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Schematic of the maxilla with the nasopalatine nerve. Fig 2. Radiographs of the central incisors area and nasopalatine canal (Case 1).
Source publication
The presence of a wide nasopalatine canal and the lack of an adequate ridge width may affect the correct placement of implants in the central incisor area. This could lead to functional and esthetic problems. This article describes bone grafting of the canal and concurrent ridge augmentation to obtain adequate bone quantity and quality and to allow...
Contexts in source publication
Context 1
... before exiting the bony surface of the hard palate (incisive foramen or incisive fossa), the paired incisive canals usually fuse to form a common canal in a Y shape, which is located just posterior to the central incisor teeth. 6 The nasopalatine nerve and the terminal branch of the nasopalatine artery pass through these canals and provide sensation to the anterior palate, as shown in the Figure 1 schematic of anatomy/innervation. ...
Context 2
... bone was placed in the canal and on the buccal and crestal sides of the edentulous ridge. The area was covered with a titanium-reinforced expanded polytetrafluoroethylene (e-PTFE) barrier membrane ( Figure 10) and sutured with a 5.0 e-PTFE suture after periosteal releasing. Postoperative appointments were scheduled at 1, 2, 4, and 8 weeks and then at 4 and 6 months. ...
Context 3
... membrane removal, a copious ridge was present, and the nasopalatine canal was completely filled in with bone. An implant 4.3-mm in diameter and 13-mm in length was placed in the No. 8 area, while a 4.3-mm x 11.5-mm (NobelReplace, Nobel Biocare USA, LLC) implant was placed in the No. 9 area ( Figure 11 and Figure 12). ...
Context 4
... membrane removal, a copious ridge was present, and the nasopalatine canal was completely filled in with bone. An implant 4.3-mm in diameter and 13-mm in length was placed in the No. 8 area, while a 4.3-mm x 11.5-mm (NobelReplace, Nobel Biocare USA, LLC) implant was placed in the No. 9 area ( Figure 11 and Figure 12). ...
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Citations
... The mean diameter of nasal openings was found to be 3.49 mm, with a wider incisive foramen of 4.45 mm creating a funnel shape, with an average length of the canal being 10.99 mm. 2 The nasopalatine canal may also enlarge following extraction of the adjacent central incisors, with larger canals found on average in patients missing those teeth. 9,21 Bone regeneration into the nasopalatine canal has been reported with lateralization of the canal contents at the level of the foramen in situations where the nasopalatine canal encroaches on the implant position [22][23][24] or in more invasive approaches, such as severing the neurovascular bundle, removal of the contents, and obliteration of the canal 25,26 or implant placement directly into the nasopalatine canal. 27 These procedures are technically challenging and significantly increase patient morbidity and risks. ...
Purpose:
This study aimed to assess the influence of implant diameter and taper on the proximity of virtually planned maxillary central incisor implants to the nasopalatine canal and adjacent anatomical structures.
Materials and methods:
Virtual implant planning was performed in the maxillary central incisor position. The distance between the implant and the incisive canal (IC) and the thickness of the surrounding buccal and palatal bone walls were measured. Implants were categorized as having an exposed implant surface, thin bone, or moderate/thick bone. Measurements were repeated for regular-/narrow-diameter and parallel/tapered implants.
Results:
A total of 60 patients were included, and 240 implants (60 of each type: 3.3-bone level [BL], 3.3-bone level tapered [BLT], 4.1-BL, and 4.1-BLT) were planned. The percentages of implants with between 0 and 0.5 mm of remaining bone in the coronal aspect of the IC were 31.6% for 4.1-BL/BLT and 6.6% for 3.3-BL/BLT (P < .001). The percentage of implants with IC exposure was 13.3% for 4.1-BL/BLT and 6.6% for 3.3-BL/BLT (P < .001). The frequency of sites that required bone augmentation at the coronal facial aspect (< 1 mm) was 52.6% and 33.9% for 4.1-BL/BLT and 3.3-BL/BLT, respectively. At the apical portion, the percentages of sites requiring bone augmentation at the facial aspect were 59.9%, 49.9%, 31.6%, and 23.3% for 4.1-BL, 3.3-BL, 4.1-BLT, and 3.3-BLT, respectively (P < .001).
Conclusion:
The proximity of the nasopalatine canal is often < 0.5 mm from regular-diameter virtually planned implants at the most coronal aspect in the maxillary central incisor position. In these situations, the selection of narrowdiameter implants significantly lowers the incidence of implant exposure and the need for additional management of the nasopalatine canal and also results in greater residual buccal and lingual bone thicknesses surrounding the implant. As expected, tapered implants reduced the risk of implant exposure through the buccal cortex at the apical aspect.
... The current literature extensively reports on the problematic nature of the incisive canal and dental implants. Various studies have shown how reducing the width of the incisive canal with various bone grafting materials has proven to provide additional boney support for dental implants and also preserve the integrity of nasopalatine arteries and nerves [25][26][27][28]. Artzi et al. described a method where bone graft was used to partially obliterate the diameter of the incisive canal [26]. ...
... A few patients in this case series reported sensory palatal changes that were subsequently resolved [25]. Veradi and Pastaga also reported two successful cases of canal obliteration with bone ridge augmentation without complications [28]. ...
The incisive canal, also known as the nasopalatine canal, is an interosseous conduit through the anterior maxilla connecting the oral and nasal cavities. Within this canal lies the nasopalatine nerve and the vascular anastomosis between the greater palatine and sphenopalatine arteries. The embryology of the canal has led to interesting theories explaining its function. Efforts have been made to describe the morphometrics of the incisive canal by radiologic evaluation across sex and ethnicities. This paper aims to review the current literature on the embryology, anatomy, and clinical relevance of the incisive canal.
... Ten articles out of a total 238 identified were considered relevant after title and abstract reading. The texts of these 10 articles were read in full and they were found to meet the predefined eligibility criteria; thus they were included in the final review 1,17,18,[23][24][25][26][27][28][29] . A flow chart of the study selection process is shown in Fig. 1. ...
... Of the 10 articles included in the final review, one was a pilot study 24 , five were case reports 1,23,26,28,29 , two were case series 25,27 , one was a longitudinal study 18 , and one was a retrospective study 17 . A description of the articles according to the data collected is shown in Table 1. ...
... The incisive canal deflation technique was used in seven studies 17,23,24,[26][27][28][29] and the neurovascular bundle lateralization technique was used in three 1,18,25 . Dental implant placement was concomitant with the deflation 17,24,26,27,29 or lateralization 1 surgical procedures in six articles. ...
A systematic review was conducted to evaluate the success rate of dental implants placed in the incisive canal region, and the complications related to this procedure. An electronic search was performed in the PubMed, Scopus and Web of Science databases. Articles that applied the incisive canal deflation (ICDT) or neurovascular bundle lateralization techniques (NBLT), either associated or not to dental implant installation and graft techniques were evaluated. Ten articles met the inclusion criteria, and only 1 retrospective and 1 longitudinal clinical trial were found. At the final screening, 84 implants were installed in this site, and implant success rate ranged from 84.6 to 100%. As for complications, 3 articles reported temporary sensory loss. Permanent sensory loss in the palatal mucosa region was also reported in one study applying NBLT. Quality analysis assessed in five studies, showed moderate quality in 4 studies and low quality in one study. Although a high rate of success was described in the selected studies, precaution is recommended when dental implants are installed in the incisive canal region due to the low evidence available. Regarding complications, there are no parameters for predicting the occurrence of sensory disturbance as well as damage extent using ICDT or NBLT.
... The results in this study suggested that other appropriate features of implant, for example a shorter implant or a narrower implant, or a greater embedded angle that departed from the axis of the restoration might be selected to avoid perforation in some cases. For the cases that the implant may invade into the NPC inevitably, the debridement or the displacement of the neurovascular bundle in conjunction with the guided bone regeneration were proposed to prevent direct contact of implant surface with the neurovascular bundle and to provide adequate bone (Artzi et al., 2000; Peñarrocha et al., 2014; Rosenquist & Nyström, 1992; Verardi & Pastagia, 2012). These methods could significantly improve the condition of implant placement, but more long-term studies with large samples are necessary. ...
The aims of this study were to investigate the ridge contour anterior to the nasopalatine canal, and the difference between the incidences of the nasopalatine canal perforation in dentate and partially edentulous patients by cone-beam computed tomography.
Methods.
Cone-beam computed tomography scan images from 72 patients were selected from database and divided into dentate and partially edentulous groups. The configuration of the ridge anterior to the canal including palatal concavity depth, palatal concavity height, palatal concavity angle, bone height coronal to the incisive foramen, and bone width anterior to the canal was measured. A virtual implant placement procedure was used, and the incidences of perforation were evaluated after implant placement in the cingulum position with the long axis along with the designed crown.
Results.
Comparing with variable values from dentate patients, the palatal concavity depth and angle were greater by 0.9 mm and 4°, and bone height was shorter by 1.1 mm in partially edentulous patients, respectively. Bone width in edentulous patients was narrower than in dentate patients by 1.2 mm at incisive foramen level and 0.9 mm at 8 mm subcrestal level, respectively. After 72 virtual cylindrical implants (4.1 × 12 mm) were placed, a total of 12 sites (16.7%) showed a perforation and three-fourths occurred in partially edentulous patients. After replacing with 72 tapered implants (4.3 × 13 mm), only 6 implants (8.3%) broke into the canal in the partially edentulous patient group.
Conclusions.
The nasopalatine canal may get close to the implant site and the bone width anterior to the canal decreases after the central incisor extraction. The incidence of nasopalatine canal perforation may occur more commonly during delayed implant placement in central incisor missing patients.
... Consequently, adequate knowledge of the morphology and dimensions of the nasopalatine canal is essential in order to optimize surgical planning and avoid possible complications in this region. [1][2][3][4][5][6] The most common surgical procedures in this region (also known as the premaxillary zone) include the extraction of impacted or supernumerary teeth, implant placement, endodontic treatment, periodontal surgery, the elimination of cysts, and orthognathic surgery. [7][8][9][10][11][12][13][14][15][16][17][18] Anatomically, the nasopalatine canal is a relatively long and narrow structure located on the maxillary midline. ...
Background
Surgery of the anterior maxillary zone has a strong impact upon dental and facial aesthetics and function.PurposeTo determine the anatomical characteristics and dimensions of the nasopalatine canal and alveolar bone using cone beam computed tomography (CBCT).Materials and MethodsA retrospective, cross-sectional study was made of the nasopalatine canal in 122 randomly selected CBCT scans corresponding to 66 males (44.3%) and 56 females (55.6%). The following measurements were made: maximum length and diameters of the nasal and oral openings of the nasopalatine canal; distance from the crestal margin to the buccal wall (at apical, middle, and coronal level); and angulation of the nasopalatine canal. The anatomical variants were morphologically classified as follows: A (single canal), B (double canal), or C (Y-shaped canal).ResultsThe anatomy of the nasopalatine canal showed important variability in terms of morphology and dimensions. Type A was observed in 48 patients (39.34%), type B in 10 (8.19%), and type C in 64 (52.45%). The mean diameter of the nasal opening or orifice was 3.02 ± 1.0 mm versus 3.29 ± 1.0 mm in the case of the oral opening. The mean length of the canal was 11.02 ± 2.4 mm. Significant differences were found between males and females, with greater canal dimensions and alveolar bone thickness values anterior to the nasal canal zone among males (p < .05).Conclusions
Our study shows gender to exert a significant influence upon the anatomical dimensions of the anterior maxilla and incisor canal. Given the anatomical variability characterizing the nasopalatine canal, we recommend CBCT evaluation prior to any type of surgery of the anterior maxillary zone.
... Identification of the individual anatomical variations, especially involving neurovascular structures, may play an important role in successful outcomes of surgical procedures involving the anterior maxilla. Even though surgical approaches involving either obliteration of the nasopalatine canal [10] or displacement of its neurovascular contents [1] have been proposed for implant placement, their impact on sensory function of the anterior palate is not fully understood [10]. Careful identification of the precise trajectory of the nasopalatine canal during preoperative CBCT evaluation is important because injury to its neurovascular content may have implications on the patient's quality of life, postoperatively. ...
... Identification of the individual anatomical variations, especially involving neurovascular structures, may play an important role in successful outcomes of surgical procedures involving the anterior maxilla. Even though surgical approaches involving either obliteration of the nasopalatine canal [10] or displacement of its neurovascular contents [1] have been proposed for implant placement, their impact on sensory function of the anterior palate is not fully understood [10]. Careful identification of the precise trajectory of the nasopalatine canal during preoperative CBCT evaluation is important because injury to its neurovascular content may have implications on the patient's quality of life, postoperatively. ...
The nasopalatine canal is a relatively long narrow structure located in the midline of the maxilla that contains the nasopalatine nerve and terminal branch of the descending palatine artery. Anatomical variations related to this structure have been reported. This article aimed to report a case of a complete additional nasopalatine canal on a 53-year-old female patient who underwent an examination by cone beam computed tomography. On sagittal slices, it was possible to observe the presence of an additional canal anterior and superior to the nasopalatine canal, separated by a bony septum. Each canal extended from independent superior openings (located in the nasal cavity) to independent openings located in the remaining alveolar process of the anterior maxilla. Identification of individual anatomical variations, especially involving neurovascular structures, plays an important role in the successful outcomes of surgical procedures involving the anterior maxilla.
The placement of implants in the anterior maxillary and mandibular region requires both esthetic proficiency and surgical finesse. It is important to consider the esthetic outcome while avoiding any type of nerve injury for the patient. In this literature review, anatomical structures of the anterior jaw were reviewed from a gross anatomical and radiographic interpretation. A discussion on the frequency of neurosensory complications for patients as a result of nerve damage in this region was evaluated. The purpose of this literature review was to educate the dental surgeon to consider the anterior jaw's neurological structures when performing procedures like implant surgery. The mandibular incisive canal (MIC) presents as an extension of the inferior alveolar canal that runs between the mental foramina. The MIC is a structure that is easily depicted in CBCT imaging and is present in most subjects in gross anatomical studies. The anterior loop of the mental nerve is another structure that is discussed in this paper. Although its structure is accurately depicted in CBCT images, its anatomical variations in patients can make implant treatment planning difficult. The maxilla contains two neurovascular structures that were discussed. First, the nasopalatine canal and its relation and impact on implant placement. Case reports are reviewed that outline a prophylactic enucleation and bone grafting of the canal prior to implant placement. Second, the canalis sinuosus, which houses the anterior superior alveolar nerve (ASAN), is of concern during implant placement in the lateral incisor region. Case reports involving nerve damage with follow-up are discussed.
The aims of this study were to assess the location, morphology and anatomical dimensions of the nasopalatine canal (NPC) on cone beam computed tomographic (CBCT) images and to compare our findings with recent reports on this matter. A detailed knowledge of anatomical variations is mandatory in skeletal surgery of the anterior maxilla.
Two hundred CBCT scans of the mid-facial region were analyzed from adult patients at the Outpatient Clinic of the Department of Oral and Craniomaxillofacial Surgery, University of Hamburg, Germany. Patients were scanned using standard exposure time at normal patient positioning inside the CBCT device. Three-dimensional (3D) CBCT images were carefully analyzed regarding NPC location, morphology and anatomical dimensions, and variations of radiological morphology, with respect to age and gender.
In the sagittal plane, the NPC typically appeared as a canal with a mean length±standard deviation (SD) of 11.15±2.87 mm. The oral cavity opening of the canal is the incisive foramen, with a mean diameter of 4.49±1.71 mm. At the entrance to the nasal floor, in most cases, two apertures were found (Y-canal morphology), but also three or four openings were observed. In particular cases, the canal presented a cylindrical aperture with only one exit to the nasal floor. The average width of the NPC at the level of the nasal floor was 3.43±1.54 mm. The labiopalatal width of the NPC measured perpendicular to the long axis of the canal on sagittal plane was 2.48±1.33 mm. Interpretation of NPC morphology was significantly different when analyzing the images in the sagittal plane only, but the technique allowed demonstration of all aspects using the combined 2D/3D interpretation.
The NPC may exhibit important anatomical variations, both with regard to morphology and its dimensions. To avoid any potential complications during dentoalveolar surgery, careful preoperative evaluation is required. 3D imaging is recommended to determine canal topography and dimensions, and to assess the individual anterior maxilla's dimensions prior to surgical procedures, such as dental implant insertion or bone augmentation.
Copyright © 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.
Abstract This report documents a case where the contents of the incisive canal were removed during guided bone regeneration surgery in the anterior maxilla. After full thickness flap elevation and debridement of the defect, the incisive canal was encountered. The terminal aspect of the canal was enucleated, freeze-dried cortical allograft particles were placed and guided bone regeneration utilizing a partially demineralized cancellous allograft block was performed. Sufficient bone volume was obtained for implant placement and the fixture was successfully restored without sensory disturbances . A comprehensive literature review is also presented, and this patient's result is in accordance with findings from a limited number of studies. Within the limited number of sources, it can be concluded that removal of the neurovascular contents of the incisive canal supports successful bone regeneration and/or implant integration, and does not create long term sensory disturbances.
