Dentomaxillofacial Radiology (2002) 31, 368 ± 372

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RESEARCH

Radiographic evaluation of the relationship between the projection

of genial tubercles and the lingual foramen
EZ Baldissera*,1 and HD Silveira2
1
Clinical and Diagnostic Oral Sciences Department, School of Dentistry, Universidade Federal de Pelotas, Brazil; 2Surgery and
Orthopedics Department, School of Dentistry, Universidade Federal do Rio Grande do Sul, Brazil

Objective: Reports in specialized literature present divergent opinions about what corresponds
to the radiopaque areas surrounding the lingual foramen. The purpose of this study is to
radiographically evaluate whether these areas correspond to the genial tubercles.
Methods: We selected 15 dry mandibles and obtained images of the lower incisors region by
computed tomography (CT) and periapical radiography at vertical angles of 7108, 7208 and
7308. For periapical radiography, the genial tubercles and the lingual foramen were marked
with stainless steel wire to demonstrate the relationship between them.
Results: The images on periapical radiographs, as well as on CT scans of the region, showed
that there is no relationship between radiopaque areas around the lingual foramen and the
genial tubercles.
Conclusion: The radiopaque area surrounding the lingual foramen corresponds to the walls of
a nutrient canal and not to the genial tubercles. Therefore, we recommend that the information
about this anatomical landmark be reviewed in specialized literature.
Dentomaxillofacial Radiology (2002) 31, 368 ± 372. doi:10.1038/sj.dmfr.4600733

Keywords: radiography, dental; genial tubercles; lingual foramen; tomography, X-ray

computed

Introduction

The importance of imaging studies in the diagnostic
process is well established. To interpret these studies
knowledge of imaging techniques, pathology, and
radiographic anatomy are needed.
Anatomical regions have distinct landmarks that
can be visualized, such as in the lower incisors where
we can see the mental protuberance, mental fossa,
nutrient canals, lingual foramen and genial tubercles
on periapical radiographs. Genial tubercles are small
bony protuberances on the lingual aspect of the
mandible in the area of the symphysis, slightly above
the inferior border of the mandible. They have the
form of spines often distributed as right and left
protuberances and superior and inferior tubercles.
These structures are a point of attachment for the
genioglossus and geniohyoid muscles. The genial
*Correspondence to: E Baldissera, Universidade Federal de Pelotas, Faculdade
de Odontologia, Departamento de Semiologia e ClõÂ nica, Rua GoncËalves Chaves,
457, Pelotas, Brazil; E-mail: baldis@terra.com.br
Received 25 March 2002; revised 26 August 2002; accepted 30 August 2002
tubercles are at the same level or just below the
lingual foramen, which is located in the midline in the
lingual aspect of the mandible. Di€erent de®nitions
for the periapical radiographic projection of the genial
tubercles are found in literature. Most authors of
dental radiology books1 ± 14 describe them as a radio-
paque area surrounding the lingual foramen. How-
ever, other authors do not describe these radiopaque
areas to the genial tubercles.15 ± 19 Benkow15 and
McDonnell et al.17 used di€erent methodologies to
demonstrate that the radiopaque areas around the
lingual foramen correspond to the dense bone that
forms the walls of a vascular canal that originates in
the lingual foramen.
This disagreement indicates that further investiga-
tion of these anatomic landmarks is indicated to
clarify the situation. The aim of this study was to
evaluate periapical radiographs and computed tomo-
graphy studies of the region to determine the
relationship between the genial tubercles, the lingual
foramen, and the radiopaque area surrounding the
lingual foramen.

Material and methods
Fifteen dry human mandibles from the collection of the
Human Anatomy Department in the Biology Institute,
Universidade Federal de Pelotas, Brazil were used for
this investigation.
Periapical radiographs
For each mandible, we identi®ed the genial tubercles
and the lingual foramen. We placed steel wire
(Daufenbach, CriciuÂma, Brazil) of 0.5 mm diameter
in the lingual foramen, 0.6 mm in the inferior genial
tubercles, and 0.7 mm in the superior genial
tubercles, and ®xed them with utility wax. The steel
wire was only used on periapical radiographs for the
visualization and anatomic identi®cation of these
landmarks.
Each mandible was positioned and ®xed with utility
wax to a plaster support especially made for this study
to keep the mandible in a standardized position for
the radiographs. We used number 2 size radiographic
®lm, Ektaspeed plus (Eastman Kodak, Rochester,
NY, USA), which was placed in a ®lm holding
device (Hanshin, Japan). The holding device was ®xed
with adhesive tape to the tubehead cylinder of an
intraoral X-ray machine Spectro II, 50 kVp and
10 mA (Dabi Atlante, RibeiraÄo Preto, SP, Brazil).
The machine-®lm-holding device set was brought to
the mandible at the lower incisors region, and
exposure time was 0.3 s.
We took three views of the same region for each
mandible at vertical angles of 7108, 7208 and 7308.
A total of 45 ®lms were processed in an automatic ®lm
processor model 9000 (DENT X, NY, USA).
Computed tomography
Computed tomography (CT) was performed to identify
the course of the nutrient canal and its cortical bone
wall, and to anatomically verify the location of the
lingual foramen and genial tubercles in di€erent planes.
An Elscint Twin ¯ash scanner (Haifa, Israel) and
Dental CT software were used for the spiral
computed tomography studies of the numbered
mandibles. The mandibles were ®xed to a styrofoam
support so that we could place them on the scanner
table with the occlusal plane perpendicular to the
horizontal plane, and the symphysis turned upwards.
Axial images were obtained as 1 mm thick sections
with 1 mm increments, from the base of the mandible
to the alveolar ridge. An equidistant line to the facial
and lingual cortical plates was drawn over the axial
image that best depicted the genial tubercles and the
lingual foramen. We then drew three lines perpendi-
cular to the ®rst line; at the level of the genial
tubercles on the right, at the level of the lingual
foramen, and of the genial tubercles on the left.
These lines marked the planes for cross-sectional
reconstructions (Figure 1).
Lingual foramen
EZ Baldissera and HD Silveira
369
Figure 1 Axial CT image showing lines representing the cross-
sectional reconstruction positions; lines 1 and 3 are the genial
tubercles and line 2 is lingual foramen
Results
Radiographs were evaluated by an oral and maxillo-
facial radiologist. The criterion for periapical radio-
graphs was the coincidence (yes/no) of the images
visualized by the contrast of the steel wire. The
criterion for CT was visualization of the anatomic
structures reconstructed in di€erent planes and
identi®ed with `yes' when they were coincident, or
`no' if they were visualized as distinct structures.
All the images of the genial tubercles and of the
radiopaque area around the lingual foramen were
distinct in 100% of the samples both on the periapical
radiographs and in the computed tomography studies.
The periapical radiographic images showed that the
genial tubercles marked with wire were clearly
separated from the lingual foramen and the radio-
paque area. In the computed tomography studies, the
cross-sectional reconstructions, as well as the frontal
planes (Figure 2), revealed the distinction between
these anatomic landmarks.
Figure 3 shows that the radiopaque area around the
lingual foramen does not represent the radiographic
projection of the genial tubercles on the periapical
radiographs of the lower incisors. The radiopaque area
surrounding the lingual foramen is the image of the
compact bone that forms the walls of the nutrient
canal located in that foramen (Figure 4).
Discussion
The analysis of our periapical radiographs and
computed tomography images showed that the radio-
paque area visualized around the lingual foramen on
periapical radiographs of the lower incisors region does
not correspond to the projection of the genial
tubercles. Our ®ndings agree with those of Benkow,15
Fontoura et al.,16 McDonnell et al.,17 Goaz and
Dentomaxillofacial Radiology
 Lingual foramen
EZ Baldissera and HD Silveira
370
Figure 2 Panoramic reconstruction of the CT showing the radio-
paque area surrounding the lingual foramen, indicated by arrows
White,18 White and Pharoah,19 but not with several
dental radiology textbooks.1 ± 14
We also observed that, in agreement with Benkow,15
McDonnell et al.,17 Goaz and White18 and White and
Pharoah,19 the radiopaque area around the lingual
foramen represents the bony cortical wall of the
nutrient canal leading to the lingual foramen, since
the radiopaque ring around the image of the lingual
foramen did not coincide with the image of the genial
tubercles that are seen below the lingual foramen,
identi®ed by the steel wire. When the genial tubercles
were very close to the lingual foramen, genial tubercles
were projected, depending on the angulation of the
beam, adjacently to the foramen image. However, they
did not produce the characteristic radiopaque halo. In
these cases, genial tubercles were sometimes identi®ed
only by the contrast of the wire; other times, they
Dentomaxillofacial Radiology
produced a discrete radiopacity without a de®nite
form. This is in agreement with ®ndings of Goaz and
White,18 who reported that genial tubercles may be
seen on periapical radiographs of the mandibular
incisor region as a radiopaque nondescript mass or a
mass suggestive of the muscle attachments, or that
genial tubercles sometimes are not apparent at all.
However, we noted that the mental protuberance also
produced radiopacity in this area, which makes it
dicult to clearly identify the genial tubercles on
periapical radiographs of the mandibular incisors.
Therefore, they are better identi®ed on standard
mandibular occlusal radiograph. We thus concluded
that the image of a radiopaque ring around the lingual
foramen represents the canal cortical wall and not the
projection of the genial tubercles. Whenever genial
tubercles are dense enough to produce radiopacity in
this region, they are seen as a discrete radiopaque mass
of variable form.
The lingual foramen was visualized for all mand-
ibles. Some authors report a similar frequency.
McDonnell et al.17 reported that the lingual foramen
was visualized for 99% of 314 dry mandibles. Sutton20
examined 300 mandibles, and the lingual foramen was
identi®ed in 80% of them, while Shiller and Wiswell21
report visualization in 89% of 126 mandibles. These
data show the high frequency of visualization of this
anatomic structure, which is not, surprisingly, de-
scribed by most anatomy books.22 ± 30
The lingual foramen is clearly described in dental
radiology books. In our study, some variation was
observed in its radiographic image. For mandible 5,
this anatomic landmark could only be visualized
because of the stainless steel wire contrast, while the
radiopaque area surrounding the lingual foramen was
not visualized in any of the angulations studied. The
genial tubercles, however, were recorded at a site
remote from the lingual foramen. In mandibles 2, 14
and 15, the radiopaque area around the lingual
foramen was better visualized at a vertical angle of
7308. According to Benkow,15 the lack of a radio-
paque area around the lingual foramen is explained by
individual variations of the orientation of the nutrient
canal. According to Pasler,13 the compact layers that
are in the same direction as the X-ray beam, or that
the X-ray beam touches tangentially, absorb photons
of this radiation and are visualized as radiopaque
areas. If the layers of compact bone are perpendicular
to the angulation of the X-ray beam, they permit the
passage of X-rays and the resulting image is
radiolucent. The variation in the orientation of the
nutrient canal was also con®rmed in our computed
tomography studies. When the cross-sectional plane
coinciding with the lingual foramen was reconstructed,
the resulting images did not show the full extension of
the nutrient canal.
We observed other foramina in the region of the
lower incisors, which, according to Sutton,20 are
called accessory foramina and are found in large
numbers, especially on the lingual side of the

Figure 3 Periapical radiographs showing the location of the genial tubercles projection and the lingual foramen. Vertical angulation: (a) 710
degrees; (b) 720 degrees; (c) 730 degrees
Figure 4 Cross-sectional CT reconstructions showing the genial tubercles (black arrows) and the cortical wall of the canal (white arrow) leading
to the lingual foramen
mandible. Accessory foramina are any openings in
the bone other than the tooth alveolus, the
mandibular foramen, the mental foramen and the
lingual foramen.31 The data published by Benkow,15
Fontoura et al.,16 and McDonnell et al17 have been
systematically overlooked in specialized literature,
maybe because they were not originally published in
dental radiology journals. Therefore, incorrect in-
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