Is Pterygoid hamulus fracture a pre requisite for cleft palate surgery? - A Systematic review of surgical, otologic, and speech outcomes.

Variations in the morphology of the pterygoid hamulus (PH) can lead to oropharyngeal pain, prosthodontic challenges and surgical complications, yet precise in vivo evaluations are limited. Therefore, it is of interest to assess the morphometric variations of the pterygoid hamulus (PH) in the Bagalkot population using Cone-Beam Computed Tomography (CBCT). CBCT scans of 65 adults (46 males, 19 females; mean age 39.5 years) were retrospectively analyzed, focusing on PH dimensions and shape. Results indicated that females exhibited slightly higher mean PH length, width and angulation than males, with width showing greater variability in females. Slender morphology was predominant bilaterally, followed by triangular types in both genders. The findings advance knowledge by demonstrating the utility of CBCT for accurate PH evaluation, supporting diagnosis of hamular-related pain and aiding in prosthodontic and maxillofacial procedures.

The medial pterygoid plate plays a critical role in mammalian craniofacial function during suckling and swallowing. The plate supports the tensor veli palatini (TVP) muscle, which stiffens the soft palate to create a posterior seal. Despite its functional importance, the developmental origins and structural integration of the medial pterygoid plate and associated pterygoid hamulus remain incompletely understood. In this study, we investigated the ontogeny and lineage of the medial pterygoid plate using wildtype and conditional knockout mice with immunofluorescence and lineage tracing. Analysis from embryonic day (E)14.5 to E17.5 confirmed that the medial pterygoid plate formed as a bipartite structure, which later fused to the basisphenoid. The dorsal region of the medial pterygoid plate ossified via Runx2-dependent intramembranous bone formation, while the ventral region formed as a secondary cartilage, undergoing Sox9-dependent chondrogenesis, followed by endochondral ossification. The pterygoid hamulus was evident at E14.5 as a condensation of Sox9-positive mesenchyme at the end of the medial pterygoid plate. Confirming the different modes of development, the ventral and dorsal parts of the medial pterygoid plate showed distinct timing and pattern of collagen remodelling, as shown by B-CHP. Lineage tracing with Wnt1Cre;tdTom and Mesp1Cre;tdTom mice demonstrated that the entire pterygoid process formed from neural crest-derived mesenchyme. In keeping with this, conditional loss of Runx2 in the neural crest lineage disrupted ossification of the dorsal part of the medial pterygoid plate, whereas conditional loss of Sox9 abolished chondrogenesis of the ventral part of the medial pterygoid plate and the pterygoid hamulus. Notably, TVP muscle fibres were able to maintain their orientation around the residual cartilage in conditional Wnt1creRunx2flfl mutants, while the TVP in conditional Wnt1creSox9flfl mutants formed a ball of cells that failed to extend towards the palatal region. The ventral portion of the medial pterygoid plate and hamulus is therefore required to guide early muscle pathfinding. These findings establish the medial pterygoid plate as a compound craniofacial element with distinct ossification modes and an important role interacting and directing neighbouring tissues.

PurposePterygoid implants are a viable alternative to sinus-lifting procedures; however, their placement may risk damaging adjacent soft tissues. This study aimed to clarify the morphology of the buccinator muscle (Bu), particularly its attachment to the pterygoid hamulus, and to assess the risk of injury during implant surgery.MethodsCadaveric dissection, histological analysis, and micro-computed tomography were performed. Bone morphometry was used to evaluate the maxillary tuberosity. Histological sections were analyzed to measure the distance between the Bu and the maxillary tuberosity, as well as to examine its attachment to the pterygoid hamulus.ResultsSubstantial individual variation was observed in the shape and bone density of the maxillary tuberosity, with some specimens exhibiting low bone volume fraction (BV/TV). The Bu was located immediately posterior to the tuberosity at the root of the pterygoid hamulus (mean: 0.61 mm), but more distant at the tip (mean: 2.37 mm). The muscle exhibited a dual mode of attachment: tendinous at the root and periosteal at the tip. Implant perforation near the root may therefore pose a higher risk of muscle injury.ConclusionsThis study revealed a dual attachment of the buccinator muscle to the pterygoid hamulus and emphasized its close proximity to the maxillary tuberosity. Additionally, low BV/TV values in some specimens highlight the anatomical variability of this region. Understanding individual differences in bone structure and the precise location of soft tissue attachments is essential for safer and more predictable pterygoid implant placement.

Pterygoid hamulus bursitis (PHB) is an infrequently reported condition that presents with chronic orofacial pain, often misdiagnosed as temporomandibular disorders (TMDs) or other common craniofacial pain syndromes. This condition arises from inflammation of the bursa surrounding the pterygoid hamulus (PH), a small hook-like bone structure of the sphenoid bone. Anatomical variations such as elongation of the PH or repetitive mechanical irritation are among the primary causes of this rare pathology. Clinically, PHB manifests as pain radiating to the soft palate, throat, or temporomandibular joint area, accompanied by symptoms such as dysphagia or otologic discomfort. This comprehensive review examines the current understanding of PHB, including its anatomy, pathophysiology, clinical presentation, diagnostic challenges, and management strategies, based on the available literature and clinical evidence. Early recognition and appropriate management, including surgical intervention when necessary, are essential to alleviate symptoms and prevent long-term complications.

Abstract Background: The pterygoid hamulus is a bony protrusion that protrudes medially and slightly posteriorly, like a hook. Individual differences in its size, shape, and orientation can be used as forensic identification cues. Objective: Using the angulation created by the sphenoid process and the size of the pterygoid hamulus, CBCT is used to predict age and gender. Methods: 100 CBCT images of patients were extracted from archives created with the PLANMECA PROMAX 3D MID PROFACE CBCT machine using ROMEXIS DENTAL software as part of a retrospective study. Three groups were formed out of these. The pterygoid hamulus’s dimensions were noted in the coronal plane, and the angulation created by the pterygoid processes was noted in the axial plane and measured in three dimensions. Results: Age and gender had a substantial impact on the length of PH on both left and right sides, while gender had a significant impact on the width of PH on right side alone. There was a favourable correlation on the angulation between gender on the left and right sides. The left-side angulation of females showed a positive connection. Conclusion: In forensic dentistry, the angulation created by the sphenoid bone’s pterygoid processes and the dimensions of the pterygoid hamulus are crucial. When compared to females, males’ values increased with age, which should be considered in forensics.

IntroductionThe pterygoid hamulus develops from the medial lamella of the pterygoid process. Understanding the architecture of the pterygoid Hamulus is crucial in terms of image interpretation as well as to diagnose idiopathic pain of the oral cavity and pharynx. Apart from diagnostic implications, the pterygoid hamulus can be utilised in forensic identification by studying its variations in different age groups and genders using three-dimensional imaging modalities such as cone beam computed tomography.Materials and methodsIn this study, 608 Full FOV CBCT images were evaluated for the length, width, inclination, and shape of the pterygoid hamulus on both right and left sides in 4 different age groups, i.e. 20-30, 31–40, 41–50, and 51–60 years and correlated between males and females.ResultsStatistically significant data was obtained with the assessment of pterygoid hamulus length, width, and inclination in the age groups spanning from 20 to 60 years. The distribution of shapes, i.e., slender and triangular, was found to be statistically significant in the assessed age groups. Males had a significantly longer and wider pterygoid hamulus compared to females. No statistically significant data were obtained on mean inclination and shape distribution among males and females.ConclusionThe assessment of various parameters of pterygoid hamulus using radiographic imaging modalities such as cone beam computed tomography could help in diagnosing orofacial pain of uncertain origin as well as in forensic identification, given variations noticed with age progression and amongst males and females.

The pterygoid hamulus is a bony process that protrudes from the medial pterygoid plate of the sphenoid bone. In spite of its small size and fragile structure, the pterygoid hamulus is an important anatomical structure in many clinical aspects. Orofacial pain may be related to inflammation or irritation of the pterygoid hamulus; if not, other possible explanations should be explored. In addition, the pterygoid hamulus is an important landmark in the oral cavity and is utilized in a number of dental and medical procedures. Thus, the purpose of this work was to review recent studies demonstrating the role and significance of the pterygoid hamulus in clinical practice.

The inferior border of the medial pterygoid plate extends to form the pterygoid hamulus (PH).The PH's length and location are crucial for these functions.The PH's morphology helps in interpreting the imaging and also provides information regarding anatomical determinants to limit the posterolateral borders of maxillary complete dentures.This can also aid in gender identification in forensic situations.This study analyzed 80 CBCT scans from 40 male and 40 female patients (ages 25-67, median 38).Significant differences were found in pterygoid hamulus length between sexes: males had longer hamuli on both the right (8.8400.299mm vs. 7.9400.349mm, P=0.000) and left sides (7.8990.419mm vs. 7.2770.271mm, P=0.002).However, no significant differences in hamulus width were observed between males and females.These findings suggest length variations could be useful in clinical and anthropological contexts.Dimensions of pterygoid hamulus in completely edentulous patients will aid the clinician in precisely recording the posterolateral borders of maxillary dentures; this can also aid in gender determination in fragmented skulls in forensic applications.

Understanding the characteristics of the pterygoid hamulus (PH) is crucial for diagnosing and treating various oropharyngeal and craniofacial conditions. It also aids in interpreting radiographs and diagnosing unexplained oropharyngeal pains. Cone-beam computed tomography (CBCT) is a valuable tool, offering clinical insights into this previously understudied area. Accordingly, this study aimed to evaluate the morphology and dimensions of the PH and its changes by ageing in 20-40-year-old women in the Dental Branch of Islamic Azad University of Sciences, Tehran, Iran. This cross-sectional study was conducted on CBCT scans from 258 women aged 20-40. The morphology, length, width, and angle of the PH in coronal and sagittal planes were investigated. The average length of the right and left hamulus was 5.50±1.37 and 5.37±1.36 mm. The average width of the right and left hamulus was 2.16±0.72 and 2.11±1.06 mm. The average coronal angle of the right and left hamulus was 22.3±9.79° and 30.16±8.99°. The average sagittal angle of the right and left hamulus was 26.11±7.26° and 26.34±7.63°. In contrast with the sagittal angle, the right and left hamulus's length, width, and coronal angles were not symmetrical. Slender morphology was the most frequent morphology, and it was symmetrical only in the 20-30-year-old age group. Finally, no variable was affected by ageing. Hamulus dimensions and morphology did not change with ageing in women aged 20-40. The PH symmetry varied by age group. Also, CBCT was a suitable tool for investigating hamulus changes.

Newly revealed anatomy of the bucinator muscle: An anatomical and histological study

Stertor, a clinical sign associated with obstructive airway syndrome, is often observed in non-brachycephalic dogs. This prospective, case-control study aimed to compare soft palate dimensions, nasopharyngeal cross-sectional area (CSA), and nasopharyngeal collapsibility at various locations in non-brachycephalic dogs with and without stertor. A total of 50 dogs were recruited and stratified into control (n=34) and stertor (n=13) groups. Static and dynamic computed tomography was conducted without tracheal intubation, and the following variables were calculated: normalized soft palate length and thickness, normalized maximum and minimum nasopharyngeal CSAs (rCSAmax and rCSAmin), and nasopharyngeal collapsibility at the level of the cranial end of the soft palate, pterygoid hamulus, foramen lacerum, bony labyrinth, and caudal end of the soft palate. The stertor group demonstrated significantly lower rCSAmax and rCSAmin, as well as higher nasopharyngeal collapsibility compared with the control group, while no significant differences were noted in the soft palate dimension. Evaluating nasopharyngeal collapse at the foramen lacerum level was recommended due to the clear presence of identifiable bony landmarks and lower overlap in the nasopharyngeal collapsibility between dogs with and without stertor. Physical dimensions of the soft palate may not be the primary contributing factor to nasopharyngeal collapse and clinical signs in non-brachycephalic dogs.

The pterygoid hamulus (PH), as a small and curved projection of the sphenoid bone, occupies a unique position at the skull base. Given its functional relation with the surrounding anatomical structures, the study of this rather underrepresented structure in the literature assumes paramount importance. We examined a total of 87 pterygoid hamuli (50 right-sided and 37 left-sided) out of a sample of 114 dry skulls. We measured the length, width, and angle of each PH and the interpterygoid distance in skulls with both pterygoid hamuli intact, and we calculated the mean, maximum, and minimum values. Our statistical analysis revealed the mean length (0.9 cm), width (0.3 cm), and angle (47.8°) of the PH, as well as the mean interpterygoid distance (3.31 cm). We recorded the longest-ever documented PH (1.64 cm). The obtained length values were higher than those provided by radiological studies. We also investigated possible associations between anatomy and pathological conditions related to the PH morphology, including pterygoid hamular elongation syndrome, hamular fracture, middle ear disorders, and obstructive sleep apnea syndrome. Our study uses precise measurement techniques to detail the anatomy of the PH in dry skulls. This research can be a valuable resource for future studies, advancing our understanding of the PH's structure and its clinical significance.

Cleft palate, a common congenital craniofacial defect, requires surgical repair and many surgical approaches have been employed for the same to reduce the risk of post-operative complications and improve outcomes. In order to achieve tension free closure, fracture of pterygoid hamulus has been advised. However, the effect of this manoeuvre on auditory functions remains debatable. The study was designed to evaluate the effect of hamulectomy on auditory function during the post-operative period after palatoplasty. The present study enrolled 100 participants aged 10 months-2 years with isolated cleft palate defect. They were randomly divided into two groups: palatoplasty with hamulectomy (n = 50) and palatoplasty without hamulectomy (n = 50). Hearing outcomes were evaluated using objective measures (otoscopy, tympanometry, and otoacoustic emission [OAE] tests) at 1-month and 6-month post-operative follow-up visits. The Chi-square test was used to analyse the data and significance level was kept at P ≤ 0.05. The findings of otoscopy, tympanometry and OAE tests were statistically similar between the two study groups (P > 0.05; Chi-square test) at both one month and six months follow-up visits. Another noteworthy observation was improvement in auditory function during follow-up period indicating recovery of middle ear function following palatoplasty. The addition of hamulectomy to the palatoplasty treatment may improve the hearing outcomes for cleft palate patients and can be adopted to achieve tension free closure.

Background: Pterygoid hamulus (PH) arises from the medial lamella of the pterygoid process. Its morphology can be studied on CBCT aiding in formulating differential diagnosis of orofacial pain of unknown etiology. Objectives: This study aimed to evaluate PH morphology using CBCT. Materials and Methods: A total of 496 CBCT scans, divided into four age groups with equal gender distribution, were analyzed. Measurements of PH length and width were compared according to age and gender, respectively. PH inclination was compared with age and side, and types of shapes were compared with respect to the side. Results: Length and width of PH increased with age and then progressively decreased in older age. Similarly, length and width measurements were higher in males than in females. All PHs were inclined toward the posterior and lateral sides on the sagittal and coronal planes, respectively. Inclination on the sagittal plane decreased with age, and inclination on the coronal plane increased with age. The inclinations on the right and left sides were nonsignificant. The triangular shape was more prevalent than the slender type, with no statistically significant difference according to sides. Conclusion: Understanding PH anatomy with respect to age and gender will help in formulating a differential diagnosis of orofacial pain.

We have used micro-computed tomography (CT) to elucidate the relationship between the muscle fibers in specimens with cleft palate. These findings could be useful for muscle reconstruction in cleft palate repair and to better understand cleft palate speech. Cadaveric anatomical study. This study included three specimens with cleft palate. The specimens were stained with phosphomolybdic acid and scanned by Micro-CT. The anatomy of the muscles. Using 2D projection images and 3D reconstruction models, subtle anatomical structures could be observed in the muscles. The attachment of the levator veli palatini (LVP) was not at the posterior edge of the hard palate or palatine aponeurosis (PA), but at the anterior 21.71-44.2% of the cleft edge. The palatopharyngeal (PP) was composed of two bundles: inferior and superior heads, which clasped the LVP. The uvularis was unevenly distributed, and located on both sides of the cleft edge, originating at the edge. The palatoglossus, superior constrictor of pharynx and anatomical structure around the pterygoid hamulus, were normal. The PA, PP and LVP were attached to the cleft edge from front to back, in that order. The position of the uvularis was not fixed. With the help of Micro-CT technology, detailed anatomical features and the relationship between muscles could be visualized. In the specimen with cleft palate, muscles in the soft palate were associated with the pharyngeal muscles, which formed the 3D "velopharyngeal muscles complex." These findings provide anatomical evidence for muscle reconstruction in cleft palate repair.

The online version contains supplementary material available at 10.1007/s12070-023-03853-8.

ABSTRACT Background Pterygoid hamulus syndrome, a painful oral and facial syndrome, has been described in literature to be correlated with morphological changes in the length of the pterygoid hamulus of the sphenoid bone. Clinical Presentation The current case report describes the treatment for severe, continuous pain in the posterior right palate. Despite numerous conservative treatments given to the patient, no improvement was seen. Cone beam computed tomography (CBCT) measurements revealed an elongation as well as a significant medial deviation of the lower extremity of the medial pterygoid plate. The surgical resection was performed under local anesthesia. The pain subsided two days after the surgery, and there were no relapses in the weeks that followed. Conclusion The medial deviation of the hamulus appeared to be important in the etiology of this painful syndrome. Additional research based on CBCT measurements will be required.

An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach. Retrospective single-surgeon study. Consecutive nonsyndromic patients (n = 27) with Veau I cleft palate. Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD). Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n = 24) was retrieved for comparison purposes. Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P = .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P = .546), age (10.2 ± 1.7 vs 9.6 ± 1.2 months; P = .143), rate of lateral incision (18.5% vs 4.2%; P = .195), and postoperative complication rate (0% vs 0%). This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Rapid shelf elevation and contact of the secondary palate and fusion reportedly occur due to a growth-related equilibrium change in the structures within the oro-nasal cavity. This study aimed to quantitatively evaluate complex three-dimensional morphological changes and their effects on rapid movements, such as shelf elevation and contact, and fusion. Morphological changes during secondary palate formation were analyzed using high-resolution digitalized imaging data (phase-contrast X-ray computed tomography and magnetic resonance images) obtained from 22 human embryonic and fetal samples. The three-dimensional images of the oro-nasal structures, including the maxilla, palate, pterygoid hamulus, tongue, Meckel's cartilage, nasal cavity, pharyngeal cavity, and nasal septum, were reconstructed manually. The palatal shelves were not elevated in all the samples at Carnegie stage (CS)21 and CS22 and in three samples at CS23. In contrast, the palatal shelves were elevated but not in contact in one sample at CS23. Further, the palatal shelves were elevated and fused in the remaining four samples at CS23 and all three samples from the early fetal period. For each sample, 70 landmarks were subjected to Procrustes and principal component (PC) analysis. PC-1 accounted for 67.4% of the extracted gross changes before and after shelf elevations. Notably, the PC-1 values of the negative and positive value groups differed significantly. The PC-2 value changed during the phases in which the change in the PC-1 value was unnaturally slow and stopped at CS22 and the first half of CS23. This period, defined as the "approach period", corresponds to the time before dynamic changes occur as the palatal shelves elevate, the tongue and mandibular tip change their position and shape, and secondary palatal shelves contact and fuse. During the "approach period", measurements of PC-2 changes showed that structures on the mandible (Meckel's cartilage and tongue) and maxilla (palate and nasal cavity) did not change positions, albeit both groups of structures appeared to be compressed anterior-posteriorly. However, during and after shelf elevation, measurements of PC-1 changes showed significant changes between maxillary and mandibular structures, particularly positioning of the shelves above the tongue and protrusion of the tongue and mandible. These results suggest an active role for Meckel's cartilage growth in repositioning the tongue to facilitate shelf elevation. The present data representing three distinct phases of secondary palate closure in humans can advance the understanding of morphological growth changes occurring before and after the horizontal positioning of palatal shelves and their fusion to close the secondary palate in humans successfully.