Christiano de Oliveira-Santos Neurovascular anatomical variations

Izabel R. F. Rubira-Bullen
Solange A. C. Monteiro
in the anterior palate observed on
Jorge E. León CBCT images
Reinhilde Jacobs

Authors’ affiliations:
Christiano de Oliveira-Santos, Solange A. C.
Monteiro, Jorge E. León, Department of Morphology,
Stomatology and Physiology, University of
São Paulo – Ribeirão Preto School of Dentistry,
Ribeirão Preto, Brazil
Izabel R. F. Rubira-Bullen, Department of
Stomatology, University of São Paulo – Bauru
School of Dentistry, Bauru, Brazil
Reinhilde Jacobs, Department of Periodontology,
Oral Imaging Center – Katholieke Universiteit
Leuven, Leuven, Belgium
Corresponding author:
Prof. Christiano de Oliveira-Santos
Universidade de São Paulo – Faculdade de
Odontologia de Ribeirão Preto
Avenida do Café, s/n, Bairro Monte Alegre
Ribeirão Preto – SP CEP 14040-904
Brazil
Tel.: +55 16 3602 4805
Fax: +55 16 3602 4794
e-mail: oliveirach@forp.usp.br
Key words: anatomical variations, cone beam computed tomography, CT imaging, imaging,
jaw bone neurovascularization, radiology
Abstract
Objective: This study aimed to assess the presence of additional foramina and canals in the
anterior palate region, through cone beam computed tomography (CBCT) images, describing their
location, direction, and diameter.
Materials & Methods: CBCT exams of 178 subjects displaying the anterior maxilla were included
and the following parameters were registered: gender; age group; presence of additional foramina
in the anterior palate (AFP) with at least 1 mm in diameter; location and diameter of AFP; and
direction of bony canals associated with AFP.
Results: Twenty-eight patients (15.7%) presented AFP and in total 34 additional foramina were
registered. No statistical differences between patients with or without AFP were found for gender
or age. The average diameter of AFP was 1.4 mm (range from 1 to 1.9 mm). Their location was
variable, with most of the cases occurring in the alveolar process near the incisors or canines
(n = 27). In 18 cases, AFP was associated with bony canals with upward or oblique direction toward
the anterior nasal cavity floor. In 14 cases, the canal presented as a direct extension of the canalis
sinuosus, in an upward direction laterally to the nasal cavity aperture. In two cases, the canal was
observed adjacent to the incisive and joined the nasopalatine canal superiorly.
Discussion: CBCT images have a crucial role in the recognition of anatomical variations by
allowing detailed tridimensional evaluations. Additional foramina and canals in the anterior region
of the upper jaw are relatively frequent. Practitioners should be aware and trained to identify
these variations.
Conclusions: Over 15% of the population studied had additional foramina in the anterior palate,
between 1 mm and 1.9 mm wide, with variable locations. In most cases the canals associated with
these foramina either presented as a direct extension of the canalis sinuosus, or coursed towards
the nasal cavity floor.

Date:
Accepted 10 April 2012
To cite this article:
de Oliveira-Santos C, Rubira-Bullen IRF, Monteiro SAC, León
JE, Jacobs R. Neurovascular anatomical variations in the
anterior palate observed on CBCT images.
Clin. Oral Impl. Res. 00, 2012, 1–5
doi: 10.1111/j.1600-0501.2012.02497.x
The popularization of cone beam computed
tomography (CBCT) has raised the interest in
revisiting the anatomical features of the jaws,
particularly regarding neurovascularization
and possible anatomical variations (Bornstein
et al. 2011; Oliveira-Santos et al. 2011, 2012).
Such attention is also justifiable by the
increasing number of surgeries performed
recently (e.g. orthognatic, dental implant
placement, implant for orthodontic anchor-
age, etc.). Injuries of major vascular and nerve
branches should be avoided to achieve safer
surgical procedures and better outcomes,
which require careful pre-operative observa-
tion (Mraiwa et al. 2004; Liang et al. 2006).
Modern cross-sectional imaging has allowed
better in vivo visualization of fine details of
the anatomy (Mraiwa et al. 2004; Liang et al.
2006; Jacobs et al. 2007; Oliveira-Santos et al.
2011, 2012).
The nasopalatine canal and incisive fora-
men, carrying nasopalatine nerve and artery,
represent major neurovascular bony struc-
tures in the anterior maxilla (Mraiwa et al.
2004; Liang et al. 2006). Most dentists are
familiar with these landmarks and recognize
them on conventional radiographs. The ante-
rior superior alveolar (ASA) nerve and artery
also reach this region through a bony canal
named canalis sinuosus (Jones 1939; Warwick
& Williams 1973; Heasman 1984; Balaji 2007;
Liang et al. 2008) to supply the incisors and
canines, as well as adjacent soft tissues (Jones
1939; McDaniel 1956; Warwick & Williams

© 2012 John Wiley & Sons A/S 1

de Oliveira-Santos et al
Neurovascular anatomical variations in the anterior palate
1973; Heasman 1984; Balaji 2007; Rodella
et al. 2012). Anatomical variations (e.g. addi-
tional foramina and canals) may be present in
such a mix of neurovascular structures in the
anterior region, with relevant impact on treat-
ment plans and outcomes, by posing as poten-
tial complications to surgical procedures
(Kohavi 1994). Conventional radiographs may
fail to properly display these anatomical con-
figurations (Kohavi 1994; Temmerman et al.
2011) and even anatomy textbooks may lack
detailed description of these variations.
This study aims to assess the presence of
additional foramina and canals in the anterior
palate region, through CBCT images, describ-
ing their frequency, location, direction, and
diameter, when present.
Methods
The sample consisted of consecutive patients
referred to the Oral Imaging Center at Katho-
lieke Universiteit Leuven (Belgium) for
CBCT imaging of the upper jaw for a variety
of clinical reasons (e.g. implant placement,
and third molars extraction), between May
2008 and May 2009. CBCT exams were
scanned with Scanora 3D® (Soredex, Tuusula,
Finland), acquired with FOV 10 9 7.5 cm or
14.5 9 13.5 cm, standard or high resolution
(voxel size range 0.15–0.25 mm), and those
displaying the anterior maxilla region were
included. Exclusion criteria consisted of
exams with low technical quality or partial
imaging of anterior maxilla, and presence of
bony lesions altering the course of neurovas-
cular structures. All images were viewed
with Ondemand 3DTM software (Version 1.0;
CyberMed Inc., Seoul, Korea), by two cali-
brated and experienced oral and maxillofacial
radiologists. Observations were repeated after
a minimum of 1 week interval.
The following parameters were registered:
gender (male; female); age group (  20; 21–
40; 41–60; >60 years); presence of additional
foramina in the anterior palate (AFP) at
least 1 mm in diameter; location of AFP
(central incisors region; between central and
lateral incisors; lateral incisor region; canine
region; first premolar region, and adjacent
to incisive foramen: posterior, anterior, or
lateral); diameter of AFP (in mm); and
direction of bony canals associated with
AFP.
Axial, coronal, sagittal, panoramic, and
cross-sectional reconstructions were ana-
lyzed in every case. Diameters were deter-
mined by measuring the palatine opening of
the additional canal on both coronal and
2 | Clin. Oral Impl. Res. 0, 2012 / 1–5
cross-sectional images. The results are pre-
sented using descriptive statistical analysis.
Intraobserver and interobserver agreement
were calculated (Kappa coefficient for cate-
gorical data, and paired t-test for diameter
measurements). Potential differences regard-
ing gender and age among patients with and
without AFP were assessed by Chi-square or
Fischer′s exact test (PACOTICO 5.0 software
– University of São Paulo, Bauru School of
Dentistry).
Results
CBCT exams of 178 subjects were included
(64 male, 86 female). Twenty-eight patients
(15.7%; 13 male, 15 female) presented AFP
that were at least 1 mm in diameter. In six
cases, two additional foramina (bilaterally)
were observed. A total of 34 additional
foramina were registered. Regarding age of
subjects, the distribution of the sample
among the groups was virtually even (n = 36,
n = 34, n = 41, and n = 39 for age groups
 20, 21–40, 41–60, >60, respectively). The
age group  20 years had the lowest occur-
rence of AFP (n = 2). Age groups 21–40, 41–
60, and >60 years had 8, 9, and 9 cases,
respectively. However, no statistically signifi-
cant differences between patients with or
without AFP were found for gender or age
(P = 0.71 and 0.26, respectively). Caucasian
subjects were 98.3% of the sample (n = 175).
No additional foramina were observed among
non-Caucasians (n = 3).
The average diameter of AFP was 1.4 mm
(1–1.9 mm). Their location was variable, with
most of the cases occurring in the alveolar
process near the incisors or canines. Fig. 1 is
a schematic representation of the distribution
of AFP observed according to their locations.
These AFP were associated with bony
canals that, in some cases, had an upward or
oblique direction toward the anterior portion
of the nasal cavity floor (n = 18) (Fig. 2). In
other cases (n = 14), the bony canal presented
as a direct extension of the canalis sinuosus,
in an upward direction laterally to the nasal
cavity aperture (Fig. 3). In two cases, the
bony canal associated with AFP located adja-
cent to the incisive foramen (one case poste-
riorly and one case laterally to the incisive
foramen) joined the nasopalatine canal supe-
riorly (Fig. 4).
Interobserver agreement was substantial for
the location of AFP and the direction of
canals (kappa coefficient = 0.71 and 0.74,
respectively; P < 0.001). Intraobserver agree-
ment was also substantial for these parame-
Fig. 1. Schematic representation of distribution of addi-
tional foramina observed in the palate, according to
their location relative to teeth/incisive foramen. The
number in the circle indicates the number of cases
found. Side distribution (left/right) is not represented in
this figure: • Central incisors region – four cases; •
Between central and lateral – six cases; • Lateral inci-
sors region – eight cases; • Canine region – nine cases; •
First premolar region – three cases; • Lateral to incisive
foramen – three cases; • Posterior to incisive foramen –
one case.
ters (kappa coefficient of 0.73–0.85;
P < 0.001). Intraobserver differences for the
diameter of AFP were not significant
(P > 0.05), with a mean difference of
0.09 mm (95% confidence interval: 0.05–
0.24 mm). Interobserver differences were sta-
tistically significant for diameter of AFP
(P < 0.05), however, the mean difference
between observers’ measurements was only
0.13 mm (95% confidence interval: 0.04–
0.21 mm).
Discussion
Preoperative identification of the course of
nerves and vessels through radiographic eval-
uation is essential for safe surgical proce-
dures (Kohavi 1994; Rodella et al. 2012).
Damage to major vessels represent risk of
hemorrhage, and injury to nerve may have
impact on a patient′s quality of life due to
hyperesthesia, paresthesia, or pain (Liang
et al. 2008; Rodella et al. 2012). In addition,
implants that come into contact with neural
tissue may cause failure of osseointegration
(Liang et al. 2006; Bornstein et al. 2011).
In this study, we demonstrate that addi-
tional palatine foramina at least 1 mm in
diameter may be found in around 16% of
patients of both genders and different age
groups. Such foramina and bony canals may
© 2012 John Wiley & Sons A/S

(a)
(c)
Fig. 2. Coronal (a and b) and axial (c and d) views of a cone beam computed tomography scan showing additional
foramen (arrow) and canal presenting as a direct extension of canalis sinuosus (arrow head).
(a)
Fig. 3. Axial (a) and coronal (b) views of a cone beam computed tomography scan showing additional foramen in
the anterior palate (arrow), lateral to the incisive foramen associated with bony canal with oblique upward-medial
direction toward anterior portion of nasal cavity floor. Note the circumnarial path of the canalis sinuosus, bilater-
ally (arrow heads).
be clinically relevant because they may
enclose neurovascular content of significant
caliber. It has been stated that the palate may
be pierced by many small foramina and
marked by pits for palatine glands (Warwick
& Williams 1973). However, despite a few
cases reported in the literature (Kohavi 1994;
Shelley et al. 1999; Temmerman et al. 2011),
the occurrence of anatomical variations
involving AFP region with clinically relevant
diameters and their association with bony
© 2012 John Wiley & Sons A/S
de Oliveira-Santos et al
Neurovascular anatomical variations in the anterior palate
(b)
(d)
(b)
canals that may contain major neurovascular
content has not been systematically assessed.
The bony canal associated with AFP had a
clear upward direction toward the canalis sin-
uosus in some cases (n = 14), probably repre-
senting a direct palatine extension of ASA
nerve and artery. The canalis sinuosus is a
normal anatomical feature that corresponds
to a poorly recognized neurovascular canal
that carries the ASA nerve and artery (Liang
et al. 2008). This canal was named “canalis
sinuosus” by Jones (1939), and this term was
suggested due to its doubled curved course.
Few subsequent authors have referred to this
canal (Warwick & Williams 1973; Heasman
1984; Shelley et al. 1999; Balaji 2007) and
apparently not much attention has being
given to this structure in recent literature.
However, this is a rather wide canal and car-
ries not only the ASA nerve which is a con-
siderable nerve in diameter (McDaniel 1956)
but also the ASA artery.
The ASA nerve is the largest of the supe-
rior alveolar nerves and originates from the
infraorbital nerve. On the orbital floor, it
runs laterally to the infraorbital canal in the
canalis sinuosus. It then courses downward,
forward, and turns medially in a mild curve
that passes below the infraorbital foramen
(Jones 1939; McDaniel 1956; Warwick &
Williams 1973; Heasman 1984; Balaji 2007;
Rodella et al. 2012). It then starts its cir-
cumnarial course as it reaches the lateral
wall of the nasal cavity and follows the curve
of the narial margin. At this point it gives off
neurovascular branches to form a dental
plexus in the alveolar process, supplying the
canines and incisors. The terminal branch of
the ASA nerve and artery supply the nasal
septum and runs in a small canal that opens
in the foramen septale, which is a bilateral
structure near the root of the anterior nasal
spine (Balaji 2007). The entire course of the
canalis sinuosus stretches for around 5.5 cm
in length, with the orbital floor part account-
ing for around 1.5 cm, the transverse facial
part with 2 cm, and the circumnarial part
with around 2 cm (Heasman 1984). Fig. 5
shows a schematic representation of the
course of the canalis sinuosus.
Shelley et al. (1999) reported a rare case in
which the canalis sinuosus could be observed
on a periapical radiograph as a periapical
radiolucency on around an upper canine.
Fig. 4. Cross-sectional view of a cone beam computed
tomography scan showing an additional foramen (arrow)
located posteriorly from the incisive foramen and con-
nected superiorly to the nasopalatine canal.
3 | Clin. Oral Impl. Res. 0, 2012 / 1–5
de Oliveira-Santos et al
Neurovascular anatomical variations in the anterior palate
Fig. 5. Schematic representation of the course of the ca-
nalis sinuosus.
With CBCT, the canalis sinuosus can be fre-
quently observed as a wide canal lateral to
the nasal cavity and also under the anterior
part of nasal floor.
Many variations can be expected from the
origin, course, and distribution of the maxil-
lary nerves and vessels to teeth. For instance,
the ASA nerve may present a secondary
nerve branch to the premolar region in 12%
of the cases, in cases where superior middle
alveolar nerve is absent (McDaniel 1956). In
the canine fossa region, the ASA nerve may
present as a single trunk or as a diffuse
plexus (McDaniel 1956). Although the pres-
ence of canalis sinuosus is a normal ana-
tomic aspect, their opening in the anterior
palate is an anatomical variation that has not
been properly described, and requires special
attention in surgical procedures in that
region. Kohavi (1994) reported a case in
which relatively wide canals were registered
bilaterally on computerized tomography (CT)
images, with palatine openings in the canine/
premolar region. Such canals were referred to
as “posterior superior alveolar arteries”; how-
ever, CT images available in the case report
clearly show that these structures fit the
description of canalis sinuosus with palatine
extensions, like those observed in this study.
The author highlights the fact that such
canals could not be observed on pre-operative
panoramic radiographs.
On multi-slice CT images, Temmerman
et al. (2011) observed that in one-third of
cases additional bony canals in the upper
canine region started palatally and coursed in
a latero-cranial direction. In our study, preva-
lence of additional canals was much lower
(nearly 16%) and included other locations
4 | Clin. Oral Impl. Res. 0, 2012 / 1–5
than just canine region. This difference in
prevalence is probably because those authors
took into account even minute canals with
0.5 mm in diameter.
In our study, we demonstrate two cases of
AFP in the vicinity of the incisive foramen
that were connected superiorly to the nas-
opalatine canal, representing an anatomical
variation in this neurovascular structure. The
nasopalatine canal is located in the midline
and posterior to the central maxillary inci-
sors. The incisive foramen is the funnel-
shaped oral opening of the nasopalatine canal
in the midline of the anterior palate (Mraiwa
et al. 2004). Studies with three-dimensional
exams have demonstrated considerable ana-
tomical variations in the nasopalatine canal
regarding their dimension and morphology
(Liang et al. 2006; Bornstein et al. 2011). The
number of openings at the level of the nasal
floor may vary from one to four (Liang et al.
2006).
In 18 cases, the canals associated with the
AFP had an upward or oblique path toward
the anterior portion of the nasal cavity floor.
In these cases, the canals may represent addi-
tional branches of the nasopalatine nerve/
artery. However, because the terminal por-
tion of the canalis sinuosus outlines the
nasal floor (Jones 1939; McDaniel 1956; War-
wick & Williams 1973; Heasman 1984; Balaji
2007), these canals may also be connected to
the ASA nerve/artery. We suggest that in
these cases, or even in cases without AFP,
there may be varying degrees of anastomosis
between ASA and nasopalatine nerves/arteries
in this area. Further ex-vivo studies with dis-
sections may shed some light into this issue.
It has been demonstrated that the fre-
quency of anatomical variations may be
related to ethnical-geographical context (Li-
ang et al. 2009). Although no cases of AFP
were observed in non-Caucasian subjects in
our study, our sample was over 98% Cauca-
sians (175 of 178), and so it was not possible
to infer further comparisons related to eth-
nicity. Further studies in different geographic
regions may find different results because of
these variations.
Hemorrhage and neurosensory disturbances
are the most common complications related
to implant placement surgeries (Goodacre
et al. 2003). To the best of our knowledge, a
threshold for a minimum canal diameter to
cause relevant neurovascular injury has not
been reported. However, several cases may be
found associating profuse bleeding with inju-
ries to relatively small vessels. In the anterior
region of the mandible, arteries associated
with accessory lingual foramina, which are
less than 1 mm in diameter, can be of suffi-
cient size to be implicated with severe hem-
orrhage during implant placement (Tepper
et al. 2001; Kalpidis & Setayesh 2004; Jacobs
et al. 2007; Liang et al. 2008). Although the
possibility of hemorrhagic episodes in the
maxilla is smaller (Hong & Mun 2011), even
minute canals, such as alveolar canals, if
damaged, may cause massive bleeding into
the maxillary sinus (Hong & Mun 2011). One
of the most common causes of hemorrhage
in surgical procedures in the posterior max-
illa involves injury to the descending palatine
artery (Lamas-Pelayo et al. 2008), which has
been shown to present diameters between 1.1
and 2.0 mm, with an average of 1.7 mm (Ka-
sey et al. 1996).
Excessive bleeding during surgical proce-
dures in the anterior maxilla with unidentifi-
able cause, and unclear pain associated with
implant placement in the anterior maxilla
have been reported (De Rouck et al. 2008;
Gunaseelan et al. 2009). In such cases, we
believe that possible damage to neurovascular
content in the canalis sinuosus or related
anatomical variations cannot be ruled out.
Even though the diameter of the AFP in
the present study ranged from 1.1 to 1.9 mm,
wider diameters for canals that represented
an extension of canalis sinuosus with a pala-
tal opening have been demonstrated previ-
ously. Kohavi (1994) reported bilateral canals
in the canine region and confirmed transurgi-
cally, through positive aspiration test, the
presence of arteries with diameter of approxi-
mately 3 mm. Temmerman et al. (2011)
observed, on CT images, canals that ranged
from 0.5 to 7.7 mm.
Differences between observers for the mea-
surements of AFP diameters were statisti-
cally significant, yet these differences were
clearly small (average 0.13 mm; 95% confi-
dence interval 0.04–0.21). From a clinical
point of view, such submilimetric differences
for these types of measurements are irrele-
vant. As observers must manually determine
the diameters by clicking on the limits of the
foramina, small measurement variations are
certainly expected.
Conventional images have limited value in
showing some intrabony courses of neurovas-
cular structures (Kohavi 1994; Temmerman
et al. 2011) therefore CBCT images may have
an important role in the pre-surgical recogni-
tion of anatomical variations by allowing
detailed tridimensional evaluations. Addi-
tional foramina and canals in the anterior
region of the upper jaw present clinical rele-
vance due to their relatively high frequency
among the population studied (over 15%) and
© 2012 John Wiley & Sons A/S

the possibility of causing complications if
vessels or nerves are damaged. Therefore, cli-
nicians and surgeons should be aware and
trained to identify these variations when they
are present.
References
Balaji, S.M. (2007) Textbook of Oral and Maxillofa-
cial Surgery. New Delhi: Elsevier.
Bornstein, M., Balsiger, R., Sendi, P. & von Arx, T.
(2011) Morphology of the nasopalatine canal and
dental implant surgery: a radiographic analysis of
100 consecutive patients using limited cone-beam
computed tomography. Clinical Oral Implants
Research 22: 295–301.
De Rouck, T., Collys, K. & Cosyn, J. (2008) Imme-
diate single-tooth implants in the anterior max-
illa: a 1-year case cohort study on hard and soft
tissue response. Journal of Clinical Periodontol-
ogy 35: 649–657.
Goodacre, C.J., Bernal, G., Rungcharassaeng, K. &
Kan, J.Y.K. (2003) Clinical complications with
implants and implant prostheses. Journal of Pros-
thetic Dentistry 90: 121–132.
Gunaseelan, R., Anantananrayanan, P., Veerabahu,
M. & Vikraman, B. (2009) Intraoperative and peri-
operative complications in anterior maxillary os-
teotomy: a restrospective evaluation of 103
patients. The International Journal of Oral and
Maxillofacial Surgery 67: 1269–1273.
Heasman, P.A. (1984) Clinical anatomy of the supe-
rior alveolar nerves. British Journal of Oral and
Maxillofacial Surgery 22: 439–447.
Hong, Y.-H. & Mun, S.-K. (2011) A case of massive
maxillary sinus bleeding after dental implant.
The International Journal of Oral and Maxillofa-
cial Surgery 40: 758–760.
Jacobs, R., Lambrichts, I., Liang, X., Martens, W.,
Mraiwa, N., Adriaensens, P. & Gelan, J. (2007)
Neurovascularization of the anterior jaw bones
revisited using high resolution magnetic reso-
nance imaging. Oral Surgery Oral Medicine Oral
Pathology Oral Radiology and Endodontics 103:
683–693.
Jones, F.W. (1939) The anterior superior alveolar
nerve and vessels. Journal of Anatomy 73: 583–591.
© 2012 John Wiley & Sons A/S
de Oliveira-Santos et al
Neurovascular anatomical variations in the anterior palate
Acknowledgements
The authors would like to thank Dr Lien
Stinkens, Dr Kristin Moyaert, Prof. Paulo
Couto Souza, and Prof. Soraya Berti-Couto
Kalpidis, C.D. & Setayesh, R.M. (2004) Hemorrhag-
ing associated with endosseous implant place-
ment in the anterior mandible: a review of the
literature. Journal of Periodontology 75: 631–645.
Kasey, K., Meara, J.D. & Alexander, A. (1996) Loca-
tion of the descending palatine artery in relation
to the Le Fort I osteotomy. The International
Journal of Oral and Maxillofacial Surgery 54: 822
–825.
Kohavi, D. (1994) Demonstration of unusually wide
artery in the maxillary alveolar bone using a
reformatting program of computed tomography: a
case report. The International Journal of Oral &
Maxillofacial Implants 9: 444–448.
Lamas-Pelayo, J., Peñarrocha-Diago, M., Marti-Bo-
wen, E. & Peñarrocha-Diago, M. (2008) Intraoper-
ative complications during oral implantology.
Medicina Oral, Patologı́a Oral y Cirurgı́a Bucal
13: E239–E243.
Liang, X., Jacobs, R., Corpas, L.S., Semal, P. &
Lambrichts, I. (2009) Chronologic and geographic
variability of neurovascular structures in human
mandible. Forensic Science International 190: 24–
32.
Liang, X., Jacobs, R. & Lambrichts, I. (2006) Appear-
ance, location, course and morphology of the supe-
rior and inferior genial spinal foramina and their
bony canals: an assessment on spiral CT scan.
Surgical and Radiologic Anatomy 28: 98–104.
Liang, X., Lambrichts, I., Corpas, L., Politis, C.,
Vrielinck, L., Ma, G.W. & Jacobs, R. (2008) Neu-
rovascular disturbance associated with implant
placement in the anterior mandible and its surgi-
cal implications: literature review including
report of a case. Chinese Journal of Dental
Research 11: 56–64.
McDaniel, W.M.L. (1956) Variations in nerve distri-
butions of the maxillary teeth. Journal of Dental
Research 35: 916–921.
for their valuable contributions for the
development of this research line, Prof.
Camila Tirapelli for timely statistical
support, and CAPES (Brazil) for financial
support.
Mraiwa, N., Jacobs, R., van Cleynenbreuge, J.,
Schutyser, F., van Steenberghe, D. & Quirynen,
M. (2004) The nasopalatine canal revisited using
2D and 3D CT imaging. Dentomaxillofacial
Radiology 33: 396–402.
Oliveira-Santos, C., Souza, P.H.C., Berti-Couto, S.
A., Stinkens, L., Moyaert, K., van Assche, N. &
Jacobs, R. (2011) Characterisation of additional
mental foramina through cone beam computed
tomography. Journal of Oral Rehabilitation 38:
595–600.
Oliveira-Santos, C., Souza, P.H.C., Berti-Couto, S.
A., Stinkens, L., Moyaert, K., Rubira-Bullen, I.R.
F. & Jacobs, R. (2012) Assessment of variations of
the mandibular canal through cone beam com-
puted tomography. Clinical Oral Investigations
16: 387–393.
Rodella, L.F., Buffoli, B., Labanca, M. & Rezzani, R.
(2012) A review of the mandibular and maxillary
nerve supplies and their clinical relevance.
Archives of Oral Biology 57: 323–334.
Shelley, A.M., Rushton, V.E. & Horner, K. (1999)
Canalis sinuosus mimicking a periapical inflam-
matory lesion. British Dental Journal 186: 378–
379.
Temmerman, A., Hertelé, S., Teughels, W., Dekey-
ser, C., Jacobs, R. & Quirynen, M. (2011) Are pan-
oramic images reliable in planning sinus
augmentation procedures? Clinical Oral Implant
Research 22: 189–194.
Tepper, G., Hofschneider, U.B., Gahleitner, A. &
Ulm, C. (2001) Computed tomographic diagnosis
and localization of bone canals in the mandibular
interforaminal region for prevention of bleeding
complications during implant surgery. The Inter-
national Journal of Oral & Maxillofacial
Implants 16: 68–72.
Warwick, R. & Williams, P.L. (1973) Gray′s Anat-
omy, 35th edition. Edinburgh: Longman.
5 | Clin. Oral Impl. Res. 0, 2012 / 1–5