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The Nasopalatine Canal in Adults on Cone Beam Computed Tomograms–A Clinical Study and Review of the Literature

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The Nasopalatine Canal in Adults on Cone Beam Computed Tomograms–A Clinical Study and Review of the Literature in vivo 29: 467-486 (2015) The Nasopalatine Canal in Adults on Cone Beam Computed Tomograms–A Clinical Study and Review of the Literature REINHARD E. FRIEDRICH, FRANK LAUMANN, TOMISLAV ZRNC and ALEXANDRE T. ASSAF Department of Oral and Craniomaxillofacial Surgery, Eppendorf University Hospital, University of Hamburg, Hamburg, Germany Abstract. Aim: The aims of this study were to assess the sagittal plane only, but the technique allowed demonstration location, morphology and anatomical dimensions of the of all aspects using the combined 2D/3D interpretation. nasopalatine canal (NPC) on cone beam computed Conclusion: The NPC may exhibit important anatomical tomographic (CBCT) images and to compare our findings variations, both with regard to morphology and its with recent reports on this matter. A detailed knowledge of dimensions. To avoid any potential complications during anatomical variations is mandatory in skeletal surgery of the dentoalveolar surgery, careful preoperative evaluation is anterior maxilla. Patients and Methods: Two hundred CBCT required. 3D imaging is recommended to determine canal scans of the mid-facial region were analyzed from adult topography and dimensions, and to assess the individual patients at the Outpatient Clinic of the Department of Oral anterior maxilla’s dimensions prior to surgical procedures, and Craniomaxillofacial Surgery, University of Hamburg, such as dental implant insertion or bone augmentation. Germany. Patients were scanned using standard exposure time at normal patient positioning inside the CBCT device. The nasopalatine canal (NPC) is part of the anterior maxilla. Three-dimensional (3D) CBCT images were carefully Diseases of this bone can affect the NPC. In addition, the analyzed regarding NPC location, morphology and planning surgical procedures of the anterior maxilla is based anatomical dimensions, and variations of radiological on a detailed knowledge about this region. This study morphology, with respect to age and gender. Results: In the provides new information on the topography of the NPC sagittal plane, the NPC typically appeared as a canal with with special reference to a radiological and surgical a mean length±standard deviation (SD) of 11.15±2.87 mm. perspective. The oral cavity opening of the canal is the incisive foramen, with a mean diameter of 4.49±1.71 mm. At the entrance to Anatomy of the NPC. The paired NPC is localized in the the nasal floor, in most cases, two apertures were found (Y- anterior maxilla, close behind the central incisors (1). The canal morphology), but also three or four openings were NPC forms a tube connecting soft tissues of the nasal and observed. In particular cases, the canal presented a oral cavities (2, 3). The oral aperture of the NPC lies in the cylindrical aperture with only one exit to the nasal floor. The anterior palatine bone, just dorsal to the roots of the upper average width of the NPC at the level of the nasal floor was central incisors (3). The funnel-shaped opening to the oral 3.43±1.54 mm. The labiopalatal width of the NPC measured cavity is defined as the incisive foramen or fossa (1). Inside perpendicular to the long axis of the canal on sagittal plane the bone, the NPC divides in the cranial course into two was 2.48±1.33 mm. Interpretation of NPC morphology was tubes that run separately to the nasal aperture, termed nasal significantly different when analyzing the images in the foramina (4-7). The NPC contains fibrillary connective and adipose tissues (6), minor salivary glands (8, 9), and the nasopalatine nerve and artery (10, 11). During its osseous passage, the artery maintains anastomoses with the major Correspondence to: Professor Reinhard E. Friedrich, MD, DMD, palatine artery (12). Occasionally, two additional small Ph.D., Department of Oral and Craniomaxillofacial Surgery, channels are found in the incisive bone medial to the NPC Eppendorf University Hospital, University of Hamburg, Martinistr. (canals of Scarpa). These channels carry further nerve 52, D-20246 Hamburg, Germany. Tel: +49 40741053259, e-mail: filaments of the nasopalatine nerve, terminating in the [email protected] incisive foramen as Scarpa’s foramina. In the oral cavity, the Key Words: Nasopalatine canal, incisive canal, cone beam computed left supplementary channel opens anteriorly and the right tomography, maxilla, primary palate, radiological anatomy, implant posteriorly to the oral opening of the NPC (3, 13). The NPC dentistry, local anesthesia, dentoalveolar surgery. should not be confused with the paired nasopalatine or 0258-851X/2015 $2.00+.40 467 in vivo 29: 467-486 (2015) Figure 1. Schematic representation of nasopalatine canal development according to Radlanski et al. (16), modifying illustrations of Bornstein et al. (13), axial aspect from caudal direction. The nasopalatine canal (sive incisive canal) is part of the developing primary palate and therefore the canal is located anterior to the sutura incisiva in the incisive bone (shown in B). A: Schematic drawing of the developing palate: The primary palate [1], contains the nasopalatine duct (dots). The palatine processes of the maxilla [2] have not yet conjoined in the medio-sagittal plane, leaving the gap open to the visible nasal septum [3]. B: Fused palate with two maxillary processes and incisive bone. The suture between the incisive bone and the fused palatine processes (incisive suture) is indicated as a v-shaped dotted line. The inset indicates the region presented in detail in C. C: Detail of inset shown in B: The nasopalatine canal at the 12th week of fetal development: 1: nasopalatine duct, 2: nasopalatine nerve, 3: nasopalatine artery. The nasopalatine duct is obliterated during further stages of physical development. However, remnants of the duct may persist up to post-natal life (14). The dotted line indicates the border with the fused palatine processes of the maxilla and the vertical line indicates the anterior end of the median palatine suture. incisive duct (2, 14). This duct develops prenatally in the 6th (34, 35), topography (36), volumetry of the maxilla for to 12th fetal weeks from epithelia within the NPC and forms estimation of donor sites for bone grafts (37), computer- a temporary connection between the nasal and oral cavities aided manufacturing (38), and basic science in dentistry (39). during the 13th and 14th fetal weeks (15-17) (Figure 1). Some studies were recently published on the radiological morphology of NPC on CBCT images, revealing substantial Surgery of the anterior maxilla. Knowledge of precise variation in the radiological morphology of the canal (13, 40- anatomical descriptions, dimensions, and the location of the 48). The purpose of this study was to generate our own NPC is crucial in the fields of dentistry and oral and relevant data on the morphological characteristics of NPC maxillofacial surgery, e.g. for local anesthesia of the anterior derived from CBCT and to compare our findings with recent maxilla, and the planning of surgical procedures concerning radiological and morphological data on NPC anatomy this region, such as dental implant placement or apical root generated with different morphometric and imaging resection. Surgery in the anterior maxilla can give rise to techniques. Finally, we compared the measurements of contact of surgical instruments and implants with the current CBCT studies and findings derived from anatomical structures running through or close to the NPC (18-22). This dissections (49). situation may cause surgical problems (23, 24), and lead to sensory dysfunction (20, 25) or poor osseointegration of Patients and Methods implants. Patients. The NPC was analyzed on CBCTs of 200 adult patients (female: 94, male: 106; mean age=44.96 years, range=20-98 years) Radiology of the anterior maxilla. Computed tomographic undertaken at the Department of Oral and Craniomaxillofacial (CT) studies are performed to better visualize this anatomical Surgery, Hamburg University, Germany, between 2011 and 2013 region as a prerequisite to more precise surgery of the (Table I). The radiographs were made for diagnosis of dental or anterior maxilla (26-29). Within the past decade, limited jaw diseases unrelated to the present analysis. We excluded cone beam computed tomography (CBCT) has become a patients from the evaluation who were subjected to radiography of useful tool for investigating the facial bones in detail (30). the anterior maxilla for cysts of the nasopalatine duct or had apical CBCT allows imaging of osseous structures with less jaw lesions in proximity to the upper incisors; likewise radiographs of patients with known craniofacial deformities or radiation exposure than conventional multi-slice CT (31). dental implants in the frontal maxilla were also excluded. This CBCT has already been widely applied for several study was approved by the Institutional Review Board of indications in the fields of oral and maxillofacial disciplines, Eppendorf University Hospital to fulfill the requirements for a such as trauma (32), periodontal disease (33), morphometry medical thesis in dentistry (FL). 468 Friedrich et al: Nasopalatine Canal Morphometry by CBCT Table I. Age and gender of patients studied for radiological morphology of the nasopalatine canal. Age (years) Female, n Male, n Total, n 20-29 33 29 62 30-39 11 14 25 40-49 14 20 34 50-59 13 16 29 60-69 13 18 31 70-79 7 4 11 80-89 2 5 7 90-100 1 0 1 Total 94 106 200 Cone beam computed tomography. All CBCTs were performed with the same equipment (3D Accuitomo 170, Model MCT-1 EX-1 F17; Morita MFG Corp., Kyoto, Japan). All images were made using ‘slow mode’ with 100 single projections over 2 min with a required exposure time of 18 seconds (360˚). Thickness of the performed slices was 1.00 mm, voxel size was 80-250 μm, and exposure volume 170 mm ×120 mm. Evaluation of all dental images performed pre- and postoperatively was carried out using iDixel™ 2.0 3D Imaging Software (J.
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