|Year : 2018 | Volume
| Issue : 2 | Page : 76-84
Mental foramen: A predictor of age and gender and guide for various procedures
Vijay K Asrani, Jigna S Shah
Department of Oral Medicine and Radiology, Government Dental College and Hospital Ahmedabad, Ahmedabad, Gujarat, India
|Date of Web Publication||29-Jun-2018|
Dr. Jigna S Shah
Government Dental College and Hospital Ahmedabad, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The distance from the inferior border of mental foramen (MF) to lower border of mandible remains constant throughout the life. Considering this fact the present study was carried out to determine role of MF in age and gender estimation and also its importance in planning various treatments. Aims and Objective: (1) To determine the most common type and shape of MF 2) To measure the height of the mandibular body (H), the distance between the superior margin of the MF to the alveolar crest (SM-AC), the distance between the superior margin of the MF to the inferior border of the mandible (SM-IB), the distance between the inferior margin of the MF to the inferior border (IM-IB) on the right side and left side. (3) To compare the above measurements for age and gender determination. (4) To determine effect of various factors on above measurements (5) to evaluate whether any significant difference in measurement occurs on right and left side. (6) To derive a regression equation for age estimation. Materials and Methods: A total of 300 Orthopantomogram were studied. Measurements such as H, SM-AC, SM-IB and IM-IB were carried out on both sides on type II MF in males and females in all the six age groups. Statistical analysis was carried using IBM SPSS version 24 to determine differences in measurements and linear regression analysis was carried out to determine age of individuals. Result: The most common appearance of MF was type II and shape was oval. Statistically significant differences occurred in measurements using which regressive equation for age estimation was derived for males & females. Conclusion: MF, being a stable landmark in mandible, serves as a good indicator for the determination of age and gender. Hence, using certain measurements related to MF, it can help in determining the age of the individual. Further, its position and distance from the alveolar crest serve as a guide for orthognathic surgeries, implant placement, and pre-prosthetic surgery.
Keywords: Age, gender, mental foramen, orthopantomogram
|How to cite this article:|
Asrani VK, Shah JS. Mental foramen: A predictor of age and gender and guide for various procedures. J Forensic Sci Med 2018;4:76-84
| Introduction|| |
Out of many anatomical landmarks in human skull, the mental foramen (MF) is a stable landmark on the mandible. It is a funnel-like opening on the lateral surface of the mandible at the terminus of the inferior alveolar canal. It lies near the apices of premolars and transmits mental nerves and vessels. The opening is directed outward, upward, and posteriorly.
MF's anatomical position is of significant importance in giving local anesthesia, treatments of fractures related to para symphysis area, osteotomies required for orthognathic and implant placement, for planning complete denture in mandible, and also as an aid in forensic identification.,,
The position of mental foramina in newborns and children is near the lower border of mandible; in adults, it is situated on the half way between the superior and lower borders of mandible; and in elders, it is near the crest of the alveolar ridge.,,
Age estimation, a subdiscipline of the forensic sciences, is of immense importance in forensic medicine for identification of deceased victims as well as in connection with crimes and accidents. The importance of age determination also pertains to many medical and paramedical fields such as treatment planning in orthodontics and pediatric dentistry, pediatric medicine, and endocrinology.
In human civilization, the face and hands are the only remnants of the original individuality. As such, they are more accessible, more familiar sociobiologically, and have been extensively studied. It is not surprising that these parts have been used commonly for identification purposes, the teeth and the bones of the craniofacial skeleton being also usually the best preserved parts of human remains. Furthermore, their inherent complexity is expressed by a large variability in size, shape, and proportions, which leads to individualization.
The identification and actual location of the various anatomical structures is of great importance in clinical dentistry; for instance, in the administration of local anesthesia for surgery, operative or diagnostic purposes, in endodontic treatment, as well as for predicting age. Thus, remodeling of the mandible with age, gender, and dental status also occurs throughout the life in many parameters such as gonial angle, antegonial angle, MF, mandibular foramen, and mandibular canal. These changes can be easily evaluated in dried mandible as well as on radiographs.,,
Various methods of gender determination have been established, in which the mandible plays an important role. The mandible is the strongest bone in the human body and persists in a well-preserved state longer than any other bone. Therefore, the use of morphological features of the mandible is a common approach used by anthropologists and forensic dentists in the determination of sex. Various morphologic differences occur when comparing mandibles of males and females; they include height of a mandible, distance from the superior and the inferior border of MF to the lower border of mandible and alveolar crest, and distance from the superior border of mandibular foramen to the lower border of mandible, using gonial angle (i.e., by drawing tangent to the lower border of the mandible).,
The distance from the inferior border of MF to the lower border of mandible remains more or less constant throughout the life. The distance from the superior border of MF to alveolar crest changes throughout the life. This is because of various factors responsible for alveolar bone resorption which include age changes; period of edentulism; periodontitis; and various systemic diseases such as diabetes mellitus, hyperparathyroidism, and patients on steroid therapy. Considering the height of the mandible in relation to the MF, it has been noted that the height of mandible is usually longer in males as compared to that of females. The reason that might be hereditary factors, especially polymorphisms in the genes that influence bone metabolism, physical activity, muscle strength, diet, and hormonal state, also makes important contributions.,,
Various studies have been carried out regarding gender estimation using MF on orthopantomogram (OPG), but no study has been done regarding age estimation using MF. Hence, considering the fact that the distance between inferior border of mandible and MF remains constant throughout the life, the present study aims to signify the average measurements from the superior and the inferior borders of the MF to the lower border of the mandible and to the alveolar crest on digital panoramic radiographs on the right side and left side in determining the gender, age, and effect of various factors responsible for resorption of mandible in various age groups.
Objectives of the study
- To determine the most common shape and appearance of the MF
- To measure the height of the mandibular body (H), the distance between the superior margin of the MF to the alveolar crest (SM-AC), the distance between the superior margin of the MF to the inferior border of the mandible (SM-IB), and the distance between the inferior margin of the MF to the inferior border (IM-IB) on the right side and left side
- To compare the above measurements for age estimation and gender determination
- To determine the effect of various factors such as periodontitis, systemic diseases, and partial/total edentulism on the above measurements
- To evaluate whether any significant differences occur in measurements on the right and left sides
- To derive a regression equation for age estimation in dentulous and edentulous patients.
| Materials and Methods|| |
A total of 300 patients were selected visiting our outpatient department of different age groups. Each group consisted of fifty patients, with an equal number of gender distribution, i.e., 25 males and 25 females.
The groups were as follows: Group I – patients from 11 to 20 years, Group II – from 21 to 30 years, Group III – from 31 to 40 years, Group IV – from 41 to 50 years, Group V – from 51 to 60 years, and Group VI – above 60 years.
Approval from ethical committee was obtained dated 03/02/2016 with No: IEC GDCH/5.5/16.
Any patients aged above 11 years subjected to OPG for various purposes such as preorthodontic assessment, Wisdom tooth assessment, dentition assessment, and prosthetic assessment were included in the study.
Patients with hereditary facial asymmetries, a history of surgical interventions on the lower jaw, presence of pathologies in the lower jaw, congenital anomaly in the mandible that could affect the interpretation of radiographic image, and having a history of orthodontic treatment were excluded from the study.
After selecting the patients, patients' data and relevant information were recorded in a prescribed pro forma. Data included general information such as case number, name, age, sex, birth date, birth place, address, and contact number. Patients' chief complaints, past medical history, past dental history, and period of edentulism were also recorded. Clinical examination was done to assess the presence/absence of teeth and the presence/absence of periodontitis.
All the patients were then subjected to panoramic imaging. The machine and parameters used were as follows: Planmeca machine “Proline XC” (Roselle, Illinois, USA) operated at 65–80 kVp and 8–10 mA for 18 s [Figure 1].
|Figure 1: Panoramic machine and patient position while taking orthopantomogram|
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Only high-quality radiographs were selected to evaluate the MF in detail. Radiographs with distortion of images, presence of artifacts, or presence of any pathologies were excluded from the study.
Various appearances of MF were identified on the panoramic radiographs and were classified according to the criteria by Yosue and Brooks as Types I, II, III, and IV.
Out of the 300 OPGs analyzed on both sides, 34 were Type I continuous on the right side and 38 on the left side, 244 Type II mental foramina were visualized on the right side and 243 type II mental foramina were visualized on the left side, 12 Type III diffuse type of MF were visualized on the right side and 11 on the left side, and 10 Type IV were categorized on the right side and 8 were Type IV on the left side [Figure 2].
|Figure 2: Various appearance of mental foramen on orthopantomograph (a) Type I – continuous type (b) Type II – separate type (c) Type III – diffuse type (d) Type IV – unidentified type|
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The study was carried out in detail on Type II MF as the borders of this appearance can be traced and hence various markings can be done to record various measurements. In case of other types, i.e., Type I continuous and Type III diffuse, the margins of the MF cannot be visualized and therefore were not included in the study.
The study was finally conducted on 244 Type II foramen on the right side and 243 Type II foramen on the left side.
The shape of Type II MF was analyzed as either round or oval and was marked on both the right and left sides using shape tool in Planmeca Romexis 2.1.1 software (Planmeca, Roselle, Illinois, USA). Then, two vertical lines were drawn in relation to the each MF, dividing the MF into two equal parts. Further, two horizontal lines were drawn; one at the superior margin of MF and the other at the inferior margin of MF. Horizontal lines were also drawn on the alveolar bone and lower border of mandible at the point where the vertical line bisecting the MF made contact.
After marking these lines, calculation of the measurements was done by a single observer which included height (H), SM-AC, SM-IB, and IM-IB [Figure 3].
|Figure 3: Marking of reference lines in orthopantomogram using Planmeca Romexis software 2.1.1|
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These measurements were then tabulated, and Student's t-test, one-way ANOVA test, post hoc test, paired sample t-test, independent sample t-test, and ANOVA test was carried out to determine significant differences in the measurements considering for age, gender, and various systemic factors. Linear regression analysis was carried out to determine age of the patients. All these analyses were carried out in IBM SPSS software version 24 (IBM (International Machines Business Corp., Armonk, New York, USA).
| Results|| |
Out of the 244 MF seen on the right side, 190 (77.1%) had an oval shape, while 54 (22.9%) had round shape. On the left side, out of 243 MF, 182 (74.1%) had an oval shape, while 61 (25.1%) had round shape.
Males had higher values of all the four parameters, i.e., H, SM-AC, SM-IB, and IM-IB as compared to females in Groups I–V, which was statistically significant, while in Group VI, only SM-IB and IM-IB were statistically significant.
On intergroup comparison of H, SM-AC, SM-IB, and IM-IB, it was found that all these parameters had higher value in Group III except SM-IB on the right side which was having the highest value in Group IV [Table 1].
|Table 1: Comparison of various parameters in males and females in each group|
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The patients without periodontitis had higher values of H and SM-AC as compared to those without periodontitis, which was statistically significant (P< 0.001), while the other two parameters were statistically nonsignificant [Table 2].
|Table 2: Comparison of various parameters between patients with and without periodontitis|
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Dentulous patients had higher values of all the four parameters as compared to edentulous patients, which was statistically significant (P< 0.001) [Table 3].
|Table 3: Comparison of various parameters in dentulous and edentulous patients|
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Further, on comparing difference in measurements on the right and left sides of the mandible, H was slightly higher on the left side as compared to the right side with P = 0.018, while the rest of the measurements were nonsignificant [Table 4].
|Table 4: Comparison of various parameters on the right and left sides in patients without any edentulous area|
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Patients with systemic disease having diabetes mellitus and hypertension showed lower values of all the four parameters, i.e., H, SM-AC, SM-IB, and IM-IB as compared to those without any systemic disease [Table 5].
|Table 5: Comparison of various parameters in patients with and without any systemic diseases|
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Linear regression of all parameters to determine age in males and females resulted in the following regression formulae:
Regression equation for patients without periodontitis
- Left side: Age = (−9.745) + (−1.946 × 1) + (1.781 × 2) + (5.799 × 3) + (−1.386 × 4) ± 8.86 years
- Right side: Age = (−17.434) + (32.291 × X1) + (−32.369 − X2) + (−27.396 × X3) + (2.159 × X4) ± 10.95 years.
- Left side: Age = (−8.927) + (−7.158 × X1) + (6.756 × X2) + (11.024 × X3) + (−0.758 × X4) ± 9.14 years
- Right side: Age = (−44.068) + (3.904 × X1) + (−2.973 × X2) + (1.502 × X3) + (−1.050 × X4) ± 8.42 years.
Regression equation for patients with periodontitis
- Left side: Age = (10.379) + (−5.123 × X1) + (4.378 × X2) + (7.502 × X3) + (1.057 × X4) ± 11.38 years
- Right side: Age = (39.118) + (−11.656 × X1) + (8.444 × X2) + (13.084 × X3) + (2.545 × X4) ± 9.70 years.
- Left side: Age = (29.599) + (237.663 × X1) + (−236.710 × X2) + (−235.193 × X3) + (−2.634 × X4) ± 4.3 years
- Right side: Age = (63.008) + (−1.923 × X2) + (5.026 × X3) + (−5.108 × X4) ± 8.21 years.
Regression equation for edentulous patients
- Left side: Age = 83.494+ (4.557 × X1) + (−4.194 × X2) + (−4.930 × X3) + (−1.162 × X4) ± 9.29 years
- Right side: Age = 85.570+ (6.988 × X1) + (−7.586 × X2) + (−7.035 × X3) + (−1.026 × X4) ± 7.92 years.
- Left side: Age = 95.223+ (8.541 × X1) + (−10.680 × X2) + (−10.281 × X3) + (−0.914 × X4) ± 2.76 years
- Right side: Age = 91.048+ (−7.556 × X1) + (6.017 × X2) + (6.434 × X3) + (0.125 × X4) ± 3.48 years.
where X1 – H, X2 – SM-AC, X3 – SM-IB, X4 – IM-IB.
| Discussion|| |
Panoramic radiographs are known to show greater part of maxillofacial skeleton as a continuous image, thus allowing for more accurate localization of both mental foramina in both vertical and horizontal dimensions, whereas periapical radiographs may not reveal the position of the MF if it is below the edge of the film. Moreover, comparative analysis between the right and left foramen is also difficult on other conventional radiographs., Hence, panoramic imaging was used in our study.
In 1974, Wical and Swoope  described that, despite the alveolar bone resorption above the MF, the distance from the foramen to the inferior border of the mandible remains relatively constant throughout life. Lindh et al. in 1995 and Güler et al. in 2005 also suggested that the stability of this region does not depend on resorption of alveolar process above the foramen. Therefore, the vertical measurements in panoramic radiography are clinically applicable for the quantification of height of alveolar bone in this region. Due to stability of the basal bone and MF, these landmarks were selected as a point of reference for the present study.
MF varies in position according to the age and sex as substantiated in various researches. Out of 600 MF analyzed both on the right and left sides, Type II MF was highly prevalent. The number reported was more as compared to those reported by Youse and Brookes, al Jasser and Nwoku, Ngeow and Yuzawati, Swamy et al., Suragimath et al., and Gupta et al. This can be attributed to the use of digital panoramic imaging and use of various tools such as contrast adjustment and inversion tool in the software to visualize the foramen.
The reasons for the absence of mental foramina on panoramic radiographs include superimposition of tooth buds in mixed dentition radiographs, inability to distinguish from the trabecular pattern in complete dentition radiographs, and thin mandibular bone in edentulous radiographs.
The oval shape of MF was common in our study, which was consistent with those observed by Gershenson et al., Prabodha and Nanayakkara, and Sheikhi and Kheir. In our study, we found that all the measurements, i.e., H, SM-AC, SM-IB, and IM-IB were statistically significant with higher in males as compared to females in age groups I–V [Table 1]. The difference in these measurements can be explained on the basis of the fact that sexual hormones such as androgens and estrogen contribute to the development of a morphologic difference in craniofacial skeletons between the genders and even to different velocities of growth in later adulthood. The speed of bone growth in adult women is lower than that in men, as observed by Enlow in (1982) who further stated that local factors such as masticatory muscles and bite force play an important role in craniofacial skeletal change.
In general, men have stronger muscles and greater bite force than women, so more amount of bone deposition along the lower border of the mandible is observed in men as compared to women. The sexual hormones and various strengths of force of masticatory muscles together explained the difference in height of mandibular basal bone between the genders.,,
In Group VI (age 51–60 years), SM-IB and IM-IB had higher values in males as compared to females and were statistically significant, while H and SM-AC were statistically nonsignificant. The higher values can be attributed to greater mandibular basal bone in males as compared to females.
On intergroup comparison, it can be observed that the mean highest height is in Group III in both males and females. Further, it can be noted that, as age increases till 40 years, increase in the height of mandible is noted which later on decreases as age advances. Increase in the height of mandible, as age progresses, can be explained on the basis that bone deposition takes place along the lower border of the mandible in the adulthood., Further, the distance from the superior border of MF to alveolar crest increases till 40 years which later regresses. This variation can be attributed to alveolar bone resorption which can occur as a result of periodontitis, age changes, edentulism, and systemic diseases. Furthermore, women in postmenopausal age had accelerated rate of resorption of residual edentulous ridge due to osteoporosis, which was found in a study by Jayam et al. and Xie et al.
The difference in measurements in all the four parameters in patients with and without periodontitis is noted due to alveolar bone resorption in patients with periodontitis.
Edentulous patients had lower values of all the four parameters as compared to dentulous patients. The differences in these findings are mainly attributed to the increased alveolar bone resorption with age, period of edentulism, gender, systemic osteopenia, systemic disorders such as diabetes mellitus and calcium deficiency, etc. This suggests that there is a negative association with period of edentulism with all the other parameters. These findings are consistent with those observed by Thakur et al. and Kalinowski and Różyło-Kalinowska  in their study.
On comparing measurements on the right and left sides, it was found that only H was variable and was statistically significant. This finding is contradictory to that obtained by Thakur et al. and Kalinowski and Różyło-Kalinowska. The variability in these measurements can be attributed to the location of the MF, likely more distal of the 2nd premolar on the left side where the height of the mandible is more in that region.
All the four parameters had lower values in patients with systemic diseases. Hence, it can be said that patients having diabetes mellitus have a significant effect on alveolar bone resorption. This can be because of association of diabetes mellitus with periodontitis.
From the study, it was also found that the vertical position of the MF varies in different age groups. In younger age groups, it is nearer to the lower border of mandible; in middle age group, the MF is at an equidistance from the alveolar crest and lower border of mandible; and in older age groups, it is nearer to the alveolar crest. These findings were consistent with those obtained by Popa et al. Hence, a relative position of MF was obtained from our study which will help in planning the orthognathic surgery, for accurate delivery of local anesthesia in the terminal branches of inferior alveolar canal, to prevent trauma to the nerve during periapical surgery, in the extraction of impacted teeth, and in the enucleation of cyst or tumor in order to avoid paresthesia of nerve.
Moreover, the area in relation to the MF is the preferred site for the placement of osseo-integratable implants in completely edentulous patients, mainly because it has adequate bone morphology and supports sufficient bone. Hence, knowledge regarding the position and appearance of MF is of critical importance in preoperative planning.,,
Due to variation in the findings on the right and left sides, in dentulous and edentulous patients, between various age groups, gender, in patients with periodontitis, and also in patients with systemic disease, linear regression was carried out and various equations were derived for measurement of age.
Considering the drawback of this study, all the measurements were carried out by a single observer. Further, the formulation for age estimation should be evaluated in various age groups with a larger sample size to determine its range of variations.
| Conclusion|| |
From the present study, it can be concluded that:
- The most common appearance of the MF on panoramic radiographs was Type II separate type on both right and left sides, followed by Type I – continuous, Type III – Diffuse, and lastly Type IV – unidentified type
- The most common shape of the MF was oval
- It was noted that, in case of Groups I–V where most of the patients were dentulous, males had higher values of all the four parameters, i.e., H, SM-AC, SM-IB, and IM-IB as compared to females which will be helpful in determining age and gender for forensic dentistry, also in case of planning of orthognathic surgery and implant placement
- On the other hand, in case of Group VI, where most of the patients were edentulous, males had higher values of SM-IB and IM-IB as compared to females because of higher mandibular basal bone in males. This will give information regarding the bone height and will guide in implant placement
- Considering comparison of all groups, it was found that H, SM-AC, SM-IB, IM-IB increase with age till 40 years and had the highest values in Group III (31–40 years) and then later on decline with age, but the decline is more pronounced in females
- In patients with periodontitis, H and SM-AC were reduced as compared to that of patients without periodontitis, which suggests alveolar bone resorption in patients with periodontitis. Hence, decreased bone height would be there in case of periodontitis patients which will be helpful in planning periapical surgeries and implant placement
- Patients with diabetes mellitus showed significantly lower values of H and SM-AC as compared to patients without any systemic disease. Hence, appropriate bone height would be less in patients with diabetes mellitus, which should be considered while planning implant placement
- In edentulous patients, all the four parameters had significantly lower values as compared to dentulous patients. Hence, it can be said that duration of edentulism affects alveolar bone resorption
- Statistical significance difference occurred in measurement of the height of mandible (H) on the right and left sides, while the rest of the measurements were statistically nonsignificant on comparing measurements on the right and left sides
- Age estimation can be determined in dentulous and edentulous patients by the regression equation provided.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]