Cone-beam computed tomography of accessory canals of the canalis sinuosus and analysis of the related risk factors

doi:10.21203/rs.3.rs-3233483/v1

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Research Article

Cone-beam computed tomography of accessory canals of the canalis sinuosus and analysis of the related risk factors

https://doi.org/10.21203/rs.3.rs-3233483/v1

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published 22 Mar, 2024

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Purpose

Cone-beam computed tomography (CBCT) was used in this study for evaluating the diameter, prevalence, spatial location, and risk factors of the accessory canal (AC) of the canalis sinuosus.

Methods

A comprehensive assessment of the incidence rate, diameter, three-dimensional (3D) spatial location, and direction of travel of AC was performed on 1003 CBCT images. The CBCT data were used to reconstruct a 3D model of the maxilla to determine the alveolar bone volume. The obtained data were further analyzed and processed.

Results

AC was present in 50.1% of images. Male patients more frequently had ACs than female patients did (P < 0.01) and was positively correlated with the maxillary alveolar bone volume (P < 0.001, OR 1.554). Age or nasopalatine canal diameter were not significantly associated with the occurrence of AC (P > 0.05). Among the 502 patients with AC, AC was present on the left side, right side, and bilaterally in 189, 98, and 215, respectively. The maximum number of ACs observed per individual was eight. The average AC diameter was 0.89 ± 0.26 mm (minimum, 0.5 mm; maximum, 2.02 mm).

Conclusions

As the prevalence of AC and its trajectory display considerable variation among individuals, surgeons must consider the possibility of the presence of AC when devising surgical plans involving the anterior maxillary region.

maxilla

cone-beam computed tomography

canalis sinuosus

anterior superior alveolar nerve

Surgical intervention is often required for the management of various pathologies and injuries affecting the anterior maxilla. The anterior maxilla is generally considered a safe place for surgical intervention as there are no neural structures, other than the nasopalatine nerve, which has a relatively stable course, are present in this region. However, there has been a rise in the reports of neurovascular complications resulting from intraoperative injury to the accessory canal (AC) in recent years due to an increasing number of patients undergoing implant surgery in the anterior region [8, 18, 26].

The canalis sinuosus (CS), which was initially identified by Jones, is a bony canal that houses the anterior neurovascular bundle of the upper alveolus. AC is an anatomical variation of the CS that traverses through the anterior region of the alveolar bone of the maxilla, as depicted in Fig. 1. There is an inherent risk of iatrogenic injuries to AC during surgery involving the anterior region of the maxilla, which can give rise to neurovascular complications [4, 6, 7, 14, 25]. Lopes et al. [11] investigated seven potential AC injuries, with five cases involving implant placement. Postoperative symptoms, such as intense pain, swelling under the nasal region, and epistaxis, were reported by the patients. Volberg et al. [24] reported that patients with AC injuries experienced severe pain and sensory abnormalities that were distributed in the left maxillary incisor area, palate, and nose, in addition to a burning sensation in the occipital region. Thus, the preoperative examination of AC is crucial.

It is often impossible to identify AC during conventional radiographic examinations, or they may be misdiagnosed as apical lesions [10, 21]. Cone-beam computed tomography (CBCT) is the preferred technique for identifying AC as they offer advantages in terms of visualizing the changes in the maxillofacial bone, teeth, and periodontal tissue. CBCT enables the visualization of bony canal structures within the jawbone and provides a more visual representation of the three-dimensional (3D) spatial position of these canal structures [1, 5, 8, 12, 17].

Most previous studies on AC had a limited sample size and primarily focused on the prevalence of AC. Furthermore, most of these studies only considered ACs with diameters of > 1 mm. The predictive factors, morphological characteristics, and spatial relationships associated with the presence of AC remain unknown. Therefore, this study comprehensively analyzed the CBCT images of 1003 patients to evaluate the diameter, prevalence, spatial positioning, and distribution patterns of AC and assess the relevant risk factors contributing to the presence of AC.

Among the CBCT images of 1,767 patients who visited the Affiliated Dental Hospital of Jinzhou Medical University (Jinzhou, China) for various treatments between June 2022 and April 2023, 1,003 images that satisfied the study's inclusion criteria were included.

The following were the inclusion criteria: CBCT image of the maxilla and image quality that did not affect 3D model building. The following were the exclusion criteria: presence of prosthetic artifacts that would affect the assessment; presence of unerupted teeth, maxillary cysts, and apical lesions in the anterior maxilla; and alveolar bone resorption affecting up to 20% of the root length.

All images were acquired by a highly experienced physician with over 15 years of experience in image acquisition. The CBCT scanner used for imaging was an Orthophos SL 3D (Dentsply Sirona, USA). The following were the scanning parameters: voltage, 85 KV; exposure time, 14 s; tube current, 6 mA; voxel size, 0.16 mm³; and reconstructed layer thickness, 0.1 mm. The scanned images were evaluated, and precise measurements were obtained using SIDEXIS 4 Sirona.

Data Acquisition

The CBCT images were corrected and adjusted for brightness and contrast using SIDEXIS 4 Sirona as required. Subsequently, the presence of the AC was assessed in the sagittal, coronal, and axial planes using multi-angle adjustments, as shown in Fig. 2. Further analysis and processing were performed based on the identification of AC.

As shown in Fig. 3, the morphology of the coronally recorded AC can be described as straight, curved, or bifurcated. The sagittal plane records the exit site and direction of the AC. The distance between the crest of the alveolar ridge and the lower border of the exit location on the alveolar bone was measured. The diameter of the nasopalatine canal (NPC) on the axial plane and the position and diameter of the AC were recorded. The measurement standard for the diameter of AC was the point where it exited the alveolar bone. The position of AC in the maxillary alveolar bone was divided into six regions, namely L3, L2, L1, R1, R2, and R3, based on the area of the alveolar bone corresponding to its opening point in the axial plane.

The process of establishing and measuring the volume of the alveolar bone in the anterior part of the maxilla is depicted in Fig. 4. The CBCT file was imported into the Mimics Research software (version 21.0). The anterior part of the maxilla required for the experiment was captured as a 3D model. The lower limit of the model was the incisal edge of the upper central incisors, while the upper boundary was parallel to the bottom edge of the piriform aperture. The model was truncated along the mesial aspect of the alveolar crest of the first premolar on both sides following the direction of the long axis of the tooth. The excess palatine bone on the inner side was removed by cutting along the curve of the dental arch along the posterior edge of NPC. Subsequently, individual models of the maxillary canines, lateral incisors, and central incisors were constructed from the maxillary bone model, and each tooth model was then separated from the maxillary bone model. The maxillary alveolar bone model was established, and the volume of the alveolar bone was measured.

Statistical analysis

The IBM SPSS Statistics software (version 25.0) was used to analyze and manipulate the collected data. Skewness and kurtosis measures were used to evaluate the normality of continuous variables. In order to compare the prevalence of AC in the groups divided by sex and age, Pearson's chi-square test was utilized. The independent samples t-test or Mann–Whitney U-test was used to analyze continuous variables related to sex. One-way ANOVA or the Kruskal–Wallis test was used to analyze continuous variables related to different age groups. In addition, a binary logistic regression model was constructed to identify the risk factors for the presence of AC. A significance level of α = 0.05 was used, and statistical significance was set at P＜0.05.

After comprehensively analyzing the CBCT images of 1,003 patients aged between 20 and 69 years, including 534 males and 469 females, our study detected AC in 502 (50.1%) of these patients. Only one AC was detected in 259 patients, whereas ≥ 2 ACs were detected in 243 patients. The highest number of ACs detected in the alveolar bone in male and female patients was eight and seven, respectively. Table 1 presents the distribution of AC in the maxillary anterior region among different individuals. The number of ACs varied significantly across the sexes according to Spearman's correlation analysis (r = -0.109, P = 0.001).

Table 1

Number and distribution of accessory canals in patients according to sex.
Number of patients
Number of AC	Male	Female	Total
0	244	257	501
1	140	119	259
2	85	62	147
3	53	27	80
4	7	3	10
5	2	0	2
6	2	0	2
7	0	1	1
8	1	0	1
Total	290	212	502
AC, accessory canal

The prevalence of AC was 54.3% among male patients, which was considerably higher than the prevalence of 45.2% among female patients (Table 2). The detected differences were statistically significant (P < 0.01). However, no significant difference was noticed when comparing the prevalence of AC across the different age groups (P > 0.05).

Table 2

Frequency and distribution of the accessory canal in different sex and age groups.
Variable	Total (N = 1003)	Presence of AC N (%)	c²	P
Age Group (y)
20–39	543	267 (49.2%)	0.366	0.833
40–59	415	212 (51.1%)
≥ 60	45	23 (51.1%)
Sex
Male	534	290 (54.3%)	8.279	0.004
Female	469	212(45.2%)	8.279	0.004
Total	1003	502(50.05%)
AC, accessory canal

Table 3 presents the results of the comprehensive analysis of the correlation between the alveolar bone volume in the anterior maxillary region and various factors, including sex, age group, and the prevalence of AC. The mean alveolar bone volume in males and females was 5.613 ± 0.972 cm³ and 4.885 ± 0.833 cm³, respectively. Between the sexes, there was a substantial difference in alveolar bone volume (P < 0.001). Furthermore, the volume of the alveolar bone showed significant differences between the individuals with and without ACs (P < 0.001).

Table 3

Volumetric characteristics of alveolar bone in different sexes, age groups, and individuals with and without accessory canals.
Variable	Volume of maxillary alveolar bone (cm³)	P
Age group(y)
20–39	5.264 ± 0.964	0.890
40–59	5.289 ± 1.015
≥ 60	5.232 ± 0.852
Sex
Male	5.613 ± 0.972	＜0.001
Female	4.885 ± 0.833	＜0.001
AC
Presence of AC	5.474 ± 0.917	＜0.001
Absence of AC	5.071 ± 0.999	＜0.001
AC, Accessory canal

A total of 870 ACs were detected in 502 patients in this study. Figure 5A provides a graphical representation of the distribution of ACs among the male and female participants. A total of 527 ACs were detected in the 290 male patients, whereas a total of 343 ACs were detected in the 212 female patients. The prevalence of ACs was slightly higher on the left side than that on the right side. Among the six regions categorized by tooth position, the maxillary left lateral incisors region (L2 region) exhibited the highest frequency of ACs. As shown in Fig. 5B, AC was present on the left side, right side, and bilaterally in 189 (37.6%), 98 (19.5%), and 215 (42.8%) patients, respectively.

Among the 870 identified ACs, 295 were excluded owing to blurry morphology. Thus, 575 ACs were selected. Among these 575 ACs, the morphology was straight, curved, and bifurcated in 188 (32.7%), 355 (61.7%), and 32 (5.6%) ACs, respectively.

Males and females had NPCs with average diameters of 3.59 ± 0.84 mm and 3.47 ± 0.73 mm, respectively, indicating a significant difference between these measurements based on sex (P < 0.05). The diameter of AC was 0.89 ± 0.26 mm (minimum, 0.5 mm; maximum, 2.02 mm). Only the area of the anterior teeth was found to have AC perforation on the palatal side of the maxillary alveolar bone. Perforation of AC on the buccal side has been reported in previous studies. However, no evidence of AC perforation on the buccal side of the maxilla has been found in this study. The average distance between the alveolar ridge and the palatal opening site of AC was 5.78 ± 2.25 mm (minimum, 1.10 mm; maximum, 15.72 mm).

Among the 870 ACs observed, 845 (97.1%) ACs exhibited a horizontal relationship between the opening site of AC and the roots of the anterior teeth. AC was located above the roots of the teeth in 25 (2.9%) patients. Figure 6 presents the distribution patterns.

Figure 7 shows the outcomes of the binary logistic regression analysis performed to evaluate the existence of AC with variables including age, sex, alveolar bone volume, and NPC diameter. The maxillary bone volume was found to be a risk factor for the presence of AC (P < 0.001, OR 1.554). The receiver operating characteristic (ROC) curves presented in Fig. 8 further demonstrate that the maxillary alveolar bone volume can predict the likelihood of the presence of AC to some extent (area under the ROC curve [AUC] = 0.626, P < 0.001).

AC serves as an osseous pathway for the anterior superior alveolar neurovascular bundle in the anterior region of the maxilla [7]. Surgical procedures that result in damage to AC can result in various complications, such as pain, bleeding, sensory impairments, failure of implant osseointegration, burning sensation at the posterior head region, and neurological disorders [13, 15, 18, 20, 22, 23, 24]. Thus, it is imperative that clinicians gain a comprehensive understanding of these anatomical variations.

Through a comprehensive analysis and evaluation of CBCT images of the maxilla obtained from 1003 patients, this study confirmed that AC was observed in the maxillary region of approximately 50.1% of these patients. The prevalence observed in this study is comparable with the prevalence of 52.1% and 55.1% reported by Machado et al. [12] in a Brazilian population and von Arx et al. [25], respectively. However, Shan et al. [19] reported a lower prevalence of AC of 36.9% in the Chinese population. This difference is attributed to the fact that the study by Shan et al. only included ACs of > 1 mm in diameter, whereas the present study included ACs of > 0.5 mm in diameter. The prevalence of AC varies widely across different populations. For instance, a CBCT study involving 178 participants reported a prevalence of 15.7% for ACs of > 1 mm in diameter [4]. In contrast, Orhan et al. [16] conducted a study with a larger sample size of 1460 participants and reported a notably higher prevalence of 70.8%. Beyzade et al. reported a prevalence of 100% in their study conducted on a Cypriot population. These disparities can be ascribed to several factors, including the differences in imaging techniques, voxel resolution, sample size, inclusion and exclusion criteria, ethnic variations, and the lack of a universally accepted standardized approach for evaluating the presence of AC [3]. Moreover, some of these studies had small sample sizes, and most studies excluded AC with diameters of < 1 mm, which directly affected the final assessment results.

In the current study, there were appreciable differences in the prevalence of AC between males and females. The prevalence of ACs among males was 54.31%, whereas that among females was 45.20%. This result is consistent with that of another study, which reported a prevalence of 58.0% in males and 46.6% in females in a sample of 1000 patients [12]. It is noteworthy that the presence of AC was unrelated to age in the current study, which is consistent with the results of previous investigations [2, 3, 9, 12, 16, 19, 27].

In the sagittal plane on CBCT, the course of the AC course mostly originates from the CS at the bottom of the nose, descends or curves within the maxillary alveolar bone, and ultimately terminates in the palatal mucosa. The exit points of AC are typically located on the palatal side of the maxilla; however, some studies have reported rare instances of AC exiting on the buccal side [12, 25]. In the present study, AC was found to exit through the palatal foramen of the maxilla only, and such an exit was more prevalent on the left than on the right side of the maxilla. Furthermore, the majority of these exit locations were found in the alveolar bone, which corresponds to the maxillary left lateral incisors area. This incidence pattern is in line with the findings of the study by Machado et al. [12].

The average diameter of AC was 0.89 ± 0.26 mm in the present study. It should be noted that previous studies used varying inclusion criteria, including ACs with canal diameters of > 1 mm. Consequently, there are some variations in the reported AC diameters. However, even injuries to ACs with a small diameter can result in severe complications. Previous reports have documented cases of significant bleeding caused by injury to ACs with diameters of < 1 mm during dental implant placement [25]. Therefore, it is important to exercise caution and precision to avoid such complications.

The average distance between the final position of AC and the peak of the alveolar ridge was 5.78 ± 2.25 mm. This outcome is in line with the findings of two more studies [3, 19], where the longest distance recorded was 15.72 mm, and the shortest distance recorded was 1.1 mm. In the assessment of the position relationship between AC and the maxillary anterior teeth, 845 among 870 ACs showed a horizontal relationship with the roots of the anterior teeth within the alveolar bone, whereas only 25 ACs were located above the roots. Among these, 489 (56.2%) had an opening within the middle one-third of the root.

To assess the relationship between the existence of AC and alveolar bone volume in this study, a 3D model of the anterior maxillary alveolar bone was made. The volume of the alveolar bone in males and females was 5.613 ± 0.972 cm³ and 4.885 ± 0.833 cm³, respectively. The results of this study differ slightly from those reported by Shan et al. [19]., who reported an average alveolar bone volume of 7.448 ± 1.405 cm³ and 6.474 ± 1.152 cm³ in males and females, respectively. This discrepancy may be attributed to the fact that this study separated the dental tissues from the alveolar socket during model construction, whereas Shan et al. truncated the crown portion and preserved the root to establish a model and perform volume measurements, resulting in larger volume results. Statistical analysis confirmed a positive correlation between the alveolar bone volume and the presence of AC in the present study, which is consistent with the findings of the study by Shan et al. A ROC curve based on alveolar bone volume and the presence of AC was constructed to validate whether the presence of AC can be predicted using alveolar bone mass, yielding a significant result (P < 0.001) with an AUC of 0.626. This confirms that alveolar bone volume can only predict the presence of AC to a certain extent, and that the actual occurrence should be combined with imaging findings.

This study had certain limitations that should be acknowledged. First, measurement of the maxillary alveolar bone volume was necessary in the present study. Consequently, a considerable amount of image data depicting alveolar bone absorption exceeding 20% of the root length were excluded during the sample selection process. Thus, the sample size of individuals aged > 60 years is small. In addition, horizontal bone resorption not reaching 20% of the root length still affects the measurements to some extent. In this study, the criterion for measuring the diameter of the AC was based on the end diameter. However, this method may have limitations when addressing bifurcation-type ACs. Second, this study did not integrate imaging data with gross anatomical findings. Therefore, further in-depth research in future experiments is necessary.

The prevalence of AC in the anterior maxilla is significantly high, and it displays considerable variation in the trajectory among individuals. The vast majority of ACs show a horizontal relationship with the roots of the anterior teeth. Although a substantial volume of alveolar bone is often perceived as advantageous for dental implant surgery, it simultaneously increases the risk of encountering AC. Therefore, surgeons must consider the possibility of the presence of AC when devising surgical plans involving the anterior maxillary region.

Ethical Approval

The Affiliated Dental Hospital of Jinzhou Medical University's Ethics Committee approved this study, which scrupulously adhered to the guidelines set forth in the Declaration of Helsinki. All patients provided their informed consent before being enrolled in the trial and having their CBCT images taken.

Competing interests

The authors declare no competing interests or conflicts of interest.

Authors’ contributions

Zhenwei Sun actively contributed to various aspects of this research project, including the research design, data collection, manuscript writing, figure creation, and data interpretation.

Dan Li participated in data analysis and article translation.

Xuan Zhang and Jiaxin Zhang participated in collecting and organizing the data.

Chunyan He contributed to experimental direction and planning, participated in paper writing and revision, and provided valuable critical feedback.

The final manuscript was reviewed and approved by all authors.

Funding

This study did not receive any financial assistance, grants, or other forms of support.

Availability of data and materials

Due to privacy considerations, the datasets created and/or analyzed for the current work are not publicly available but are available from the corresponding author on reasonable request.

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Cone-beam computed tomography of accessory canals of the canalis sinuosus and analysis of the related risk factors

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