Anatomy of the greater palatine foramen and canal and their clinical significance in relation to the greater palatine artery: a systematic review and meta-analysis.

PURPOSE: Accurate knowledge of greater palatine foramen (GPF) and greater palatine canal (GPC) anatomy is necessary to avoid injury to the greater palatine artery (GPA) when performing a variety of anesthesiologic, dental or surgical procedures. The aim of this paper was to perform a systematic review and meta-analysis of literature on the anatomy and localization of bony structures associated with the GPA, namely the GPF and GPC. METHODS: A systematic literature search was performed using PubMed, Embase, ScienceDirect, and Web of Science databases. Seventy-five studies were included in the meta-analysis (n = 22,202 subjects). RESULTS: The meta-analysis showed that the GPF is positioned 17.21 mm (95% CI = 16.34-18.09 mm) from the posterior nasal spine, 2.56 mm (95% CI = 1.90-3.22 mm) from the posterior border of the hard palate, 46.24 mm (95% CI = 44.30-48.18 mm) from the anterior nasal spine, 15.22 mm (95% CI = 15.00-15.43 mm) from the midline maxillary suture, 37.32 mm (95% CI = 36.19-38.45 mm) from the incisive foramen, and opposite the third maxillary molar (M3) in 64.9% (58.7-70.7%) of the total population. CONCLUSION: An up-to-date, comprehensive analysis of GPF and GPC clinical anatomy is presented. The results from this evidence-based anatomical study provides a unified set of data to aid clinicians in their practice.

Identifying the course of the greater palatine artery using intraoral ultrasonography: cohort study.

AIMS: The greater palatine artery (GPA) is one of the most important anatomical structure for free gingival grafts or connective-tissue grafts during soft tissue surgery for dental implants. Several studies have identified the approximate location of the GPA, but it is impossible to detect its exact location during surgery due to large variability between individuals. The authors, therefore, investigated the course of the GPA using intraoral ultrasonography to determine the feasibility of using real-time nonionizing ultrasonography for implant surgery. MATERIALS AND METHODS: This study included 40 healthy young participants. The courses of the GPA were identified using intraoral ultrasound probes from the first premolar to the second molar. The distance from the gingival margin to the GPA (GM-GPA) and the depth of the palatal gingiva from the GPA (PG-GPA) were measured by two independent examiners. Measurements were analyzed statistically, and interexaminer reliability was determined. RESULTS: The distance of the GM-GPA and the mean depth of the PG-GPA were 14.8 ± 1.6 mm and 4.10 ± 0.51 mm (mean ± SD), respectively. GM-GPA decreased when the GPA ran from the second molar to the first molar, and GM-GPA was significantly shorter in females (P < 0.05). PG-GPA increased when the GPA ran to the posterior teeth. Interexaminer measurement agreements were excellent, with intraclass correlation coefficient values of 0.983 and 0.918 for GM-GPA and PG-GPA, respectively. CONCLUSIONS: Using an intraoral ultrasound probe, real-time GPA tracking is possible, which is expected to help reduce the possibility of bleeding during surgery.

Greater palatine artery pedicled flap for nasal septal perforation repair: radiological study and case series.

PURPOSE: The greater palatine artery (GPA) is one of the main vessels supplying the nasal septum. We recently described a novel technique to reconstruct a nasal septal perforation (NSP) using a GPA flap. This radiological study explores the feasibility and limits of using a GPA flap for an anterior NSP repair. METHODS: We describe our technique for repairing anterior-most NSP. Radiological measurements of the GPA flap and their limits were analysed. Additionally, a cohort of four patients who underwent reconstruction of a NSP with a GPA flap was included. RESULTS: The radiological study of 150 nasal cavities showed a 31.5 ± 2.7 cm2 maximum flap area. Taking into account the retraction process (30%), the remaining area was 22.0 ± 1.9 cm2. The septal area anterior to the GPA was 6.1 ± 2.1 cm2. The septal portion of the flap was larger than the area anterior to the GPA pedicle in all cases. Complete NSP repair was achieved in four patients. All cases of NSP remained closed during the follow-up. CONCLUSION: The unilateral GPA pedicled flap is a useful technique suitable for the reconstruction of anterior-most perforations that are difficult to cover with other endonasal techniques.

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.

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.

Topography of the greater palatine artery and the palatal vault for various types of periodontal plastic surgery.

The purpose of the present study is to provide useful data that could be applied to various types of periodontal plastic surgery by detailing the topography of the greater palatine artery (GPA), looking in particular at its depth from the palatal masticatory mucosa (PMM) and conducting a morphometric analysis of the palatal vault. Forty-three hemisectioned hard palates from embalmed Korean adult cadavers were used in this study. The morphometry of the palatal vault was analyzed, and then the specimens were decalcified and sectioned. Six parameters were measured using an image-analysis system after performing a standard calibration. In one specimen, the PMM was separated from the hard palate and subjected to a partial Sihler's staining technique, allowing the branching pattern of the GPA to be observed in a new method. The distances between the GPA and the gingival margin, and between the GPA and the cementoenamel junction were greatest at the maxillary second premolar. The shortest vertical distance between the GPA and the PMM decreased gradually as it proceeded anteriorly. The GPA was located deeper in the high-vault group than in the low-vault group. The premolar region should be recommended as the optimal donor site for tissue grafting, and in particular the second premolar region. The maximum size and thickness of tissue that can be harvested from the region were 9.3 mm and 4.0 mm, respectively.

Endoscopic "Racket-on-Donut" Technique for Large Anterior Nasoseptal Perforations.

Endoscopic Racket-on-Donut technique is a combination of a modified greater palatine artery and inverted edges flaps. Endoscopic Racket-on-Donut technique is very useful for anterior NSP repair. Laryngoscope, 134:143-147, 2024.

Oroantral Fistula Closure Using Double-Layered Flap: Greater Palatine Artery Flap and Buccal Fat Pad.

A novel surgical technique based on a combined approach to oroantral fistula closure using a double-layered flap: greater palatine artery pedicled flap and buccal fat pad combination. Laryngoscope, 133:1824-1827, 2023.

Anatomical Variations of the Greater Palatine Foramen in Different Facial Skeletal Relationships and its Implications on LeFort 1 Osteotomy (Trimble's Modification).

Purpose: To determine the positional variations of the greater palatine foramen in different facial skeletal relationships and discuss its surgical implications on the Trimble's modification of Lefort I osteotomy. Materials and Methods: This retrospective study examined 50 computed tomography scans of patients a total of 100 sides. The sample was divided into four groups: Class 1, Class 2, Class 3 malocclusion and Unilateral cleft lip and palate). The outcome variables included the distance between anterior, middle and posterior points of the GPF to the distal of second molar and variables to assess relative position of the GPF to the posterior maxilla. Outcome measures were to demonstrate intra- and intergroup variability. Results: Fifty patients (100 sides) were divided into four groups. This included 23 males and 27 females with a mean age of 24.1 years. Significant intergroup variability was observed between all the parameters that demonstrate the relative position of the GPF to (i) the maxillary second molar and (ii) the posterior maxilla. The analysis revealed that the GPF was positioned significantly anterior in Class 2 patients when compared with Class 3 patients. Conclusion: The GPF exhibits significant positional variability in different facial skeletal relationships which should be borne in mind while designing and performing the Trimble's modification of the Lefort 1 osteotomy.

Targeted Endodontic Microsurgery: Implications of the Greater Palatine Artery.

INTRODUCTION: Targeted Endodontic Microsurgery (TEMS) combines trephine burs and 3D-printed guides to make flapless maxillary palatal root-end surgery possible. This study assessed the location of the greater palatine artery (GPA), the relationship of the GPA to maxillary molar root ends, and the feasibility of flapless palatal-approach TEMS. METHODS: Three endodontists analyzed 250 cone-beam computed tomographic images of maxillary molars for (1) transition morphology between the hard palate and the alveolar process adjacent to first and second molars as an indication of the most likely location of the GPA, (2) the superior-inferior relationship between the GPA and root ends, and (3) the feasibility of palatal-approach TEMS. RESULTS: Palatal transition morphology included 20% Spine, 72% Bridge, and 8% Smooth. GPA position as related to palatal root ends was classified as 34% superior, 40% adjacent, and 21% inferior. Five percent of classifications were undefined. TEMS was deemed feasible for 47% of maxillary first molars and 52% of second molars, and was significantly more feasible with GPAs superior to palatal root ends. Reasons for infeasibility included GPA proximity and unfavorable resection angle or level. Maxillary first molar palatal roots were 11.13 ± 2.68 mm from the greater palatine foramen (GPF) and 2.37 ± 1.46 mm from the GPA. Second molar palatal roots were 4.94 ± 2.55 mm from the GPF and 2.53 ± 1.77 mm from the GPA. CONCLUSIONS: Palatal transition morphology and GPA position adjacent to maxillary molars, as manifested in cone-beam computed tomographic coronal views, suggested maxillary palatal root TEMS could be accomplished with a 2-mm safety margin in 47% of first molars and 52% of second molars. Historical paradigms that do not consider flapless palatal surgical approaches may need to be revised.

Clinical Outcomes after Apical Surgery on the Palatal Root of the Maxillary First Molar Using a Palatal Approach.

INTRODUCTION: Clinicians are often reluctant to use the palatal approach in apical surgery for the maxillary first molar. This study aimed to investigate the outcomes and complications associated with apical surgery on the palatal root of the maxillary first molar by using a palatal approach. METHODS: We searched for patients who underwent apical surgery with a palatal approach on the palatal root of the maxillary first molar between March 2010 and September 2017 by a single operator. A total of 46 teeth from 46 subjects were included, and they were examined at 6 and 12 months after surgery and annually thereafter. To evaluate whether there was nerve damage on the surgical side, a pinprick test and cotton swab test were used with a 0-10 numerical rating scale, and the results were statistically compared by using the Wilcoxon signed-rank test. RESULTS: Of the total 35 recall cases (recall rate, 76%; average follow-up time, 3.5 years), success was considered achieved in 32; 30 cases showed complete healing, and 2 had incomplete healing. Three cases resulted in failure, all occurring within 1 year after surgery. The pinprick test results showed that all the numerical rating scale scores were higher than 7, and the responses on the surgical site were not statistically different from those on the contralateral site (P = .109). All subjects showed normosensitivity to the cotton swab test. CONCLUSIONS: Apical surgery on the palatal root of the maxillary first molar using a palatal approach was predictable and successful, and the number of complications resulting from artery and nerve damage was small.

A novel clinical protocol for the greater palatine compression suture: A case report.

Bleeding from the palatal donor site is a worrisome complication of palatal soft tissue harvesting procedures and leads to considerable stress to both the patient and the surgeon. Several methods to control palatal hemorrhage have been suggested in literature, including a palatal suture, but a precise protocol has not been suggested. The present case report aims to suggest a protocol for the greater palatine compression suture (GPCS). Five patients who experienced profuse bleeding from the palatal free gingival graft donor site were treated with the GPCS. The palatal midline was used as a landmark and the location of the greater palatine foramen was estimated. The suture was placed anterior to the estimated location of the foramen and was passed deep into the palatal tissue with the aim of looping and compressing the vascular bundle. In all the patients, an immediate reduction and arrest of bleeding from the palatal wound was observed with blanching of the soft tissues around the suture. The proposed technique is a predictable method to control palatal hemorrhage and can be used if other less invasive techniques fail to stem the blood flow from an injured palatal vessel.

Endoscopic endonasal greater palatine artery cauterization at the incisive foramen for control of anterior epistaxis.

OBJECTIVES/HYPOTHESIS: To describe the anatomy of the incisive foramen and the transnasal endoscopic approach to the greater palatine artery at this foramen, and to evaluate the importance of the greater palatine artery as a cause of recurrent anterior epistaxis. STUDY DESIGN: Anatomical dissection, radiographic study, and prospective case series. SETTING: Academic Medical Center. METHODS: Sixty-nine computed tomography scans were reviewed, and measurements were made of the incisive foramina's distance to the anterior nasal spine and subnasale. Twenty-two cadavers had sagittal split craniotomies performed prior to the measurements. The distance from the anterior nasal spine to the incisive foramen was documented. We also present an illustrative case series of patients who underwent endoscopic cautery of the greater palatine artery at the incisive foramen. RESULTS: Radiographic review of the incisive foramen revealed a mean anterior nasal spine to incisive foramen distance on the right and left of 7.9 and 8.1 mm, respectively. The mean distance from the subnasale to incisive foramen on the right and left were 24.7 and 24.9 mm, respectively. CONCLUSIONS: Endoscopic cauterization of the greater palatine artery at the incisive foramen is a safe and effective method to control recurrent anterior epistaxis. The incisive foramen can be predictively found within 1 cm of the anterior nasal spine. Our case series corroborates the above. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1033-1038, 2016.

A computed tomography study in the location of greater palatine artery in South Indian population for maxillary osteotomy.

INTRODUCTION: The greater palatine artery is one of the important feeding vessel to the maxilla. The surgeon should know the surgical anatomy of greater palatine artery to avoid trauma in maxilla which leads to ischemic problems. AIM: The CT evaluation of the distance between Pyriform aperture and the greater palatine foramen in various ages of both sexes. RESULT: The distance varies according to sex and age which are measured by CT and standardised. DISCUSSION: The lateral nasal osteotomy can be done upto 25 mm depth, instead of 20 mm. CONCLUSION: By this study it shows that the lateral nasal wall osteotomy can be performed without injury to greater palatine artery.

Palatal perforation secondary to tuberculosis: a case report.

Palatal perforation though rarely seen in adults but may have infectious, inflammatory, neoplastic, or traumatic cause. We present here a case of palatal perforation due to tuberculosis which was managed successfully using greater palatine artery pedicled flap closure at our centre.

Histological assessment of the palatal mucosa and greater palatine artery with reference to subepithelial connective tissue grafting.

This study aimed to measure the thickness of the epithelium and lamina propria of the palatal mucosa and to elucidate the location of the greater palatine artery to provide the anatomical basis for subepithelial connective tissue grafting. Thirty-two maxillary specimens, taken from the canine distal area to the first molar distal area, were embedded in paraffin and stained with hematoxylin-eosin. The thickness of the epithelium and lamina propria of the palatal mucosa was measured at three positions on these specimens, starting from 3 mm below the alveolar crest and in 3-mm intervals. The location of the greater palatine artery was evaluated by using image-processing software. The mean epithelial thickness decreased significantly in the posterior teeth; it was 0.41, 0.36, 0.32, and 0.30 mm in the canine, first premolar, second premolar, and first molar distal areas, respectively. The lamina propria was significantly thicker in the canine distal; it was 1.36, 1.08, 1.09, and 1.05 mm, respectively. The mean length from the alveolar crest to the greater palatine artery increased toward the posterior molar; it was 7.76, 9.21, 10.93, and 11.28 mm, respectively. The mean depth from the surface of the palatal mucosa to the greater palatine artery decreased from the canine distal to the first premolar distal but increased again toward the posterior molar; it was 3.97, 3.09, 3.58, and 5.50 mm, respectively. Detailed histological assessments of the lamina propria of the palatal mucosa and the greater palatine artery are expected to provide useful anatomical guidelines for subepithelial connective tissue grafting.

Histological assessment of the palatal mucosa and greater palatine artery with reference to subepithelial connective tissue grafting / 대한해부학회지

This study aimed to measure the thickness of the epithelium and lamina propria of the palatal mucosa and to elucidate the location of the greater palatine artery to provide the anatomical basis for subepithelial connective tissue grafting. Thirty-two maxillary specimens, taken from the canine distal area to the first molar distal area, were embedded in paraffin and stained with hematoxylin-eosin. The thickness of the epithelium and lamina propria of the palatal mucosa was measured at three positions on these specimens, starting from 3 mm below the alveolar crest and in 3-mm intervals. The location of the greater palatine artery was evaluated by using image-processing software. The mean epithelial thickness decreased significantly in the posterior teeth; it was 0.41, 0.36, 0.32, and 0.30 mm in the canine, first premolar, second premolar, and first molar distal areas, respectively. The lamina propria was significantly thicker in the canine distal; it was 1.36, 1.08, 1.09, and 1.05 mm, respectively. The mean length from the alveolar crest to the greater palatine artery increased toward the posterior molar; it was 7.76, 9.21, 10.93, and 11.28 mm, respectively. The mean depth from the surface of the palatal mucosa to the greater palatine artery decreased from the canine distal to the first premolar distal but increased again toward the posterior molar; it was 3.97, 3.09, 3.58, and 5.50 mm, respectively. Detailed histological assessments of the lamina propria of the palatal mucosa and the greater palatine artery are expected to provide useful anatomical guidelines for subepithelial connective tissue grafting.