The Surgical Anatomy of the Greater Palatine Artery: A Human Cadaver Study

Identifying the accurate location of the greater palatine artery (GPA) can be challenging. The purpose of the present cadaver study was to determine the location of the GPA from the cementoenamel junction (CEJ) of the maxillary canine to second molar teeth and to define its relationship with the palatal vault height (PVH) in Caucasian cadavers. Sixty-six sections from fully or partially dentate cadavers were examined. The location of the GPA from the CEJ ranged from a minimum of 8.7 ± 2.1 mm at the canine to 14.5 ± 1.3 mm at the second molar. The minimum distance of the GPA to the CEJ in different PVH ranged from 6 to 12 mm. There was a significant difference between male and female cadavers regarding shallow PVH. Only the PVH as an independent variable had a significant correlation with the GPA location. The present study is the first to identify the different PVHs with customized stents and to correlate them with the distance of the GPA to the CEJ of maxillary teeth.

Assessment of Palatal Mucosal Wound Healing Following Connective-Tissue Harvesting by Laser Speckle Contrast Imaging: An Observational Case Series Study

Postoperative complications may occur during the healing of palatal donor sites due to disturbed blood circulation of palatal tissues. Therefore in this study, blood flow was measured by Laser Speckle Contrast Imaging (LSCI) in seven patients after connective-tissue harvesting. The slope in blood-flow elevation within the first 3 days as well as time needed for maximum reperfusion were calculated. Each surgical site was assessed by clinical examination on day 3. In donor sites with secondary-intention wound healing, postoperative blood flow was elevated with significant delay compared to the surrounding tissues and to the primarily healed wound. Reperfusion time and healing score were strongly correlated (r = 0.87, P < .001), as were the slope and clinical rank (r = -0.85, P < .001). LSCI proved to be an objective method to assess individual wound-healing time and to predict the quality of wound healing.

Contemporary CBCT diagnostics-discovery of a new artery with possible impact on surgical planning: the anterior superior palatal alveolar artery

PURPOSE

An ongoing clinical trial regarding intra- and post-surgical morbidity in maxillary apicoectomies showed significant higher morbidity for upper canines and palatal roots of upper 1st premolars. Analysis of available presurgical cone beam computed tomography (CBCT)-scans revealed the existence of an unknown bone-canal branching off from the bone-canal or groove of the anterior superior alveolar artery (asaa). Aim of the study was the determination of the contents of this newly found bone canal in human cadaver heads, its prevalence as possible standard anatomical structure and its automatized detection with a contemporary high-resolution TRIUM-CBCT-device in vivo.

METHODS

35 human cadaver heads were dissected, the prevalence of the bone-canal determined and its contents analyzed by histology. 835 consecutive routine high-resolution TRIUM-CBCT-scans from routine patients were analyzed by an automatized detection- and tracing-algorithm for in vivo-determination of prevalence of this bone canal. Automatized detection and additional manual tracing were statistically evaluated by SSPS 20.0 software.

RESULTS

The bone-canal was found in 96% of the anatomical specimens, its content identified as artery not described until now and named after the first finder "Arteria Kurrekii". Automatized tracing of TRIUM-CBCT-scans with additional manual tracing revealed an in vivo prevalence of this newly found artery of 95% (p ≤ 0.05).

CONCLUSIONS

The newly found anterior superior palatal alveolar artery (aspaa-"Arteria Kurrekii") might have the same clinical impact for surgical procedures in the maxilla as the posterior superior alveolar artery (psaa). Its first detection was enabled by high-resolution TRIUM-CBCT devices and prevalence as standard anatomical structure proven in vivo by automatized CBCT-scan analysis.

Rapid palatal expansion: the role of microcirculation

AIM

Transverse palate modifications fall under expansive orthopedic therapy of the upper maxilla. The only practical approach to the problem on the transverse plane is that of performing the expansion of the maxillary arch through an opening of the median palatal suture. It is important to understand the changes of the vascular network in midpalatal suture following the starting of rapid maxillary expansion. It is critical to maintain the blood supply and circulation for the osteogenesis and bone remodeling after the expansion. The aim of this research was to evaluate the effects of rapid orthopedic expansion (REP) at the microcirculatory level through capillaroscopic examination.

METHODS

Fifteen patients in their developing years between 9 and 15 years of age (average age 12.16 years) were examined. The application of the REP was the first step in the planning of orthopedic-orthodontic treatment which foresaw further stages in the odonto-osseous movement. The method of Biomicroscopic Video-Imaging of the microcirculation of oral mucosa is performed through the technique of computerized capillaroscopy and the related software.

RESULTS

From the results it is evident that immediately after achieving the expansion of the upper maxilla (t1), a slight decrease in the number of vessels per mm² can be observed. In addition, a slight ectasia can be observed in these vessels in comparison to t0. Comparing the videocapillaroscopic images of t1 and t2, an increase in the capillaries per mm² can be observed.

CONCLUSION

Ectasia of the capillaries, though subject to strictly individual variables, can be considered perfectly normal and it is compatible with the normal biology and physiology of vessel microcirculation.

Anatomical study of the pterygomaxillary area for implant placement: cone beam computed tomographic scanning in 100 patients

PURPOSE

The aim of this study was to describe the average angulation and dimensions of the pterygomaxillary area in the atrophic maxilla to facilitate the orientation of pterygoid implants during their placement.

MATERIALS AND METHODS

A retrospective radiologic study was made. A virtual pterygoid implant, 13, 15, or 18 mm long, was placed in the pterygomaxillary area following the axis of the bone, with a distance of at least 2 mm maintained between the artery and palatine nerve and the implant. The long axis of the implant was inclined slightly toward the palatal to follow the cortical palatal bone. The angles between the long axis of the virtual implant and Frankfort horizontal were measured in both sagittal and frontal views. To calculate the average length of the pterygomaxillary area, the virtual long axis of the implant was measured from the alveolar crest to the pterygomaxillary suture.

RESULTS

The average anteroposterior axis inclination of the pterygomaxillary area was 72.5 ± 4.9 degrees relative to Frankfort horizontal. The average angulation of the palatal vestibule was 81.3 ± 42.8 degrees relative to Frankfort horizontal. The average length of the pterygomaxillary area was 22.5 ± 4.8 mm.

CONCLUSION

Pterygoid implant placement requires thorough knowledge of each patient's anatomy and individual needs. The mean position of the pterygomaxillary buttress axis was 72.5 ± 4.9 degrees to the distal and 81.3 ± 2.8 degrees to the palatal relative to Frankfort horizontal. Placement of pterygoid implants in this inclination may increase accuracy of implant placement. The average length from the tuberosity to the most apical point of the pterygoid apophysis was 22.5 ± 4.8 mm. These results suggest that an implant 15 to 18 mm in length would fit in the pterygomaxillary area to reach the cortical bone.

Complications associated with cheek tooth extraction in the horse

Common indications for cheek tooth extraction in the horse include dental fracture, periodontal disease, severe decay/ caries, mandibular fracture with alveolar/tooth involvement, and periapical abscess. Complications secondary to extraction of cheek teeth are prevalent. Typical complications may include retained root tip(s), collateral damage of neighboring teeth and alveolar bone, mandibular fracture non-union or delayed union, cemental ankylosis, dilacerated root(s), oroantral/oronasal fistula, palatal deviation of cheek teeth, bone sequestration, sinus involvement, alveolar plug failure, and palatine artery laceration. This paper presents a series of cases that had complications following cheek tooth extraction. Anticipation of problematic extractions, recognition of complications, and appropriate treatment will aid the clinician in managing the inevitable cheek tooth extraction complication.

[Using three-dimensional CT to guide Le Fort I osteotomy in maxillary retrognathism patients]

OBJECTIVE

To analysis the maxillary bony structures by three-dimensional CT in maxillary retrognathism patients so as to provide information for Le Fort I osteotomy.

METHODS

20 maxillary retrognathism patients underwent Le Fort I osteotomy, while 20 patients with simple mandibular fractures were included as control group. All the patients received Skull 3-D CT before operation. The measurement about descending palatine artery and wing palatal was performed by Surgicase 5.0. The data were analyzed statistically.

RESULTS

The average distance from the piriform aperture margin to wing palatal tube was (33.74 +/- 6.74) mm in the retrognathism group; while (35.67 +/- 7.50) mm in the control group, showing a significant difference between the two groups (P < 0.05), but there was no statistically difference in the height of pterygomaxillary junction between the two groups.

CONCLUSION

The safe depth for Le Fort I osteotomy in patients with hypoplasia maxilla is 32 mm. CT scanning can provide guidance for osteotomy.

Sphenopalatine artery ligation with nerve resection in patients with vasomotor rhinitis and polyposis: a prospective, randomized, double-blind investigation

CONCLUSIONS

Sphenopalatine artery ligation relieves symptoms of rhinorrhea, sneezing, and nasal itching in patients with vasomotor rhinitis associated with nasal polyps.

OBJECTIVES

Nasal polyps often arise in a setting of vasomotor rhinitis. Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching. Sphenopalatine pedicle resection with autonomic denervation could potentially reduce related symptoms.

METHODS

In a prospective, double-blind setting, 60 patients with vasomotor rhinitis and bilateral nasal polyps randomly assigned to functional endoscopic surgery either with (group A) or without (group B) sphenopalatine artery ligation completed a 3-year follow-up. Preoperative and postoperative (at 1 and 3 years) evaluations included symptom score, fiberendoscopy, and active anterior rhinomanometry.

RESULTS

In both treatment groups nasal breathing had improved at 1-year and 3-year follow-up (p < 0.001), whereas an improvement in rhinorrhea (p < 0.001) and sneezing and itching (p < 0.01) was attained only in group A. The inter-group comparison showed that a statistically significant improvement in rhinorrhea and nasal itching (p = 0.002) and in sneezing (p < 0.001) was present in group A at both follow-up visits. Rhinomanometry improved in both treatment groups (p < 0.01). Inter-group comparison showed a significant difference only at the 3-year follow-up visit (p < 0.05).

Update on epistaxis

PURPOSE OF REVIEW

The treatment of epistaxis has undergone significant changes in recent years. Gone are the days when patients had an uncomfortable posterior nasal pack inserted then spent several days on the ward only to bleed again on its removal. New packing devices, ingenious haemostatic agents and endoscopic surgical approaches have been developed to provide a variety of effective and well-tolerated treatment options. This paper will discuss the evolution and utility of these devices and techniques for managing difficult epistaxis patients.

RECENT FINDINGS

Modern packing devices are much easier to insert than traditional gauze packs and are no less effective. A major advance in the management of posterior epistaxis has been the development of the technique of endoscopic ligation.

SUMMARY

Anterior epistaxis is generally easy to control with local cautery. The optimal management of posterior epistaxis is to insert a pack to control the bleeding before taking the patient to the operating theatre to ligate the sphenopalatine artery endoscopically.

[Endoscopic ligation of maxillary and sphenopalatine artery for intractable epistaxis]

We report the endoscopic ligation of the maxillary and sphenopalatine arteries for the treatment of intractable epistaxis. From March 2003 to February 2005, 17 patients (12 men, 5 women) with epistaxis were hospitalized in our department. Patient age ranged from 25 to 83 years, with an average age of 62 years. 8 patients were successfully treated using the conventional packing method, 2 patients were treated using electrocauterization, and 1 patient with macroglobulinemia was treated using plasma exchange therapy. 6 patients underwent endoscopic ligation of the maxillary and sphenopalatine arteries while under general anesthesia. The post operative courses were uneventful, and no recurrent bleeding has been noted. Endscopic ligation of the maxillary and sphenopalatine arteries is safer than intraarterial embolization and less invasive than conventional surgical approach for the ligation of maxillary artery. This technique appears to be a safe and effective surgical treatment for patients with intractable epistaxis.

Endoscopic sphenopalatine artery ligation--when, why and how to do it. An on-line video tutorial

KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, http://nhsgg.org.uk/content/streams/Figure3.wmv * Flap elevation, http://nhsgg.org.uk/content/streams/Figure4.wmv * Pedicle location, http://www.nhsgg.org.uk/content/streams/Figure5.wmv * Clip application, http://www.nhsgg.org.uk/content/streams/Figure6.wmv.

Treatment of vascular lesions in the head and neck using Nd:YAG laser

INTRODUCTION

Vascular lesions in the head and neck region, including both haemangiomas and vascular malformations, are common and many different treatment modalities have been used for their removal. In the past decade, the Nd:YAG laser has emerged as a new mode of treatment for vascular lesions, and the purpose of this paper was to determine its clinical value.

PATIENTS AND METHODS

A prospective study was conducted in 111 patients with vascular lesions in the head and neck region. They were treated with the Nd:YAG laser by photocoagulation. Of these, 96 had small lesions, with surface diameters of less than 3 x 3cm(2), and 5 had large lesions, with surface diameters of more than 3 x 3cm(2). The patients were all followed-up carefully until complete healing was recorded, along with any complications.

RESULTS

In both groups of patients, tissue sloughing occurred within 2-3 days. Healing time in small lesions was 2-3 weeks, and in large lesions 3-4 weeks. Three patients with small lesions and one patient with a large lesion experienced minor complications.

CONCLUSION

The Nd:YAG laser is a safe and effective tool for treating vascular lesions.

Angioarchitecture of the anterior and medium parts of the palatine mucosa of the gerbil, Meriones unguiculatus

The aim of this study was to examine the microvasculature of the anterior and medium portions of the hard palatine mucosa in the adult gerbil (Meriones unguiculatus) using scanning electron microscopy. The vascular corrosion casts were obtained by injection of Mercox CL-2B synthetic resin and tissue corrosion was performed using sodium hydroxide solution. These casts revealed the presence of capillary loops in the palatine plicae and a smoother/flatter vascular network in the interplicae areas. The capillary loops consisted mainly of anteriorly oriented hair-pins and we also verified a differentiation in the shape of endothelial cell nuclei, which were elongated in arterial and circular in venous vessels.

Variations of the location of the greater palatine foramina in dry human skulls

Seventy-one adult skulls (58 dentulous skulls: 56 bilateral and 2 unilateral, 13 edentulous: 11 bilateral and 2 unilateral) of unknown sex were examined for the variations of the location of the greater palatine foramen. The location of greater palatine foramen (GPF) was noted with relation to mid sagittal suture (MSS), posterior palatal border (PPB), and maxillary molars by measuring the distances using a sliding caliper to the nearest millimeter. Difference in the distance of the foramen from MSS and PPG in both the skull types was found to be statistically insignificant. Commonest location of the foramen was found to be opposite to third molar tooth (85.95%), followed by the interval between second and third molar teeth (13.15%), and opposite to the second molar tooth (only one case - 0.88%). Well-formed bony canals were found along the groove for the palatine nerves and vessels unilaterally in the right side in two skulls. These observation may be of help to the dental surgeon during the peripheral block of maxillary nerve for the maxillo-facial surgery.

Endoscopic electrosurgical management of posterior epistaxis: shifting paradigm

Recent literature has embraced the use of electrosurgery, sphenopalatine vascular clipping, and endoscopy in posterior epistaxis. With the advent of endoscopy, the surgical treatment of posterior epistaxis has shifted from internal maxillary ligation to endoscopic sphenopalatine artery control. This article introduces an endoscopic electrosurgical approach for patients suffering from idiopathic posterior epistaxis that combines one or more of the following methods: endoscopic selective branch cauterization, endoscopic sphenopalatine artery cautery, and endoscopic posterior nasal cauterization. This approach is currently used in a hospital-based community otolaryngology practice and is presented from a Canadian health care perspective (Quebec). This article presents the experience in a series of 17 patients treated during a 35-month period and prospectively followed and discusses the surgical technique, patients' outcome, and the implications of such a practice.

Endovascular treatment of a pseudoaneurysm of the descending palatine artery after orthognathic surgery: technical note

We report the clinical presentation (relapsing epistaxis after Le Fort I osteotomy), craniofacial digital subtraction angiography findings, and endovascular embolization through a microcatheter, in a 26-year-old patient with a pseudoaneurysm of the descending palatine artery.

Economic analysis of the treatment of posterior epistaxis

BACKGROUND

The aim of this study was to compare the economic impact of controlling posterior epistaxis by transnasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular embolization.

METHODS

We conducted a retrospective chart review of patients undergoing treatment of posterior epistaxis by either TESPAL or embolization. International Classification of Diseases 9 code 784.7 (epistaxis) was the initial screen followed by common procedural terminology codes for TESPAL and angiography with embolization. The total charges and direct costs for TESPAL and endovascular embolization were determined. An unpaired Student's t-test was used to evaluate statistical significance.

RESULTS

Analysis revealed 25 patients that met inclusion criteria. The mean total charge was $14,088 for embolization and $7561 for TESPAL. The differences were statistically significant (p < 0.00006). Costs, defined as reimbursement by third-party payers and direct payments, varied widely and their difference did not reach statistical significance in this sample.

CONCLUSION

Our data established no economic advantage for angiography and, in fact, show a trend toward this treatment being more expensive than TESPAL. TESPAL is a procedure that can be performed quickly and on an outpatient basis without the need for angiography equipment or expertise. Additionally, the procedure provides the advantage of a comprehensive endoscopic nasal evaluation for ruling out tumors or other intranasal lesions. With equal efficacy, at least equal costs and equal risk, and additional diagnostic advantages, TESPAL is a more rational treatment for posterior epistaxis.

Le Fort I osteotomy using an ultrasonic bone curette to fracture the pterygoid plates

PURPOSE

The purpose of this study was to evaluate the advantageous use of an ultrasonic bone curette and to assess the mobilization of the pterygoid process after a Le Fort I osteotomy.

MATERIAL AND METHODS

14 Japanese adults (ranging in age from 17 to 30 years, mean 22.4) with jaw deformities diagnosed as mandibular prognathism or bimaxillary asymmetry underwent Le Fort I osteotomy with bilateral sagittal split ramus osteotomy or intraoral vertical ramus osteotomy. During the Le Fort I osteotomy, the Sonopet UST-2000 ultrasonic bone curette was used to fracture the pterygoid process slightly above the level of the maxillary osteotomy without damaging the descending palatine artery or other blood vessels and nerves. After surgery, the pterygoid process osteotomy and its mobility were evaluated from three-dimensional computed tomographic images.

RESULTS

In all cases, the mobility of the pterygoid process could be achieved by using the device safely with minimal bleeding and no notable complications. The maxillary segment could be fixed in an ideal position and in all 14 cases, an ideal profile was achieved.

CONCLUSION

Ultrasonic bone curette offers a safe procedure for performing pterygoid process fractures without damaging the surrounding tissue such as the descending palatine artery.

Bulbar pathway for contralateral lingual nerve-evoked reflex vasodilatation in cat palate

We investigated the brain-stem pathway(s) by which electrical stimulation of the central cut end of the lingual nerve (LN) evokes parasympathetic reflex vasodilatation in the palate contralateral to the stimulated side. This occurs in artificially ventilated, cervically vagosympathectomized cats deeply anesthetized with alpha-chloralose and urethane. For this purpose, we made microinjections within the brain stem to produce nonselective, reversible local anesthesia (lidocaine) or soma-selective, irreversible neurotoxic damage (kainic acid). Local anesthesia of the trigeminal spinal nucleus (Vsp) ipsilateral to the stimulated side produced by microinjection of lidocaine (2%; 1 microl/site) reversibly and significantly reduced the LN stimulus-evoked palatal blood flow (PBF) increases. PBF increases ipsilateral and contralateral to the stimulated nerve were equally affected. In contrast, microinjection of lidocaine into the Vsp contralateral to the stimulated side did not affect these responses. Microinjection of kainic acid (10 mM/site; 1 microl) into the Vsp ipsilateral to the stimulated side led to a bilateral irreversible reduction in reflex vasodilatation in the palate. Microinjection of lidocaine into either superior salivatory nucleus (SSN) attenuated the PBF increase only on the side ipsilateral to the microinjection site. Hexamethonium (1.0 mg/kg iv) significantly reduced the vasodilator responses to electrical stimulation of Vsp by blocking ganglionic transmission on both sides. The simplest interpretation of these results is that the LN-evoked parasympathetic reflex vasodilatation in the contralateral palate depends on activation of a pathway originating from the Vsp ipsilateral to the stimulated nerve and crossing to the contralateral SSN.

Early Operative Intervention versus Conventional Treatment in Epistaxis: Randomized Prospective Trial

OBJECTIVE

This prospective randomized trial was designed to compare intranasal endoscopic sphenopalatine artery ligation (ESAL) with conventional nasal packing in the treatment of recurrent epistaxis.

METHODS

Patients were registered in the study databank following referral for epistaxis control to the otolaryngology service at the University of Alberta. All patients were initially packed using Merocel (Xomed Surgical Products, Jacksonville, FL) nasal dressings bilaterally. Patients were enrolled in the study following failure of Merocel packings. Informed consent was obtained in accordance with the Health Research Ethics Board. The patients were then managed with Vaseline nasal packs or ESAL. Patient demographics, treatment characteristics, number of hospitalization days, and rates of recurrence were recorded prospectively. The total cost of treatment for each patient was calculated.

RESULTS

Nineteen patients were enrolled in the study. There was a significant reduction in cost and length of hospitalization of the patients undergoing ESAL compared with the conventional nasal packings. ESAL was also 89% effective in controlling the bleeding and had minimal sequelae or complications. The overall calculated cost of patients undergoing ESAL was dollars 5133 compared with dollars 12213 in the conservative group, resulting in an average saving of dollars 7080 per patient. There was overwhelming patient satisfaction with ESAL compared with nasal packings.

CONCLUSION

ESAL is an excellent, well-tolerated, and cost-effective method of treating recurrent epistaxis.

Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation?

The optimal surgical management for failed conservative measures in epistaxis remains unclear. Given the growing enthusiasm for endoscopic transnasal sphenopalatine artery ligation, it is prudent and timely to evaluate the evidence base for this technique. This study aims to analyse the current evidence for transnasal endoscopic sphenopalatine artery ligation by reviewing the literature and also by comparing the results with other approaches to the management of epistaxis. A detailed literature search identified 11 publications relating to endoscopic sphenopalatine artery ligation. The total number of patients in the pooled series was 127, of which 98% had control of epistaxis following surgery. These results compared favourably to the results of most other techniques used in the modern treatment of epistaxis. Nonetheless, the total number of patients in the 11 case series is small. It is therefore recommended that all units using this technique audit their results to see if the high success rates achieved in the literature are reproducible. If this is the case, then endoscopic sphenopalatine artery ligation may indeed be the surgical answer to intractable posterior epistaxis.

Increased fistula risk following palatoplasty in Treacher Collins syndrome

OBJECTIVE

Patients with Treacher Collins syndrome have abnormal vascular supply to the palate, yet it is unknown whether there are increased postoperative healing problems following palatoplasty. This study investigated the correlation between Treacher Collins syndrome and postoperative palatal fistula formation.

DESIGN

Retrospective chart review was performed.

PATIENTS

Children undergoing palatoplasty at Children's Hospital Los Angeles from 1987 to 2000 were evaluated. Ten children with Treacher Collins syndrome, 92 children with other syndromes and cleft palate, and 458 nonsyndromic patients with isolated cleft palate were studied.

INTERVENTIONS

All children were treated with a one-stage, double-reversing Z-plasty cleft palate repair.

MAIN OUTCOME MEASURES

Outcome measures included intraoperative observations of surgical anatomy and postoperative clinic follow-up of fistula formation. Palatal fistula rates between patients with Treacher Collins syndrome, other syndromes, and no syndrome were compared with chi-square analysis.

RESULTS

Children with Treacher Collins syndrome had significantly greater palatal fistula rates (50%) than children with other syndromes (8.7%) or no syndrome (4.1%). Treacher Collins patients demonstrated large palatal fistulas and poor flap vascularity.

CONCLUSIONS

Children with Treacher Collins syndrome and cleft palate have significantly higher palatal fistula risk than other children with cleft palate when double-reversing Z-plasty palate repair is performed. Our findings suggest that children with Treacher Collins syndrome and cleft palate may have poor vascularity to palatal flaps created during palatoplasty. Furthermore, we recommend that surgeons performing palatoplasty minimize the dissection of mucoperiosteal flaps around the greater palatine arterial pedicle and utilize closure techniques creating the least vascular disruption of palatal tissue.

[Vascular complications after cranio-facial trauma]

Despite recent advances in automobile safety, facial trauma remains a common event. Cranio-facial trauma, which usually occurs within a context of multiple trauma, can, in some patients, lead to serious life-threatening vascular complications. Such injury usually involves the carotid system (hemorrhage, aneurysm, dissection). Management of these vascular injuries must be given the same priority as other multiple trauma injuries. We present few typical cases illustrating carotid-cavernous or vertebro-vertebral fistulae, false aneurysms, arterial dissections or oro-facial bleeding. Bleeding is generally controlled by ligation or compression, other lesions being diagnosed secondarily by arteriography depending on the particular clinical situation. Treatment may involve endovascular procedures to achieve intravascular embolism or vascular occlusion.

Transnasal sphenopalatine artery electrocautery for posterior epistaxis

BACKGROUND

To evaluate the effects of sphenopalatine artery electrocautery for the treatment of recurrent posterior epistaxis.

METHODS

Nine patients were enrolled in the study. Seven patients had hypertension, two had diabetes, two received irradiation for nasopharyngeal carcinoma, one had congestive heart failure and one was a heavy drinker. Three patients needed blood transfusion for profound blood loss. The sphenopalatine artery electrocautery was performed transnasally with endoscope. After the sphenopalatine foramen was identified through dissecting the mucosa of middle meatus posteriorly one centimeter from the choana, the neurovascular bundle in the sphenopalatine foramen was cauterized.

RESULTS

Most operations can be performed within fifty minutes with minimal blood loss under local anesthesia. One patient developed minor epistaxis 2 months after surgery, and the bleeding was controlled with medical treatment. The other patients had no recurrent epistaxis after surgery. Thus, epistaxis was well controlled in all patients without complications. The follow-up duration was 2 to 14 months after surgery, with a mean duration of 10 months.

CONCLUSIONS

Transnasal sphenopalatine artery electrocautery is a simple, effective and safe method for the treatment of posterior epistaxis.

Vascularization of the palate in maxillary osteotomies: anatomical study

Le Fort 1 maxillary osteotomy carries a risk of injury to the descending palatine arteries which vascularize the bulk of the mucosa of the bony palate. Some authors believe that injury to these arteries in the greater palatine canal is intrinsic to the procedure without any consequence for the trophicity of the mucosa or bony palate. In order to assess the risk of injury to the descending palatine arteries during such surgery, and to demonstrate the supplementary vascularization which would avoid ischemia of the palate, we carried out a study of the vascularization of the palate on 11 fresh cadavers. We used intra-arterial injection of colored latex and dissection of the vessels running to the palate. The study was done without osteotomy in the first subject, after a Le Fort 1 osteotomy in the five following subjects and after a Le Fort 1 osteotomy and ligation of the two descending palatine arteries in the last five subjects. Our results show that injury of the descending palatine arteries is not intrinsic to the procedure in spite of mobilization of the palatine plateau. When the descending palatine arteries are ligated there is diminution in coloration of the mucosa of the bony palate but there is substitution by the arteries vascularizing the soft palate, essentially the ascending palatine artery and the pharyngeal branch arising from the ascending pharyngeal artery. However, this substitute vascularization has individual variations.

Angiographic study of the arterial supply to the palatine mucoperiosteum

Studies on the arterial supply of dog palatal mucoperiosteum have contributed to the success of surgical procedures on the hard palate of humans. We decided to undertake a more detailed anatomical study of the arterial supply of the canine palate. 15 male dogs of the species Canis familiaris were used. Contrast solution (barium sulfate) was injected into the palatal arterial system, followed by the removal of the dog's palate together with its mucoperiosteum. To obtain good radiographic imaging of the arterial network of the palatal mucoperiosteum, decalcification of the palatal bone was carried out. X-ray images were taken by a mammography X-ray machine set for 23 kV and 10 mA. The X-ray images showed that the mucoperiosteal arterial network is composed of a left and a right major artery which enters the mucoperiosteum through the left and right foramen, respectively. Anastomoses were observed between these two major arteries along their path from the posterior to the anterior regions of the mucoperiosteum. These anastomoses always occurred at the palatal transversal crests. The statistical study of the collected data showed that, for the posterior third of the palate, there is a proportionality between the number of the arterial derivations from the two major arteries and the mucoperiosteal area. The X-ray images also showed that the middle third of the palate is the least supplied with arterial derivations.

Endoscopically assisted Le Fort I osteotomy

OBJECTIVES

A new technique of the Le Fort I osteotomy using endoscopic techniques through limited approaches has been evaluated.

PATIENTS

This technique was first carried out successfully in a study on six cadavers. Thereafter we performed endoscopically assisted Le Fort l osteotomy in two patients.

METHODS

Four vertical incisions were used in the vestibule (paranasally and posteriorly) as approaches. The endoscope allowed direct visualization of the osteotomy of the maxilla including the pterygomaxillary junction. The osteotomies could be accomplished with a straight 4 mm osteotome for medial and lateral antral walls and nasal septum and a curved osteotome for the pterygomaxillary junction.

RESULTS

The procedures were successful. The descending palatal arteries could be preserved in all cases as a result of endoscopic control. Rigid fixation of the downfractured maxillae was carried out using self-drilling titanium screws and plates.

CONCLUSION

Endoscopic visualization allowed safe osteotomy of the medial antral wall preserving the descending palatal artery in all cases and hence less bleeding. Postoperative oedema and swelling in the two clinical cases was definitely reduced when compared with the conventional technique. The time needed for these first two clinical cases was approximately 1 h 30 min, i.e., about 30 min more than with the open technique. Further experience and experimental work, and refinements in technique will help to improve this procedure in its clinical application.

The use of palatal island flaps as an adjunct to microvascular free tissue transfer for reconstruction of complex oromandibular defects

OBJECTIVE

To determine the efficacy of using palatal island flaps in combination with free tissue transfer for reconstruction of large, complex oral cavity defects.

STUDY DESIGN

Prospective evaluation of patients with large, combined defects of the oral cavity reconstructed with palatal flaps in conjunction with microvascular free tissue transfer.

METHODS

Elevation of a palatal flap was performed after completion of tumor resection. The flap was rotated and secured into place. A free flap was then harvested and inset to reconstruct the remaining oromandibular defect. Free flaps included the rectus abdominis (6), fibula (16), and radial forearm (6).

RESULTS

Large complex oral cavity defects were repaired with a palatal island flap in conjunction with microvascular free tissue transfer in 28 consecutive patients. There were no complications associated with this flap.

CONCLUSION

Maximal functional rehabilitation of large, complex oral defects requires independent reconstruction of the various regions of the oral cavity rather than single flap reconstruction. When used as an adjunct to free tissue transfer, the palatal island flap offers a reliable method for reconstructing large combination defects.

[Applied anatomical study of blood supply in human palate]

OBJECTIVE

To investigate the origins and distributions of palatal vasculature and the three dimensional architecture.

METHODS

Materials consisted of 14 normal and 10 cleft palate head-and-neck specimens. After vascular infusion, specimens were seprately analysed by stereomicroscopy, radiography, histological study and scanning electron microscopy.

RESULTS

The greater palatine artery was the main vessel to supply the hard palate and the ascending palatine artery provided the principal supply of soft palate. The branches of greater palatine artery formed abundant anastomoses with the neighbor vessels. The ascending palatine artery divided into two branches in the soft palate. The artery branches in hard palate took on tree-like appearance and were arranged parallel. The capillary network was loosely packed. Whereas, the arteries in soft palate were always found to be crooked. The angles of the branches from the main trunk were changeable. The capillary network was packed densely. The vascular origins and courses of the cleft palate specimens were the same as the normal person, but the distributions and anastomoses were different.

CONCLUSIONS

The blood supplies of hard and soft palate come from different vascular vessels and their vascular architectures have their own character.

Corrosion casts of young rabbit palatine mucosa angioarchitecture

The microvascular system arrangement of the palatine mucosa in young rabbits was studied using vascular corrosion casts. Specimens were obtained by injecting low viscosity resin. Superficial microvessels were observed mainly by scanning electron microscopy (SEM). The blood microvessels showed differing features in the areas considered palatine rugae, inter-rugal areas and posterior region of the palatine raphe. Larger vessels were noted in deeper layers. Several capillary loops were distributed all over the palatine rugal surface. In spite of being a young animal, the rabbit's palatine mucosa demonstrated a complex angioarchitecture.

Analysis of scar tissue distribution on rat palates: a laser Doppler flowmetric study

OBJECTIVE

The aim of this study was to evaluate the effectiveness of laser Doppler flowmetry (LDF) to discriminate postoperative scar tissue distribution on the palate.

METHODS

Nineteen male Wistar rats at the 20th postnatal day were divided into experimental and control groups. In the experimental group, lateral palatal mucoperiosteum was excised to form scar tissue on the palate. At the 11th postnatal week, changes in the palatal blood flow were recorded with LDF in both groups by occluding exposed common carotid arteries. Perfusion values of nonoccluded (stable) and occluded states and the ratio of occluded to stable states were compared for scar tissue and normal tissue areas, and also for the normal tissue areas. After the LDF measurements, India ink-injected specimens and tissue sections were prepared for histological observations.

RESULTS AND CONCLUSIONS

Scar tissue areas showed lower perfusion values both in the stable and occluded states, reflecting a lower vascular density in the scar tissue. The ratio of the occluded to stable states was higher in the scar tissue than in the normal tissue areas. In normal tissue areas, perfusion values of both the stable and occluded states appeared to vary, but the ratio did not vary among the areas. In the LDF study, the ratio of the occluded to stable states was considered to be the better parameter for discriminating scar tissue from normal tissue.

Neurosensory recovery after ligation of the descending palatine neurovascular bundle during Le Fort I osteotomy

PURPOSE

The effect of ligating the descending palatine neurovascular bundle (DPNB) on the recovery of palatal sensation has not been clearly established. The purpose of this study was to determine the effect of ligation of the DPNB on the recovery of palatal sensation after Le Fort I osteotomy.

PATIENTS AND METHODS

Using a retrospective study design in a randomized protocol, patients who had undergone Le Fort I osteotomy were assigned to either treatment group 1 (DPNB ligated) or treatment group 2 (DPNB preserved). A third group of control patients (group 3, unoperated) on whom no surgery had been performed served as a baseline for examination of normal palatal sensation. The predictor variables were ligation and preservation of the DPNB. The outcome variables were mean tactile sensation and mean nociception. Other study variables included age, sex, follow-up, surgical movements, and number of segments.

RESULTS

There were 11 patients in group 1, 7 in group 2, and 10 in group 3. For tactile sensation, the mean Von Frey hair size detected was 4.26 +/- 0.37, 4.11 +/- 0.17, and 3.68 +/- 0.24 for groups 1, 2, and 3, respectively. The difference between group 1 and group 2 was not significant (P > .05). The differences between group 1 and group 3 and between group 2 and group 3 were significant (P < .05). For nociception, the mean pressure was 51.09 +/- 21.73, 50.89 +/- 19.19, and 56.25 +/- 19.02 for groups 1, 2, and 3, respectively. The difference between the 3 groups was not significant (P = .8064).

CONCLUSION

The results of this study suggest that recovery of palatal sensation is not adversely affected by ligation of the DPNB.

Sequential cleft management with the sliding sulcus technique and alveolar extension palatoplasty

Conventional methods of cleft lip repair deprive the anterior (buccolingual) alveolar mucoperiosteum of blood supply from the facial-internal maxillary arcade. Six months later, at palatoplasty, lingual incisions permanently isolate the lingual mucoperiosteum from its blood supply--the greater palatine artery. The osteogenic alveolar mucoperiosteum is thus converted from a richly supplied boundary zone between the two angiosomes into an isolated tissue dependent on osseus backflow. Cleft-sided growth disturbance is considered from this perspective. Subperiosteal techniques that preserve the blood supply to this tissue are considered in a sequential plan of cleft management.

Dentoalveolar growth inhibition induced by bone denudation on palates: a study of two isolated cleft palates with asymmetric scar tissue distribution

OBJECTIVE

This report presents two cases of isolated cleft palate with asymmetric distribution of postsurgical scar tissue determined by laser Doppler flowmetry. To determine the effect of mucoperiosteal denudation of the bone on maxillary alveolar growth, the analysis of dentoalveolar structures compared the affected side to the unaffected side of each case.

METHOD

Two Japanese girls with isolated cleft palates were examined. Both subjects had undergone pushback operations (a modified version of the procedure of Wardill) for palatal repair at 18 months of age. Palatal blood flow was examined by laser Doppler flowmetry when the girls were 12 years old to determine the extent of postsurgical scar tissue over the denuded bone. To analyze the maxillary dentoalveolar structures three dimensionally, the whole surface of the upper dental cast was measured and recorded by an optical measuring device when the girls were 7 years old.

RESULTS AND CONCLUSIONS

Analysis via flowmetry showed that the palatal scar tissue area was limited to the anterior tooth region on the right (unaffected) side but extended posteriorly to the premolar region on the left (affected) side in both subjects. The two girls had similar dentoalveolar structures, with the dental and alveolar arches deflected lingually at the deciduous molar area on the affected side. There were no differences in the buccolingual inclination of deciduous molars or in the vertical growth of the alveolar processes between the affected and unaffected sides. In both girls, bone denudation in the premolar region appeared to result in less than 3 mm of displacement of the teeth palatally, with no change in lingual inclination. Any effects of scar tissue on the vertical development of the alveolus were not substantiated.

The role of the crista ethmoidalis in endoscopic sphenopalatine artery ligation

Posterior epistaxis is a significant medical problem that can be challenging to treat. Endoscopic surgery could potentially reduced operative time and patient risk; however, surgeons report difficulty in endoscopically isolating the major offending artery, the sphenopalatine. These difficulties could be reduced if a recognizable anatomic structure marked the region of the artery. The study objective is to characterize the relationship of a relatively unknown anatomic structure, the crista ethmoidalis, to the sphenopalatine foramen/artery, in an effort to facilitate location of the sphenopalatine artery during endoscopic ligation. Using 22 human cadaveric sagitally sectioned heads and standard gross anatomic dissection techniques, the presence of the crista ethmoidalis was sought and recorded as well as its relative location to the sphenopalatine foramen/artery. The crista ethmoidalis was present and closely related to the sphenopalatine foramen and artery in all specimens. In 21/22 specimens, the crista was located just anterior to the sphenopalatine foramen, whereas in one specimen it was located 3 mm directly inferior to the foramen. Our investigation indicates that the crista ethmoidalis is a helpful and reliable landmark for endoscopically locating the sphenopalatine artery and foramen. Using this landmark, the initial problems reported with endoscopic ligation, i.e., locating the foramen and artery, should be greatly reduced. We offer our observations regarding the crista ethmoidalis to assist endoscopic surgeons in the care of their difficult epistaxis patients.

Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis

Transantral ligation of the internal maxillary artery is the most widely used surgical technique for control of intractable epistaxis. Although this technique is highly efficacious, significant complications may occur, including oroantral fistula, damage to the infraorbital nerve, and recurrent bleeding. An endoscopic transnasal approach for ligation of the terminal branch of the internal maxillary artery, the sphenopalatine artery, provides an alternative to transantral ligation. We have used endoscopic ligation of the sphenopalatine artery to treat 38 patients requiring surgical therapy for epistaxis. These cases were retrospectively reviewed to analyze the efficacy and morbidity of our technique. Five patients (13%) had significant recurrence of their epistaxis, of whom two required further surgical intervention. There were no major complications in this series. There were some minor sequelae including nasal crusting (34%) and paresthesia of the palate and nose (13%). The median hospital stay was 3 days (range 1 to 10). Endoscopic transnasal sphenopalatine artery ligation seems to be a safe and effective technique for management of posterior epistaxis.

A light microscopic investigation of the human midpalatal suture

Biopsy samples of the human midpalatal suture, obtained from patients (age range: 10 and 30 yrs), were embedded in resin, cut with ultramicrotome and analyzed at light microscopy. The sutural connective tissue was made up of fibroblasts, collagen fibers, capillaries and nerve fibers. The sutural bone was made up of lamellar and bundle bone which alternated along both sides of the sutural connective tissue. No osteoblasts or osteoclasts were found, no signs of synostosis were ever detected. Our findings suggest that the lamellar bone replaces bundle bone when the suture is no longer involved in the growth of the palatal bones. The absence of bone remodelling shows that the sutures, at the time of sampling, were in a resting stage. Tissue architecture and cell types, so similar in samples from patients of such different ages, lead us to suppose that the sutures under examination are subject in time to very slow bone turnover.

Posterior maxillary anatomy: implications for Le Fort I osteotomy

The most common site of haemorrhage in maxillary osteotomies is the posterior maxilla. Better understanding of the anatomy in this region may minimize possible vascular complications. The aim of the study was to study the osteology of the posterior maxillary region and establish clinical safety guidelines for the Le Fort I osteotomy Thirty human dry skulls were selected and assessed by a combination of direct inspection, computerized imaging and computed tomography (CT) scan analysis. Results showed that the presence of maxillary third molars influenced the transverse angulation of the posterior vertical cut. Synostosis of the pterygomaxillary junction was noted in 12% of samples. The mean length of the medial sinus wall from the piriform rim to the descending palatine canal at the Le Fort I level was 34 mm. The three-dimensional CT-reconstructed descending palatine canal ran at 60 degrees anteroinferiorly to the palatine plane and slightly medially to the exit through the greater palatine foramen.

Sympathetic attenuation of parasympathetic vasodilatation in oro-facial areas in the cat

1. The present study was designed to examine the interaction between sympathetic and parasympathetic influences on blood flow in oro-facial areas such as lower lip, palate and submandibular gland (SMG) and in the common carotid artery (CCA) in anaesthetized cats. 2. Section of the ipsilateral superior cervical sympathetic trunk (CST) increased the basal CCA blood flow significantly. The control level with the nerve intact was comparable with that seen at 0.5-1 Hz CST stimulation, suggesting a spontaneous discharge of around 0. 5-1 Hz in the CST fibres innervating the beds supplied by the CCA. The basal blood flow at all sites examined was reduced by CST stimulation in a frequency-dependent manner. 3. Electrical stimulation of the central end of the lingual nerve (LN) evoked blood flow increases in the lower lip and palate. These blood flow increases were markedly reduced by concurrent CST stimulation in a manner that was frequency dependent, but not simply related to the vasoconstrictor effect of CST stimulation. This effect of CST stimulation was not observed in tongue or SMG, even though CST stimulation evoked vasoconstriction in these tissues. A significant reduction in the level of CCA blood flow attained during LN stimulation was observed on repetitive CST stimulation only at 10 Hz, indicating that this response behaved in a fashion different from that seen in the lower lip, palate, tongue and SMG. 4. The present study suggests that concurrent repetitive CST stimulation reduces parasympathetically mediated blood flow increases in certain oro-facial areas (such as the lower lip and palate), but not in the tongue and SMG. This inhibitory action was not a simple additive effect (between vasoconstriction and vasodilatation) and it disappeared rapidly after the cessation of CST stimulation.

The effect of rapid eye movement (REM) sleep on upper airway mechanics in normal human subjects

1. It has been proposed that the upper airway is more compliant during rapid eye movement (REM) sleep than during non-rapid eye movement (NREM) sleep. The purpose of this study was to test this hypothesis in a group of subjects without sleep-disordered breathing. 2. On the first night, the effect of sleep stage on the relationship of retropalatal cross-sectional area (CSA; visualized with a fibre-optic scope) to pharyngeal pressure (PPH) measured at the soft palate during eupnoeic breathing was studied. Breaths during REM sleep were divided into phasic (associated with eye movements) and tonic (not associated with eye movements). There was a significant decrease in pharyngeal CSA during NREM sleep compared with wakefulness. There was no further decrease observed during either tonic or phasic REM sleep. Pharyngeal compliance, defined as the slope of the regression CSA versus PPH, was significantly increased during NREM sleep compared with wakefulness and REM sleep, with the compliance during both tonic and phasic REM sleep being similar to that observed in wakefulness. 3. On the second night, the effect of sleep stage on pressure-flow relationships of the upper airway was investigated. There was a trend towards the upper airway resistance being highest in NREM sleep compared with wakefulness and REM sleep. 4. We conclude that the upper airway is stiffer and less compliant during REM sleep than during NREM sleep. We postulate that this difference is secondary to differences in upper airway vascular perfusion between REM and NREM sleep.

Scar tissue distribution on palates and its relation to maxillary dental arch form

OBJECTIVE

This study investigated the relationship between maxillary dental arch form and distribution of postsurgical scar tissue on previously denuded bone in isolated cleft palate patients.

METHOD

The palatal blood flow of 21 Japanese isolated cleft palate patients (6 males, 15 females) was examined by laser doppler flowmetry to determine the scar tissue areas. All had undergone pushback operations for palatal repair at around 18 months of age. Tissue blood flow was examined at a time ranging from 11 years, 5 months to 19 years, 9 months of age. To evaluate the maxillary dental arch form, dental casts obtained at the start of orthodontic treatment (a mean age of 8 years, 4 months) were analyzed.

RESULTS/CONCLUSIONS

Scar tissue distribution in the 21 cases was classified into five types. Characteristic features in the maxillary dental arch form were found in each of the five types according to the extent of the scar tissue. It was evident that the severity of the maxillary dental arch constriction was closely related to the scar tissue distribution on palates.