Pictorial Essay

CT Imaging of Mental Nerve Neuropathy:

The Numb Chin Syndrome
Jacob Bar-Ziv1 and B. Simon Slasky

F acial
distribution
numbness
of the mental
localized to
nerve-
the thesia,
destruction.
pain, local swelling, and bone important anatomic
are the relationship
features
of each
displayed
tooth
in this
to the mandibular
plane

mental nerve neuritis or mental canal, the buccal and lingual cortical margins of the
mandible, and the spongiosa between these cortices.
nerve neuropathy-has been labelled the
Materials and Methods Figure 1 shows the normal anatomy of the man-
numb chin syndrome. The inferior alveolar
dibular, inferior alveolar. and mental nerves.
nerve may also be involved. This uncom- We present I 5 causes of the numb chin syndrome
mon neuropathy is almost always unilateral, in I 5 patients. These cases were evaluated by CT
with anesthesia or hypoesthesia of the chin scans of the mandible in axial, panoramic. and buc-
colingual planes. Nine of the patients were female,
Causes
and lower lip found on physical examina-
six were male. and they ranged in age from 7 to 79 The causes of this syndrome can be
tion. When not associated with iatrogenic
years old.
local anesthesia, the condition is most corn- grouped into several categories. Dental causes
CT imaging of the mandible was performed on
monly due to dental diseases. In the absence are by far the most common. They may be iat-
Elite 2400 CT scanners (Elscint, Haifa, Israel) using
of these causes. the condition is clinically dedicated software for dental imaging (Denta CT,
rogenic (following anesthesia or as a compli-
significant because of its frequent associa- Elscint). Thin-section overlapping axial cuts ( I .2- cation of a dental procedure) (Fig. 2); due to
tion with malignant diseases [1-4). In some mm sections at 1.0-mm intervals) were acquired at pressure from an ill-fitting denture in an eden-
cases the numb chin syndrome may even be I 20 kVp and 165 mAs parallel to the alveolar pro- tulous atrophic mandible in an elderly person
the presenting symptom of an unsuspected cess of the mandible. These axial scans formed the (Fig. 3); or associated with infection of the
malignancy: more frequently it heralds a scaffold for generating reformatted panoramic and root of a tooth (Fig. 4), acute or chronic osteo-
cross-sectional (buccolingual) images using the myelitis of the mandible (Figs. 4 and 5), or
relapse in a patient with a known neoplasm
Denta CT software.
[1]. In such cases this finding, despite its odontogenic or nonodontogenic tumors or
The direct-CT axial images and the reformatted-
seemingly clinically benign symptoms, is cysts of the mandible (Figs. 6-8).
CT panoramic views show the mandibular canal
ominous because it usually implies a grave Second to dental causes are neoplasms,
partially or in its entire horizontal length, depending
prognosis [2, 4]. Although painless mental on the section obtained. The reformatted buccolin-
malignant much more commonly than benign,
nerve neuropathy may be the only symptom gual images uniquely show the cross-sectional anat- and metastatic much more commonly than pri-
of distant malignant disease, mandibular omy of the mandibular canal, including the mental mary. Any type of malignancy can metastasize
metastases may be accompanied by pares- foramen on the buccal side of the mandible. Other to the mandible; however, by far the most fre-

Received June 4, 1996; accepted after revision July 29, 1996.

1 Both authors: Department of Radiology, Hadassah University Hospital, Hebrew University, Box 12000, Jerusalem 91120, Israel. Address correspondence to J. Bar-Ziv.

AJR 1997;168:371-376 0361-803X/97/1682-371 © American Roentgen Ray Society

AJR:168, February 1997 371

 Bar-Ziv and Slasky

I
,.
B

Fig. 1.-Normal anatomy of mandibular, inferior alveolar, and mental nerves.

A, Line drawing of mandible in lateral view showing mandibular division (long arrow) of
trigeminal nerve (curved arrow). Mandibular nerve exits from base of skull through foramen
ovale. Posteriortrunk of mandibular nerve divides into three branches, one ofwhich is inferior
alveolar (inferior dental) nerve (short arrow), which has mostly sensory function. Inferior al-
veolar nerve descends vertically between medial and lateral pterygoid muscles to enter ra-
mus of mandible at its lingual aspect at mandibular foramen (open arrow). Upon entering body
of mandible, inferior alveolar nerve courses horizontally in spongiosa within mandibular canal
(large arrowhead), lying below level of teeth that it innervates. Inferior alveolar nerve exits
through mental foramen (small arrowhead), where it divides into mental and incisive nerves.
B, CT scan in panoramic plane shows horizontal course of right and left mandibular canal
D (arrowheads) within spongiosa of mandible.
C, CT scan in axial plane shows most of left mandibular canal (arrowheads). Only portion of
right canal is seen, with anterior segment about to enter buccal cortex en route to mental fo-
ramen (arrowheadin white circle). Plane of scan must be parallel to body of mandible to show
mandibular canal.
D, CT scan in axial plane (different patient from that in C) shows oval-shaped right and left
mental foramina (arrowheads) on buccal aspect of anterior mandible, lying at level slightly
higher than that of mandibular canal.
E, CT scan in buccolingual plane shows mandibular bony canal (arrowhead) within lowerthird
of spongiosa of mandible.
F, CT scan in buccolingual plane 2 mm anterior to E shows mandibular canal (arrowhead)
entering buccal cortex in oblique upward direction and exiting at mental foramen (arrow in
white circle) on buccal aspect of mandible. Here, inferior alveolar nerve terminates as inci-
sive and mental nerves.

Fig. 2.-41-year-old man with retained tooth remnant as complication of dental procedure.
A, CT scan in panoramic plane reveals cavity (long arrow) of extracted tooth, with remnant of root (short arrow) lying in mandibular canal (arrowhead).
B, CT scan in axial plane shows tooth remnant (short arrow) in mandibular canal (arrowhead).
C, CT scan in buccolingual plane shows fragment of tooth (short arrow) in mandibular canal (arrowhead).

quent is carcinoma of the breast (Figs. 9 and mandible of a primary squamous cell carci- (Fig. 15) and benign and malignant nerve
10). The numb chin syndrome has been noma of the lower lip (Fig. 12). Other associ- sheath tumors (Fig. 16)]. Leptomeningeal car-
reported in primary carcinomas of the lung, ated neoplasms include acute lymphocytic cinomatosis and tumors involving the base of
thyroid, kidney, prostate, and nasopharynx and leukemia, Hodgkin’s and non-Hodgkin’s lym- skull have been implicated in a small percent-
also in melanoma. The syndrome can occur phoma (Fig. 13), myeloma (Fig. 14), and age of patients. Malignant cells are usually
with primary osteosarcoma of the mandible tumors of the inferior alveolar nerves and found in the CSF in such patients.
(Fig. 11) and from direct extension into the mental nerves and their sheaths [neurofibroma Trauma, through fracture of the ramus or

372 AJR:168, February 1997

 The Numb Chin Syndrome

Fig. 3.-Pressure trauma of dentures on exposed mandibular canal as result of resorption of alveolar bone in edentulous 71-year-old man.
A, CT scan in panoramic plane reveals resorption of alveolar bony ridge of right side of mandible (arrow). Loss of bone height progresses significantly from posterior to
anterior.
B, CT scan in buccolingual plane at level of posterior body of mandible shows mild loss of height of alveolar bony ridge (arrow) relative to mandibular canal (arrowhead).
C, CT scan in buccolingual plane at level of mid anterior body of mandible shows severe loss of height of alveolar bone (arrow), with unroofing of mandibular canal
(arrowhead) exposing inferior alveolar nerve.

Fig. 4.-Root abscess with acute osteomyelitis in 62-year-old man.

A, CT scan in panoramic plane reveals marked caries of molar tooth,
with root abscess (arrow) and extension into mandibular canal
(arrowhead), which is widened by infection.
B, CT scan in buccolingual plane shows periapical infected cavity in-
volving mandibular canal (arrowhead), with destruction of buccal
cortex of mandible (arrow).

Fig. 5.-Chronic osteomyelitis in 11-year-old girl.

A, CT scan in panoramic plane reveals reparative new bone thickening cortex (long arrow) and spongiosa (shortarrow) constricting mandibular canal (arrowhead).
B, CT scan in buccolingual plane shows displacement and compression of mandibular canal (arrowhead) as result of marked bony overgrowth of spongiosa and cortex
(arrow).
C, CT scan in axial plane shows bony hypertrophy of body of left side of mandible (arrow).

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 Bar-Ziv and Slasky

body of the mandible, is a third cause of the been reported in some patients and is attrib-
syndrome. uted to a viral inflammation analogous to other
A fourth cause is systemic disease such as transient cranial mononeuropathies, such as
sickle cell anemia, multiple sclerosis, amyloi- Bell’s palsy. Careful follow-up of such
dosis, sarcoidosis, and diabetes mellitus. patients is, however, necessary before the
Spontaneous remission of symptoms has

Fig. 6.-Radicular cyst in 20-year-old man.

A, CT scan in panoramic plane reveals well-defined solitary cystic lesion (arrow) eroding through roof of right mandibular canal (arrowhead).
B, CT scan in buccolingual plane shows well-marginated cyst (arrow) below root of tooth (open arrow), with focal erosion of roof of mandibular canal (arrowhead).

Fig. 7.-Giant cell granuloma in 25-year-old woman.

A, CT scan in panoramic plane reveals large lytic lesion, with ballooning of cortical margins displacing and flattening mandibular canal (arrowhead).
B, CT scan in axial plane shows long, oval lytic lesion expanding bony margins of body of mandible, with thinning and focal disruption of lingual cortex (arrow). Mandibular
canal was incorporated within this lesion. Numbered lines are used to reformat images in buccolingual plane.

Fig. 8.-Hemangioma in 7-year-old boy who needed two units of blood following extraction of tooth.
A, CT scan in panoramic plane shows expanding lytic lesion (arrow) thinning bony margins of mandible and involving mandibular canal (arrowhead). Lesion enhanced
markedly after injection of contrast material during other studies (not shown).
B, CT scan in buccolingual plane reveals ballooning of cortical margins by large lytic lesion that has eroded through roof of mandibular canal (arrowhead). Canal has en-
larged considerably.

374 AJR:168, February 1997

 The Numb Chin Syndrome

IE 9.-Lytic metastases from breast carcinoma involving right mental

foramen in 50-year-old woman.
A, CT scan in axial plane reveals destructive lesion in region of right
mental foramen (arrow) and mass in adjacent soft tissues (arrow in
). Note normal left mental foramen (arrowhead).
. T scan in buccolingual plane shows destruction of buccal cortex ex-
tending into mental foramen (arrowhead) and periosteal elevation
(arrow).

Fig. 10.-Osteoblastic metastases from breast carcinoma in 57-year-old woman.

A, CT scan in axial plane reveals blastic lesion in spongiosa of body of mandible
(arrow) incorporating mid portion of right mandibular canal (arrowhead). Note left
mental foramen (arrowheadin white circle).
B, CT scan in panoramic plane reveals blastic lesion in body of mandible (arrow)
with involvement of right mandibular canal (arrowhead).

Fig. 11.-Primary osteosarcoma of mandible in 19-

year-old woman.
A, CT scan in panoramic plane reveals cloud of new
bone (arrow) in spongiosa that has engulfed mandib-
ular canal (arrowhead) and penetrated through cor-
tex into soft tissues (open arrow) below inferior
margin of mandible.
B, CT scan in buccolingual plane shows new bone in
spongiosa (arrow) that has incorporated part of man-
dibular canal (arrowhead) and has permeated
through lingual cortex into soft tissues (open arrow).

A B

Fig. 12.-Primary squamous cell carcinoma of lip in-

volving mandible in 70-year-old woman.
A, CT scan in panoramic plane reveals irregular lytic
lesion destroying bone (arrows) and left mandibular
canal (arrowheads).
B, CT scan in buccolingual plane shows ill-defined le-
sion destroying cortex from without (arrow), extend-
ing into spongiosa, and penetrating roof of mandibular
canal (arrowhead).
A

Fig. 13.-Non-Hodgkin’s lymphoma in 50-year-old

woman.
A, CT scan in panoramic plane reveals destructive le-
sion in body of mandible (arrow), with involvement of
mandibular canal (arrowhead).
B, CT scan in buccolingual plane shows irregular lytic
lesion within spongiosa (arrows) that has invaded
mandibular canal (arrowhead).

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 Bar-Ziv and Slasky

Fig. 14.-Myeloma in 33-year-old .....n.

A, CT scan in panoramic plane reveals well-demarcated lytic lesion (arrow) in posterior body of mandible invading and widening mandibular canal (arrowheads).
B, CT scan in axial plane shows endosteal scalloping (arrows) from lytic lesion extending toward mandibular canal (arrowhead).
C, CT scan in buccolingual plane shows lytic lesion (arrow) and destruction of roof of mandibular canal (arrowhead), which is enlarged.

Fig. 15.-Neurofibroma of mental nerve in 31-year-old woman.

A, CT scan in axial plane shows focal enlargement of left mentalfora-
men and mass in adjacent soft tissues (arrow). Note undercutting of
proximal bony margin of foramen (arrowhead).
B, CT scan in buccolingual plane shows enlargement of mental foramen
(arrow).

Fig. 16.-Malignant nerve sheath tumor in 42-year-

old woman.
A, CT scan in panoramic plane reveals uniform widen-
ing of most of left mandibular canal (arrowheads).
B, CT scan in buccolingual plane shows enlargement
of entire circumference of left mandibular canal
(arrowheads).

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