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Anatomic Characteristic of Infraorbital Nerve Course in Relation With Maxillary
Sinus.
:‫بیان مسأله‬
The maxillary nerve is the second division of trigeminal nerve. It begins at the
middle of the trigeminal ganglion and leaves the skull through the foramen
rotundum. It then crosses the pterygopalatine fossa, inclines lateralward on the back
of the maxilla, and enters the orbit through the inferior orbital fissure. From this
point the nerve runs forward on the floor of the orbit, at first in the infraorbital groove
and then in the infraorbital canal remaining outside the periosteum of the orbit. It
then emerges on the face through the infraorbital foramen and terminates by dividing
into palpebral, lateral nasal and labial branches . The maxillary nerve branches may
be divided into four groups, depending upon where they branch off: in the cranium,
in the pterygopalatine fossa, in the infraorbital canal, or on the face. Branches of
maxillary nerve in infraorbital canal are infraorbital nerve and anterior superior
alveolar nerve. The anterior superior alveolar nerve also pass through a canal or
groove along the internal wall of the maxillary sinus and communicate with the
middle and posterior superior alveolar nerve (1,2,3,7).
The infraorbital canal is an essential morphological feature that is used during facial
injections in the same way the infraorbital foramen and nerve are important surgical
parameters for the caldwell-luk surgery(4).
The infraorbital foramen is located in the maxilla bilaterally on its front side and is
guided in the inferomedial direction located under the inferaorbital edge, varying
from 4 to 12 mm (4,10).
Search in the literature we have found that the foramen may be close to another
foramen called infraorbital accessory (5). In japanese macaque the nerves and blood
vessels that passed through the accessory canals mainly supplied the canines and
incisors (6). However there is no information about assessing the multi infraorbital
canal foramens by 3D analysis in humans due to its low incidence (7).
Most of the research about Infraorbital canal are performed on cadaver through
anthropometric analysis. Although some studies have searched IOC using CT
images, no studies have been performed on human based on CBCT images (8).
The course of the Infraorbital canal and accessory foramens affects the morphology
of the maxillary sinus (9).
Knowledge about the infraorbital nerve course is important because it is involved in
different surgical procedures on maxillofacial structures (10).
During an expanded endoscopic approach, if the back wall of the maxillary sinus is
removed to gain access to the infratemporal fossa, the infraorbital nerve will be at
risk(1).
Culdwell-luck is a type of maxillotomy which produces an external access to the
maxillary sinus. Most frequent related complications are lesions of the infraorbital
nerve which lead to paresthesia or anesthesia of the facial region (11).
Surgeons should avoid injury to infraorbital nerve and vessels during operations of
maxillary sinus scaling, centesis and cyst expiration (12).
Infraorbital nerve permanent damage and nerve palsy can happen during rhinoplasty
and maxillofacial trauma; such as zygomatic complex fracture (13,14)
Of rare anatomic variations; is the presence of infraorbital nerve in maxillary sinus
septum, there are two case report and one retrospective articles about it (2,10,11). In
a recent study the prevalence of %10.6 is reported for this variation (2). In these
cases, any surgical attempt to breakdown this septum would result in ION palsy,
with permanent paresthesias in the maxillary region (15).The passage of the ION
and its branches within the center of the maxillary antrum within thin bony
trabeculae has also been observed. Therefore, radiologists and dentists should be
aware of these anatomical variations in the maxillary sinus. Rare anatomical
variations like the presence of a bony trabecula containing the middle superior
alveolar nerve in the center of the maxillary antrum should also be kept in mind by
radiologists for proper image interpretation and by anesthesiologists, since complete
anesthesia cannot be achieved by targeting the ION just in the infraorbital foramen,
when some of the fibers escape through this bony trabecula (16,17,18).
Ference et al. have reported that the proportions of infraorbital nerve protrusion into
maxillary sinus increased when a haller cell was present (19). Haller cells are
anterior ethmoid air cells located in the medial orbital floor immediately lateral to
the maxillary infundibulum. In a study based on CBCT images, the prevalence of
haller cell was reported to be remarkably high (%60) this study also provides
evidence for the usefulness of CBCT scan in delineation of the bony anatomy of
sinonasal complex at substantially higher precision and lesser radiation (20,21).
According to Ference et al., some haller cells contained the infraorbital nerve within
their lamellae. Descent infraorbital nerve is also a common finding (1).
The morphological details of maxillary sinus septa, particularly their location and
anatomical planes, will guide dentists in performance of safe implant surgeries
(22).
Regarding the anatomical relationships of ION and its importance in facial
anesthesia and oral and facial surgical procedures, this study is designed to improve
the knowledge of dentists and surgeons about ION course in relation with maxillary
sinus using CBCT images. The results will help, preventing ION damage upon
surgical procedures and preparing more profound anesthesia of midface.
Literature Review:
In 2015 Ference et al. have evaluated the surgical anatomy and variations of the
infraorbital nerve in 100 consecutive computed tomography of sinus. Measurements
were made on 200 IONs. Anatomic variants were classified into three types based
on the degree to which the nerve course descendence from the maxillary roof into
the sinus lumen. A total of %60.5 of IONs were entirely contained within the sinus
roof. In %27 the nerve canal descended below the roof but remained juxtaposed to
it. In %12.5 the ION descended into the sinus lumen. The proportion of IONs
descended into the sinus significantly increased to %27.7 when an infraorbital
ethmoid cell was present. Descended nerve terminated in a foramen located an
average of 11.9 mm below the infraorbital rim, significantly further below the orbit
compared with nondescended nerves. Descended nerves were located a mean
distance of 8.6 below the sinus roof and traversed the sinus lumen diagonally for a
mean length of 15.4. They concluded that descent of the ION into the maxillary sinus
is a common anatomic variant that is more prevalent in the setting of an ipsilateral
ethmoid cell. Descended nerves are associated with foramens significantly further
below the inferior orbital rim. These observations may help surgeons avoiding
iatrogenic ION injury(1).
Gandhi et al., in 2015, showed that sagittal septae of maxillary sinus( septa type
III) may contain one of the branches of ION. If these septae were cut accidentally
during sinus surgeries, ION palsy will result (12).
In 2014 Lantos et al. evaluated the protrusion of the infraorbital nerve into the
maxillary sinus on CT. They performed a retrospective review of 500 consecutive
sinus CTs. The infraorbital nerve protruded into the maxillary sinus if the entire
wall of the infraorbital canal was separate from the walls of the sinus. They
recorded the length of the bony septum that attached the infraorbital canal to the
wall of the maxillary sinus and noted whether the protrusion was bilateral. They
also measured the distance from the inferior orbital rim where the infraorbital canal
begins to protrude into the sinus. There was a prevalence of 10.8% for infraorbital
canal protrusion into the maxillary sinus and 5.6% for bilateral protrusion. The
median length of the bony septum attaching the infraorbital canal to a maxillary
sinus wall, which was invariably present, was 4 mm. The median distance at which
the infraorbital nerve began to protrude into the sinus was 11 mm posterior to the
inferior orbital rim. They concluded that the infraorbital canal protrusion into the
maxillary sinus was present in >10% of patients(2).
in 2014 Satwik et al. reviewed the literatures about the anatomical variations of
supraorbital, infraorbital and mental foramen based on gender and side. They
found that supraorbital foramen lies 23.9mm right and 25.6mm left from the nasion
approximately. Similarly they found that Infraorbital foramen lies in the maxillary
bone lower to the edge of the orbital canal and it is bilateral, which contain
Infraorbital nerve and vessels. The mean distance from the lower edge of the
orbital cavity to the center of Infraorbital foramen do not show any significant
differences regarding laterality in male and female individuals, both between
genera, regardless of the side and regardless of genus. Likewise mental foramen is
found in the mandible which is oval or round in shape located at the interval
between mandibular premolar, through which mental nerves and vessel passes.
They understood from the comparisons of results of previous studies makes the
large variation of the anatomical characteristics of all the foramen evident, not only
due to diversity of the used parameters, but also due to the distinct investigated
populations (8).
In 2013 Zaizen et al. investigated the multi infraorbital canals in the Japanese
macaque by cone-beam computed tomography. The superior and lateral margins of
the orbit were correlated with the infraorbital canal on three dimensional
reconstruction images. They classified three types of multi infraorbital foramen, and
type 3 had three accessory foramina in the infraorbital canal . The infraorbital canal
also formed three structures, specially a tube-like shape, a funnel-shape, and a
pinched shape. The accessory canals also contained nerves and blood vessels, and
the canals ran downward and supplied the maxillary sinus, teeth, and midfacial
region of the craniofacial skeleton, while passing through a few branch canals. These
accessory canals proved valuable for blood vessels and nerves, also affects the
morphology of the maxillary sinus (6).
In 2012 Hongzhao et al. valuated the morphological structure of infraorbital canal
using 3D reconstruction. This study was based on 64-slice computed tomographic
multiple planar reconstruction technique and can improve the success rate of
infraorbital nerve blockade. The observations were carried out in 224 normal
infraorbital canals (112 people): the length, angle and adjoined relation of initial
infraorbital canal, to reveal the anatomic characteristics of the canal and to compare
the difference between left and right or male and female. They measured Six
indicators: (1) the length of initial infraorbital canal; (2) the distance between skin
and the first obvious turn of infraorbital canal along the direction of initial
infraorbital canal; (3) the vertical distance between the infraorbital canal and nasal
septum; (4) the vertical distance between the infraorbital canal and infraorbital rim;
(5) the angle between the infraorbital canal and Frankfort plan; and (6) the angle
between the infraorbital canal and the sagittal plane. The difference was statistically
significant between 2 sides on the depth of puncture. For other values, the difference
between left and right and between women and men were of no statistical
significant(7).
In 2012 Wu-Chul Song et al. investigated the anatomy of the infraorbital canal (IOC)
and its related small canals in the maxilla. Twenty-eight hemimaxillae from human
cadavers were studied. The samples were scanned using microcomputed
tomography, and then images were three-dimensionally reconstructed using
computer software. The branch point of the canal into the anterior superior alveolar
nerve from the IOC occurred at about one third along the length of the IOC in the
anterior direction. Just over half of the cases had 1 canal. The branch arose either
laterally (21/28) or inferiorly (7/28) from the IOC. There was a canal located at the
inferior lateral border of the piriform aperture in all cases. The distribution of the
canals in the maxilla is represented indirectly by the course and distribution of the
nerve and blood vessels. This distribution could explain various phenomena
encountered in the clinical field (3).
In 2012 Junior et al. studied the morphological and biometric of the infraorbital
foramen in adult skulls. 60 dry skulls were analyzed. On the right side, the FIO was
measured at a distance of 6.49(±1.68) mm from the lower, 39.65(±3) mm from the
upper, 17.7(±2.97) mm from the medial and 20.46(±2.9) mm from the lateral
margin of the orbit; its pear-shaped opening distance was 13.67(±2.17) mm. On the
left side, the distance of the FIO to the lower margin of the orbit was 6.52(±1.82)
mm; to the upper margin was 39.9(±2.62) mm and to the lateral and medial margin
were 17.93(±2.58) mm and 21.12(±3) mm, respectively; its distance to the pearshaped opening was 14.26(±1.83) mm. It was found predominately in an oval
shape, in 39(65%) of the skulls, on both sides. Accessory foramens were present in
11 samples on the right and in 15 samples on the left side. The FIO was most
frequently found on the side of, or laterally to the sagittal plane that passes through
the middle of the supraorbital foramen/incisures, in 38 skulls (63.3%) on the right
side and in 45 skulls (75%) on the left and middle to the zigomatic-maxillary
suture, in 41 skulls (68.3%) on right and in 42 skulls (70%) on the left side, besides
being most frequently found in a region between the first and second premolars, in
22 skulls (36.7%) on the right side and in 17 skulls (28.3%) on the left (5).
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