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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 329-332

Assessment of Mandibular Anterior Nutrient Canals in Patients with and without Periodontal Disease: A Cone Beam Computed Tomographic Study


1 Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Digdoh Hills, Hingna Road, Nagpur, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Government Dental College and Hospital, Hanuman Nagar, Medical Chowk, Nagpur, Maharashtra, India
3 Department of Periodontics and Implantology, Aditya Dental College, Vipra Nagar, Beed, Maharashtra, India

Date of Submission12-Feb-2022
Date of Decision15-Aug-2022
Date of Acceptance15-Aug-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Surekha Ramrao Rathod
Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Digdoh Hills, Hingna Road, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_45_22

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   Abstract 


Background: Nutrient canals (NCs) are radiolucencies in the bone that transit blood vessels and nerves. Aim: To use cone beam computed tomography (CBCT) to assess the incidence, diameter, and location of NC in healthy and periodontal disease patients and correlate it with the extent of alveolar bone loss. Materials and Methodology: About 200 CBCTs (100 healthy and 100 with periodontal disease) were selected and analyzed. The prevalence, diameter, and location of the NCs were comparatively evaluated between the two groups. The frequency and diameter of the canals were also correlated with the severity of bone loss, age, and gender. Results: Subjects in group II had a significantly greater frequency of NCs (P = 0.0001). NCs in group II had a larger mean diameter. The NCs were nearer to the alveolar crest in group II (16.70 ± 6.31 mm) than in group I (18.08 ± 5.72 mm). Their frequency was significantly greater when the bone loss was greater than two-thirds of the root length (P = 0.043). Conclusion: In patients with periodontal diseases, the incidence and diameter of NCs were higher and correlated positively with the extent of bone loss.

Keywords: Cone beam computed tomography, mandible, nutrient canals, periodontal disease


How to cite this article:
Rathod SR, Lathiya V, Rathod Y, Bhide A. Assessment of Mandibular Anterior Nutrient Canals in Patients with and without Periodontal Disease: A Cone Beam Computed Tomographic Study. J Indian Acad Oral Med Radiol 2022;34:329-32

How to cite this URL:
Rathod SR, Lathiya V, Rathod Y, Bhide A. Assessment of Mandibular Anterior Nutrient Canals in Patients with and without Periodontal Disease: A Cone Beam Computed Tomographic Study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:329-32. Available from: http://www.jiaomr.in/text.asp?2022/34/3/329/356969




   Introduction Top


Nutrient canals (NCs) are radiolucencies in the bone representing spaces that transit blood vessels and nerves. Hirschfeld first described them in 1923.[1] Circulatory canals, vascular channels, and interdental NCs are the various terms used to describe NCs.[2] Interdental and inter radicular arteries, lymph vessels, nerves, and veins are housed in these Zuckerkandl and Hirschfeld perforating canals.[3]

The mandibular canal continues as the NC and is visible as radiolucent lines on the intraoral periapical radiograph (IOPAs) of the anterior mandible.[4] Many accessory foramina are situated on the midline and lingually on the mandible, on the lateral aspect of the lingual foramen, and also in the canines or premolars.[5] Furthermore, there is a huge disparity in the size and morphology of these canals.[6],[7]

These NCs can be visualized by the routinely employed 2D radiography techniques such as an intraoral periapical radiograph or a panoramic radiograph.[8],[9] However, these techniques are not reliable.[10] Advanced techniques such as computed tomography (CT) and magnetic resonance imaging help better visualization of these NCs.[11] Cone beam computed tomography (CBCT) can identify significant anatomical landmarks in the anterior mandible that are crucial for preoperative assessment before surgical treatments.[12]

NCs that go unnoticed are responsible for inefficient mandibular nerve block anesthesia, intra-operative and postoperative complications, such as paraesthesia, and postoperative bleeding because of the accidental trauma caused when performing various surgical procedures.[11]

Some researchers believe that NCs are a natural anatomic feature, whereas others ascribe their radiographic appearance to pathologies. Periodontal diseases, hypertension, diabetes mellitus, tuberculosis, rickets, calcium insufficiency, disuse atrophy, aortic coarctation, etc., have been linked to their radiographic appearance.[13]

Few studies have assessed the occurrence of NCs in periodontal disease.[4],[14],[15] Current literature reveals a lack of information regarding three-dimensional assessment of NCs in periodontal disease. Therefore, this investigation aimed to assess the incidence, diameter, and location of NCs in healthy and periodontal disease patients and to correlate it with the extent of alveolar bone loss using CBCT.


   Materials and Methods Top


The study was conducted from March 2019 to February 2020 at our institute's Department of Periodontics and Implantology. It was approved by the institutional ethics committee dated 12/02/2019, reference no. IEC/VSPMDCRC/20/2019 and performed by the Helsinki Declaration of 1975, as revised in 2013. CBCT scans of patients aged between 20 and 60 were selected and assessed. A special proforma was designed to record a detailed case history and medical history validated before the study. Written informed consent was taken from all participants.

Study sample

Sample size estimation

Based on the study by Gupta et al.,[9] the sample size for this study was calculated according to the Cochrane formula, which came out to be 150. As there were chances of dropout and distortion of images, we took 200 patients, 100 in each group.

The exclusion criteria

Presence of 1) pathology at the site of interest, 2) lower jaw fractures, 3) root canal treated teeth, prosthesis, 4) systemic diseases, 5) CBCT showing artifacts and distorted pictures of the bone crest, and 6) intake of medicines affecting bone metabolism.

About 200 CBCT images that satisfied the inclusion criteria were split into two groups.

Group I: About 100 systemically and periodontally healthy individuals Gingival Index[16] (GI) and Plaque Index[17] (PI) = 0, probing pocket depth (PPD) ≤3mm, clinical attachment loss (CAL) = 0, and no radiographic evidence of bone loss, i.e., level of alveolar crest not more than 2 mm below the cementoenamel junction (CEJ).[18]

Group II: About 100 systemically healthy patients with generalized chronic periodontitis with GI and PI score >1, PPD ≥3mm, CAL ≥1 mm, and showing radiographic evidence of bone loss with alveolar crest ≥2 mm below CEJ.

Analysis of CBCT images

The CBCT images were acquired using Orthophos® XG 3D/Ceph, Sirona Dental Systems GmbH, Germany, at kVp = 84 and mA = 16 with a field of view (FOV) of 8 × 8 cm and a standard resolution of 160 μm. All images were processed using the software 3Diagnosys 4.2 (3 Diemme Bioimaging Technologies, Italy). The presence, frequency (number), diameter, and location of the NCs were assessed on all the images [Figure 1]. Cross-sectional pictures were used to determine the presence and diameter of the NCs, whereas cross-sectional and axial scans were used to determine their position. If the canal could not be seen, it was considered absent. The foramen's distance was measured from the midline and the alveolar crest. The diameter of the NC was assessed in the mediolateral direction of the NC [Figure 2].
Figure 1: Mandibular axial and cross-sectional images demonstrate the incidence of nutrient canals (yellow arrows) in the anterior region (a-d)

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Figure 2: CBCT images of the mandible.(A) cross-sectional image of mandible demonstrating measurement of the mediolateral diameter of the nutrient canals (NCs) (B) cross-sectional image of mandible demonstrating the measurement of the distance of NCs from the crest of alveolar bone (C) axial section demonstrates the distance of the NCs from the midline

Click here to view


Furthermore, the extent of alveolar bone loss was measured using the criteria mentioned below:

  1. No alveolar bone loss
  2. Alveolar bone loss extending till 1/3rd of root length.
  3. Alveolar bone loss extending till 2/3rd of root length.
  4. Alveolar bone loss greater than 2/3rd of root length.


Statistical analysis

Measurements for the presence, frequency (number), diameter, and location of the NCs and demographic parameters such as age and gender were obtained. The Chi-square test, Student's unpaired t-test, and ANOVA were used for descriptive and inferential statistics. SPSS version 20.0.3 (IBM Corp, Armonk, USA) was used for the analyses. A P value of <0.05 was considered statistically significant.


   Results Top


The individuals in group I had a mean age of 41.90 ± 9.27 years, whereas in group II, it was 45.27 ± 8.47 years; however, the difference was insignificant. [Table 1] depicts the frequency of the NCs in the two groups. In group I, 24 individuals (24%) had NCs visible on their CBCT scans, whereas for Group II, 53 images (53%) revealed NCs. In both groups, the maximum images showed the presence of one NC (58.33% and 43.39%, respectively). The presence of NCs differed significantly among both groups (P = 0.0001).
Table 1: Comparison of frequency of NCs in the two groups

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The NC was present nearer to the midline in group I. These were present at a mean distance of 18.08 ± 5.72 mm and 16.70 ± 6.31 mm from the alveolar crest in group I and group II, respectively, and the difference was statistically significant (P = 0.023) [Table 2]. The mean diameter of the NC in group I was 0.63 ± 0.32 mm, whereas in group II it was 0.75 ± 0.56 mm, but this difference was statistically non-significant (P = 0.68).
Table 2: Comparison of the location of NCs in the two groups

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When the severity of bone loss was compared with the frequency and diameter of NCs in group II, 11 (20.75%) NCs were associated with an alveolar bone loss lesser than one-third of the length of the root, 18 (33.96%) NCs with up to two-third, and 24 (45.28%) with greater than two-third, the difference being significant statistically (P = 0.043). The mean diameter of the NCs also showed a statistically significant rise with the increasing severity of alveolar bone loss [Table 3].
Table 3: Correlation of bone loss with frequency and diameter of NCs

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The comparison of the frequency and the diameter of the NCs with age and gender is shown in [Table 4]. In group I, seven NCs were found in individuals <40 years of age, whereas 17 NCs were found in individuals >40 years. A similar pattern was seen in group II; the difference in the frequency of canals was statistically significant among the two groups (P < 0.05). However, the difference in the diameter between the two age groups was insignificant (P = 0.17). The difference in the frequency and diameter of NCs among males and females in both groups was statistically non-significant (P = 0.55 and P = 0.86, respectively).
Table 4: Correlation of age and gender with the two groups' frequency and diameter of NCs

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   Discussion Top


Several issues about clinical importance and association of NCs with several pathologic diseases remain unanswered.[19] CBCT is useful for examining images three-dimensionally and has the benefit of being more accurate, greater resolution, and less expensive.[20]

In the present study, the NCs could be seen in 24% of the patients in group I. These findings are by those of Sweet[21] (15.8%). In group II, the incidence of NCs is 53%. Other similar investigations conducted by Kishi et al.[4] (62%) and Patni et al.[15] (70%) demonstrated a greater incidence of NCs in periodontitis patients. This discrepancy could be because these studies did not exclude the patients suffering from systemic illness.

The NCs were frequently found to be associated most commonly with the central incisors and the lateral incisors. The findings of the investigations done by Kawashima et al.,[22] Patel et al.,[8] Kishi et al.,[4] and Ogawa et al.[10] support these findings. Determining the location of the NCs is of utmost importance when planning surgery in this region because there remains a possibility of accidentally damaging the nerve and vessels, which may cause intraoperative complications and interfere with the healing process.[23]

This study's findings indicate that subjects with periodontal disease exhibited a greater diameter of the NCs than the healthy. Kawashima et al.[22] reported the most frequently encountered diameter to be 0.5–0.7 mm, in accordance with our study's results. Although NCs with a small diameter usually do not cause surgical complications, canals with larger diameters should be recognized and planned accordingly.

In the study group, the incidence of NCs and their diameter rose as the extent of alveolar bone loss increased. Similarly, Singh etal.[14] and Pandarinath[24] demonstrated an increased incidence of NCs when bone destruction was greater than two-thirds of the root. Thus, the probability of encountering NCs plus those having larger diameters is more in cases of severe alveolar destruction.

Age and frequency, as well as the diameter of the NCs, were found to have a positive correlation. These findings are consistent with those of other similar investigations that demonstrated an affirmative association of age with the prevalence of NCs.[15],[25] Furthermore, the incidence of NCs was greater in females compared to males, but the diameter of the canals was greater in males. Gupta et al.[9] demonstrated results comparable to ours, where the authors evaluated IOPAs of 60 males and 60 females and found a higher incidence of NCs in females.

The study has demonstrated a substantial variation in the incidence, diameter, and location of NCs on the CBCT images of patients with periodontal disease. Identification of NCs can serve as a diagnostic marker for various pathologic conditions.

Limitations

Further research incorporating a bigger sample size is required to better validate the study's findings. The trabecular pattern of the bone that could have affected the NC's visibility was not considered.

Future prospects

Radiographic recognition of NC can help to detect various pathologies. Further confirmation by a referral to the physician can contribute to the diagnosis of the underlying systemic disease through the window of the oral cavity.


   Conclusion Top


The incidence and the diameter of NCs were greater in periodontal disease patients. NCs in periodontal disease patients were situated closer to the alveolar crest. The incidence of NCs rose with the increasing severity of alveolar bone loss. The prevalence of NCs was higher as the age of the patients advanced.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Gupta P, Naik SR, Tiwari A, Gupta M. Nutrient canals of the alveolar process as an anatomical feature for age and gender determination. J Indian Acad Oral Med Radiol 2017;29:358-61.  Back to cited text no. 9
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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