Is the collateral circulation pattern in the hard palate affected by cleft deformity?

OBJECTIVES: To evaluate the influence of collateral vascularization on surgical cleft palate closure and deformities. MATERIALS AND METHODS: Corrosion casting was performed using red-colored acrylic resin in twelve fresh adult cadavers with a normal hard palate. Additionally, white-colored barium sulfate was injected into a fetus with a unilateral complete cleft palate, and layer-by-layer tissue dissection was performed. Both substances were injected into the external carotid arteries. Corrosion casting involved dissolving the soft and hard tissues of the orofacial area utilizing an enzymatic solution. RESULTS: In normal palates, bilateral intraosseous infraorbital arteries formed a network in the premaxilla with the intraosseous nasopalatine- and greater palatine arteries (GPAs). The perforating GPAs anastomosed with the sphenopalatine artery sub-branches. Bilateral extraosseous GPA anastomoses penetrated the median palatine suture. Complex vascularization in the retrotuberal area was detected. In the cleft zone, anastomoses were omitted, whereas in the non-cleft zone, enlarged GPAs were distributed along the cleft edges and followed the anatomical course anteriorly to initiate the network with facial artery sub-branches. CONCLUSIONS: The anatomical subunits of the palate exhibited distinct anastomosis patterns. Despite omitted anastomoses with collateral circulation in the cleft zone, arteries maintained their anatomical pattern as seen in the normal specimen in the non-cleft zone. CLINICAL RELEVANCE: Based on the findings in normal- and cleft palates, surgeons may expect developed anastomosis patterns in the non-cleft zone. Due to the lack of microcirculation in the cleft zone, the existent anastomoses should be maintained as much as possible by the surgical technique. This applies anteriorly in the incisive canal territory, alveolar ridges, and posteriorly in the retrotuberal area.

An Intraoperative Salvage After Transection of the Greater Palatine Artery During Cleft Palate Repair: A Case for Buccal Fat and Buccal Myomucosal Flaps.

Recently, several adjunctive procedures have gained traction to aid cleft surgeons in repairing especially challenging palatal clefts. Buccal fat flaps and buccal myomucosal flaps have demonstrated particular utility in reinforcing thin palatal flaps or tissue deficits. Although their use has not been widely accepted, they may be particularly helpful in the setting of significant scarring or vascular compromise. Here the authors describe the case of an intraoperative salvage using bilateral buccal fat flaps and a right buccal myomucosal flap after transection of the right Greater Palatine artery (GPA) during palatoplasty on a 14-month old female with Pierre Robin Sequence and a wide Veau II cleft palate. For this operative salvage, bilateral buccal fat flaps were used to reinforce the hard-soft palate junction and a 4 cm × 2 cm flap of the right-sided buccal mucosa and buccinator muscle was inset along the majority of the right-sided soft and posterior hard palate. At 2 years follow-up, the patient had no significant complications and was doing well with healthy-appearing palatal tissue and age-appropriate speech.

Revisiting major anatomical risk factors of maxillary sinus lift and soft tissue graft harvesting for dental implant surgeons.

The anatomical variations of the maxillary sinus septa, greater palatine artery, and posterior superior alveolar arteries might cause unexpected complications when they are damaged. Dentists who know these structures well might hope to learn more practical knowledge to avoid and assess injury preoperatively. Therefore, this review paper aimed to review the reported anatomy and variations of the maxillary sinus septa, greater palatine artery/nerve, and posterior superior alveolar artery, and to discuss what has to be assessed preoperatively to avoid iatrogenic injury. To assess the risk of injury of surgically significant anatomical structures in the maxillary sinus and hard palate, the operator should have preoperative three-dimensional images in their mind based on anatomical knowledge and palpation. Additionally, knowledge of the average measurement results from previous studies is important.

Cost-effectiveness of trans-nasal endoscopic sphenopalatine artery ligation vs arterial embolisation for intractable epistaxis: Long-term analyses.

OBJECTIVES: Trans-nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost-saving strategy. Our main aim was to perform cost-effectiveness analyses on TESPAL compared with embolisation to treat patients with epistaxis. DESIGN: We performed retrospective, monocentric, comparative analyses on patients referred to our centre and treated with embolisation or TESPAL. SETTING: This economic evaluation was carried out from a payer's perspective (ie French National Health Insurance) within a time horizon of 12 months. PARTICIPANTS: Thirty-seven TESPAL procedures and thirty-nine embolisation procedures to treat intractable epistaxis were used in the analyses. MAIN OUTCOME MEASURES: The primary outcome is presented as the cost per 1% of non-recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1-year follow-up. Cost estimates were performed from the payer's perspective. RESULTS: Hospitalisation costs were higher for embolisation compared with TESPAL (5972 vs 3769 euros). On average, hospitalisation costs decreased by 41% when a patient was treated by TESPAL compared with an embolisation strategy (P = 0.06). The presence of comorbidities increased hospitalisation costs by 79% (P = 0.04). TESPAL enabled 1867€ to be gained in intractable epistaxis. CONCLUSIONS: The outcomes from our decision model confirm that TESPAL is more cost-effective for patients with intractable epistaxis.

Supernumerary incisive canals in a cadaver: a rare anatomical variation.

We present a rare anatomical variation in which an additional incisive canal was observed during the routine dissection of the palatal region in a cadaver. The diameter of the incisive and additional incisive canals measured 4.59 mm and 0.91 mm, respectively. Even though this variation is rare, oral surgeons should be aware of such anatomical variations for a better understanding.

Anatomy of the sphenopalatine artery and its implications for transnasal neurosurgery.

BACKGROUND: The knowledge of sinonasal vasculature is inevitable in transnasal neurosurgery. We performed an anatomical study on the sphenopalatine artery from the perspective of skull base procedures. METHODOLOGY: To analyse the anatomical landmarks of the sphenopalatine artery, arterial skull corrosion casts (26 head halves) underwent endoscopic transnasal phantom surgery. Furthermore, we performed microsurgical dissection on formaldehyde-fixated cadavers with arterial perfusion (14 head halves) as well as studied Cone Beam CT-scans of anonymised patients and cadavers (115 head sides). RESULTS: In our cadaveric material, the sphenopalatine foramen is located at the transition of the superior and middle nasal meatus (95.0%) or in the superior nasal meatus (5.0%). It is the main entry point of the branches of the sphenopalatine artery into the nasal cavity. In most cadaveric cases (25.0%), at this level there are 2 branches superiorly and 1 vessel inferiorly to the ethmoid crest. An average of 2.4 vessels leave the sphenopalatine foramen superiorly to the ethmoid crest, 97.8% of them belong to the sphenopalatine arterys posterior septal branches. An average of 2.1 branches leave the sphenopalatine foramen inferiorly to the ethmoid crest; all of them belong to the posterior lateral nasal branches. There are no cases with a single artery at the plane of the sphenopalatine foramen. We describe a triangular bony structure bordering the sphenopalatine foramen anteriorly which is built up by the palatine and ethmoid bone as well as the maxilla. According to the radiographic studies, this triangular prominence is surrounded superiorly by a posterior ethmoid cell (57.4%), the sphenoid sinus (41.7%) or the orbit (0.9%) with a varying contribution of the superior nasal meatus; inferolaterally by the maxillary sinus (98.3%) or the pterygopalatine and infratemporal fossa (1.7%) and inferomedially by the middle nasal meatus. The medial vertex of the bony triangle corresponds to the ethmoid crest of the palatine bone. In transnasal endoscopic surgery, the posterior lateral nasal branches of the sphenopalatine artery appear at the triangle's inferomedial edge, the posterior septal branches emerge at its superior edge. CONCLUSIONS: The triangular bony structure is a landmark to find and differentiate the posterior lateral nasal and posterior septal branches of the sphenopalatine artery and to identify the sphenoid sinus.

Unilateral Hard Palate Necrosis After Ascending Palatine Artery Embolization.

Embolization is a common treatment modality for refractory epistaxis. Here, the authors reported that the first patient with unilateral necrosis of the mucosa overlying the hard palate developed after embolization of ascending palatine artery. A 46-year-old man with a history of maxillofacial trauma complicated by 2 episodes of significant unilateral epistaxis. Although he did not experience any epistaxis after embolization, unilateral necrosis of the mucosa overlying the hard palate developed gradually 2 weeks after embolization. The necrotic tissue of hard palate was treated by surgical debridement and followed by antibiotic and analgesic.

Morphological observation and CBCT of the bony canal structure of the groove and the location of blood vessels and nerves in the palatine of elderly human cadavers.

PURPOSE: The greater and lesser palatine nerves and vessels supply the hard and soft palates, and the roots of these vessels and nerves run through a bony structure. However, the arrangement of blood vessels in the maxilla requires attention during clinical treatments, but detailed morphological information about changes in the greater and lesser palatine arteries and nerves during aging is unavailable. We therefore need detailed investigations of the morphology of the donor cadaver palatine using cone-beam computed tomography (CBCT) and macroscopic observations. METHODS: We investigated 72 donor cadavers using macroscopic segmentation and CBCT. The results' analysis examined differences in skull measurement parameters and differences between dentate and edentulous cases. RESULTS: The greater palatine artery and nerve showed different macroscopic arrangements in dentate and edentulous cadavers. We also classified three types of bony structures of the nerve and vessel roots in the molar regions of the palatine using CBCT images: the shallow groove, deep groove, and flat groove. The deep groove is the deepest of the three and is remarkable in edentulous elderly cadavers. CONCLUSION: This study of macroscopic and CBCT data provides information useful for planning dental implant surgeries and autogenous bone harvesting.

Computerized analysis of the greater palatine foramen to gain the palatine neurovascular bundle during palatal surgery.

OBJECTIVE: Investigation of the computerized dimensional anatomic location of the greater palatine foramen (GPF) and lesser palatine foramens (LPF) is important indicating site to collect palatal donor tissue, reconstructioning the orofacial area of the oncology patient and applying the greater palatine nerve block anesthesia. The aim of this study is to determine a patient-friendly landmark and to specify the precise location of the GPF in order to standardise certain anatomical marks of safe neurovascular bundle. MATERIALS AND METHODS: 120 bony palates were examined to detect the position of the GPF and the LPF related to adjacent anatomical landmarks using a computer software program. The GPF was assessed regarding the position, the diameter and the distances between each foramen and the midline maxillary suture (MMS), the inner border of alveolar ridge (AR), posterior palatal border (PBB), and incisive foramen (IF). RESULTS: The GPF was identified as single in 81 %, double in 16 %, triple in 2 % and absent in 2 % of the specimens. The mean distances between the GPF and the MSS, the GPF and the AR, the GPF and the PPB, the GPF and the IF were 16, 4, 4, and 40 mm, respectively. In majority of the cases, the GPF was seen between the distal surfaces of the third maxillary molar (78 %). Single LPF was observed in 53.45 % of the skulls, two LPF were observed in 31 % of the skulls bilaterally and five LPF were rare in 2.1 % of the specimens. The LPF was most commonly at the junction of the palatine bone and the inner lamella of the pterygoid plate (71.9 %). CONCLUSIONS: This study made possible to investigate the variability of the GPF and the feasibility of the greater palatine neurovascular bundle, and to calculate the lengths of some parameters with the help of certain software. To collect the donor tissue of the neurovascular greater palatine network, each distance among the AR-GPF-PPB were equal to 4 mm. To estimate the possible length of the graft, the incision was made along the third and the second molar to the IF as 4 cm. The data we obtained within this study have been presented to help the surgeons avoid unexpected hemorrhage during the palatinal procedures such as posttraumatic dental reconstruction, maxillofacial tumor resections, palatal micro-implants, and dentofacial orthopedic surgery.

Type III transforming growth factor beta receptor regulates vascular and osteoblast development during palatogenesis.

BACKGROUND: Cleft palate occurs in up to 1:1,000 live births and is associated with mutations in multiple genes. Palatogenesis involves a complex choreography of palatal shelf elongation, elevation, and fusion. Transforming growth factor ß (TGFß) and bone morphogenetic protein 2 (BMP2) canonical signaling is required during each stage of palate development. The type III TGFß receptor (TGFßR3) binds all three TGFß ligands and BMP2, but its contribution to palatogenesis is unknown. RESULTS: The role of TGFßR3 during palate formation was found to be during palatal shelf elongation and elevation. Tgfbr3(-) (/) (-) embryos displayed reduced palatal shelf width and height, changes in proliferation and apoptosis, and reduced vascular and osteoblast differentiation. Abnormal vascular plexus organization as well as aberrant expression of arterial (Notch1, Alk1), venous (EphB4), and lymphatic (Lyve1) markers was also observed. Decreased osteoblast differentiation factors (Runx2, alk phos, osteocalcin, col1A1, and col1A2) demonstrated poor mesenchymal cell commitment to the osteoblast lineage within the maxilla and palatal shelves in Tgfbr3(-) (/) (-) embryos. Additionally, in vitro bone mineralization induced by osteogenic medium (OM+BMP2) was insufficient in Tgfbr3(-) (/) (-) palatal mesenchyme, but mineralization was rescued by overexpression of TGFßR3. CONCLUSIONS: These data reveal a critical, previously unrecognized role for TGFßR3 in vascular and osteoblast development during palatogenesis.

Topographical relationship of the greater palatine artery and the palatal spine. Significance for periodontal surgery.

AIM: The aims of this study were to (1) identify the branching pattern and course of the greater palatine artery (GPA), (2) carry out a morphological analysis of the palatal bony prominence that divides the medial and lateral grooves and (3) characterize the topographical relationships between these two structures. METHODS: Thirty-six hemimaxillae were studied with the aid of a surgical microscope to elucidate the GPA. A further 25 dry skulls were examined to establish the morphology of the palatal spine. RESULTS: The most common GPA branching pattern was type I (41.7%, 15 sides), which gave off the medial and canine branches after the bony prominence. The distances from the CEJ to the lateral branch of the GPA were 9.04 ± 2.93 mm (canine), 11.12 ± 1.89 mm (first premolar), 13.51 ± 2.08 mm (second premolar), 13.76 ± 2.86 mm (first molar) and 13.91 ± 2.20 mm (second molar). The palatal spine was frequently observed as the bony prominence (66.3%, 57 sides), and was located at 6.49 ± 1.76 mm from the greater palatine foramen, with a length of 10.42 ± 2.45 mm. There was no a correlation between the bony prominence shape and the GPA branching pattern. CONCLUSIONS: These results could provide the reference data regarding the topography of the GPA for periodontal surgery.

Neurovascular anatomical variations in the anterior palate observed on CBCT images.

OBJECTIVE: This study aimed to assess the presence of additional foramina and canals in the anterior palate region, through cone beam computed tomography (CBCT) images, describing their location, direction, and diameter. MATERIALS & METHODS: CBCT exams of 178 subjects displaying the anterior maxilla were included and the following parameters were registered: gender; age group; presence of additional foramina in the anterior palate (AFP) with at least 1 mm in diameter; location and diameter of AFP; and direction of bony canals associated with AFP. RESULTS: Twenty-eight patients (15.7%) presented AFP and in total 34 additional foramina were registered. No statistical differences between patients with or without AFP were found for gender or age. The average diameter of AFP was 1.4 mm (range from 1 to 1.9 mm). Their location was variable, with most of the cases occurring in the alveolar process near the incisors or canines (n = 27). In 18 cases, AFP was associated with bony canals with upward or oblique direction toward the anterior nasal cavity floor. In 14 cases, the canal presented as a direct extension of the canalis sinuosus, in an upward direction laterally to the nasal cavity aperture. In two cases, the canal was observed adjacent to the incisive and joined the nasopalatine canal superiorly. DISCUSSION: CBCT images have a crucial role in the recognition of anatomical variations by allowing detailed tridimensional evaluations. Additional foramina and canals in the anterior region of the upper jaw are relatively frequent. Practitioners should be aware and trained to identify these variations. CONCLUSIONS: Over 15% of the population studied had additional foramina in the anterior palate, between 1 mm and 1.9 mm wide, with variable locations. In most cases the canals associated with these foramina either presented as a direct extension of the canalis sinuosus, or coursed towards the nasal cavity floor.

Clinical measurements of hard palate and implications for subepithelial connective tissue grafts with suggestions for palatal nomenclature.

PURPOSE: The objectives of the present study were to 1) identify a reliable measuring technique for a palatal graft, 2) observe the patterns of the neurovascular bundle, and 3) identify the morphology of the hard palate. Subepithelial connective tissue grafts are performed at an increasing rate to improve esthetics and oral health. Palatal graft techniques began in 1963, and today the subepithelial connective tissue graft is the most widely accepted technique. The greater palatine nerve and artery are critical neurovascular structures to identify. Their pattern and palate morphology are not well defined. MATERIALS AND METHODS: Anatomy texts, atlases, and specialty texts were analyzed. We dissected 17 palates (17 left and right halves) from embalmed human cadavers, implementing a measuring technique to locate the most coronal structure of the greater palatine artery and greater palatine nerve bundle, observing the patterns and palatal morphology. Electronic digital calipers and a periodontal probe were used for data collection. RESULTS: The dissection results revealed a reliable measuring technique, a common pattern of the bundle, and osseous palatal landmarks not clearly defined in contemporary texts. The dissections also demonstrated a medial and lateral groove, along with a crest in the palatine process of the maxillary bone. The greater palatine artery traversed the lateral groove, and the greater palatine nerve traversed the medial groove consistently. The crest was located anteroposteriorly between the grooves. CONCLUSIONS: The results of our study suggest a useful measurement technique, a consistent neurovascular pattern, and the need to reconsider the palatal nomenclature.

Effect of soft laser in bone repair after expansion of the midpalatal suture in dogs.

INTRODUCTION: The purpose of this research was to study the influence of soft laser treatment on the process of bone repair after expansion of the midpalatal suture. METHODS: The sample for this case-control experimental study was 11 dogs. They were randomly divided into 2 groups, both of which underwent rapid maxillary expansion with a hyrax appliance. The animals in group 1 were also treated with laser therapy. They were killed, and histologic specimens of the palatal suture were prepared. The Student t test was applied for independent data, and the Mann-Whitney test was used for nonparametric data. RESULTS: A significant difference was observed in the quality of the palatal sutures between the animals in groups 1 and 2. The connective tissues of the sutures in the group 1 animals were similar to the original configurations, with more advanced osteogenesis and fibrogenesis, compared with those of group 2. CONCLUSIONS: Soft laser appears to influence the behavior of the repair process, contributing to suture reorganization and palatal bone osteogenesis during and after expansion.

Augmentation in proximity to the incisive foramen to allow placement of endosseous implants: a case series.

PURPOSE: To assess whether augmentation in the proximity of the incisive foramen with an intraoral bone graft to allow for reliable placement of implants is achievable, not jeopardizing the nasopalatine nerve and vessels in a way causing patients' distress. PATIENTS AND METHODS: Five patients who had lost a central maxillary incisor due to trauma, and in whom a deficiency of bone at the palatal side was present in the proximity of the incisal canal, were augmented with autogenous cancellous bone harvested from the retromolar region. After a healing period of 3 months, implants were inserted. Patients' acceptance, complications, and postoperative morbidity of the procedure were prospectively evaluated by standardized clinical and radiographic examinations up to 12 months after augmentation. RESULTS: At the time of implant surgery, in all cases there was sufficient bone for insertion of the implants with adequate primary stability. Up to now (follow-up of 12-15 months) no fixtures have been lost and all peri-implant tissues have a healthy appearance. All patients were satisfied. CONCLUSION: Augmentation in the proximity of the incisive foramen to enable implant placement appears to be feasible, both from the perspective of the patient and the professional.

Clinical implications of the topography and distribution of the posterior superior alveolar artery.

The aim of this study was to clarify the arrangement of the anatomic courses and distribution of the intraosseous branch (IObr) of posterior superior alveolar artery. The anatomic variations in the topographic relationships were described to provide beneficial data to minimize injury to the IObr during surgical procedure of the buccal wall of the maxillary sinus. The IObrs in 42 hemifaces of embalmed Korean cadavers were examined. The courses of the IObr of the posterior superior alveolar artery were classified into 2 categories: the straight (type 1) and the U-shaped (type 2). The type 1 was the most common (78.1%), and the type 2 was observed in 21.9% of the specimens. The minimum mean height from the cervix to the IObr was 21.1 mm in the first molar region. The IObr ran at the lowest level from the maxillary sinus floor at the first premolar region. These anatomic findings in the current study could represent useful information for the various surgical procedures of the maxilla.

The anatomy of a horizontally impacted maxillary wisdom tooth.

A completely horizontally impacted upper third molar was revealed after routine dissection of a 62-year-old human cadaver of a Caucasian male. The molar was penetrating into the maxillary sinus and there was antral dehiscence of its bony alveolus. The bony alveolus was immediately in front of the greater palatine canal contents, and the bottom of the alveolus was dehiscent towards the greater palatine foramen. Within the greater palatine canal and foramen the greater palatine artery was duplicated and the nerve was found. Such antral relations of an impacted upper third molar predispose to oroantral communications if extraction is performed, while the close neurovascular relations represent a risk factor for postextractional haemorrhage and neurosensory disturbances and must be borne in mind when deciding on or performing the extraction.

Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks.

OBJECT: The pterygopalatine fossa is an area that lies deep within the skull base. The recent extensive use of the endoscopic endonasal approach has provided neurosurgeons with a method to reach various areas of the skull base through a less invasive approach than traditional transcranial or transfacial approaches. This study aims to provide neurosurgeons with new data concerning direct endoscopic measurements and precise anatomical topography features of the pterygopalatine fossa. METHODS: An anatomical dissection of six fixed cadaver heads (12 pterygopalatine fossae) was performed to analyze spatial relationships and distances between the most important neurovascular structures in this region, and to estimate the size of the endoscopic surgical field for operations in this area. The endoscopic endonasal approach offers direct access to the pterygopalatine fossa through its anteromedial walls. CONCLUSIONS: Using an endoscopic endonasal approach makes it possible to identify all of the anatomical landmarks of the pterygopalatine fossa and almost all of the contiguous skull base areas.

The identification and protection of the descending palatine artery in Le Fort I osteotomy: a forgotten technique?

We describe the advantages of a simple technique of identification and preservation of the descending palatine artery during Le Fort I osteotomy.