JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 67-70

A retrospective study detecting the neurovascular anatomical variations in the anterior palate observed on cone beam computed tomography images

Department of Oral Medicine and Radiology, MGV KBH Dental College, Nashik, Maharashtra, India

Date of Web Publication21-Dec-2017

Correspondence Address:
Dr. Ashni Chatterjee
MGV KBH Dental College, Off Mumbai Agra Road, Panchwati, Nashik - 420 033, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_21_17

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Introduction: Premaxilla or the anterior maxilla is one of the most important sites for different surgical procedures, and any variations in the normal anatomic features can lead to misdiagnosis and altered treatment planning for a clinician. Hence, it is very necessary for the early detection and evaluation of the anatomical variations associated with anterior maxillary region, and the procedure becomes easy with the incorporation of the specific radiologic appliances such as cone beam computed tomography (CBCT). Materials and Methods: One hundred CBCT scans were collected retrospectively for examination of additional foramina and canals in the anterior palatal region, through CBCT images, describing location, and diameter. Results: The mean canal diameter was 1.4 mm, out of the 100 scans evaluated 11 scans were found in which additional foramina were detected and 9 scans wherein canalis sinosus was detected. The mean canal diameter was 1.4. Conclusion: Although there are variations in each patient, with the knowledge of the anatomic landmarks and with the use of advanced imaging techniques, the chances of error in diagnosis and treatment planning can be greatly reduced.

Keywords: Anterior palatine foramen, cone beam computed tomography, canalis sinosus

How to cite this article:
Chatterjee A, Bhoosreddy A, Bhoosreddy S, Chaudhary M, Bhandari A, Patil A. A retrospective study detecting the neurovascular anatomical variations in the anterior palate observed on cone beam computed tomography images. J Int Clin Dent Res Organ 2017;9:67-70

How to cite this URL:
Chatterjee A, Bhoosreddy A, Bhoosreddy S, Chaudhary M, Bhandari A, Patil A. A retrospective study detecting the neurovascular anatomical variations in the anterior palate observed on cone beam computed tomography images. J Int Clin Dent Res Organ [serial online] 2017 [cited 2022 Dec 5];9:67-70. Available from: https://www.jicdro.org/text.asp?2017/9/2/67/221393

   Introduction Top

Premaxilla or also commonly known as the anterior maxilla is one of the most important sites for a variety of oral surgical procedures ranging from implant placement in the canine region for better prosthetic outcomes in consideration with underlying bone quality in this region. Furthermore, this region of the maxilla finds its use in oral graft surgeries for the purpose of oral rehabilitations. On the other hand, if we see, this area is also prone to surgical injuries and treatment failure because of the blood vessel and nerves which supply causing paresthesia in the postoperative phase.[1],[2],[3]

The nasopalatine canal and incisive foramen, carrying the nasopalatine nerve and artery, represent major neurovascular bony structures in the anterior maxilla. Most clinicians are well familiar with these landmarks and recognize them on conventional radiographs. The anterior superior alveolar (ASA) nerve and artery also reach this region through a bony canal named canalis sinosus (CS).[4],[5],[6]

This small canal, i.e., the CS, runs forward and downward to the inferior wall of the orbit, lateral to the infraorbital canal, and medially bent to the anterior wall of the maxillary sinus, passing below the infraorbital foramen. Finally, reaching the anterior margin of the nasal aperture in front of the anterior end of the inferior concha, it follows the lower margin of the aperture and opens next to the nasal septum in front of the incisive canal. The CS transmits the ASA nerve besides the corresponding veins and arteries and is responsible for supplying the incisors, canines, and the adjacent soft tissues.[7],[8],[9]

With such intricate neurovascular anatomy involved in the anterior maxillary region, chances of complications in the surgical procedures are common in relevance with treatment planning with the use of conventional radiography.[10] Hence, this study was conducted to determine the presence of additional foramina and canals in the anterior palatal region, through cone beam computed tomography (CBCT) images, describing location, and diameter.

   Materials and Methods Top

A total of 100 CBCT scans were collected retrospectively for examination of additional foramina and canals in the anterior palatal region, through CBCT, who reported to the Department of Oral Medicine and Radiology at KBHS MGV Dental College and Hospital, Nashik, for their CBCT scans for dental treatment purposes.

Patients with any anterior palatal region pathology and low-quality imaging scans were excluded.

Machine specifications used are as follows:

  • Model designation - Orthophos × G 3D
  • Nominal voltage - 200–240 v
  • Focal spot size - 0.1 mm 3
  • Kv - 85 Kv
  • mA - 5 mA/7 mA
  • Field of view - 8 cm × 8 cm.

Demographic detail registered was gender (male/female) and age, in the range of 20–60 years.

Following parameters were evaluated, and measurements were done in the sagittal, cross-sectional, and axial sections.

  1. Presence of additional foramen and canal
  2. Location
  3. iameter.

Diameters were determined by measuring the palatine opening of the additional canal on both coronal and cross-sectional images, and diameter of at least 1 mm was considered.

Location was determined under three regions, namely, in central-lateral incisor region, canine region, and premolar region.

Finally, the presence of CS was registered.

   Results Top

The study comprised of 100 CBCT scans, in which there was equal gender distribution seen, that is 50 scans each of male and female. Twenty-seven patients out of 100 (27.5%; 11 males, 17 females) presented with additional palatine foramen that was at least 1 mm in diameter [Figure 1]. The average diameter of the foramen was 1.4 mm (1–1.9 mm). Their location was variable, with most of the cases occurring in the alveolar process near the incisors region, followed by the canines and then premolars (incisor = 17, canine = 6, and premolar = 4). Out of the 100 scans, 22 scans showed the presence of CS (%), in which 14 were male and 8 were female scans [Figure 2].
Figure 1: red arrowhead showing additional foramina

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Figure 2: red arrowhead showing the presence of canalis sinosus, seen unilaterallyxs

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   Discussion Top

With the advent of newer technologies in dental radiographic investigations, it becomes very simple as well as necessary to identify and evaluate anatomical variations associated with the respective region of concern, wherein the treatment is to be given to eliminate chances of failure in the procedure during as well as postoperatively. Early detection of the anatomical variations also saves the patient from further procedures to correct any mishaps during the procedure. Impact of patient's quality of life in the form of paresthesia, hyperesthesia, or pain can occur due to injury to nerve or damage to the major blood vessels. In addition to all these, treatment like implant placement can be a failure if the implant comes in contact with such neural tissue in their vicinity ultimately leading to problem in osseointegration.

In this study, the prevalence of the occurrence of additional palatine foramen was determined along with the average diameter and the most common site of their occurrence. The results showed a prevalence of 27% in the occurrence of the additional foramen with their average diameter being 1.4 mm which was in accordance with study conducted by de Oliveira-Santos et al., in which the prevalence of additional foramen was 19.11%. A total of 178 CBCT scans were evaluated in their study, of which 34 scans depicted additional foramen of at least 1 mm with their average diameter being 1.4 mm and the range being 1–19 mm.[11] Another study conducted by von Arx et al., where of 176 patient's scans, 67 accessory canals were seen with an average diameter of 1.31 mm and a range of 1.01–2.13 mm.[12]

The region of occurrence of these additional foramina was grouped into three regions, being the incisor region, canine region, and finally the premolar regions, and the highest number of foramina was seen in the central and lateral incisor region. Similar findings were found in the study done by de Oliveira-Santos et al., wherein the maximum number of foramen was found in the anterior region, i.e., near the central and lateral incisor.[11]

The presence of CS was also described in the study, and of the 100 scans which were examined, 22 scans showed the presence of CS, which comprised to be 22% of the scans. Other studies with larger sample size have been carried out in the past with similar results with higher prevalence. The study conducted by Wanzeler et al. contained examination of 100 CBCT scans, of which 88% of it showed the presence of CS and 87 scans showed the presence of the structure bilaterally.[1] Another study conducted by Manhães Júnior et al. for detecting the presence of CS, in which they had grouped the scans according to gender and named as female and male group. The results showed the presence of 99 scans with CS out of 284 scans in the female group and 82 out of 216 scans in the male group, comprising of 34.86% and 37.97% to be the prevalence rate in both groups, respectively.[13]

The present study has its strength in a way that it gives a detailed view about the identification of the anterior accessory foramen and the presence of CS in anterior maxillary region in three-dimensional radiograph in all three sections which is more appropriate than a two-dimensional radiograph. Furthermore, the radiation exposure is comparatively less in CBCT as compared to conventional CT. Limitation of the study includes its small sample size. Thus, the study with larger sample size should be carried out. While we consider the scope of the present study, we can say that a thorough knowledge of anatomic structures of the anterior maxilla and its variations is essential to reduce the chances of complications in any operative procedures carried out in the anterior maxilla.

   Conclusion Top

Presurgical evaluation of the operating site for the identification of the various anatomical variations using CBCT for the tri-dimensional evaluation is very essential before planning the treatment to avoid the postoperative complications resulting due to invading such important anatomical structures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Wanzeler AM, Marinho CG, Alves Junior SM, Manzi FR, Tuji FM. Anatomical study of the Canalis sinuosus in 100 cone beam computed tomography examinations. Oral Maxillofac Surg 2015;19:49-53.  Back to cited text no. 1
Costa C, Tavano O, Juqueira JL, Frederiksen NL. Foundation of radiographic planning for dental Implants. Rev ABRO 2004;5:63-6.  Back to cited text no. 2
Sahuinco HL, Souza RP. Edentulous Arch Jaw analysis through computed tomography and panoramic radiography in surgical planning of dental implants. Rev Imag 2006;28:73-7.  Back to cited text no. 3
Mraiwa N, Jacobs R, Van Cleynenbreugel J, Sanderink G, Schutyser F, Suetens P, et al. The nasopalatine canal revisited using 2D and 3D CT imaging. Dentomaxillofac Radiol 2004;33:396-402.  Back to cited text no. 4
Liang X, Jacobs R, Lambrichts I. Appearance, location, course and morphology of the superior and inferior genial spinal foramina and their bony canals: An assessment on spiral CT scan. Surg Radiol Anat 2006;28:98-104.  Back to cited text no. 5
Liang X, Jacobs R, Corpas LS, Semal P, Lambrichts I. Chronologic and geographic variability of neurovascular structures in the human mandible. Forensic Sci Int 2009;190:24-32.  Back to cited text no. 6
Jones FW. The anterior superior alveolar nerve and vessels. J Anat 1939;73:583-91.  Back to cited text no. 7
Neves FS, Crusoé-Souza M, Franco LC, Caria PH, Bonfim-Almeida P, Crusoé-Rebello I, et al. Canalis sinuosus: A rare anatomical variation. Surg Radiol Anat 2012;34:563-6.  Back to cited text no. 8
Gunaseelan R, Anantanarayanan P, Veerabahu M, Vikraman B, Sripal R. Intraoperative and perioperative complications in anterior maxillary osteotomy: A retrospective evaluation of 103 patients. J Oral Maxillofac Surg 2009;67:1269-73.  Back to cited text no. 9
Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent 2003;90:121-32.  Back to cited text no. 10
de Oliveira-Santos C, Rubira-Bullen IR, Monteiro SA, León JE, Jacobs R. Neurovascular anatomical variations in the anterior palate observed on CBCT images. Clin Oral Implants Res 2013;24:1044-8.  Back to cited text no. 11
von Arx T, Lozanoff S, Sendi P, Bornstein MM. Assessment of bone channels other than the nasopalatine canal in the anterior maxilla using limited cone beam computed tomography. Surg Radiol Anat 2013;35:783-90.  Back to cited text no. 12
Manhães Júnior LR, Villaça-Carvalho MF, Moraes ME, Lopes SL, Silva MB, Junqueira JL, et al. Location and classification of Canalis sinuosus for cone beam computed tomography: Avoiding misdiagnosis. Braz Oral Res 2016;30:e49.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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