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Year : 2016  |  Volume : 8  |  Issue : 2  |  Page : 109-114

The evaluation of relationship between body mass index and mental foramen area using computer-aided methods

1 Sakarya Karapurcek Community Health Center, Ministry of Health, Republic of Turkey, Sakarya, Turkey
2 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Ege University, İzmir, Turkey
3 Department of Anatomy, Faculty of Medicine, Ege University, İzmir, Turkey

Date of Web Publication16-Dec-2016

Correspondence Address:
Dr. Figen Govsa
Department of Anatomy, Faculty of Medicine, Ege University, İzmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-8844.195914

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Objective: Anatomical structure of the mental foramen (MF) is an essential orientation point particularly for implant planning at surgical clinics of dentistry, for genioplasty operations, and plastic surgery. The aim is to determine the influential factors such as the patient age, gender, and body mass index (BMI) on MF anatomy of dental periapical radiograms. Materials and Methods: Our study evaluated the BMI, gender, and age relationship with the calculated areas of the MF based on symmetrically taken 202 periapical dental radiography with a parallel technique of the bottom premolar region of total 101 people ages ranging from 17 to 70 weighing 46–108 kg. Patient age, BMI, and gender were recorded and statistically tested for correlations on the area of the MF. Digital imaging and communications in medicine were measured MF area. Results: Right MF area was measured as 0–20.8 mm2 (mean: 4.98 mm2) and left as 0–17.3 mm2 (4.93 mm2). There was not a difference in the areas of MF between the two sides. Furthermore, it was determined that ANOVA test and BMI, Pearson test with age and gender did not appear to have an effect on MF areas. Only within the obese people, left MF area was significantly different than those with other BMI groups. A negative effect on image quality was found statistically significantly correlated with age and MF. None of the investigated MFs were garbled by any of the investigated influence factors. Conclusion: In incidences in which the anatomical structure of the MF and the areas were crucial; age, gender, height, and weight of the individual were not determinant factors. BMI and MF appeared to have a negative impact.

Keywords: Body mass index, implant, mental foramen, surface reconstruction

How to cite this article:
Ozyanik A, Guneri P, Sirinturk S, Govsa F, Pinar Y. The evaluation of relationship between body mass index and mental foramen area using computer-aided methods. J Orofac Sci 2016;8:109-14

How to cite this URL:
Ozyanik A, Guneri P, Sirinturk S, Govsa F, Pinar Y. The evaluation of relationship between body mass index and mental foramen area using computer-aided methods. J Orofac Sci [serial online] 2016 [cited 2021 Aug 3];8:109-14. Available from:

  Introduction Top

The mental foramen (MF) lets one of the terminal branches of the inferior alveolar nerve to exit the body of mandible on each side.[1],[2] This nerve also provides sensation to the lower lip, buccal vestibule, and gingiva mesial of the first mandibular molar.[3],[4],[5] Anatomical structure of the MF is an important landmark notably for implant planning at surgical clinics of dentistry, for genioplasty operations, and plastic surgery.[6],[7],[8],[9] Especially, the placement of MF, dimensions, and the structure are indisputable factors in implant planning.[10],[11] Therefore, the locations of the MF should be specified preoperatively to anticipate confusion with bony pathosis defects.[12],[13] Furthermore, the location of the root apices in relation to the MF should be identified before root-canal treatment of the premolars and molars, placement of dental implant, and surface reconstruction of the mandible.[8],[14],[15]

In clinical practice, radiography is often used to detect anatomical variations. Within the research conducted so far, the structure and location of the MF, the number of holes, and diameter have been measured with panoramic radiography technique on dried bone of the mandible.[12],[16],[17],[18],[19] Using conventional radiography has several drawbacks. Superimposition of anatomical structures perplexes interpretation of the images and identification of the landmarks, and such distortion and magnification may give rise to errors of identification.[20],[21] Besides, as the bone density increases, it becomes more difficult to specify the MF by relying on conventional radiography.[15]

The body mass index (BMI) is considered as a factor interferes with the attenuation of the X-rays. When the mass is big, the attenuation of X-rays increase and this, in return, could affect the image quality. Second, provided that the percentage of body mass increases as water declines from 60% of body weight in young men to 45% in elderly women,[1],[2],[21],[22] the age of the patients should be taken into consideration on the composition of body mass, and indirectly, on the image quality.

Although studies analyzing the relationship of the BMI with the bone structure exist, there is limited research examining the effects of the anatomical structures.[23],[24],[25] The term “diagnostic quality” was defined in this context by the ability to detect pathologic findings to improve the subjective impression of exposure quality, and to ascertain the location of relevant anatomic structures correctly.[26],[27]

The aim of the present study was to determine the influence of patient age, gender, and BMI on MF using dental periapical radiograms.

  Materials and Methods Top

Our study consisted of patients who appealed to Ege University, Faculty of Dentistry, Oral Diagnosis and Radiology Clinic with dental complaints. The study contained 101 patients whose periapical radiological scans of the lower premolar region were taken for diagnostic purposes. The patients were chosen arbitrarily, informed about the study, and asked for their written consent. The study was approved by the Ethics Committee of the Medical Faculty of the Ege University (approval no. 05-111).

Age, gender, height, and weight of the patients were recorded onto an evaluation sheet. Periapical radiological scans were taken using parallel technique. Metric calibration on the images was achieved by placing a 10 mm orthodontic wire over the periapical films before radiation [Figure 1]. E Fast (CEADENT, Strangnas, Switzerland) 202 apical films were used under standard conditions (70 kVP, 10 mA, 0.20 s) with a standard radiograph (Trophy, Vincennes, France). The films were developed automatically (XR 24, Bietigheim, Germany).
Figure 1: Obtaining periapical radiography of the patients with paralleling technique (approval no. 05-111)

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All the data obtained from 101 patients, a total of 202 films of the right and the left premolar region were recorded on a personal computer using a transparent adaptor (Epson Expression 1680 pro, Seiko Epson Corp Lagano, Japan) with 300 dpi resolution in gray scale.

Films were evaluated using a computer program called UTHSCSA Image Tool 3.0 (UTHSCSA, San Antonio, TX, USA. All images were assessed retrospectively by a single oral and maxillofacial radiologist with 25 years of experience (Pelin Guneri). Orthodontic wire of 10 mm length was placed over the film to enable the metric calibration. Ten millimeter length was converted to pixel [Figure 2]a.
Figure 2: (a) Determining the pixel values equivalent to 10 mm length in calibration. (b) Marking of the mental foramen area and identifying the area as mm2

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Mean area values were calculated by measuring the MF for three times after each X-ray [Figure 2]b. The patients were evaluated in terms of age, gender, and BMI. BMI was calculated as kg/m 2. The results were classified into four categories as slim, normal, fat, and obese. BMI range definitions were as follows: <18.5 slim, 18.5–24.9 normal, 25–29.9 fat, and 30 or more obese.

Statistical analysis

Whether a statistically significant difference existed between the right and the left MF area values was counted with individual t-test. The size of the area and its relation with the BMI was calculated with ANOVA and the relationship of the BMI with the right and the left MF with paired t-test. In all analysis, P value was accepted as P < 0.05.

  Results Top

Our study consisted of 42 females and 59 males, a total of 101 patients whose ages ranged from 14 to 70 (mean 36), weight 46–108 kg (mean 70.3). The right side MF area figures were as 0–20.8 mm2 (4.98 mm2) and the left as 0–17.3 mm2 (4.93 mm2).

Assessment of the effect of body mass index

  • Right side MF area measurement values ranged between 0 and 0.97 mm2 with a mean value of 4.4 mm2 in people with BMI figures <18.5 and classified as slim. Left MF area was calculated as 1.64–8.07 mm2. The significance level of the area difference between the right and the left MF was analyzed with paired t-test, and no significant level was assessed between the right and the left sides (P = 0.31) [Figure 3] and [Figure 4]
  • Right side MF area measurement values ranged between 0 and 14.45 mm2 with a mean value of 4.47 mm2 in people with BMI figures between 18.5 and 24.9 and classified as normal. Left MF area was measured as 0–17.3 mm2 (mean 5.6 mm2). The significance level of the area difference between the right and the left MF was analyzed with paired t-test, and no significant level was assessed between the right and the left sides (P = 0.074) [Figure 3] and [Figure 4]
  • Right side MF area measurement values ranged between 0 and 15.2 mm2 with a mean value of 4.68 mm2 in people with BMI figures between 25 and 29.9 and classified as fat. Left MF area was measured as 0–12.6 mm2 (mean 4.4 mm2). The significance level of the area difference between the right and left MF was analyzed with paired t-test and no significant level was assessed between the right and left sides (P = 0.7) [Figure 3] and [Figure 4]
  • Sixteen people with an age range of 29–69, with BMI values thirty and over were categorized as obese. In this group, the right side MF measurement values lined up between 2.3 and 20.8 mm2 and the mean value was 7.2 mm2. On the left side, it was 0–10.5 mm2 (mean 4.47). When the significance level of the difference between the right and left MF was analyzed with paired t-test, unlike the other groups, the difference in both MF groups was significant (P = 0.04). When the BMI relationship between the right and left MF area was analyzed with ANOVA test, the investigation parameters did not present a significant result. In other words, MF areas were not related with BMI (right MF P = 0.067; left MF P = 0.256) [Figure 3] and [Figure 4].
Figure 3: Right, left, and mean measurements of the mental foramen areas of the patients classified in terms of body mass index values

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Figure 4: Mental foramen areas of patients with slim, normal, fat, and obese. Difference in obese group was not statistically significant (P < 0.05)

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Assessment of the effect of gender

  • The right side MF areas of 42 female patients with the age range of 15–60 and weight range of 48–94 kg were measured as 0–11.93 mm2 (mean 4.86 mm2) and the left MF area as 0–16.6 mm2 (mean 5.12 mm2) [Figure 5]
  • The right side MF areas of 59 male patients with the age range of 14–70 and weight range of 46–108 were measured as 0–20.8 mm2 (mean 5.06) and the left MF area as 0–17.2 mm2 (mean 4.8 mm2). The significance level of the relationship between gender and the right and left MF area was analyzed with independent sample t-test. In conclusion, no significant relation between the right and left MF areas and gender was observed (right MF P = 0.80; left MF P = 0.622) [Figure 5].
Figure 5: Mean mental foramen area values in reference to gender

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Assessment of the effect of age

In the analysis of the right and left MF areas and their relation with age using Pearson correlation test, the examined parameters did not appear to present a significant relationship (MF P = 0.089 for the right and 0.789 for the left side).

  Discussion Top

Determining the positions of the MF and the mandibular canal accurately is an important part of managing dental implant or periapical surgery in the posterior segment of the mandible.[6],[7],[8],[9],[10],[11] Anatomical and morphological placement of the MF has gained importance in performing plastic surgery, dental surgery, dental operations, and genioplasty operations and planning oral implants. In the literature, studies are present focusing on the symmetry, asymmetry, and localization of the MF to the teeth.[4],[5],[6],[11],[12],[15],[16],[18],[28],[29] Among these, the localization of the MF was documented as (1) in line with the first molar, (2) between the second premolar and the first molar, (3) in line with the second premolar, (4) between the first and second premolars, (5) in line with the first premolar, or (6) anterior to the first premolar. Even though researchers frequently determined the place of the MF on the alignment of the second premolar, there are studies reporting the location anterior to the first premolar, inferior to the apex of the first premolar, mesial to the apex of the first and the second premolars, mesial to the second premolar, and the first premolar even inferior to the first premolar teeth.

As the previous reports suggested, panoramic radiograms were used to determine MF in Turkish population and revealed that MF was located between the first and second molars most commonly.[6],[7],[11],[13],[16],[19],[29] In the previous studies, bilateral symmetry was found in the position of the MF,[11],[17],[29] and gender did not present a significant difference in the measurements of the MF.[15],[17] Among these, Yosue and Brooks (1989) stated the mean diameter of the MF as 3.5 mm, and Solar et al. (1994) recorded the mean width as 5 mm.[11],[17] Oguz and Bozkir's study indicated that MF dimensions did not differ between sides but were significantly greater in males than in females (P < 0.05). Therefore, it can be concluded that female mandibles appear to have been smaller than male mandibles as the population of this study, in accordance with some previous studies revealed.[11]

Few studies are available evaluating the MF area based on computer software. Although the number of research focusing on the relationship of the BMI and the anatomical structures is limited, the body figure of the individual may contribute to the formation of the pathological incidences.[22],[23],[30],[31],[32],[33] Zlatatic has statistically exhibited the difference in both the linear measurements and the bone mineral density of different BMI groups and presented that the values of the obese individuals were higher in comparison with the other groups.[32]

The influence of individual factors such as gender, age, size, weight, and MF has not been analyzed extensively in the literature.[31],[32],[33],[34] The present study suggests a negative correlation between patients' age and the criteria findings such as detection, artifacts, and exposure quality. In addition, the detection of several anatomical structures, such as MF, nasal floor, and mandibular canal, seems to degenerate as the age increases. The first assumption would be that the decrease in diagnostic quality of cone-beam computed tomography for the elderly can be interpreted by the fact that older patients have more dental restorations.[22],[23],[26] Different radiopaque materials are used for these restorations. Both the age and amount of the dental restoration seem to have a negative influence for these. However, in Ritters' study, although age was a negative effect present on the image quality of the MF, nasal floor, and mandibular canal, there was no correlation detected for those mentioned items with the amount of dental restorations.[31],[33]

As age can be a negative factor influencing the image quality of the mandibular canal, MF, and nasal floor, further studies may serve to analyze more specific factors that are linked with age. The assessment we did in our research was based on periapical films taken in vivo conditions with the parallel technique, which is the method preferred. Using the right angle technique, also known as Fitzgerald technique, the aim was to obtain the most actual images of the teeth and the supporting tissues. In this way, the enlargement of the images and penumbra in the radiograms has been prevented. The image sizes in this study were one-to-one. Our research which was based on dental films taken by paralleling technique of the 101 patients, age range of 17–70, weight range of 46–108 kg included the MF area calculations of the individuals and evaluations were done by comparing the measurements of the BMI with gender and age. Although the literature contains studies evaluating the relationship of the BMI with the bone structure, little is known about the effects of the anatomical formation. With this study, we concluded that there were no differences between the right and left MF areas [Figure 3] and [Figure 4]. We also determined that BMI, gender, and age did not have an influence on the MF areas. Only the left MF areas of these obese individuals in comparison with the other BMI groups were significantly different.

Similar findings exist in the literature. Although there are different measuring techniques, previous studies have proved that the right and left dimensions in bilateral MF ranged between 0.52 mm × 0.52 mm and 5.5 mm × 3 mm and the mean MF dimension was 2.43 mm × 1.76 mm (4.3 mm 2) and dimensions were not different.[7],[11],[13] In the same way, the results of our study did not reach to a significant difference in bilateral MF areas.

The variations in bone structures we have detected with this study lead to the findings we have observed. Similar conclusions on bone variations were made by researchers who also studied both the localization and the diameter of the MF.[4],[5],[18],[19] Nevertheless, a limited number of participants in this study prevented us from making more conclusive results.

  Conclusion Top

Provided that such anatomical variations of MF area may cause pain and discomfort in prosthesis usage and paresthesia during anesthetic, surgical, and endodontic applications.[4] Accurate dental treatment planning may be conducted by evaluating and projecting the findings of MF areas, local vascularization, and innervation levels with the body structure of the individuals. Therefore, clinicians must be aware of the variability of the MF positions when radiographically examining periapical areas before performing periodontal or endodontic surgical treatments in the area between the first premolar and mesial root of the first molar.

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.

  References Top

Barbu HM, Levin L, Bucur MB, Comaneanu RM, Lorean A. A modified surgical technique for inferior alveolar nerve repositioning on severely atrophic mandibles: Case series of 11 consecutive surgical procedures. Chirurgia (Bucur) 2014;109:111-6.  Back to cited text no. 1
Islam MS. A case report of developmentally missing mental foramen. Northwest Dent 2013;92:15-6.  Back to cited text no. 2
Jham BC, Costa NL, Batista AC, Mendonça EF. Traumatic neuroma of the mandible: A case report with spontaneous remission. J Clin Exp Dent 2014;6:e317-20.  Back to cited text no. 3
Orhan K, Aksoy S, Bilecenoglu B, Sakul BU, Paksoy CS. Evaluation of bifid mandibular canals with cone-beam computed tomography in a Turkish adult population: A retrospective study. Surg Radiol Anat 2011;33:501-7.  Back to cited text no. 4
Shen EC, Fu E, Fu MM, Peng M. Configuration and corticalization of the mandibular bifid canal in a Taiwanese adult population: A computed tomography study. Int J Oral Maxillofac Implants 2014;29:893-7.  Back to cited text no. 5
Aktekin M, Celik HM, Celik HH, Aldur MM, Aksit MD. Studies on the location of the mental foramen in Turkish mandibles. Morphologie 2003;87:17-9.  Back to cited text no. 6
von Arx T, Friedli M, Sendi P, Lozanoff S, Bornstein MM. Location and dimensions of the mental foramen: A radiographic analysis by using cone-beam computed tomography. J Endod 2013;39:1522-8.  Back to cited text no. 7
Kremer U, Schindler S, Enkling N, Worni A, Katsoulis J, Mericske-Stern R. Bone resorption in different parts of the mandible in patients restored with an implant overdenture. A retrospective radiographic analysis. Clin Oral Implants Res 2016;27:267-72.  Back to cited text no. 8
Chu RA, Nahas FX, Di Martino M, Soares FA, Novo NF, Smith RL, et al. The enigma of the mental foramen as it relates to plastic surgery. J Craniofac Surg 2014;25:238-42.  Back to cited text no. 9
Cantekin K, Sekerci A. Evaluation of the accessory mental foramen in a pediatric population using cone-beam computed tomography. J Clin Pediatr Dent 2014;39:85-9.  Back to cited text no. 10
Kalender A, Orhan K, Aksoy U. Evaluation of the mental foramen and accessory mental foramen in Turkish patients using cone-beam computed tomography images reconstructed from a volumetric rendering program. Clin Anat 2012;25:584-92.  Back to cited text no. 11
Neves FS, Nascimento MC, Oliveira ML, Almeida SM, Bóscolo FN. Comparative analysis of mandibular anatomical variations between panoramic radiography and cone beam computed tomography. Oral Maxillofac Surg 2014;18:419-24.  Back to cited text no. 12
Yesilyurt H, Aydinlioglu A, Kavakli A, Ekinci N, Eroglu C, Hacialiogullari M, et al. Local differences in the position of the mental foramen. Folia Morphol (Warsz) 2008;67:32-5.  Back to cited text no. 13
Vu DD, Brockhoff HC 2nd, Yates DM, Finn R, Phillips C. Course of the mandibular incisive canal and its impact on harvesting symphysis bone grafts. J Oral Maxillofac Surg 2015;73:258.e1-258.e12.  Back to cited text no. 14
Ngeow WC, Yuzawati Y. The location of the mental foramen in a selected Malay population. J Oral Sci 2003;45:171-5.  Back to cited text no. 15
Fujita A, Suzuki T. Computed tomographic analysis of the mental foramen and nerve in Japanese patients. Implant Dent 2014;23:471-6.  Back to cited text no. 16
Apinhasmit W, Methathrathip D, Chompoopong S, Sangvichien S. Mental foramen in Thais: An anatomical variation related to gender and side. Surg Radiol Anat 2006;28:529-33.  Back to cited text no. 17
Udhaya K, Saraladevi KV, Sridhar J. The morphometric analysis of the mental foramen in adult dry human mandibles: A study on the South Indian population. J Clin Diagn Res 2013;7:1547-51.  Back to cited text no. 18
Torres MG, Valverde Lde F, Vidal MT, Crusoé-Rebello IM. Accessory mental foramen: A rare anatomical variation detected by cone-beam computed tomography. Imaging Sci Dent 2015;45:61-5.  Back to cited text no. 19
Kumar V, Ludlow JB, Mol A, Cevidanes L. Comparison of conventional and cone beam CT synthesized cephalograms. Dentomaxillofac Radiol 2007;36:263-9.  Back to cited text no. 20
Nalçaci R, Oztürk F, Sökücü O. A comparison of two-dimensional radiography and three-dimensional computed tomography in angular cephalometric measurements. Dentomaxillofac Radiol 2010;39:100-6.  Back to cited text no. 21
Saito T, Shimazaki Y, Koga T, Tsuzuki M, Ohshima A. Relationship between upper body obesity and periodontitis. J Dent Res 2001;80:1631-6.  Back to cited text no. 22
Saito T, Shimazaki Y, Kiyohara Y, Kato I, Kubo M, Iida M, et al. Relationship between obesity, glucose tolerance, and periodontal disease in Japanese women: The Hisayama study. J Periodontal Res 2005;40:346-53.  Back to cited text no. 23
Passos JS, Gomes Filho IS, Sarmento VA, Sampaio DS, Gonçalves FP, Coelho JM, et al. Women with low bone mineral density and dental panoramic radiography. Menopause 2012;19:704-9.  Back to cited text no. 24
Seeman E. Structural basis of growth-related gain and age-related loss of bone strength. Rheumatology (Oxford) 2008;47 Suppl 4:iv2-8.  Back to cited text no. 25
Ritter L, Mischkowski RA, Neugebauer J, Dreiseidler T, Scheer M, Keeve E, et al. The influence of body mass index, age, implants, and dental restorations on image quality of cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e108-16.  Back to cited text no. 26
Valerio CS, Trindade AM, Mazzieiro ET, Amaral TP, Manzi FR. Use of digital panoramic radiography as an auxiliary means of low bone mineral density detection in post-menopausal women. Dentomaxillofac Radiol 2013;42:20120059.  Back to cited text no. 27
Kqiku L, Weiglein A, Kamberi B, Hoxha V, Meqa K, Städtler P. Position of the mental foramen in Kosovarian population. Coll Antropol 2013;37:545-9.  Back to cited text no. 28
Ari I, Kafa IM, Basar Z, Kurt MA. The localization and anthropometry of mental foramen on late Byzantine mandibles. Coll Antropol 2005;29:233-6.  Back to cited text no. 29
Willerhausen B, Blettner M, Kasaj A, Hohenfellner K. Association between body mass index and dental health in 1,290 children of elementary schools in a German city. Clin Oral Investig 2007;11:195-200.  Back to cited text no. 30
Klemetti E, Kröger H, Lassila V. Relationship between body mass index and the remaining alveolar ridge. J Oral Rehabil 1997;24:808-12.  Back to cited text no. 31
Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity and periodontal disease in young, middle-aged, and older adults. J Periodontol 2003;74:610-5.  Back to cited text no. 32
Kathirvelu D, Anburajan M. Prediction of low bone mass using a combinational approach of cortical and trabecular bone measures from dental panoramic radiographs. Proc Inst Mech Eng H 2014;228:890-8.  Back to cited text no. 33
Zlataric DK, Celebic A, Kobler P. Relationship between body mass index and local quality of mandibular bone structure in elderly individuals. J Gerontol A Biol Sci Med Sci 2002;57:M588-93.  Back to cited text no. 34


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