Dimitrios Apostolakis

Jackie E. Brown

The anterior loop of the inferior alveolar nerve: prevalence, measurement of

its length and a recommendation for
interforaminal implant installation
based on cone beam CT imaging

Authors affiliations:
Dimitrios Apostolakis, Maxillofacial Radiology and
Diagnosis Center, Chania, Crete, Greece
Jackie E. Brown, Department of Dental Radiology,
Kings College London Institute of Guys, Kings
and St. Thomas Hospitals, London, UK

Key words: anterior loop, cone beam computed tomography, inferior alveolar nerve,

Corresponding author:
Dr Dimitrios Apostolakis
Maxillofacial Radiology and Diagnosis Center
Plateia 1866
No 39, Chania
73100 Crete, Greece
Tel.: +302821097757
Fax: +302821060095
e-mail: dentalradiology@hotmail.com

quate information on the location of the various landmarks of significance such as the mental fora-

symphysis
Abstract
Objectives: Interforaminal implant surgery requires anatomical knowledge of the area and ademen, the anterior loop of the inferior alveolar nerve and the mandibular incisive canal. Cone beam
computed tomography (CBCT) is a relatively new imaging modality that provides a multi-dimensional view of the facial skeleton with, in most instances, lower radiation dose to the patient compared to medical CT. The present study aims to use CBCT to identify and measure variation in the
presence and extent of the anterior loop of the inferior alveolar nerve. This information may be
used to provide recommendations to the surgeon without access to a 3D scan of the dento-alveolar
region.
Material and methods: Ninety-three patients scanned with a Newtom VG device for a variety of
clinical indications were included in this retrospective study. Using the multiplanar capabilities of
the devices software the prevalence and length of the anterior loop was assessed.
Results: The results show that an anterior loop could be identified in 48% of the cases with a
mean length (range) of 0.89 mm (05.7).
Conclusions: In almost half of the surveyed cases an anterior loop was present. Even though in
95% of the study cases the loop was <3 mm, a 100% safety margin in the placement of anterior
mandibular implants, in the absence of a CBCT scan, would only be achieved with a distance of
6 mm between the anterior border of the mental foramen and the most distal interforaminal
implant fixture.

Date:
Accepted 30 May 2011
To cite this article:
Apostolakis D, Brown JE. The anterior loop of the inferior
alveolar nerve: prevalence, measurement of its length and a
recommendation for interforaminal implant installation
based on cone beam CT imaging.
Clin. Oral Impl. Res. 23, 2012, 10221030
doi: 10.1111/j.1600-0501.2011.02261.x

1022

The final part of the inferior alveolar nerve

sometimes passes below the lower border and
the anterior wall of the mental foramen.
After giving off the smaller mandibular incisive branch, the main branch curves back to
enter the foramen and emerge to the soft tissues, as the mental nerve. The section of the
nerve in front of the mental foramen and just
before its ramification to the incisive nerve
can be defined as the anterior loop of the
inferior alveolar nerve.
Selective surgery in the area of the anterior
mandible such as implant installation in the
interforaminal region or symphysis bone
harvesting, may violate the anterior loop
resulting in neurosensory disturbances in the
area of the lower lip and chin (Misch &

Crawford 1990; Wismeijer et al. 1997). To

avoid such a sequel a 5-mm safe distance to
the most distal fixture from the anterior loop
(Magnusson 1992) and a 5-mm distance from
the mental foramen for chin bone harvesting
have been proposed (Hunt & Jovanovic 1999).
Even though these general safety margins do
exist, the problem relates to the ability of the
surgeon to identify the anterior loop preoperatively or even intra-operatively to safely
plan his actions, thus avoiding the risk of
altered lip and chin sensation and permitting
the placement of the implant fixtures in a
more favourable position from a prosthetic
standpoint (i.e. close to the mental foramen
increasing the available useful interforaminal
space).
2011 John Wiley & Sons A/S

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

Exposure of the mental foramen during

implant surgery in the symphysis area
provides a direct view of the mental nerve.
Safe implant placement would always be in
the space above the level of the foramen.
However, in many cases the limited bone
available in the anterior mandible above that
level and the need for longer implants will
force the surgeon to place the distant implant
at or more commonly below the level of the
foramen risking violation of the anterior
loop, if present.
Clinical identification of the anterior loop
with the use of a probe has been suggested;
however, it is recognized that it is not possible to differentiate between an anterior loop
and an incisive canal, by probing (Greenstein
& Tarnow 2006).
Radiography provides the clinician with
information not readily available by any other
diagnostic method. However, the ability of
conventional two dimensional radiological
methods (panoramic tomography, periapical
radiographs etc.) to reveal the anterior loop is
limited and their reliability and accuracy,
questioned (Mraiwa et al. 2003; Jacobs et al.
2004; Ngeow et al. 2009). In recent years the
use of medical CT with special dental software programs has been recognized as a useful
adjunct to implant surgery (White et al. 2001).
However, its use is complicated by limited
availability of implant software, cost and the
potentially high radiation dose to the patient.
It might be because of these reasons or
because old habits die hard that panoramic
radiography is still used by the great majority
of surgeons as the only imaging modality
when it comes to implant installation in the
mandible (Zitzmann et al. 2008). This is especially true for the more experienced of the
surgeons, who advocate the placement of
implants using only a panoramic radiograph
(Vazquez et al. 2008). Even though panoramic
tomography has some reliability when it
comes to the identification of the mental foramen (Yosue & Brooks 1989), this is not the
case with the anterior loop (Mraiwa et al.
2003; Jacobs et al. 2004; Ngeow et al. 2009),
raising amongst others, questions of liability
in the case of an untoward sequel.
Cone beam computed tomography (CBCT)
is a relatively new imaging modality which
provides multiplanar views of the facial skeleton with a reduced radiation dose, compared
to the most commonly used by MDCT, exposure protocols (Tsiklakis et al. 2005; Ludlow
& Ivanovic 2008; Suomalainen et al. 2009)
whilst the accuracy and reliability of the
measurements done with a CBCT device has
been proved by a number of in vitro studies
2011 John Wiley & Sons A/S

(Lascala et al. 2004; Baumgaertel et al. 2009;

Liu et al. 2010; Sherrard et al. 2010).
Taking into account the inability of the
clinical and common radiographical methods
to give accurate information about the anterior loop, it is the aim of the present observational study of 3D data to provide evidence
and recommendations about the safe distance
of the most distal interforaminal implant
from the anterior border of the mental foramen. These recommendations are based on
details of the prevalence and on the measurements of the length of the anterior loop
acquired with the use of a CBCT device in a
population of patients.

Material and methods

From a pool of 320 CBCT consecutive scans
taken for various clinical indications such as
implant planning, trauma, assessment of
impacted teeth, etc. using a Newtom VG
CBCT device in a private radiological practice, cases were selected for the measurements of the anterior loop length (ALL). The
selection criteria were: (i) the front part of
the body of the mandible bilaterally, at least
2 cm distal to the mental foramen and up to
the lower cortical border, had to be included
in the volume (ii) no pathology that could
affect the position of the mandibular canal
and mental foramen should be identified by
imaging or history and (iii) the images must
be of adequate diagnostic quality.
A total number of 320 volumes were examined. The first selection criterion (the border
of the mandible depicted) was satisfied by 101
volumes. Of these 101 volumes, five were
excluded due to pathology affecting the image
(one implant in mental foramen, one osteoradionecrosis, one giant cell lesion, one dense
bone island, one artefact due to gunshot
pellets). Furthermore, three volumes were
excluded due to motion artefacts that rendered
the images non-diagnostic. Therefore 93
volumes, representing 93 different patients,
were available for evaluation. The cases were
categorized by side (left or right), gender, age,
dental status and mode of scanning.
For statistical analysis, the patients were
divided into six age groups: (i) 2130, (ii)
3140, (iii) 4150, (iv) 5160, (v) 6170 and
(vi) 7189 years.
The cases were considered dentate when
even one tooth was present in front of the
mental foramen.
The scanning of the patients was accomplished using, for each patient, one of the
following imaging protocols available with

this CBCT unit: Standard mode with a field

of view (FOV) of 11 9 15 cm and a 0.3-mm
voxel size, Zoom mode (FOV 6 9 12 cm,
0.24 mm voxel size), High resolution mode
(FOV 6 9 12 cm, 0.15 mm voxel size) and
each always included the full area of interest.
There were five patients scanned with high
resolution mode, 16 patients scanned with
zoom mode and 72 patients scanned with
standard mode.
The KVp was 110 kv, the exposure time
ranged between 3.6 and 5.4 s, whilst the mA
setting was computed by the device based on
the anatomy of the patient within a range of
120 mA.
There were 51 female and 42 male
patients. The mean age was 53 years and the
range was between 21 and 89 years. Most of
our patients (82%) were between 41 and
70 years old. There were three edentulous
and 90 dentate patients.
Measurements

All the reconstructions and measurements

were accomplished with the use of the
propriety Newtom VG software (NNT 2.19/
NNT 2.21).
On each volume the axial slices were reconstructed parallel to the lower border of the
mandible and on the appropriate selected axial
slice the most anterior part of the mental foramen was marked (Figs 1 and 2). Then using
again the axial views, the most anterior part
of the inferior alveolar nerve was marked. It
was defined as the most mesial area of the
mental nerve just before a sudden reduction
of the width (constriction) of the nerve was
noted as the incisive nerve divided to pass
anteriorly in the incisive canal (Fig. 3). It was
not clear in every case, however, where the
end of the supposed anterior loop was. So the
mark was taken as an indication of the border
of the anterior loop and the loop was again
evaluated and marked on the cross sections
and on all other available reconstructed

Fig. 1. Lateral scout view to identify and position the

region of interest. The axial images were reconstructed
parallel to the lower border of the mandible.

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Clin. Oral Impl. Res. 23, 2012 / 10221030

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

Fig. 2. Axial reconstruction; the anterior border of the

mental foramen (right side) is identified.

Fig. 3. Axial reconstruction; the anterior border of the

anterior loop is seen as a constriction of the canal. The
narrowest position of the mandibular canal-incisive
canal complex is marked as an indication of the anterior border of the anterior loop. In the image shown the
mark is absent to demonstrate the difficulty in the
accurate positioning of the border of the anterior loop.

views. Based on the available literature of the

size of the incisive canal, we devised a cut-off
point of 3 mm for the maximum diameter of
the incisive canal. That is, a canal of more
than 3 mm was always considered part of the
mandibular canal (anterior loop) and never of
the mandibular incisive canal.
The length of the loop was measured by
counting the number of the consecutive con-

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Clin. Oral Impl. Res. 23, 2012 / 10221030

tiguous vertical cross sections performed

between the anterior border of the mental
foramen and the anterior border of the loop
(Fig. 4). This number was multiplied by the
thickness of the slices. The initial slice for
measurement was considered to be the first
slice just after the anterior margin of the
mental foramen disappeared. For example in
a case where the number of cross sections
between the anterior border of the mental
foramen and the edges of the anterior loop
were 6, the length of the loop would be
6 9 0.3 = 1.8 mm (in standard mode).
For the development of our method and for
the evaluation of its precision a small pilot
study was undertaken. The available literature on a protocol on the measurement of the
anterior loop on a CBCT or even on a medical CT is limited. Actually there are only
four studies that tried to measure the anterior loop using CT or CBCT (Jacobs et al.
2002; Kaya et al. 2008; Uchida et al. 2009;
Watanabe et al. 2010). In the first three studies all the measurements were done on vertical cross sections on printed film (no other
slices were used). The method of Uchida
et al. (2009) used the capabilities of the software to do the measurements.
We decided to employ the method used by
Uchida et al. (2009). In their study in seven
cadaver hemimandibles they used transverse
(not vertical cross sections) reconstructions
to measure the length of the anterior loop.
The linear distance between the most anterior border of the mental foramen to the
most anterior margin of the anterior loop was
defined as the ALL. Five cases (10 sides) were
evaluated with this method. Fifteen days
later we re-examined the cases and we
discovered large variations in our measurements. It became obvious that the above
method was not precise enough, maybe due
to the different capabilities of the software
used in our case. After that we decided
to use all the available reconstructions,
achieved by our software, to mark the nerve
and finally perform the measurements on the
vertical cross sections. We re-examined the
five cases 2 weeks later to discover adequate
intra-rater reliability. These five cases that
were measured four times were used for the
development of the instructions and for training at the same time.
All measurements were done by the first of
the authors with more than 15 years of experience in oral surgery and in dental implant
installation with the use and interpretation
of DentaScan CT software and 3 years recent
experience in the acquisition, manipulation
and interpretation of CBCT images.

The second author, a consultant in dental

and maxillofacial radiology in a large London
teaching hospital, provided advice on the
method and the interpretation of the images.
Statistics
Descriptive

The prevalence of the anterior loop was

calculated and an ALL distribution chart was
produced (Fig.5).
The mean values, range, SD of the ALL
measurements were calculated and categorized by side, gender, age group, dental status
and mode of scanning. From Fig. 5 it can be
seen that our data were severely skewed. As
a consequence, median and interquartile values were also calculated to give a better
description of our data set (Table 1).
Comparative

To compare the measured values for differences between gender, mode and dental
status, multiple group comparisons were
made using KruskalWallis ANOVA whilst
the MannWhitney U test was used for two
group comparisons. These analyses were
performed for each side (left or right) separately. Differences between left and right
sides were investigated using the Wilcoxon
matched pairs, signed-rank test.
The results were considered significant
where P  0.05. Spearman correlation was
used to estimate the relationship between
the length of the anterior loop and age. The
difference in age between the presence and
absence of the anterior loop was assessed
using a MannWhitney U test.
Ten cases (20 sides), representing the 11%
of the total cases were re-examined after a
month by the same examiner. Intraclass
correlation was used to provide an estimate
of the reliability of the measurements. Also
the range of absolute errors between the two
measurements and the average absolute
mean error of the two measurement attempts
was calculated. Finally, BlandAldman analysis was undertaken to investigate whether or
not there is a relationship between the difference between the two measurements and the
mean size of the ALL.

Results
The ALL was evaluated in all 93 patients
(186 sides). An anterior loop was identified in
91 sides (48% of the sides). The mean and
the range of the ALL were 0.89, 0.05.7 mm,
respectively, whilst the median and the inter 2011 John Wiley & Sons A/S

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

Fig. 4. Cross-sectional reconstructions; the anterior loop can be seen on the images No 211-215 (arrows). The length is measured as 5 9 0.3 = 1.5 mm (standard mode).

Table 1. Our findings on the length of the anterior loop of the inferior alveolar nerve

140
120

116

Anterior loop length (mm)

No of cases

100
80
60
41

40

19

20
0

6
01

1.12

2.13 3.14 4.15 5.16

mm

Fig. 5. Length of the anterior loop.

quartile range values were 0.0 and 0.0

1.5 mm, respectively. The 95% confidence
intervals for the median were 0.00.9 mm.
Table 1 summarizes our findings on the
length of the anterior loop.
In Figs 68 the images of the longest anterior loop, and in Figs 9a,b and 10 the images
of another case of anterior loop, are shown.
In 62% of the cases with an anterior loop,
the length was up to 1 mm, whilst it was up
to 2 mm in 85% of the cases. Up to 3 mm
was in 95% of the cases. Two per cent of the
sides showed an ALL more than 4 mm
(Fig. 5). The longest loop measured was
2011 John Wiley & Sons A/S

Group

Range

Median

IQR

Mean

SD

All (n = 186)
Right (n = 93)
Left (n = 93)
Gender
Male (n = 84)
Female (n = 102)
Age
2130 (n = 8)
3140 (n = 18)
4150 (n = 52)
5160 (n = 52)
6170 (n = 48)
7189 (n = 8)
Dental status
Dentate (n = 180)
Edentulous (n = 6)
Mode
Standard (n = 144)
Zoom (n = 32)
Hi Res (n = 10)

05.7
05.7
04.8

0.00
0.70
0.00

0.001.50
0.001.80
0.001.50

0.89
1.03
0.75

1.17
1.25
1.07

05.2
05.7

0.80
0.00

0.001.75
0.001.50

0.99
0.81

1.15
1.18

02.1
02.2
05.2
05.7
02.9
01.5

1.25
0.35
0.35
0.00
0.00
0.30

0.001.65
0.001.20
0.001.80
0.001.50
0.001.40
0.001.50

0.99
0.71
0.98
1.08
0.69
0.64

0.87
0.81
1.26
1.45
0.89
0.74

05.7
01.5

0.00
0.00

0.001.50
0.000.00

0.91
0.25

1.18
0.61

05.7
02.9
03.4

0.00
0.85
0.70

0.001.50
0.002.10
0.001.55

0.85
1.00
1.06

1.15
1.27
1.17

5.7 mm with one more loop measuring

5.2 mm, on patients aged 57 and 49 years
old, respectively.
In 95 sides (95/186, 52%) no loop could be
identified. In 84% of these cases (80 sides, 40
patients) the absence of the loop was bilateral
and in 16% (14 sides, 14 patients) an anterior

loop could not be identified only on one side

of the mandible (it was visible on the other
side).
Analysis of differences revealed no statistically significant differences between ALL and
mode of scan, dentate or edentulous patients.
A significant difference was revealed with

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Clin. Oral Impl. Res. 23, 2012 / 10221030

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

Fig. 6. Cross-sectional reconstructions through the body of the right mandible. The longest anterior loop; 19 9 0.3 = 5.7 mm. The first slice for the measurements is No 205
and the last is No 223.

Mental nerve/anterior
loop

Fig. 7. Cross-sectional slice No 212 (2.4 mm in front of

the mental foramen). The anterior loop of the inferior
alveolar nerve can be seen as a double canal (arrows).
B = buccal and l = lingual.

the ALL being longer on the right side of the

mandible (P = 0.025). Spearman correlation
coefficient revealed no relationship between
ALL and age (r = 0.092, P = 0.211). There
was also no difference in age between the
presence and absence of the anterior loop
(P = 0.248).
In the reproducibility study the difference
between each measurement ranged between
0 and 2 mm with a mean absolute difference
of 0.5 mm. The intraobserver agreement, as
calculated with intraclass coefficient was
excellent, with r = 0.817 for the left side and
0.848 for the right side (Table 2). BlandAld-

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Clin. Oral Impl. Res. 23, 2012 / 10221030

Fig. 8. Para-sagittal section of the same case illustrating measurement parameters where R = posterior and
L = anterior.

man analysis of the results revealed that a

change on the mean length of the loop is not
related to a change in the difference (error)
between the measurements. The arithmetic
mean of the error was 0.24 mm (95% CI
0.58, 0.1) with the apparent bias just
expected by the sampling variation (Fig. 11).

Discussion
There are a number of studies, where the
authors using various methods, (anatomical,
radiographical and combined), have attempted
to measure the length of the anterior loop
of the inferior alveolar nerve (Greenstein &
Tarnow 2006; Uchida et al. 2007, 2009). The

actual existence of the loop has been debated

(Rosenquist 1996) and large variations on the
mean length and on the range have been
noted.
To our knowledge this is the first study to
use CBCT scans of actual patients to identify
the anterior loop.
Concerning the methods used, different
studies have shown that panoramic radiographs do not accurately identify the incidence or the extent of the anterior loop
(Arzouman et al. 1993; Kuzmanovic et al.
2003; Jacobs et al. 2004; Kaya et al. 2008;
Ngeow et al. 2009). Considering therefore
that the validity of the studies where panoramics were used as a sole method for detection and measurement is questioned, it is our
intention to exclude these particular studies
from the present discussion.
In almost half of our cases (48%) an anterior loop could be identified radiographically.
This lies approximately in the middle of the
range of existing anatomical studies reporting
either no anterior loop or a universal existence of an anterior loop. Considering that
CBCT has been used only once for the
measurement of the anterior loop and in a
limited number of cadaver mandibles (Uchida
et al. 2009), the current study is useful in
illustrating the value of CBCT in implant
assessment.
Kieser et al. (2002) in an anatomical study
reported that no anterior loop could be found
in a large sample of Negro, Maori and Caucasian units (skulls and cadavers). It is striking,
however, that in that study the main pattern
of emergence for the mental nerve was type
2011 John Wiley & Sons A/S

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

(a)

Fig. 10. Cross-sectional slice through the right body of

mandible just anterior to the mental foramen. The anterior loop is seen as a double canal (arrows).

(b)

4.8 mm

Fig. 9. (a) Para-sagittal slice through the anterior loop

of the mandible of another case. R = anterior and
L = posterior. (b) Measurement of the size of the anterior loop. R = anterior and L = posterior. The estimation
of the anterior loop length is not based on this image
only.

1, a posterior inclination, which is shown in

a diagram in their article. It is obvious that
this pattern of emergence creates an anterior
loop that would have been accounted for, in
our study. The conclusions of this study
came in support of earlier studies of Rosenquist (1996) and Bavitz et al. (1993) where a
small number of short anterior loops were
identified. The conclusions of Rosenquist
(1996) were derived from measurements
taken during surgical procedures performed
on actual patients. Taking into account the
various factors that could have affected the
surgical field, their conclusion should be
viewed with caution.
A number of anatomical studies present a
prevalence of anterior loops that could be
2011 John Wiley & Sons A/S

considered slightly higher or lower than the

number of loops identified in our study (Solar
et al. 1994; Kuzmanovic et al. 2003; Hu et al.
2007; Uchida et al. 2007, 2009) whilst Arzouman et al. (1993) reported a 100% incidence
of anterior loops with Neiva et al. (2004) following with 88%.
On the right side of the male patients the
loop was statistically longer. This finding
suggests clinically insignificant gender and
side relationship with the length of the anterior loop.
The CBCT resembles medical computerized tomography on the bone windowed
images it produces and in the capabilities of
the software. Results from CBCT and CT

imaging of the mandible would therefore be

expected to be similar. Jacobs et al. (2002)
reported an incidence of 7% on the anterior
loop on their CT sample whilst Kaya et al.
(2008) 34%. In the most recent CT study
Watanabe et al. (2010) reported a prevalence
of 55%, a percentage that lies very near our
finding.
The mean length of the anterior loop in
our study was 0.89 mm whilst various studies report a mean length ranging from 0.4 to
6 mm. The longest loop in the literature is
reported by Neiva et al. (2004) being 11 mm,
followed by Uchida et al. (2009) with a
length of 9 mm. Our longest anterior loop
was 5.7 mm whilst another case had an ALL
of 5.2 mm. Taking into account the preference of the surgeons for panoramic radiographs when implants are placed into the
anterior region of the mandible along with
the limited accuracy of the panoramics concerning the anterior loop, our results may
suggest a strategy for the surgeon who
exposes the mental foramen to place
implants in the interforaminal region and a
computed tomography scan is not available.
In 52% of the cases in this study no loop
was found to exist, whilst in 95% of all the
cases where the loop did exist the anterior
loop was measured with CBCT, up to 3 mm.
Placing the implants 3 mm from the anterior
border of the mental foramen can be considered safe even without the use of CBCT for
the great majority of the cases (95% of the
sites). However, since the longest loop identified in our study was 5.7 mm and in 5% of
the cases the anterior loop was more than
3 mm, there is always the possibility that a

Table 2. The reproducibility study. The values are in mm

L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
Mean

Patient no

Measurement 1

Measurement 2

Absolute difference

45

2.7
0
3
4.8
0.3
1.5
1.8
1.8
0.9
0
1.8
0
0.9
0
0
0
2.1
0.9
0
0
1.12

3.2
2
2.1
4.8
1.2
2.4
1.8
1.8
1.2
0
1.5
0
2.1
1.2
0
0.5
1.5
0
0
0
1.36

0.5
2
0.9
0
0.9
0.9
0
0
0.3
0
0.3
0
1.2
1.2
0
0.5
0.6
0.9
0
0
0.5

53
1
68
72
36
60
90
38
42

R, right; L, left.

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Measurement 1 - measurement 2

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

1.5

+1.96 SD
1.18

1.0
0.5
0.0

Mean
0.24

0.5
1.0

1.96 SD
1.66

1.5
2.0
2.5
0

Average of measurement 1 and measurement 2

Fig. 11. BlandAltman plot with the arithmetic mean
( 0.24 mm), the 95% CI of the limits of agreement
(mean 1.96SD) and the 95% CI of the mean of differences.

long anterior loop may be encountered during

implant surgery (Figs 1214). This may
explain the findings of Wismeijer et al. (1997)
who, in their prospective study of 110 edentulous patients found sensory dysfunction at
the area of the lower lip in 7% of the cases,
16 months after the operation, even with a
safety margin of 3 mm. The 100% safe
distance, without the use of CBCT would be
6 mm, limiting the space available for
implant placement to the diameter of approximately three implants. The suggestion that
the implants must be placed 5 mm from the
loop (Magnusson 1992) limits even more
dramatically the interforaminal space. It
should also be remembered that in many
situations the most distal implant should be
located as close as possible to the mental
foramen, to extend the distal cantilever as far
as it is biomechanically tolerable (Bou Serhal
et al. 2002). Therefore when a CBCT scan is
not available a 100% safety in the placement

Fig. 12. The mental foramen of one of the patients

examined. The volume 3d reconstruction is done with
the Newtom VG software. No anterior loop can be
identified in this view, as it is the case in a real clinical
situation.

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Clin. Oral Impl. Res. 23, 2012 / 10221030

Anterior
loop

Fig. 13. Raycast 3d rendering of the same patient. The

mandibular canal has been marked using a panoramic
reconstruction of the data and the Newtom VG software. The anterior loop is represented as the part of the
canal between the yellow lines. Measurement of the
length is not based on this image.

of implants may be achieved, but at the

expense of the available space; not an advisable strategy from a prosthetic standpoint.
Using 93 CBCT volumes, the incidence
and length of the anterior loop of the inferior
alveolar nerve was examined for this study.
A very low number of edentulous cases (on
the anterior mandible) were examined. It
seems that even though a large number of
edentulous patients are restored with
implants, panoramic radiographs remain the
preference of the dentists for the anterior
region. A similar low number of cases
scanned with high resolution and zoom
imaging protocols were examined. Even
though the smaller voxel size of these modes
should increase the identification of small
structures, any difference between these
modes and standard mode could not be statistically proven in our study, due to the low
number of the scans undertaken with zoom
and high resolution protocols. So the larger
mean values of the ALL for high resolution

and zoom modes identified in our study

(1.06, 1.00 mm, respectively) when compared
to the standard mode (0.85 mm) may show a
trend but it is not statistically significant.
Sources of errors in linear measurements
in this study include the voxel size, the
partial inclusion of endpoints within the first
and last cross-sectional slices, the partial
volume averaging effect, small movement
artefacts, artefacts introduced by dental
materials, limited contrast resolution, mouse
sensitivity and radiologists time. Concerning
the last, it became obvious during our study
that identification of the various landmarks
is not a trivial task and took considerable
time to perform. Frustration and time restrictions on a busy radiological practice may
influence the accuracy of the measurements.
Experience in the identification of the anatomy and in the use of the software was felt
to increase the accuracy of the measurements
in the real clinical situation; a fact that needs
further investigation. These errors, however,
are random in nature and no systemic errors
have been introduced in our study.
The reliability of our measurements was
high (r = 0.822 for the single observer) even
though it must be stressed that appropriate
selection and manipulation of the reconstructed images was paramount for the reliable identification of the anterior loop. In
support of that came the estimation of the
absolute error between the two measurements. The mean absolute difference
between the two measurements was 0.5 mm,
a number that can be considered small. However, the largest absolute difference was
2 mm. Even though we could be considered
experienced users of the software, a 2-mm
possible difference between the measurements would be clinically significant in borderline cases with limited interforaminal
space. Inexperienced users and surgeons with
a limited time available may expect to vary

Fig. 14. Another patient. Panoramic reconstruction, thin section. The mandibular canal, the anterior loop and the
mandibular incisive canal are depicted. The red line marks the anterior border of the mental foramen. The green
line marks the anterior border of the anterior loop. The distance between the 2 lines is measured as 4.2 mm. Placement of the implant 4 mm from the anterior border of the mental foramen may violate the anterior loop in this
case. Measurement of the anterior loop length in this study was not based on this image alone.

2011 John Wiley & Sons A/S

Apostolakis & Brown
The anterior loop of the inferior alveolar nerve

more in their measurement of the anterior

loop.
The identification of the anterior loop was
based on signs such as the existence of two
separate canals beyond the anterior border,
an oval or elongated shape of the same canal
and finally on its size.
Concerning the size of the anterior loopincisive canal complex a review of the literature on the diameter of the incisive canal
was undertaken to clarify the subject. In the
studies of Mardinger et al. (2000) and Bavitz
et al. (1993) anatomical measurements were
included and the diameter of the incisive
canal ranged between 0.5 and 2 mm.
However, there are two studies from the
same group of researchers that report a maximum incisive canal diameter of 6.6 mm
(Uchida et al. 2007, 2009).
The size of the mandibular canal has been
reported as ranging from 2 to 5 mm (Rajchel
et al. 1986; Ikeda et al. 1996; Sato et al. 2005)
with the actual mean nerve size being 2.2
with a SD of 0.4 (Ikeda et al. 1996).
Since the incisive nerve is a part of the
inferior alveolar nerve we hypothesized that
its diameter should always be less than the

size of the mandibular canal, i.e. <5 mm and

we devised a cut-off point of 3 mm for the
maximum diameter of the incisive canal. We
feel that this cut-off point includes the vast
majority of the true maximum diameters of
the incisive canal at its origin. Even though
it seems possible to encounter incisive canals
with larger diameters, the possible overestimation of the ALL resulting by our method
is clinically more significant than its probable underestimation.
Another possible drawback of this study
was the fact that the measurements were performed by the same observer, allowing some
consistency but this always includes the possibility for methodological bias.
In conclusion, CBCT scans of patients,
taken for various reasons, were used to provide information on the prevalence and on
the length of the anterior loop of the inferior
alveolar nerve.
1
2

In 48% of the cases an anterior loop was

identified.
The mean length (range) of the anterior
loop was 0.89 mm (05.7).

No statistically and clinically significant

differences between the various groups
examined were identified.
The intrarater reliability of our measurements was excellent.

Finally taking into account the inability of

two dimensional imaging modalities to accurately and reliably depict the anterior loop
and that in almost half of our cases an anterior loop existed and was measured with a
length of up to 5.7 mm, we recommend the
use of CBCT for implant planning in the
anterior region. If this is not possible, our
findings suggest that a safe distance of at
least 6 mm between the anterior border of
the mental foramen and the most distal interforaminal implant fixture must be
observed.

Acknowledgement:

The authors
would like to thank Dr Wilson Ron,
Statistical Advisor, Kings College London for
his help with the statistics of this paper.

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