Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Dr. Saumya Navit

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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2012 | Month : May | Volume : 6 | Issue : 4 | Page : 557 - 560

Osteometric Analysis Of Mandibular Foramen In Dry Human Mandibles

VARSHA SHENOY, S VIJAYALAKSHMI, P SARASWATHI

1. Corresponding Author, 2. Assistant Professor, Department of Anatomy, 3. Professor & HOD, Department of Anatomy, Saveetha Medical College, Saveetha University, Thandalam, Chennai - 602 105, India.

Correspondence Address :
Dr. Varsha Shenoy
Assistant Professor, Department of Anatomy,
Saveetha Medical College, Thandalam,
Chennai- 602105, India.
Phone : 919566275320
E-mail: varsha.shenoy@hotmail.com

Abstract

Context (Background): Adequate anaesthesia is a prerequisite of most of the dental procedures. Effective pain control in dentistry may be achieved by the local anaesthetic techniques; the most common procedure which is followed being the inferior alveolar nerve block. The Traditional Halstead method is a direct technique in which the inferior alveolar nerve is approached by an intraoral access before it penetrates the mandibular canal. According to previous studies, the failure rate of this procedure was 20%, reaching to even higher percentages in the pulpal anaesthesia. The success of this technique highly depends on the proximity of the needle tip to the mandibular foramen at the time of the anaesthetic injection. For this reason, the technique must be based on the precise anatomical knowledge of the correct location of the mandibular foramen.
Aim: The aim of this study was to locate the mandibular foramen in relation to the borders of the mandibular ramus and also to locate the quadrant of the ramus in which the foramen was located in the vertical and horizontal directions.
Materials and Methods: 50 human mandibles were studied to determine, A. The distance of the mandibular foramen to (a) the anterior border of the ramus (b) the posterior border of the ramus (c) the mandibular incisure (d) the lower border of the ramus. B. The gonial angle and the correlation of the gonial angle to other parameters which were studied and C. To categorize the lingula into various patterns depending on its shape and to measure the bi-lingular distance.
Results: This study revealed that the mandibular foramen was located on the third quadrant antero-posteriorly and at the junction of the second and third quadrant of the ramus supero- inferiorly. There was a negative correlation between the gonial angle and other linear parameters which were studied. The most common type of lingula which was found was of the nodular variety.
Conclusion: Localization of the mandibular foramen is a prerequisite prior to the inferior alveolar nerve block and during any surgical procedures on the mandibular ramus.

Keywords

Mandibular foramen, Lingula, Osteometry, Sagittal split osteotomy, Inferior alveolar nerve, Gonial angle

INTRODUCTION
The mandible is the strongest and largest bone of the face which forms the lower jaw. It has a ‘U’ shaped anterior part, the body of the mandible, which bears the lower jaw teeth and a quadrilateral bony plate which is known as the ramus, which projects posterior and superior to the body. The ramus of the mandible has got anterior, posterior, superior and inferior borders and two surfaces, namely, the lateral and the medial surfaces. The mandibular foramen (MF) is an irregular foramen on the medial surface of the ramus, which is located near the centre. The MF leads into the mandibular canal (MC), a canal which traverses the body of the mandible. The inferior alveolar (IA) nerve and the vessels, after passing through the MF, traverse the MC to supply the mandibular teeth. The lingula is a tongue shaped bony projection which is just medial to the MF (1). Previous studies have classified the lingula into the truncated, triangular, nodular and the assimilated type, depending on its shape (2). The IA nerve block is the commonest local anaesthetic technique which is used for anaesthetizing the lower jaw in dentistry. The success of this technique highly depends on the proximity of the needle tip to the MF at the time of the anaesthetic injection (3). For this reason, this technique must be based on the precise anatomical knowledge of the MF.
The aim of the present study was to locate the MF in relation to the borders of the mandibular ramus and also to locate the quadrant of the ramus in which the foramen was located in the vertical and horizontal directions. It was also aimed to study the pattern of the lingula based on its shape.

Material and Methods

The following parameters were studied on both the sides of 50 human mandibles (Table/Fig 1):
1) The smallest distance between the anterior border (Ab) of the mandibular ramus and the anterior limit of the MF (Ab-MF).
2) The smallest distance between the posterior limit of the MF and the posterior border (Pb) of the mandibular ramus (MF-Pb).
3) The smallest distance between the inferior limit of the MF and the mandibular base (MF-MB).
4) The smallest distance between the lowest point of the mandibular incisure (superior border) and the inferior limit of the MF (MI-MF).
5) The smallest antero-posterior measurement of the ramus which passes through the MF (Ab-Pb).
6) The gonial angle of the mandible (Go).
7) The types of lingula –Depending on its shape, the lingula was categorized into four types: truncated, triangular, nodular and the assimilated types.
8) Bi-lingular distance –Distance between the lingulae of both the sides.
All the linear distances (1-5 and 8) were measured by using a vernier caliper and Go was measured by using a goniometer. The distances from the MF to various landmarks and the lingular parameters were tabulated as an average of two measurements which were recorded independently by two people. The data were recorded separately for both the sides and they were expressed as average (Avg) and standard deviation (SD). The correlation between Go and the other distances was analyzed by the Pearson’s linear correlation test.
The antero-posterior localization of the MF was obtained by identifying the distance between the Ab of the mandibular ramus and the mean point of the MF opening. This was calculated as follows: from Ab-Pb, the sum of Ab-MF and MF-Pb was subtracted. This gave the width of the MF. This was divided into halves to get the mean point of the MF opening and this was added to the distance, Ab-MF. Then, the percentage of the distance between Ab – the mean point of the MF with the Ab-Pb distance was calculated to locate MF antero-posteriorly.
The vertical localization of the MF was obtained by calculating how much MI-MF represented in the percentage of the addition of the MI-MF and the MF-MB distances.

Results

The average, standard deviation and the minimum and maximum values of various parameters which were studied on either sides of the mandible are shown in (Table/Fig 2). It was found that there was no significant difference in the values on the right and left sides. The correlation between Go and other distances were analyzed by the Pearson’s linear correlation test. The coefficient could vary from -1 to +1. The positive scores indicated a direct proportional correlation, the negative scores indicated an inversely proportional correlation and zero indicated no correlation, the p value being ≤ 0.05. As has been described in (Table/Fig 3), in the present study, the correlation of Go with other linear distances of the mandibular foramen were negative.
In (Table/Fig 4), the average values of various parameters of both the sides have been illustrated. The Avg (average) measurement of the shortest antero-posterior distance (Ab- Pb) of the mandibular ramus which passed through the MF was found to be 3.07cm. The Avg of Ab-MF was 1.62 cm, that of MF- Pb was 1.15 cm, that of MI-MF was 2.36 cm and that of MF- MB was found to be 2.32 cm. The Avg measurement of Go of the mandible was found to be 124.28 degrees.
(Table/Fig 5) shows that the centre of the MF was located on a point which was 57.71% from the anterior border of the ramus on an antero-posterior (AP) plane.
If we divided the surface area of the ramus into four quadrants (Table/Fig 6), then this study could locate the MF centre to the third quadrant antero-posteriorly. At the same time, on a superoinferior (SI) plane, the MF was found to be at 50.41% from the MI, thus indicating that it was located at the junction of the second and third quadrants on a SI plane.
This study found that the nodular variety of the lingula was the most common type which was found (39 out of 100 sides), which was followed by the truncated type (29 out of 100 sides), the triangular type (23 out of 100 sides) and the assimilated type (9 out of 100 side) respectively. (Table/Fig 7) and (Table/Fig 8) have shown the distribution of various types of the lingula on the right and left sides. (Table/Fig 9) describes the minimum, maximum, Avg and the SD of the bi-lingular distance which was measured on 50 mandibles.

Discussion

The localization of the MF presented great variations, but in this study, there was no significant variation between the right and left sides, which was in accordance with the findings of previous studies (4),(5),(6).
A study on 34 adult Turkish mandibles showed that the Ab-MF was 16.9 mm and 16.78 mm on the right and left sides respectively. The MF-Pb was found to be 14.09 mm on the right side and 14.37 mm on the left side.The MI-MF was 22.37 mm on the right side and 22.17 mm on the left side. The MF- MB was 30.97 mm on the right side and 29.75 mm on the left side (7). According to the present study, the Ab-MF was 1.61 cm on the right side and 1.63 cm on the left side, the MF-Pb was 1.17 cm on the right side and 1.13 cm on the left side, the MI-MF was 2.36 cm on both the right and left sides and the MF-MB was 2.35 cm on the right side and 2.28 cm on the left side.
The IA nerve block was the most frequently used local anaesthetic technique for restorative and surgical procedures on the mandible, with several million blocks being administered each year. According to previous studies, the traditional Halstead method had shown a 20% failure rate. The most common reason for the failure of the technique was the inappropriate location of the tip of the anaesthetic needle due to inappropriate localization of the MF (3),(6),(8). There are some anaesthetic protocols which proclaim the utilization of long needles for the IA nerve blockage. On an average, the long needles are 33mm long and the short needles are 21.5mm long (6). If the long needles are used in patients with small mandibles, the procedure can end in a technical failure, since there is a risk of perforating the parotid gland capsule where the infiltration of the anaesthetic solution may lead to the blockage of the facial nerve branches. On the other hand, the use of short needles in big-sized mandibles might lead to needle fracture (6). In this study, the Avg distance between the Ab and the MF was found to be 1.6 cm (Table/Fig 4), which was the ideal place for the anaesthetic infiltration. The maximum value for the same parameter was found to be 2.1 cm and the minimum was 1.0 cm. According to the values of the present study, the IA nerve block could probably be accomplished with short needles.
Bilateral sagittal split osteotomy (BSSO) and vertical ramus osteotomy (VRO) are the common procedures which are done for the correction of the mandibular prognathism, to reposition the mandible surgically. A thorough anatomical knowledge of the mandibular ramus is essential for these procedures, since they are technically difficult procedures and as they are also associated with a higher incidence of complications (9),(10). According to many studies, the posterior and the superior thirds of the ramus constitute a ‘safety zone’ where the MF is unlikely to be found. This area can be used in VRO with a low incidence of IA nerve damage (11). In the present study also, the MF was found to be located in the third quadrant antero-posteriorly and at the junction of the second and third quadrants supero-inferiorly (Table/Fig 5), which was in accordance with the findings of older studies (6),(11). Thus, familiarity with the described relationships of the MF will assist in the correct localization of the MF, which in turn, might reduce the chances of an undesired split as well as IA nerve morbidity. Thus, the correct localization of the MF will assist in performing proper and safe split osteotomy procedures on the mandible.
The average of Go was found to be 124.28 degrees in the present study, which was similar to the findings of Ennes and Medeiros (6) but to be different from that which was described by other studies (7). It was worthwhile observing that the Go was related to the Ab- Pb width of the mandibular ramus and to the distance between the MF and the borders of the ramus in an inversely proportional relation (Table/Fig 3), as was also found in some other studies (6),(12). This meant that in individuals with a wide Go, it was possible to accomplish the IA nerve blockage with a puncture lower than the conventional one with short needles. In individuals with a smaller Go, it was possible to accomplish the IA nerve blockage with a puncture which was higher than the conventional one, with a lower probability of success with the use of short needles.
The lingula of the mandible is a sharp, tongue-shaped, bony projection on the medial aspect of the ramus. It is an important landmark on the medial side of the ramus as it is in close proximity to the MF. Hence, both the MF and the lingula are of clinical significance for the orodental surgeons. According to a study which was conducted on 165 mandibles, triangular lingulae were found in 226 sides, truncated ones were found in 52, nodular ones were found in 36 and assimilated ones in 16 sides (13). Another study revealed that truncated lingulae were most commonly found (47%), which was followed by the nodular (23%), triangular (17%) and the assimilated shapes (13%) (14). This study revealed that the nodular variety was the most common one which was found, followed by the truncated, triangular and the assimilated varieties (Table/Fig 7) and (Table/Fig 8).

Conclusion

Since some investigators (3) have stated that anaesthesia is essential for both the patients and the dentists, quoting that the opinion of the patients about their dentists was strictly based on their experience with local anaesthesia, it was preferred to infiltrate the anaesthetic solution in close proximity to the MF in the IA nerve block. Despite the great variation of the MF, it should be kept in mind that it is located in the third quadrant of the ramus antero-posteriorly and supero-inferiorly. It is also preferable to locate the MF by a CT scan prior to any surgical approach to the ramus, to prevent inadvertent injury to the IA nerve.

References

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Datt AK. Essentials of Human Anatomy, Head and Neck. 3rd ed. Kolkata: Current Books International; 1999.
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Jansisyanont P, Apinhasmit W, Chompoopong S. Shape, height, and location of the lingula for sagittal ramus osteotomy in Thais. Clin Anat 2009 Oct; 22(7):787-93.
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Palti DG, Almeida CM, Rodrigues AC, Andreo JC, Lima Jeo. An anesthetic technique for the inferior alveolar nerve block: a new approach. J Appl Oral Sci. 2011; 19(1):11-5.
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Hayward J, Richardson ER, Malhotra SK. The mandibular foramen: its anteroposterior position. Oral Surg. Oral Med. Oral Pathol. 1977; 44(6):837-43.
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Narayana K, Soubhagya RN, Prashanthi N, Latha VP. The location of the mandibular foramen maintains absolute bilateral symmetry in mandibles of different age-groups. Hong Kong Dental Journal 2005; 2: 35-7.
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