, the nerve and artery supply the teeth on that side of the dental arch (Weisse, 1886). Opposite the mental foramen, the inferior alveolar artery and nerve give off, respectively, the mental artery and nerve which emerge onto the superficial region of the face through the mental foramen (Weisse, 1886). This foramen is located in the region inferior to, or between, the first and second premolar teeth (Sicher & Du Brul, 1975) or, in about 50 % of cases, below the apex of the second premolar tooth (Dixon, 1986). In man, the mental foramen is usually single but may be multiple, the usual number of foramina being two (de Villiers, 1968). Starkie & Stewart (1930) noted that, immediately after entering the mandibular canal, the nerve divides into several branches which run forward in a plexiform manner and then re-unite. This procedure is then repeated and results in an increased number of branches, so that, at the level of the mental foramen, there are fifteen or more of these. Le Double (1903) discussed multiple mental foramina in some detail but did not mention the foramen complex under discussion in this paper. Double mental foramina are well described in the literature and are presumed to be the result of branching of the mental nerve prior to its exit from the mental foramen. There is a slight variation according to tribal and racial groups with regard to the number of mental foramina. The number of foramina ranges from 1 02 % on the left side in the Egyptian and Polynesian groups to 111 % on the right side in the Melanesian group (Riesenfeld, 1956). Whether the mental foramen on one side of the mandible is single or multiple, it is accepted in the literature that in all cases, the nerve emerges from the mental foramen. Serman (1987), working on dry human mandibles, put forward the hypothesis that, in a small percentage of cases, there exists an anatomical variation where there is a (mandibular) incisive foramen complex. In these instances the nerve and blood vessels re-enter the mandible through the anterior foramen to supply the anterior part of the body of the mandible and to form its main nerve and blood supply. The results of dissection are now presented in support of that hypothesis. In these cases, the inferior alveolar nerve has a short extra-osseous course where the division of the nerve into its two terminal branches occurs outside the bone (Fig. 1) and the incisive nerve then re-enters the bone.

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N. J. SERMAN

........

Fig. 1. The extra-osseous course of the inferior alveolar nerve between the arrows No. I and 2. Arrow No. 3 indicates the mental nerve and vessels.
MATERIALS AND METHODS

Some 408 dry human mandibles from the Department of Anatomy and Histology, Faculty of Medicine, University of Stellenbosch, South Africa were examined in the region of the mental foramina; the mental foramen region of 88 cadavers from the Department of Anatomy, Faculty of Medicine, Medical University of Southern Africa as well as the mental foramen region of 12 cadavers from the Department of Anatomy, College of Physicians and Surgeons, Columbia University, New York were dissected.
RESULTS

A mental-incisive foramen complex that is distinct from double mental foramina, as described in the literature, was found in seven mandibles, with two cases being bilateral, making a total of nine cases (0-88 %). Three cases (two unilateral and one bilateral) were found in dry human mandibles as previously described (Serman, 1987) with four cases (one bilateral) found on dissection. The races of the dry specimens were not known. The examples found at the Medical University of Southern Africa are not significant with regard to race as that hospital serves only black people. Both cases

Mandibular incisive foramen

197

Fig. 2. Mental-incisive foramina complex showing larger posterior foramen with an anteriorly directed lumen. The smaller anterior, mandibular incisive foramen has its lumen directed in a posterior direction. Both foramina are on the same horizontal plane.

found at Columbia University were black people. Thus the sample is too small to make any assumption regarding racial predilection in these cases. At first glance, the cases under discussion appear similar to other double mental foramina described in the literature. On closer examination it can be seen that in all these cases the larger foramen is always situated more posteriorly, with an anteriorly directed lumen. The smaller foramen is situated anteriorly but with a posteriorly directed lumen. Both foramina are always situated on the same horizontal plane with a groove between them in most cases (Fig. 2). No intra-osseous canal or alternate nerve supply were found between these two foramina. This mental foramina complex could not be distinguished radiologically from other double mental foramina and in many cases it could not be recognised radiologically at all. The increased film-object distance and the intervening bone of the mandible may, in part, be the reason for this.
DISCUSSION

The foramen complex under discussion can be explained in the following manner. The undivided inferior alveolar nerve (Fig. 1) leaves the canal through the mental foramen. Once it has reached the surface, lying in the groove between the foramina, the nerve divides into the terminal mental and incisive branches. The incisive nerve thus has an extra-osseous commencement and runs a short extra-osseous course before re-entering the mandible through the more anteriorly situated foramen. The posteriorly situated foramen therefore has a larger lumen to accommodate the undivided inferior alveolar nerve and has an anteriorly directed lumen (Fig. 2). The more anteriorly situated foramen is smaller as it only has to accommodate the incisive nerve and is directed posteriorly as the incisive nerve is coursing in an antero-mesial direction as it re-enters the mandible. It must be stressed that in these cases the incisive

N. J. SERMAN 198 foramen represents the re-entry of the incisive nerve into the mandible. In these cases too, the blood vessels follow the course of the nerve. An important feature of these cases is the lack of a mandibular canal between the two foramina. The groove between the foramina may be the remnant of the mandibular canal which has lost its covering. As stated previously (Serman, 1987) it is important for surgeons operating in this area to be aware of this anatomical variant. It is suggested that the anterior foramen in the mandible be named the mandibular incisive foramen.
SUMMARY

An anatomical variant in the region of the mental foramen is discussed. In these cases the inferior alveolar nerve divides into its two terminal branches only after it has exited through the mental foramen. The incisive nerve thus commences outside the mandible, and has a short extra-osseous course before it enters the mandible through a separate foramen on the same horizontal plane. For the distance between these two foramina there is no nerve supply within the mandible. The groove between the two foramina may be the remnants of the mandibular canal. The foramen through which the nerve enters the bone is a separate anatomical entity from the mental foramen and should be recognised as such. It is proposed that this foramen be named the mandibular incisive foramen.
REFERENCES

DE VILLIERS, H. (1968). The Skull of the South African Negro, Ch. 10, pp. 148-154. Johannesburg: Witwatersrand University Press. DIXON A. D. (1986). Anatomy for Students of Dentistry, 5th ed., Ch. 4, p. 132. Edinburgh: Churchill

Livingstone.
LE DOUBLE, A. F. (1903). Traite des Variations des Os de la Face de l'Homme. [Characteristics of the variations of the facial bones of man]: maxillaire inferieure, pp. 328-334. Paris: Vigot Freres. RIESENFELD, A. (1956). Multiple infra-orbital, ethmoidal and mental foramina in the races of man. American Journal of Physical Anthropology 14, 85-99. SERMAN, N. J. (1987). Differentiation of double mental foramina from extra bony coursing of the incisive branch of the mandibular nerve. An anatomic study. Journal of Dental Medicine 5(3), 20-22. SICHER, H. & Du BRUL, E. L. (1975). Oral Anatomy, 6th ed., Ch. 2, pp. 115-121. St Louis: C. V. Mosby Co. STARKIE, C. & STEWART, D. (1930). The intramandibular course of the inferior dental nerve. Journal of Anatomy 65, 319-323. WEISSE, F. D. (1886). Practical Human Anatomy, p. 352. New York: William Wood & Co.