CBCT Evaluation of the Position of Palatal Neurovascular Bundle and the Greater Palatine Foramen in an Iranian Population

Introduction: The Greater Palatine Foramen (GPF), a key structure in the hard palate, serves as a critical anatomical landmark connecting the Pterygopalatine Fossa (PF) to the oral cavity via the Greater Palatine Canal (GPC). The PF contains essential structures, including the maxillary nerve, its branches, the pterygopalatine ganglion and maxillary artery. Aim: To assess the morphological and morphometric variations of GPF and canal by using Cone Beam Computed Tomography (CBCT). Materials and Methods: This retrospective observational study was conducted in the Department of Oral Medicine and Radiology, at Vishnu Dental College, Vishnupur, Bhimavaram, Andhra Pradesh, India in a time of six months, data collection from May 2024 to September 2024 and analysis in October 2024. A total of 100 scans of maxillary arch were analysed. CBCT images covering the full arch maxilla within the age range of 20 to 70 years were included. Parameters such as the shape of the foramen and distance from GPF centre to Mid-Maxillary Suture (MMS) and Anterior Nasal Spine (ANS) in axial sections and shape of the canal in sagittal sections were evaluated on both right and left-sides and compared between genders. Results: A statistically significant differences were observed in the mean distance from the GPF to the MMS on the rightside for both genders p-value=0.001. The most common shape of the GPC was straight with frequency of 22% on both right and left-sides in males and 14%, 17% on right and left-sides respectively in females in the sagittal plane and oval with a frequency of 17%- right, 18%- left-side in males and 13%- right, 11%- left in females in the axial plane. Regarding the location of the GPF in relation to molars, the most prevalent position was E, with a frequency of 24%- right and left-sides in males, 23%- on both right and left-sides in females, where the GPF is distal to the upper third molar. Conclusion: The study emphasises the importance of morphometric variations in dental procedures, using CBCT for accurate assessment and improved surgical precision. CBCT, which offers precise three-dimensional imaging that improves surgical planning, patient safety and diagnostic accuracy, is essential for precisely evaluating these variances.

Introduction: A known method for maxillary nerve block is through the greater palatine canal (GPC). Poor knowledge about the anatomy might result in undesired conditions such as perforation of the arteries, nerve damage and blindness. This study aimed at determining variations of the GPC and greater palatine foramen (GPF) on cone beam computed tomography (CBCT) images. Materials and Methods: This cross-sectional descriptive study was carried out at Islamic Azad University dental school and private clinics of Isfahan in 2018. A total of 92 CBCT images of adults over 18 years old were evaluated and GPC length, GPF diameter and its distance to the anterior nasal spine (ANS), posterior nasal spine (PNS) and mid-maxillary suture (MMS) were measured. The data were analyzed using SPSS 18. Results: The mean distance of GPF to ANS (47.96 mm in men and 45.36 mm in women), to PNS (18.9 mm in men and 17.21 mm in women), and to MMS (15.93 mm in men and 14.73 mm in women), as well as the diameter of the GPF (6.07 mm in men and 5.01 mm in women) were significantly higher in men on both right and left sides (P<0.05). The mean GPC length in men and women was 34.36±2.5 and 31.39±1.9 mm, respectively, which was significantly larger in men. The more common canal pathway in sagittal plane was inferior/inferior-anterior (70%) in both genders. The inferior/inferior-anterior pathways were more common in both genders in coronal plane; however, this difference was not significant (P>0.05). Conclusion: Since the maxillary nerve block technique might cause irreparable complications through GPC, it is very important to know the position of the foramen and the canal direction. Therefore, it is advisable to use CBCT in order to better understand the GPF and GPC anatomy.

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. 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). 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 40mm, 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%). 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 4mm. To estimate the possible length of the graft, the incision was made along the third and the second molar to the IF as 4cm. 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.

Morphometric assessment of greater palatine canal and foramen variations in cleft lip and palate patients using CBCT.

ObjectiveThe aim of this study was to evaluate the morphology and morphometry of the greater palatine foramen (GPF) using cone‐beam computed tomography (CBCT).Materials and MethodsThis study included 300 CBCT images and a total of 600 GPFs were evaluated bilaterally. GPF morphology was categorised as round, antero‐posteriorly elongated (APE), or latero‐medially elongated (LME). The distance of GPF relative to the palatine suture (PS), the incisive foramen (IF), and the palatine alveolar ridge (PAR), the distance between the right GPF (GPFr) and left GPF (GPFl) and the angle formed by GPF, IF, and PS were evaluated. The GPF location was also assessed in reference to the maxillary molars.Results64.1% of total GPFs were APE in shape. Male patients presented higher GPF‐related linear and angular measurements on both sides (p &lt; 0.05). Patients aged ≥25 years had larger distances between GPFr–PS, GPFl–PS, GPFr–GPFl, and GPFl–IF (p = 0.001, p = 0.009, p &lt; 0.001, and p = 0.048, respectively; p &lt; 0.05). Patients aged ≤24 years showed a larger distance between GPFl–PAR (p = 0.011; p &lt; 0.05). The distance between GPFl–IF was larger compared to the distance between GPFr–IF, but the angle between GPFr–IF–PS was larger than the angle between GPFl–IF–PS (p = 0.043 and p = 0.004, respectively; p &lt; 0.05). 64.83% of all GPFs were located opposite the maxillary third molar.ConclusionThe shape and location of the GPF exhibit considerable variability. CBCT is a valuable diagnostic modality for assessing anatomical differences in the GPF.

The block anesthesia of the greater palatine foramen (GPF) is largely used in minor oral surgeries, periodontics and general dentistry. Furthermore, the area of the GPF serves as a donor of soft tissue graft. So, the aim of this study was to evaluate the position and characteristics of the GPF in Brazilian patients using cone beam computed tomography (CBCT) providing anatomical information for the greater palatine nerve block anesthesia and indicate site to collect palatal donor tissue. Fifty CBCT exams of Brazilian patients with a mean age of 35.8years (27 male/23 female) were evaluated. All patients had erupted first, second and third upper molars. A total of 100 GPF were evaluated bilaterally. The GPFs were assessed regarding position, diameter and distances to the midline maxillary suture (MMS) and to alveolar ridge (AR). Guidelines were drawn in the CBCT axial image depicting all molar interproximal surfaces, bilaterally. The guidelines were located between first, second and third molar and in the center of the second and third, performing five guidelines in each side. These guidelines and the molars were landmarks to assess the GPF anatomic position. From the 100 GPF analyzed, 92 were located in the third molar region (24 male/22 female). The 92 GPF were distributed as 47 in the left side and 45 in the right side. The average GPF diameter and the distance to both the AR and the MMS were 3.1mm; 7.9 and 15.3mm, respectively. Within the limits of this study, we concluded that the in Brazilian patients studied, the GPF location was more closely related to third molar. Therefore, whenever the third molar is erupted, it could be used as landmark for successful GPN block anesthesia. Moreover, harvesting palatal mucosa graft around the third molar should be done cautiously to prevent damage to the GPF vascular-nerve complex.

Objectives: Biotype conversion around both natural teeth and implants with subepithelial connective tissue graft (SCTG) has been advocated. The harvesting procedure should be carefully conducted to avoid violating the greater palatine neurovascular bundle (GPB). The GPB, which comprises the greater palatine artery, vein, and nerve, travels through the pterygopalatine fossa, passes through the pterygopalatine canal, and exits into the greater palatine foramen (GPF). This study assessed the accuracy of predicting the location of the GPF and measured the thickness of the palatal masticatory mucosa and the distance from the GPB in the posterior palatal area, using cone beam computerized tomography (CBCT). Methods: CBCT images of 21 patients (13 men and 8 women, 22~46y) were evaluated retrospectively. The inclusion criterion was complete dentition from the maxillary first premolar to the third molar (first premolar: P1, first molar: M1, second molar: M2, area between second molar and third molar: M2-M3, third molar: M3, distal area of third molar: M3D). The distance from the cemento-enamel junction (CEJ) of the P1 and M1 to the GPB (P1d and M1d, respectively) was defined as the safe zone of the palate. The perpendicular distance from the middle P1d and M1d to the palatine bone was defined as the thickness of the palate (P1t and M1t, respectively). Foramen of transversal diameter (FTD) is the transverse diameter of the GPF. The location of the GPF in relation to the tooth and the distance from the CEJ to GPF (M3d) was also determined. Results: The most frequent location of the GPF was M3 (59.5%), followed by M2-M3 (26.2%) and M3D (14.3%). The mean diameter of FTD was 3.4±0.7mm. The mean M3d was 14.6±1.4mm. P1d and M1d were 12.1±1.4mm and 13.3±1.4mm, respectively. P1t and M1t were 3.7±0.5mm and 3.6±0.8mm, respectively. No significant difference was observed between P1d and M1d, but significant difference was noted between P1t and M1t. Conclusion: The thickness of palatal masticatory mucosa increased from the first premolar but decreased at the first molar region. The results of this study can assist clinicians in planning the location for harvesting SCTG on the hard palate.

BACKGROUND The greater palatine foramen (GPF) is anatomically located distal to the third maxillary molar tooth, midway between the midline of the palate and the dental arch. The GPF contains the major palatine artery, vein, and nerve, traversing the palatine sulcus. This study aimed to evaluate the anatomical position of the GPF in 93 women and 67 men at a single center in Cyprus using cone beam computed tomography (CBCT). MATERIAL AND METHODS A retrospective analysis was conducted on 160 CBCT scans. Measurements of the GPF's horizontal and vertical diameters, distances from GPF to the incisive foramen, posterior nasal spine, anterior nasal spine, and midaxillary suture, and positional relationships to molars were recorded. Statistical analyses compared these measurements between males and females. RESULTS The study included 93 females and 67 males with an average age of 46.6 (±11.6) years. Significant sex differences were observed in most GPF measurements, with males showing larger dimensions such as the anterior nasal spine, posterior nasal spine, mid-maxillary suture, and incisive foramen to the GPF. The GPF was predominantly located in the third molar region (96.25% on the right, 96.9% on the left). The left GPF showed a significantly larger horizontal diameter than the right (P<0.05). CONCLUSIONS There was a significant difference in the average distances from the anterior nasal spine, posterior nasal spine, mid-maxillary suture, and incisive foramen to the GPF, as well as in the size of the GPF, between males and females. Recognizing these variations enhances clinical planning and reduces the risk of complications.

To determine morphological variations of the hard palate in dry human skulls, 85 skulls of unknown age and sex from nine medical schools in Khyber Pakhtunkhwa, Pakistan were examined. The transverse diameter, number, shape and position of the greater (GPF) and lesser (LPF) palatine foramina; canine to canine inter-socket distance; distance between greater palatine foramen medial margins; on each side, the distances between greater palatine foramen and base of the pterygoid hamulus, median maxillary suture and posterior border of the hard palate; palatal length, breadth and height; maximum width and height of the incisive foramen; and the angle between the median maxillary suture and a line between the orale and greater palatine foramen were determined. Palatine index and palatal height index were also calculated. An oval greater palatine foramen was present in all skulls, while a mainly oval lesser palatine foramen was present in 95.8% on the right and 97.2% on the left. Single and multiple lesser palatine foramina were observed on the right/left sides: single 44.1%/50.7%; double 41.2%/34.8%; triple 10.2%/11.6%. The greater palatine foramen was located above the third molar in 74.7% (right)/87.8% (left), between the second and third molars in 25.3%/9.5%, and above the second molar in 2.7% (left). A single oval-shaped incisive foramen was observed in 87.1%. The median maxillary suture angle was 13.74±1.58° on the right and 13.14±1.68° on the left. In conclusion, no significant differences were observed in any distances on the right and left side related to greater palatine foramen; however a significant difference (p <0.05) was observed between the right and left sides for median maxillary suture angle.

ObjectiveThis study aimed to use cone beam computed tomography (CBCT) scans to compare the morphometric characteristics of the greater palatine foramen (GPF) in unilateral and bilateral cleft lip/palate patients (CL/P) and non-cleft (NC) individuals.Method and materialOne hundred patients with CL/P (78 unilateral and 22 bilateral) and 100 non-cleft individuals had their GPF morphometrically assessed in CBCT images. The antero-posterior width and medio-lateral width of the GPF, the distance between the right and left GPFs, the mesio-distal location of the GPF with respect to the molar teeth, the distance between the GPF and the hamulus of the medial pterygoid plate, and the distance between the GPF and the palatine alveolar ridge were measured on these images. The Kruskal-Wallis and Chi-square tests were employed to ascertain if there were any notable disparities across the 3 groups.ResultsThe GPF's antero-posterior width and medio-lateral width, and distance from the hamulus and palatine alveolar ridge were considerably smaller in the unilateral cleft lip/palate (UCL/P) and bilateral cleft lip/palate (BCL/P) patients than in the NC individuals. However, no significant difference was observed between the BCL/P and UCL/P groups in terms of these parameters. The distance between GPFs and the location of the GPF did not exhibit any significant differences among the 3 groups.ConclusionCertain morphometric parameters of the GPF were significantly different in CL/P patients. Understanding the anatomy of this area is crucial for successful treatment of individuals with CL/P with minimal complications.

This study aims to investigate the anatomy of the greater palatine foramen (GPF), greater palatine canal (GPC) and pterygopalatine fossa (PPF) with special reference to the blockage of the maxillary nerve. A correlation between the length of GPC and PPF and the heights of the orbit and the maxilla was also studied using simple linear regression analysis. The morphology of the GPF, GPC and PPF as well as heights of the orbit and the maxilla were assessed in 105 Thai skulls. The thickness of the mucosa over the GPF was also measured from the dissection of 55 cadavers. The results showed that most GPF appeared as an oval foramen located at the palatal aspect of the upper third molar. The GPF was 16.2+/-1.3 mm lateral to the median sagittal plane of the hard palate, 2.1+/-1.3 mm anterior to the posterior border of the hard palate and 5.1+/-1.3 mm from the greatest concavity of the distolateral margin of the hard palate. The mean length of GPC and PPF was 29.7+/-4.2 mm. The mean angles of the GPC in relation to the hard palate and the vertical plane were 57.9+/-5.8 degrees and 6.7+/-5.2 degrees , respectively. In attempting to insert a needle to reach the foramen rotundum through the GPF, 31.7% passed into the orbit while 8.7% passed into the brain. The mean thickness of the mucosa over GPF was 6.7+/-2.3 mm. Two models for estimating the depth of needle injection in maxillary nerve block have been developed as follows: Length of GPC and PPF=19.038+0.314 (orbital height) and length of GPC and PPF=21.204+0.187 (maxillary height). The calculated length combined with the mucosal thickness was the estimated depth of needle injection. In conclusion, our results concerning the GPF, GPC and PPF will provide the useful reference for clinicians to anesthetize the maxillary nerve with a greater degree of success.

Introduction: The greater palatine foramen (GPF) is located in the posterior part of the hard palate between the articulations of hard palate with the maxilla. GPF continues posteriorly and upwards as greater palatine canal (GPC) which opens in to the inferior wall of pterygopalatine fossa. Exiting the foramen rotendum, maxillary nerve enters the pterygopalatine fossa where it can be blocked. The intraoral route of GPF approach can be preferred for maxillary nerve block because of its low incidence of complications and high success rate. For achieving a painless intra operative period in procedures involving the maxillary region and for tooth extraction achieving a perfect maxillary nerve block is of at most importance. Our present study is aimed at correctly locating the position of GPF, its shape and patency in south Indian population which will be helpful for the intra oral approach of maxillary nerve block through the GPF Materials and Methods: The study was conducted in 30 dry adult skull bones of both sex. The molar relation, shape and the patency of the GPF were observed, the readings were obtained, statistically analyzed and compared with other studies. Results: In our observation on both side of skull, it was noted that GPF was located opposite to the 3rd molar in 90% of cases. Oval shaped GPF is most commonly found in our study which accounts to 53.35% and the overall patency rate for GPF was 95% in our study. Conclusion: Analysis and comparison of data has proven that the position, shape and patency of GPF may vary according to different races. This study has also confirmed that the maxillary nerve block via GPF is relatively safe and easier due to the consistency of the position, shape and the patency of the GPF in south Indian population. KEY WORDS: Greater palatine foramen, maxillary nerve block, regional blocks, Greater palatine canal, pterygopalatine fossa, Maxillary nerve.

Accurate knowledge of greater palatine foramen (GPF) anatomy is necessary when performing a variety of anaesthesiological, dental or surgical procedures. The first aim of this study was to localize the GPF in relation to multiple anatomical landmarks. The second aim was to perform a systematic review of literature, and to conduct a meta-analysis on the subject of GPF position to aid clinicians in their practice. One-hundred and fifty dry, adult, human skulls and 1200 archived head computed tomography scans were assessed and measured in terms of GPF relation to other anatomical reference points. A systematic literature search was performed using the PubMed, Embase and Web of Science databases, and a meta-analysis on the subject of GPF relation to the maxillary molars was conducted. On average, in the Polish population, the GPF was positioned 15.9 ± 1.5 mm from the midline maxillary suture (MMS), 3.0 ± 1.2 mm from the alveolar ridge (AR) and 17.0 ± 1.5 mm from the posterior nasal spine (PNS); 74.7% of GPF were positioned opposite the third maxillary molar (M3). Twenty-seven studies were included in the systematic review and 23 in the meta-analysis (n = 6927 GPF). The pooled prevalence of the GPF being positioned opposite the M3 was 63.9% (95% confidence interval = 56.6-70.9%). Concluding, the GPF is most often located opposite the M3 in the majority of the world's populations. The maxillary molars are the best landmarks for locating the GPF. In edentulous patients the most useful points for approximating the position of the GPF are the AR, MMS and PNS. This study introduces an easy and repeatable classification to reference the GPF to the maxillary molars.

Background As the hard palate is an essential region of the skull its gross anatomy and morphological variations have been of interest in many studies. Aim The aim of the present study was to describe the gross anatomy of the hard palate in Egyptian skulls, and determine sex from the morphometric study of the hard palate and location of the position of the greater palatine foramen (GPF) in relation to certain fixed intraoral anatomical reference points, all of which are visible or palpable in a living patient. Materials and methods In this study, 100 skulls (64 male and 36 female skulls) were subjected to the following measurements: palatal length, breadth, and height, the diameters of the GPF and its shape, the direction of opening of the GPF onto the palate, the relation of GPF to the maxillary molar teeth; the distance from the GPF to the midline maxillary suture, to the incisive foramen, to the posterior border of the hard palate, and to the tip of the hamular process of the pterygoid; the angle between the axis of the greater palatine canal (GPC) and the hard palate; the length of GPC plus the length of the pterygopalatine fossa; and the height of the maxilla. Twenty cadaveric heads were also dissected to measure the thickness of the palatal mucosa over the GPF. Results The mean palatal length was 51.65 ± 4.7 mm and palatal breadth was 38.68 ± 2.9 mm, with a highly significant difference between male and female skulls. Palatal height was 11.8 ± 2.7 mm with no significant difference between the two sexes. Of the total skulls 64% had narrow palates, 24% had intermediate ones, and 12% had wide palates with no significant difference between the two sexes; 36% had low palates, 56% had intermediate, and 8% of the sample had high-arched palates with a significant difference between the two sexes. The mean anteroposterior and transverse diameters of GPF were 4.86 ± 0.9 and 3.02 ± 0.7 mm, respectively. It was frequently an oval opening in 71%, a rounded opening in 22%, and lancet and slit in the remaining. Its direction in 69% was anteromedial, that in 28% was anterior, and that in 3% was anterolateral. The majority (84%) of the total foramina were opposite the maxillary third molar tooth. The mean distance from the GPF to the midline maxillary suture was 14.25 ± 1.7 mm, that from the GPF to the incisive foramen was 35.93 ± 3.5 mm, and that from the GPF to the posterior border of the hard palate was 3.89 ± 0.9 mm. The mean length of GPC and the pterygopalatine fossa was 29.39 ± 3.1 mm, the height of the maxilla was 30.44 ± 3.4 mm, and the difference between the two sexes was significant. The angle between the GPC and the horizontal plane of the hard palate was 40.48 ± 9.1°. The mean thickness of the palatal mucosa over the GPF was 4.92 ± 1.93 mm. Conclusion As the measurement studies of the hard palate show considerable variations among races, the data in this study will help clinicians to localize the GPF more precisely in Egyptian patients and to predict the depth of a needle to anesthetize the maxillary nerve with a low rate of complications.

What Is the Safety Zone for Palatal Soft Tissue Graft Harvesting Based on the Locations of the Greater Palatine Artery and Foramen? A Systematic Review