|Year : 2022 | Volume
| Issue : 2 | Page : 135-140
Assessment of the greater palatine foramen position in an Indian population: A cone-beam computed tomography study
Surekha Rathod, Srushti Dhande, Vrushali Lathiya, Abhay Kolte
Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Nagpur, Maharashtra, India
|Date of Submission||01-Feb-2022|
|Date of Acceptance||26-Aug-2022|
|Date of Web Publication||29-Dec-2022|
Dr. Surekha Rathod
Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Digdoh Hills, Hingna Road, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: During minor dental surgical procedures, the greater palatine nerve block is commonly utilized to achieve anesthesia. The greater palatine nerve and arteries are transmitted through the greater palatine foramen (GPF). Furthermore, this region serves as a soft-tissue donor site. The goal of this research was to interpret the location of the GPF and its diameter in an Indian population by utilizing cone-beam computed tomography (CBCT). Materials and Methods: The position of GPF relative to the maxillary molars was estimated by utilizing 120 CBCT scans. Furthermore, the GPF's diameter and distance between the mid-palatine suture and the alveolar ridge were also determined. Results: Of the 120 GPFs examined, 102 were found to be in the third molar region. The GPF's distance from the mid-palatine suture and alveolar ridge was 14.01 ± 1.12 mm and 6.74 ± 1.95 mm, respectively. The mean anteroposterior diameter was 3.43 ± 0.3 mm. On considering the age group ≤45 years, the GPF's average distance from the mid-palatine suture (14.35 ± 1.10 mm) and alveolar ridge (7.87 ± 2.09 mm) was significantly higher than >45 years (P = 0.0329 and P < 0.0001, respectively). All the measurements were significantly higher in males. Conclusion: The location of GPF is variable but more closely related to the third molar. Sound knowledge of the GPF anatomy is crucial for an effective nerve block and also for preventing complications.
Keywords: Alveolar ridge, cone-beam computed tomography, greater palatine foramen, mid-palatine suture
|How to cite this article:|
Rathod S, Dhande S, Lathiya V, Kolte A. Assessment of the greater palatine foramen position in an Indian population: A cone-beam computed tomography study. J Int Clin Dent Res Organ 2022;14:135-40
|How to cite this URL:|
Rathod S, Dhande S, Lathiya V, Kolte A. Assessment of the greater palatine foramen position in an Indian population: A cone-beam computed tomography study. J Int Clin Dent Res Organ [serial online] 2022 [cited 2023 Feb 8];14:135-40. Available from: https://www.jicdro.org/text.asp?2022/14/2/135/365841
| Introduction|| |
The greater palatine foramen (GPF) is an opening located posteriorly to the hard palate, which is produced by the connection between the greater palatine sulcus of the palatine bone and the maxillary bone. The greater palatine nerve and the descending palatine artery are transmitted to the palate through this foramen. Furthermore, it provides innervation to the mucosal membrane, gums, and palatine glands situated on the roof of the mouth. The greater palatine nerve block is frequently utilized to achieve anesthesia for surgeries including the maxillary molars, nasal region, and maxillary sinus. The inability to accurately locate the GPF can lead to the failure of anesthesia and also increase the possibility of accidental injury to the greater palatine nerve and vessels.
Another clinical application is the mucogingival surgical procedures that require the harvest of a soft-tissue graft from the palate., By making an incision through the palatal mucosa, the graft is harvested from the area extending from the molar to the premolar region. The possibility of injuring the greater palatine artery while harvesting the graft from the palate has sparked widespread concern. Therefore, to reduce the risk of hemorrhages and anesthetic failure, a comprehensive study of the anatomical landmarks including the variations of the GPF is required.,,
Unfortunately, the commonly described guidelines for locating the GPF, as being palatally to the second molar, near the second molar and third molar, adjacent to the palatal suture's lateral border, etc. are frequently inaccurate. Furthermore, several anatomical examinations on dry skulls have shown that GPF is located in the third molar region.,, However, there is a wide variation in its reported prevalence ranging from 47% to as high as 92% showing a significant disparity in the results., A major limitation of these studies is that the gender is often not known and hence one cannot distinguish between the males and females making the applicability of the results questionable.,
Recent advances in radiographic imaging, particularly cone-beam computed tomography (CBCT) and computed tomography (CT) grant a more precise evaluation of the anatomic structures. Few studies have utilized CT and CBCT to evaluate the dimensions of GPF.,, However, to the best of our knowledge, the studies utilizing CBCT to analyze the GPF in the Indian population are sparse. Hence, the goal of this research was to determine and to locate the GPF and its diameter in an Indian population using CBCT.
| Materials and Methods|| |
The research was conducted in the department of Periodontics and Implantology in our institute in the period of March 2020–September 2021. The study protocol got approval by the Institutional Ethics Committee and complied with the Helsinki Declaration of 1975 as revised in 2013. Overall, 120 CBCT scans from patients aged 20 to 60 years old were evaluated. These patients were advised CBCT imaging mostly for dental implant treatment planning, intrabony defects, and impacted third molar extractions. The study included high-quality CBCT images. The presence of three upper molars on both sides and individuals aged 20–60 years were the study's inclusion criteria. The images were excluded if there was a fracture in the upper jaw, missing posterior teeth, or any pathological lesions involving the upper jaw.
All images were analyzed by two examiners SR and SD. For assessing the intraexaminer variance, each examiner measured randomly selected 50 CBCT images twice at an interval of at least 1 month. All patients provided written informed consent for the images to be used in scientific research. The trial received its registration with the Clinical Trial Registry of India (Ref No: CTRI/2021/07/045729).
Image analysis by radiography
The CBCT (Orthophos® XG 3D/Ceph, Sirona Dental Systems GmbH, Germany, at kVp = 84 and mA = 16) scans were analyzed using commercially available CBCT software.
Assessment of the location of the greater palatine foramen
The location of GPF in relation to the maxillary molars was assessed using the axial reconstruction of the CBCT image. The foramen's position was determined by drawing five tangents parallel to the middle of and interproximally along the second and third maxillary molars, in the following manner [Figure 1]a:
|Figure 1: assessment of GPF location in relation to maxillary molars on the axial reconstruction. (a) The primary axial reconstruction. (b) The axial section is used to determine the position. GPF = Greater palatine foramen|
Click here to view
- Presence of the GPF between the medial face and center of the second maxillary molar.
- Presence of the GPF between the center and distal face of the second maxillary molar.
- Presence of the GPF between the medial face and center of the third maxillary molar.
- Presence of the GPF between the center and distal face of the maxillary third molar.
- Presence of the GPF distally of the third molar.
The overlap of the previously drawn tangents with the GPF at a new depth of axial reconstruction suggesting the exact position of the foramen was noted and recorded [Figure 1]b.
Distance of the greater palatine foramen from mid-palatine suture and alveolar ridge
The extent of GPF from the mid-palatine suture was measured on the axial reconstructions. A line was drawn perpendicular extending from the center of the GPF to the mid-palatine suture and the distance was measured [Figure 2]. For measuring the extent of the GPF to the alveolar ridge, axial reconstruction was used. In the depth of the maxillary molars, a tangent to the alveolar ridge was drawn [Figure 3]a. The distance present between the alveolar ridge and the medial wall of the GPF was measured by drawing a line perpendicular to this tangent in the depth of the GPF [Figure 3]b.
|Figure 2: assessment of the distance of GPF from the mid-palatine suture on axial reconstruction. GPF = Greater palatine foramen|
Click here to view
|Figure 3: assessment of the distance of GPF from the alveolar ridge on axial reconstruction. (a) The primary axial reconstruction. (b) The axial section is used to determine the distance from the alveolar ridge to the medial wall of GPF. GPF = Greater palatine foramen|
Click here to view
Measurement of the greater palatine foramen's diameter
The mediolateral diameter of GPF was measured in the axial section [Figure 4].
|Figure 4: assessment of the mediolateral diameter of the GPF on axial reconstruction. GPF = Greater palatine foramen|
Click here to view
All the measurements were done using the measurement tools of the CBCT software.
All the measurements were continuous and reported in terms of mean and SD. The intra and interexaminer reproducibility determination was done using the Intraclass Correlation Coefficient (ICC). Statistical analysis was carried out by means of descriptive and inferential statistics using Chi-square test and Student's unpaired t-test. The SPSS version 20.0 (IBM Corp, Armonk, USA) was used and P < 0.05 was considered statistically significant.
| Results|| |
This study evaluated a total of 120 CBCT scans (59 males and 58 females). [Table 1] shows descriptive statistics for the study population's demographic characteristics. As evidenced by P > 0.05, the mean age of males and females, as well as the gender distribution, differed insignificantly. The intraexaminer reproducibility coefficient for the measurement of the different parameters was 0.97 (SR) and 0.95 (SD) demonstrating high measurement agreement between the two examiners. Furthermore, the interexaminer reproducibility coefficient found for the first set of measurements was 0.963, demonstrating excellent agreement between the two examiners regarding the measurements.
The anatomic position of the GPF differed significantly throughout the group studied. The GPF was discovered to be most commonly positioned between the center and the medial face of the maxillary third molar in 57% of the total images, followed by 28% between the center and the distal face of the maxillary third molar. The occurrence of GPF was distal to the third molar in 4% of the instances and in the remaining 11% of the images, it was found to be located between the middle and the distal face of the second molar. No CBCT scan showed the presence of GPF between the middle and the center of the maxillary second molar. Out of the total 120 GPFs that were examined, 102 were identified to be associated with the maxillary third molar area.
The GPF was located at a mean distance of 14.01 ± 1.12 mm and 6.74 ± 1.95 mm, respectively, from the mid-palatine suture and the alveolar ridge. According to the results of the research, the mean mediolateral diameter of the GPF was 3.43 ± 0.33 mm. The correlation between the distance of GPF from the alveolar ridge and mid-palatine suture and its diameter with age and gender has been demonstrated in [Table 2]. The age group ≤45 years demonstrated the mean distances of the GPF from the mid-palatine suture and the alveolar ridge to be 14.35 ± 1.10 mm and 7.87 ± 2.09 mm, respectively, whereas it was 13.90 ± 1.14 mm and 5.68 ± 1.14 mm, respectively, in the age group >45 years and these differences were significant (P = 0.0329, P < 0.0001, respectively). Similarly, the mean diameter of the GPF was found to be significantly high in ≤45 years in comparison to those >45 years but the difference could not reach a statistical significance (P = 0.4318). When the mean distances of the GPF between the mid-palatine suture and the alveolar ridge, as well as its mean diameter, were compared between the two genders, the values were substantially higher in the males (P < 0.0001).
|Table 2: Relationship of demographic parameters with the distance of greater palatine foramen from the alveolar ridge and mid-palatine suture and greater palatine foramen diameter|
Click here to view
| Discussion|| |
Considering the extensive use of the greater palatine nerve block in dentistry, it is necessary to have comprehensive information regarding the anatomy of the GPF and requires the founding of an exact reference point. The studies that have evaluated the position of this foramen show varied results.,,, Furthermore, the results seem to differ among the different ethnic races.,,
This study investigated the anatomical location of the GPF relative to the maxillary molar teeth and showed the GPF to be most typically associated with the third molars in 85% of the instances. Only 4% were seen distal to the third molars; in 11% of the cases, GPF was found to be medially located to the third molar and none was located medial to the second molar. In a previous study involving the Brazilian population, the GPF was found to be associated with the third molars in 92% of the cases. In addition, no GPF was identified medial to the second molar. These findings are very similar to our study. However, a study conducted on the dry skulls of the Nigerian population showed the presence of GPF medially to the third molars in 48% of the studied cases and contrary to the findings of our study, it demonstrated that 13% of the GPFs are present medial to the maxillary second molar. Yet another anatomic study in the Indian population demonstrated the GPF to be present opposite to the third molar in 74.6% of cases; in 24.2%, it was present between the third molar and the second molar; in 0.8% of cases, it was distal to the third molar and opposite to the second molar in 0.4% of the cases. These findings are in accordance with those of our study. Majority of the studies in the literature report more than 70% of the GPFs are associated with the third molar region. Our findings of a lesser GPF predilection distal to the third molar (4%) are comparable to the findings of most previous research, which were found to be 5%, 2.9%, and 7%, respectively.
In our study, the mid-palatine suture and alveolar ridge were used as reference landmarks to assess the GPF location. The distance of GPF from these landmarks can be used to ascertain its position precisely before the greater palatine nerve block and plan the incision for harvesting the soft-tissue graft from the palate. This research demonstrated the mean distance of the GPF from the midline to be 14.01 ± 1.12 mm which is in accordance with several other studies., However, a few studies have reported comparatively lesser distances., When the alveolar ridge was used as a landmark for measuring the distance of the GPF, it was found to be 6.74 ± 1.95 mm which is consistent with the findings of Ikuta et al. who reported the mean distance of 8 mm from the GPF to Alveolar ridge (AR).
The GPF's mean diameter was found to be 3.43 ± 0.33 mm which is consistent with earlier research., A systematic review of the morphometric analysis of the greater palatine canal reported the GPF diameter to be in the range of 4.5–5.3 mm which further supports the results of our study. However, a study conducted on a Lebanese population has demonstrated a higher diameter of the GPF.
Our findings demonstrated an inverse relationship of age with the distance of GPF from the Mid-palatine suture (MMP) and the Alveolar ridge as well as the diameter suggesting a greater diameter and distance of the GPF from the MMP and AR in younger individuals and vice versa. This finding can be justified by the fact that the bone mass decreases with age and there is progressive atrophy of the maxilla, thereby bringing about numerous changes in its structure and construction. Although the diameter of the GPF could not reach statistical significance when compared between the two age groups, the reason could be measurement error or an inadequate number of cases in the two age subgroups.
Furthermore, the data of this study revealed a significant sexual dimorphism with significantly greater morphometric values of the GPF in males as compared to females and can be supported by the fact that there is enormous variability in the size and shape of the craniofacial complex between the genders.,, The size of the skull is relatively larger in males as compared to females. This finding is in accordance with the previous reports that have shown smaller dimensions of GPF in females.,,,
The majority of research on the location of the GPF has been conducted on dry skulls with finite information about the patient's age, sex, or ethnicity. This study used CBCT which provided additional information on age, gender, and ethnicity. Since CBCT is gaining increased popularity, images are more readily available and a larger sample can be studied. Furthermore, it provides subjects with specific, predetermined characteristics and allows precise measurements. Since it is crucial to find the most precise position of the GPF for several maxillary surgical procedures, the observations made in this research will be beneficial to clinicians. In the absence of the maxillary third molar, the mid-palatine suture and the alveolar ridge can be used as a reference to locate the GPF. Therefore, it is quite clear that a combination of the above measurements can help to trace the GPF accurately.
However, further research is needed to substantiate these findings, and future studies involving a larger sample are required to determine variations in the length and opening of the greater palatine canal.
| Conclusion|| |
The findings of this investigation show that the GPF was commonly associated with the maxillary third molar. In addition, in the absence of a third molar or in edentulous patients, the mid-palatine suture and the alveolar ridge can be used as anatomic references to determine the position of the GPF. The diameter and the extent of the GPF from these landmarks are influenced by age and are greater in younger individuals and subsequently reduce. There are significant differences in these dimensions between the males and females with higher values reported in the males.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ajmani ML. Anatomical variation in position of the greater palatine foramen in the adult human skull. J Anat 1994;184 (Pt 3):635-7.
Tomaszewska IM, Tomaszewski KA, Kmiotek EK, Pena IZ, Urbanik A, Nowakowski M, et al.
Anatomical landmarks for the localization of the greater palatine foramen – A study of 1200 head CTs, 150 dry skulls, systematic review of literature and meta-analysis. J Anat 2014;225:419-35.
Dave MR, Yagain VK, Anadkat S. A study of anatomical variations in the position of the greater palatine foramen in adult human skulls and its clinical significance. Int J Morphol 2013;31:578-83.
Kang SH, Byun IY, Kim JH, Park HK, Kim MK. Three-dimensional analysis of maxillary anatomic landmarks for greater palatine nerve block anesthesia. J Craniofac Surg 2012;23:e199-202.
Das S, Kim D, Cannon TY, Ebert CS Jr., Senior BA. High-resolution computed tomography analysis of the greater palatine canal. Am J Rhinol 2006;20:603-8.
Renu C. The position of greater palatine foramen in the adult human skulls of North Indian origin. J Surg Acad 2013;3:54-7.
Klosek SK, Rungruang T. Anatomical study of the greater palatine artery and related structures of the palatal vault: Considerations for palate as the subepithelial connective tissue graft donor site. Surg Radiol Anat 2009;31:245-50.
Monnet-Corti V, Santini A, Glise JM, Fouque-Deruelle C, Dillier FL, Liébart MF, et al.
Connective tissue graft for gingival recession treatment: Assessment of the maximum graft dimensions at the palatal vault as a donor site. J Periodontol 2006;77:899-902.
Saralaya V, Nayak SR. The relative position of the greater palatine foramen in dry Indian skulls. Singapore Med J 2007;48:1143-6.
Ikuta CR, Cardoso CL, Ferreira-Júnior O, Lauris JR, Souza PH, Rubira-Bullen IR. Position of the greater palatine foramen: An anatomical study through cone beam computed tomography images. Surg Radiol Anat 2013;35:837-42.
Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. 7th
ed. Baltimore, MD: Lippincott Williams and Wilkins; 2013. p. 949.
Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40th
ed. Philadelphia: Elsevier/Churchill Livingstone; 2008. p. 414.
Sarilita E, Soames R. Morphology of the hard palate: A study of dry skulls and review of the literature. Rev Argent Anat Clin 2015;7:34-43.
Tomaszewska IM, Kmiotek EK, Pena IZ, Średniawa M, Czyżowska K, Chrzan R, et al.
Computed tomography morphometric analysis of the greater palatine canal: A study of 1,500 head CT scans and a systematic review of literature. Anat Sci Int 2015;90:287-97.
Sheikhi M, Zamaninaser A, Jalalian F. Length and anatomic routes of the greater palatine canal as observed by cone beam computed tomography. Dent Res J (Isfahan) 2013;10:155-61.
Methathrathip D, Apinhasmit W, Chompoopong S, Lertsirithong A, Ariyawatkul T, Sangvichien S. Anatomy of greater palatine foramen and canal and pterygopalatine fossa in Thais: Considerations for maxillary nerve block. Surg Radiol Anat 2005;27:511-6.
Aoun G, Nasseh I, Sokhn S, Saadeh M. Analysis of the greater palatine foramen in a Lebanese population using cone-beam computed tomography technology. J Int Soc Prev Community Dent 2015;5:S82-8.
Sharma NA, Garud RS. Greater palatine foramen–key to successful hemimaxillary anaesthesia: A morphometric study and report of a rare aberration. Singapore Med J 2013;54:152-9.
Nimigean V, Nimigean VR, Buţincu L, Sălăvăstru DI, Podoleanu L. Anatomical and clinical considerations regarding the greater palatine foramen. Rom J Morphol Embryol 2013;54:779-83.
Hwang SH, Seo JH, Joo YH, Kim BG, Cho JH, Kang JM. An anatomic study using three-dimensional reconstruction for pterygopalatine fossa infiltration via the greater palatine canal. Clin Anat 2011;24:576-82.
Kim HS, Kim DI, Chung IH. High-resolution CT of the pterygopalatine fossa and its communications. Neuroradiology 1996;38 Suppl 1:S120-6.
Mendel N, Puterbaugh PG. Conduction, Infliltration and General Anaesthesia in Dentistry. 4th
ed. New York: Dental Items of Interest Publishing Co; 1938. p. 140.
Baxter-Jones AD, Faulkner RA, Forwood MR, Mirwald RL, Bailey DA. Bone mineral accrual from 8 to 30 years of age: An estimation of peak bone mass. J Bone Miner Res 2011;26:1729-39.
Bigoni L, Velemínská J, Brůzek J. Three-dimensional geometric morphometric analysis of cranio-facial sexual dimorphism in a Central European sample of known sex. Homo 2010;61:16-32.
Takegoshi H, Kikuchi S. An anatomic study of the horizontal petrous internal carotid artery: Sex and age differences. Auris Nasus Larynx 2007;34:297-301.
Didia BC, Orish C, Ibeachu PC. Macrometric and micrometric study of sexual dimorphism in moramina of middle cranial fossa of adult Nigerians. Int J Morphol 2010;28:519-24.
Teixeira C, Souza V, Marques C, Silva Junior W, Pereira K. Topography of the greater palatine foramen in macerated skulls. J Morphol Sci 2010;28:519-24.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]