Alveolar Branches of Canalis Sinuosus: A Radiographic and Morphometric Assessment by Cone Beam Computed Tomography

doi:10.21203/rs.3.rs-2495944/v1

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Alveolar Branches of Canalis Sinuosus: A Radiographic and Morphometric Assessment by Cone Beam Computed Tomography

https://doi.org/10.21203/rs.3.rs-2495944/v1

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Background: Evaluation of the alveolar branches of canalis sinuosus (ABCS) to analyze its features and whether it is a variation or an anatomical structure.

Methods: ABCS was assessed retrospectively from the ramification site to the end of its trajectory by cone beam computed tomography, considering gender, age, and the voxel size of the images. Descriptive analysis, Pearson Chi-square, Fisher’s exact and Mann-Whitney-U tests, and Spearman’s correlation were used in statistics.

Results: 167 ABCS were identified in 82 (72.6%) of 113 individuals and the incidence of ABCS wider than 1mm was 32.7% per individuals. Presence or number of ABCS was independent of age and gender (P˃.05). Ramification site of ABCS from the main canal was 96.4% below the nasal cavity floor and mostly at the level of central incisors (46.1%). A significant correlation was defined between the origin and the end of ABCS trajectory (P<.000). The end of ABCS trajectory as facio-palatal was 44.9% buccal, then 35.9% palatal surface of the bone. Voxel sizes of images was negatively correlated with ABCS presence (P≤.013) and ABCS number per individual (P≤.002).

Conclusions: ABCS is more likely to be an anatomical structure than an anatomical variation, but many are less than 1mm in diameter and the voxel size is important for radiographic observation.

Anterior maxilla

bone channel

canalis sinuosus

cone beam computed tomography

radiology

The branch of infraorbital nerve which is called anterior superior alveolar nerve as well as its accompanying vessels pass through the “canalis sinuosus (CS)” and the term was derived from the shape of the canal, due to its double curved course [1]. The anterior superior alveolar nerve arises in the floor of the orbit, slightly posterior to the infraorbital foramen and as soon as the ramification, it runs laterally in its own bony canal, CS. Following its latero-anterior and a few mm downward course, CS runs horizontally from lateral to medial along the maxilla before its vertical course in midface which is compatible with the curvilinear margin of anterior nasal aperture [1, 2]. While tunneling along the narial bony margin, adjacent to the floor of the nasal chamber, CS gives off a conspicuous dental branch to the canine, and smaller branches may be reach the incisors and terminally CS opens to foramen septale which is situated bilaterally at the root of the nasal septum [1].

Although CS has been defined with its branches extending to the alveolar ridge in the anterior maxilla a long time ago, it is still unfortunately not a well-known structure. The more recently published study reported that most dentists were unaware of CS and did not know how to diagnose it [3]. The literature includes some complications arising from this situation. There have been some case reports with treatment failures and complications, due to ignore or overlook of the alveolar branches of CS (ABCS) as instanced by neurological symptomatology following the implant surgery [4–6]. This unfamiliar structure even has been reported as a possible minor forms of clefting with name of lateral insisiv canal [7]. The appearance of ABCS on radiograph can also be misleading by mimicking the periapical inflammatory lesion or root resorption, which may result in unnecessary interventional treatments [8–10].

The incidence of ABCS in the literature has a wide range and the terminology is also some confusing as the presence of ABCS in the anterior maxilla is mentioned as an anatomic variation or accessory canals in some articles. Thus, the researchers of this study aimed to evaluate ABCS from the ramification site that adjacent to the nasal aperture to the end of its trajectory in the alveolar process of maxilla, with the radiographic and morphometric features by using cone beam computed tomography (CBCT) in order to contribute to the literature to provide a better understanding of this structure. The presence of ABCS was examined considering gender, age, and the voxel size of the images, which is likely to affect observability. The hypothesis was that ABCS was not a rare anatomical variation and the visibility of ABCS increased with decrease in the voxel size of the image.

Study design

This is a retrospective study based on evaluation of CBCT scans, approved by the university's clinical research ethics committee. Available CBCT scans in the archives of the Hospital of Dentistry Faculty of the University were used for the study. CBCTs were reviewed in order, starting with the most recent. Among the scans, images were determined, that provided the anterior region of the maxilla up to the distal aspects of the first premolar posteriorly and from the alveolar crest to superiorly at least medium height of the pyriform aperture. Images with motion or metal artefacts and failing to provide satisfactory quality were excluded from the study. Presence of bony lesions, fractures, congenital deformities or bone graft material, screw or anything suggesting previous surgeries in the anterior maxillary region were also reasons for exclusion. 116 cbct scans matching these criteria were included in the study.

CBCT image acquisition:

CBCT images were obtained using Kavo OP 3D Vision (Imaging Sciences International LLC, USA) with following parameters: 3–8 mA, 90–120 kVp. Voxel sizes of the images were between 200 and 400 µm.

Image interpretation:

Two dentomaxillofacial radiologists independently examined CBCT images. They came to a consensus in cases of disagreements to provide 1 set of data for analysis, but their initial independent examination data were compared to calculate interobserver agreement. The observers evaluated a subsample consisting of 30 CBCT images (26.5% of all) twice with a 3-weeks interval to quantify intraobserver agreement.

CBCT images were evaluated using OnDemand3D software (CyberMed, Seoul, Republic of Korea) on 27-inch Dell Precision T3620 medical monitors (Dell, Round Rock, TX, USA) with 1920 x 1200-pixel resolution and 64-bit color support.

Axial, coronal and cross-sectional reconstructions were analyzed in each case with 0.17-0.25mm interslice distance which is automatically set depending on voxel size. The presence of ABCS was investigated with the location of both the origin and the end of its trajectory according to nasopalatine canal, central and lateral incisors, canine and first premolar (Fig. 1). The end of ABCS trajectory was also examined as facio-palatal in the alveolar bone such as buccal or palatal surface of the alveolar bone or ended within the alveolar bone (Fig. 2). The diameter of ABCS was measured at the middle section of its total length (from the ramification at the base of the nasal cavity to foramen opening to the oral mucosa or where its ends). Diameters less than 1 mm were numerated with the same number, and for diameters equal to and greater than 1mm the mm values of diameters were noted. The correlation of presence, number and the diameter of ABCS with both gender and age was examined.

Besides ABCS, we also examined whether the main CS was visible until it reached the anterior nasal septum (ANS) (Fig. 3) and the distance from the observable endpoint of CS to the ANS was noted in mm. The ramification site of ABCS from the main CS was assessed as above or below considering the floor of the nasal cavity (Fig. 4).

The correlation between distance of the observable endpoint of the main CS to the ANS and the voxel size of the image was investigated. The correlation between the voxel size of the image and the presence and number of ABCS per individual was also investigated.

Statistical analysis:

SPSS software version 25.0 (IBM Corp., Armonk, NY, USA) was used to analyze the data. Intra- and inter-observer agreement were assessed by using Cohen's kappa coefficient (for categorical data) and paired samples t-test (for the distance to the ANS and the diameter). Data were analyzed by descriptively using mean, median, maximum, minimum and standard deviation. Pearson Chi-square and Fisher’s exact tests was used for categorical data such as presence of ABCS or gender. The normality of the continuous variables was analyzed by skewness and kurtosis, followed by the Pearson correlation coefficient to evaluate the data normally distributed between the two variables, and the Spearman rank correlation coefficient to evaluate the data non-normally distributed. Mann-Whitney-U test was conducted to examine age and the voxel size according to ABCS presence. Statistical significance was set at the level of P < .05.

Intraobserver agreements for the location of the origin and the end of trajectory of ABCS according to nasopalatine canal and teeth, the location of the end of ABCS trajectory as facio-palatal and ramification site of ABCS from the main CS were substantial and almost perfect agreements (kappa coefficients were between .79 and 1). Interobserver agreement of these variables were found to have almost perfect agreement with kappa coefficients of .97, .97, .95 and .92, retrospectively (P ˂ .000). Intraobserver differences for the diameter of ABCS and the distance of the observable endpoint of the main CS to the ANS were not statistically significant in both observer's measurements (P ˃ 0.05). The difference between the means of the measurements of the first and second observers for the diameter of ABCS was .01mm (95% confidence interval: − .03 − .04) mm and .01mm for distance to ANS (95% confidence interval: − .02 − .04mm) which were not statistically significant (P = .66 and .53).

This study included CBCT images of 226 right or left maxilla, belongs to 113 individuals which of 59 (52.2%) were female and 54 (47.8%) were male. Sample age ranged from 12 to 76 years with a mean of 40.69 years (± 16.1). At least one alveolar branch of CS was observed in 82 (72.6%) of total 113 and no ABCS was detected in 31 (27.4%) of individuals. A maximum of 6 branches was defined in one individual and a total of 167 ABCS were identified in the study (Table 1 and Fig. 5). Neither the presence of ABCS significantly differed with respect to age or gender, nor the number of ABCS correlated with age or showed difference with respect to gender (P ˃ .05).

Table 1

Number of ABCS per individual.
Number of ABCS	Incidence	%
0	31	27.4
1	32	28.3
2	28	24.8
3	12	10.6
4	8	7.1
5	1	0.9
6	1	0.9
Total	113	100

The main CS could be followed up to the ANS in 26 (11.5%) of 226 maxillas. The mean distance from the observable endpoint of CS to the ANS was 4.35mm (± 2.67) and among CSs that did not reach the ANS, the observable endpoint was disappeared at the maximum distance of 12.89 mm distal to the ANS. Ramification site of ABCS from the main CS was mostly below the floor of the nasal cavity (n:161; 96.4%) and only 6 (3.6%) ABCS ramified above the nasal cavity floor. Considering the teeth and the nasopalatine canal, the ramification site was most frequently at the level of the central incisor (46.1%), followed by the lateral incisor (20.4%) and the nasopalatine canal (20.4%), however the end of the trajectory of ABCS was mostly the central incisor (50.9%) but followed by the nasopalatine canal (22.8%) and then the lateral incisor (13.2%) (Table 2). Despite this difference, a significant moderate correlation at the level of .000 was defined between the origin and the end of its trajectory (r = .536). When the end of ABCS trajectory was examined as facio-palatal 75 (44.9%) ABCS terminated at the buccal surface of the alveolar bone, 60 (35.9%) reached the palatal surface and 32 (19.2%) ended within the alveolar bone (Table 3).

Table 2

Incidence of origin and end location of ABCS trajectory considering teeth and nasopalatine canal.
Location	origin	end
Central	77 (46.1%)	85 (50.9%)
Lateral	34 (20.4%)	22 (13.2%)
Canine	21 (12.6%)	12 (7.2%)
First premolar	1(0.6%)	10 (6.0%)
Nasopalatine canal	34 (20.4%)	38 (22.8%)
Total	167 (100%)	167 (100%)

Table 3

Incidence of the terminal location of the ABCS as facio-palatal.
Location	Incidence	%
Buccal surface of the alveolar bone	75	44.9
Palatal surface of the alveolar bone	60	35.9
Within the alveolar bone	32	19.2
Total	167	100

The diameter of ABCS was less than 1mm in 120 (71.9%) branches and equal to and wider than 1mm in 47 (28.1%). The highest measured diameter was 1.7mm while the mean of diameters greater than and equal to 1mm was 1.2mm (± .18). The incidence of ABCS wider than 1mm was 32.7% per individuals. While the diameter width less than 1 mm or equal to and greater than 1mm was found to be independent of gender (P = .11), weak but significantly correlated with age (P = .017 and r = .184).

The study included 4 scans with 200 µm voxel size, 63 with 250 µm, 44 with 300 µm and 2 with 400 µm. The voxel size of the images in which the presence of ABCS was determined was significantly lower than the images in which ABCS was not detected (U = 936.0, z=-2.46, P = .014). Additionally, the voxel size of the image was negatively correlated with the number of ABCS per individual, ie an increase in the number of ABCS detected as the voxel size decreased (P = .002; r = − .288). The distance from the observable endpoint of the main CS to the ANS was nevertheless not correlated with the voxel size (P = .77).

Previous studies report variable incidences for ABCS and in a recently published meta-analyses a pooled prevalence of ABCS is 0.54 in a total of 4605 patients [11]. Besides the differences in populations, the differences between the methodologies in different studies seems to be reasonably effective on variation. The incidence of ABCS reported by Aoki et al. [12], Machado et al. [13] and Tomrukçu et al.[14] were 66.5%, 52.1% and 34.7% respectively and in all with male predominance. Anatoly et al. [15] reported conversely female predominance with 67% ABCS incidence in a Russian population and Marzook et al. [16] showed ABCS in 73.53% of adult Egyptian samples. Oliveira-Santos et al. [17] reported a lower incidence, such as 15.7% without gender predilection. Here to explain the lower incidence, it would be appropriate to highlight that they did not include ABCS less than 1mm in diameter. Another study by Von Arx et al. [18] reported 55.1% ABCS incidence, however this rate dramatically decreased to 27.8% when ABCS under 1mm in diameter had not been counted. Although in our study the incidence of ABCS was 72.6% when ABCSs narrower than 1mm are excluded the incidence degreases to 32.7%, and there was no correlation between gender and presence of ABCS (p = .18). Wanzeler et al. [19] reported that the incidence of CS was 88%, by suggesting branches of CS were not only an anatomical variation, but also a common anatomical structure, with which we agree. Their study differs from the others in terms of considering all branches of CS in the region of nasal cavity floor, beside the ones in extending to the alveolar process of the maxilla, even though some of their trajectories ended at the base of the nasal cavity or maxillary sinus region. Besides that, Yeap et al. [20] recently reported 98.5% ABCS incidence in an Australian population, declaring that this is a normal anatomy. It looks more correct to think of ABCS as a variation in the anterior maxilla when it is wide, for example wider than 1 mm in diameter. The current study reports no correlation between the age and presence of ABCS which is concordant with previous studies [12, 13, 15, 17, 19, 20].

In the study by von Arx et al. [18] all the reported ABCS were palatal to anterior teeth. Two other studies reported that the ends of ABCS trajectories were on the palatal surface of the alveolar bone with rates above 91.1% [13, 14] The study by Anatoly et al. [15] was consistent with these results for the most common location of ABCS as facio-palatal, however with a relatively lower rate for palatal position (76%) and equal proportions for central and facial position. The results of the current study differ in terms of the terminal location of ABCS, with the buccal surface of the alveolar bone being the highest (44.9%), followed by the palatal surface (35.9%) and within the alveolar bone (19.2%). In examination of terminal location considering the teeth and the nasopalatine canal the most frequent location of the ends of ABCS trajectory was the central incisor (50.9%), consistent with the study by Aoki et al. [12] and von Arx et al. [18] In the meta-analysis of De Oliveira-Neto et al. [11], the most common site for the end of ABCS was reported as the palatal region of the central incisors and canines. We did not define the interdental area as a separate region in our study, considered that the ABCS observed here were located in the tooth region to which they are closest. In this respect, although there were differences in our method of examining the regions in the mesio-distal direction, unlike these data, the termination rates in the canine region were observed to be lower than in the lateral incisor and nasopalatine canals region. In addition to terminal location, the location where ABCS originates from the main CS was examined relative to the teeth and the nasopalatine canal in the current study. This is the first study to assess the consistency of both, which is important in procedures such as implant surgery that will extend along the vertical line of the alveolar bone. Although some ABCSs have progressed mesially or distally, a significant correlation was defined between the origin and the end of their trajectories (P ˂ .000).

While Aoki et al. [12] stated the diameter of ABCS was found to be homogeneous along its entire trajectory to the region of the mouth, while two other studies [14, 19] reported that the average diameter of ABCS was wider at the terminal section when compared to the upright course. Therefore, we measured the diameter of ABCS at the middle part of its total length (from the ramification at the base of the nasal cavity to foramen opening to the oral mucosa or where its ends). 96.6% of ABCS was no more than 1 mm in diameter in the study by Aoki et al. [12] In the current study also, metric measurements weren’t preferred in considering the low reliability risk in the measurements of diameters less than 1 mm and ABCSs were less than 1 mm in diameter in 71.9%. The maximum measured diameter was 1.7 mm and the mean of diameters greater than and equal to 1mm was 1.2 mm (± .18). Von Arx et al. [18] reported 1.31mm and Oliveira-Santos et al. [17] reported 1.4mm for the mean diameter, considering ABCSs only with a diameter of at least 1 mm. Machado et al. [13] found the mean diameter of ABCS to be 1.19 mm, and the rate of those with a diameter ≥ 1 mm as 20%. And Yeap et al. [20] reported the mean widest diameter as 1.08 mm for all ABCSs at the level of the tooth apex. Since the diameter of the canal is related to the thickness of the neurovascular bundle inside, wide canals are considered to be more risky in terms of serious bleeding and complications in surgical interventions. The diameter was found to be independent of gender consistent with previous studies [12, 18, 19], however was positively correlated with age unlike previous reports [12, 13, 18, 20]. According to this result in older patients it is more likely to encounter wider ABCSs.

In the current study, when floor of the nasal cavity was taken as a reference in horizontal plane, the ramification site was recorded as above or below. Ramification site in 96.4% of the total ABCSs was below the nasal cavity floor and in 3.6% were above. Kasahara et al. [21], reported that the anterior, middle, and posterior alveolar canals/grooves converged in the bottom of the nasal cavity near the piriform aperture, with at least incidence of 35%, based on 3D reconstructed CBCT images of the dry maxillas/skulls, highlighting the networks in the horizontal direction relative to the occlusal plane. Anastomosis between ABCS and the greater palatine nerve has also been shown at lower levels, such as in palate [7]. Vascular and sensory richness in this region should not be underestimated in Le Fort I osteotomy and dental surgeries. Prior to the rehabilitative treatment the identification of the anatomical structures with their variations would help the surgeon in assessing and avoiding the potential risks of the operation. Thorough preoperative CBCT examination is essential in the treatment planning and decision-making process [6, 16]. The display of ABCS in the surgery site, can also completely change the treatment decision sometimes. When the impingement on ABCS looks unavoidable at the surgery planned area, to turn to an alternative treatment such as bridges and leaving the implant placement decision will be a realistic choose as in the case reported by Shelley et al [22].

To our knowledge, this is the first study to examine the distance of the observable endpoint of the CS to the ANS on CBCT scans. Although in only 11.5% of all maxillas CS could be followed up to the ANS, the mean distance was 4.35mm (± 2.67) from the observable endpoint of CS to the ANS on CBCT images. Image quality has an important role in the diagnostic value of radiographic procedures. In this study, although the voxel size of the images wasn’t found effective on the distance of the main CS to the ANS it was significant in determination of ABCS. Voxel size of the images was significantly smaller in which ABCS was determined (P = .014). Moreover, an increase in the number of ABCS per individual was determined with the decrease in the voxel size of the image (P = .002). Yeap et al. [20], reported that they detected significantly low ABCS in scans obtained with 250 µm voxel size, which was the largest one in their study. This result indicates the effectiveness of the voxel size on the detectability of ABCS as one of the important factors affecting the resolution of the image. The detection of ABCS seems more likely on CBCT images with small voxel sizes. The increase in visibility of ABCS in recent years, has already been linked to the widespread use of CBCT in dentistry and high resolution and detail it provided [23]. Besides that, although we detected more ABCS per scan as the size of voxels decreased in our study, Yeap et al. [20] did not find a significant difference between voxel sizes in terms of the number of canals. Their study included 95.5% of scans with small voxel sizes under 200 µm. There may be a threshold in the influence of voxel size on the observability of ABCS, and voxel size is an important but not the only factor affecting image quality. Further studies examining other parameters that may affect the visibility of ABCS and containing multiple exposures in different modes on cadavers or dry skulls would be useful.

In this study, ABCS, an anatomical structure of clinical importance, was examined with its incidence, location and course, by considering age, gender and the voxel size of the image. It would be fair to accept ABCS is an anatomical structure that is frequently present, rather than a rare anatomical variation, but many are less than 1mm in diameter and the voxel size is important for radiographic observation. Well-known of this structure is important to avoid complications of treatments or malpractices such as excessive hemorrhage, nerve injury, neuropathic pain, and unnecessary interventional procedures. ABCSs, which may terminate on the buccal or palatal surface of the alveolar bone or within the bone, were most frequently localized in the central incisor neighborhood and mostly consistent in mesio-distal course between the origin and end point in the alveolar bone. While no correlation was defined between age or gender and the presence of ABCS, age was positively correlated with the diameter of ABCS.

ABCS

alveolar branches of canalis sinuosus

canalis sinuosus

CBCT

cone beam computed tomography

ANS

anterior nasal septum

Ethics approval and consent to participate

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 and informed consent was obtained from all subjects and/or their legal guardian(s). The Clinical Research and Ethics Board of Tokat Gaziosmanpaşa University reviewed and approved the study (21-KAEK-208).

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding has been provided for this study.

Authors' contributions

Uzun C designed the study, was involved in the interpretation of the data, performed the statistical analysis, and wrote the manuscript. Çitir M collected the data, were involved in the interpretation of the data and writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Authors' information (optional)

¹ Assistant Professor, Department of Dentomaxillofacial Radiology, Faculty of Dentistry, University of Health Sciences, Istanbul, Turkey. (ORCID 0000 0001 8940 5191; E-mail: [email protected] )

² Assistant Professor, Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Tokat Gaziosmanpaşa University, Tokat, Turkey. (ORCID 0000 0003 2015 8879; E-mail: [email protected] )

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Alveolar Branches of Canalis Sinuosus: A Radiographic and Morphometric Assessment by Cone Beam Computed Tomography

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