Oral Radiology

https://doi.org/10.1007/s11282-021-00563-1

ORIGINAL ARTICLE

The influence of facial types on the morphology and location

of the greater palatine foramen: a CBCT study
Jhonatan Thiago Lacerda‑Santos1 · Gélica Lima Granja1 · George Borja de Freitas2 ·
Luiz Roberto Coutinho Manhães Jr3 · Daniela Pita de Melo1 · Jalber Almeida dos Santos4

Received: 3 April 2021 / Accepted: 10 August 2021

© The Author(s), under exclusive licence to Japanese Society for Oral and Maxillofacial Radiology and Springer Nature Singapore Pte Ltd. 2021

Abstract
Objective This study aimed to assess the morphology and location of the great palatine foramen (GPF) of different facial
types using cone beam computed tomography (CBCT) scans.
Methods Sixty CBCT scans were divided into: brachyfacial (n = 20), dolichofacial (n = 20) and mesofacial (n = 20) using
Ricketts’ VERT index for the determination of cephalometric facial type and imported into ImageJ software. GPF shape
was characterized as: round, elongated in the anteroposterior direction (EAP), or elongated in the latero-medial direction
(ELM). The distances between the GPF and the palatine suture (PS), the center of the GPF and the center incisive foramen
(IF), the GPF and the palatine alveolar ridge (PAR), right side GPF (GPFr) and left side (GPFl) GPFs; and the angles formed
from the intersection of the GPF, IF and PS were assessed. The position of the GPF was evaluated in relation to the molars.
Results GPFr and GPFl mean distances from PAR presented higher values for dolichofacial patients (p < 0.05). GPFr and
GPFl location distally to the third molar (3 M) was higher for brachyfacial type, while their location distally to the second
molar was higher for mesofacial and between the mesial and distal surfaces of the 3 M for dolichofacial (p < 0.05).
Conclusions The GPF was more distant from the PAR in the dolichofacial-type group. The location of the GPF in relation
to the molars varied according to the facial type. However, the morphology of the GPF was similar in the three facial types,
and the elongated in the anteroposterior direction morphology was more frequent.

Keyword Cone-beam computed tomography · Palate · Anesthesiology · Connective tissue graft

* Jhonatan Thiago Lacerda‑Santos

[email protected] Introduction
Gélica Lima Granja
[email protected] There are two small foramina in the horizontal plate of the
George Borja de Freitas palatine bone, the greater palatine foramen (GPF) and the
[email protected] lesser palatine foramen (LPF), which provide a passage for
Luiz Roberto Coutinho Manhães Jr neurovascular nerve bundles and veins [1, 2]. The GPF is
[email protected] located posterolaterally on both sides of the palate and cor-
Daniela Pita de Melo responds to the outlet of the greater palatine canal [2, 3].
[email protected] This foramen gives way to the greater palatine nerve that
Jalber Almeida dos Santos originates from the pterygopalatine ganglion of the maxil-
[email protected] lary nerve branch (third division of the trigeminal nerve), as
well as the greater palatine artery which descends from the
1
Postgraduate Program in Dentistry, State University palatine artery (branch of the maxillary artery) [3, 4]. This
of Paraiba, Campina Grande, Paraíba, Brazil
neurovascular plexus supplies blood to the palatal mucosa
2
Department of Dentistry, UNIFIP University Center of Patos, and the periodontium of the maxillary posterior teeth and
Patos, Paraíba, Brazil
continues anteriorly where its anastomosis with branches of
3
Department of Radiology, São Leopoldo Mandic College, the nasopalatine bundle occurs [2, 5].
Campinas, São Paulo, Brazil
Detailed knowledge on the anatomical location of the
4
Department of Dentistry, FIP Campina Grande, GPF is fundamental for clinicians [3] as the palatal region
Campina Grande, Paraíba, Brazil

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is a frequently assessed area for many dental procedures as for the determination of cephalometric facial type (intra-
anesthetic techniques, upper molar extractions, mini ortho- observer kappa value = 0.90).
dontic implants installation, surgical approaches for cysts CBCT scans of patients over 18-year-old from both gen-
and tumors and as a connective tissue graft harvesting area ders, presenting all the maxillary molars bilaterally, were
[1, 3, 4, 6, 7]. Therefore, it is important to understand the included in the sample. CBCT scans with pathological max-
morphology and anatomical course of the GPF to minimize illary deformities, history of orthognathic surgery and low-
neurovascular surgical injuries and anesthetic technique fail- quality images that could compromise proper assessment of
ure, as well as contributing to treatment planning of surgical the region of interest were excluded.
procedures in the palatal region [8–10]. The sample was selected from the University’s Oral Radi-
Previous studies have assessed the morphology and loca- ology Clinics. All CBCT scans were acquired using i-CAT
tion of the GPF [1, 3, 4, 6, 11], and found that anatomical (Imaging Sciences International, Hatfield, PA, USA) scan-
variations of the GPF were associated with patient ethnicity, ner. Tube voltage, voxel size and FOV size were fixed at
gender [3, 4, 12, 13], edentulous patients and patients that 120 kV, 0.25 mm and 16 cm x 13 cm, respectively. Tube cur-
underwent surgery on the palate [14]. rent varied between 5 and 7 mA, depending on the patient’s
The location of the GPF has been previously assessed specificities.
on dry human skulls and on cone beam computed tomog- All CBCT scans were assessed by two previously cali-
raphy (CBCT) scans [3, 4, 6, 9, 12, 13, 15]. An advantage brated observers (inter-observer kappa value = 0.87), using
of GPF assessment using CBCT scans when compared to ImageJ software (NIH, Bethesda, MD, EUA). The qualita-
dry human skulls is the possibility of collecting more data tive and quantitative assessments of the morphology of the
on the studied population, such as sex, age, and any other GPF were performed according to Jaffar and Hamadah [21]
clinical information available [16]. In addition, CBCT is a and Tomaszewska et al. [6] methodologies.
three-dimensional examination that allows the assessment GPF morphology was divided into three shapes: round,
of several tomographic sections, thus allowing the observer elongated in the anteroposterior direction (EAP), or elon-
to assess precisely GPF’s location on scans of dentate and gated in the latero-medial direction (ELM). GPF shape is
edentulous patients [11]. determined by the division of the anteroposterior length and
Facial types may contribute to craniofacial morphology latero-medial length of the foramen. The resulting measure-
variations and interfere on the location of anatomical struc- ment value determines three shapes: (a) round—when the
tures [17]. Facial types can be classified as brachyfacial, result is equal to 1; (b) EAP—when the result is higher than
dolichofacial and mesofacial, and each type presents specific 1; (c) ELM—when the result is lower than 1 [21] (Fig. 1).
characteristics [18]. Craniofacial growth, muscle activity, The following linear and angular measurements of
stomatognathic functions, occlusion and genetic factors can the GPF and reference points were assessed: (a) distance
interfere with the facial type [19, 20]. Whereas facial types between the GPF and the palatine suture (PS); (b) distance
influence craniofacial morphology [17], it possibly may between the center of the GPF and the center of the incisive
influence the location of the GPF. foramen (IF); (c) distance between the GPF and the palatine
The conceptual hypothesis of this study is that the loca- alveolar ridge (PAR); d) distance between the right side GPF
tion and morphology of the GPF in the brachyfacial and (GPFr) and left side GPF (GPFl); e) angle formed by GPF,
dolichofacial types are different from the mesofacial type. IF and PS [6] (Fig. 2a–e).
Therefore, this study aimed to assess the morphology and The position of the GPF in relation to the molars was
location of the GPF of different facial types using CBCT also assessed. Initially, using a sagittal section (Fig. 2f), the
images. GPF was identified, and then in an axial section the follow-
ing points were established: (I) GPF positioned mesially to
the second molar; (II) GPF positioned within an imaginary
Material and methods line traced between the mesial and distal surfaces of the
second molar; (III) GPF positioned distally to the second
This study protocol was approved by the Institutional molar; (IV) GPF positioned within an imaginary line traced
Review Board in accordance with the Helsinki Declaration between the mesial and distal surfaces of the third molar;
(No. 69003417.7.0000.5181). (V) GPF positioned distally to the third molar [6] (Fig. 2g).
This observational study assessed 60 CBCT scans (120 Data were assessed using IBM SPSS Statistic software
GPF) divided according to the patient’s facial type into: (version 25.0, IBM SPPS Inc., Armonk, NY, USA). Facial
brachyfacial (n = 20), dolichofacial (n = 20) and mesofacial type and gender were used as independent variables. The
(n = 20). Facial-type assessment was done by a previously morphology and morphometric data of the GPF were con-
trained and calibrated observer using Ricketts’ VERT index sidered dependent variables. The analysis of the normality

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Oral Radiology

Fig. 1  Measurement to deter-

mine the morphology of the
GPF. a Anteroposterior length;
b latero-medial length

Fig. 2  Linear and angular measurements of the great palatine fora- alveolar ridge (GPF–PAR); d distance between the right side GPF
men (GPF). a Distance between the great palatine foramen and the and the left side GPF (GPFr and GPFl); e the angle formed by GPF,
incisive foramen (GPF–IF); b distance between the GPF and the pala- IF and PS; f and g position of the GPF in relation to the maxillary
tine suture (GPF–PS); c distance between the GPF and the palatine molars

of the quantitative variables was performed using Z test Results

(p < 1.96).
Parametric tests, paired t test, analysis of variance (one- There were no statistically significant differences between
way ANOVA) and Bonferroni’s post hoc tests were used GPF morphologies (p > 0.05). The GPF presented similar
to assess associations between facial types and linear and morphologies for the three studied facial types. 80% of
angled measurements of the GPF. Pearson’s Chi-square the brachyfacial (n = 16), 85% of the mesofacial (n = 17)
test was performed to assess the association between facial and 100% of the dolichofacial (n = 20) patients presented
types and the GPF morphology and location. The level of
significance was set at 5% (p < 0.05).

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Table 1  Comparison between GPF measurements acquired from the EAP-shaped GPFr, and all studied patients presented EAP-
right and left side shaped GPFl.
Right side Left side p value The mean distances between GPF–PS and GPF–PAR and
M (SD) M (SD) the angle formed by GPF, IF and PS from the left side of the
palatine bone were larger and differed from the right side
GPF–PS (mm) 14.47 (1.63) 15.16 (1.37) < 0.001*
(p < 0.001, p = 0.002 and p = 0.035, respectively). However,
GPF–IF (mm) 38.41 (3.24) 38.70 (3.32) 0.061
there were no statistical differences between the mean dis-
GPF–PAR (mm) 7.14 (1.36) 7.50 (1.43) 0.002*
tances from GPFr and GPFl to the IF (p = 0.061) (Table 1).
Angle between 22.17 (1.97) 22.63 (1.95) 0.035*
GPF–IF–PS (º) The mean distance from GPFr to the PS did not differ
between gender (p = 0.12). However, the mean distance
M mean, SD standard deviation, GPF great palatine foramen, PS pal- between GPFl and PS was statistically higher for male
atine suture, IF incisive foramen, PAR palatine alveolar ridge
patients (p = 0.02) (Table 2). GPFr and GPFl mean distances
*Paired t test p < 0.05
from PAR presented higher values for dolichofacial-type
patients when compared to brachyfacial and mesofacial type
Table 2  Comparison between GPF measurements according to gen- patients (p = 0.003 and p = 0.007, respectively) (Table 3).
der GPFr and GPFl location distally to the third molar were
Female Male p value statistically higher for brachyfacial-type patients, while their
M (SD) M (SD) location distally to the second molar was higher for mesofa-
cial and between the mesial and distal surfaces of the third
GPF–PS (mm) Right side 14.08 (1.34) 14.71 (1.76) 0.12
molar for dolichofacial patients (p < 0.001) (Table 4).
Left side 14.70 (1.06) 15.45 (1.47) 0.02*
GPF–IF (mm) Right side 37.90 (2.71) 38.72 (3.53) 0.31
Left side 37.94 (3.17) 39.17 (3.37) 0.16
GPF–PAR (mm) Right side 7.23 (1.56) 7.08 (1.24) 0.71
Discussion
Left side 7.62 (1.57) 7.42 (1.35) 0.62
Each facial type has its own characteristics specific to their
GPFr–GPFl (mm) – 29.51 (2.10) 30.34 (2.86) 0.20
different craniofacial morphology [17], which can interfere
Angle between Right side 22.00 (1.85) 22.28 (2.06) 0.58
GPF–IF–PS (°) Left side in important anatomical structures’ location. Therefore,
22.83 (2.03) 22.50 (1.91) 0.52
knowledge on the morphology of anatomical landmarks can
M mean, SD standard deviation, GPF great palatine foramen, PS pal- aid the clinician on the location of the GPF in edentulous
atine suture, IF incisive foramen, PAR palatine alveolar ridge, GPFr patients [6, 10, 22]. Studies on the location of the GPF can
right side great palatine foramen, GPFl left side great palatine fora-
men
help in the success in anesthetic techniques of the greater
palatine nerve and prevent accidents during surgical proce-
*Student’s T test p < 0.05
dures on the palate, such as removal of connective tissue for
grafting [22] and placement of mini-implants anchored on

Table 3  Comparison between Brachyfacial Mesofacial Dolichofacial M (SD) p value

GPF measurements according M (SD) M (SD)
to the studied facial profiles
GPF–PS (mm) Right side 15.07 (2.08)A 14.45 (1.18)A 13.88 (1.34)A 0.06
Left side 15.28 (1.54)A 15.09 (1.09)A 15.12 (1.51)A 0.89
GPF–IF (mm) Right side 39.14 (3.63)A 37.32 (1.92)A 38.76 (3.72)A 0.17
Left side 38.99 (3.92)A 38.01 (2.18)A 39.09 (3.66)A 0.53
GPF–PAR (mm) Right side 6.69 (1.34)A 6.69 (0.96)A 8.04 (1.32)B 0.003*
Left side 7.05 (1.18)A 7.07 (1.16)A 8.37 (1.55)B 0.007*
GPFr–GPFl (mm) – 30.72 (3.16)A 29.84 (2.03)A 29.52 (2.49)A 0.32
Angle between Right side 22.27 (1.56)A 22.76 (2.38)A 21.49 (1.77)A 0.12
GPF–IF–PS (°) Left side 22.77 (1.56)A 22.76 (1.96)A 22.36 (2.27)A 0.76

M mean, SD standard deviation, GPF great palatine foramen, PS palatine suture, IF incisive foramen, PAR
palatine alveolar ridge, GPFr right side great palatine foramen, GPFl left side great palatine foramen
*ANOVA one-way and Bonferroni post hoc (p < 0.05)
Means followed by different superscript letters show a statistically significant difference (p < 0.05)

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Oral Radiology

the palate [7]. This study used clinically viable anatomical

< 0.001
p value
landmarks that are easy to identify in most patients.
When comparing the topographic measurements between
genders, male patients presented higher mean distance

10 (50.0)*

2 (10.0)
values between the left side greater palatine foramen and

0 (0.0)
Distally
to the

n (%)
the palatine suture (15.45 mm ± 1.47), when compared to

3M
female patients (14.70 mm ± 1.06), in agreement with previ-
ous studies [12, 13, 23]. This may be because the posterior
surfaces of the 3 M
region of the palate is greater in male patients than in female
patients [8]. However, Ikuta et al. [22], when assessing the

14 (70.0)*
the mesial

location of the GPF using 50 CBCT scans, did not identify

and distal

6 (30.0)
9 (45.0)
Between

differences between genders, which can be explained by eth-

n (%)

nic differences in the studied samples and differences in the

methodologies chosen by each study.
11 (55.0)*

This study showed statistical differences between GPF

4 (20.0)

4 (20.0)
Distally
To the

measurements for the right and left sides. Small asymmetries

n (%)
2M

are common throughout the facial complex, which can be

justified by the influence of genetic and/or environmental
surfaces of
the mesial
and distal
Between

factors [6], musculoskeletal activity or any interference dur-

the 2 M

0 (0.0)
0 (0.0)
0 (0.0)
n (%)

ing the patient’s growth and development periods [24]. How-

ever, previous studies have not identified differences between
these measurements on the right and left [1, 11, 13, 23, 25,
Mesially
GPF left

0 (0.0)
0 (0.0)
0 (0.0)

26]. Further studies are needed to assess facial asymmetries

to the

n (%)
2M

for each facial type to identify the influence of the different

types on the location of the GPF.
< 0.001
p value

Regarding facial-type analysis, it was observed that

the GPF distance from PAR was greater for dolichofa-
cial facial patients (right side 8.04 mm ± 1.32; left side
10 (50.0)*

8.37 mm ± 1.55), probably because the height of the alveolar

2 (10.0)
0 (0.0)
Distally

bone in dolichofacials patients is significantly higher when

to the

n (%)
3M

compared to mesofacial and brachyfacial patients [27]. This

information is important when planning to collect connec-
surfaces of the 3 M

tive tissue from the palate for grafting, as the location of the
GPF can vary in each facial type.
As for the position of the GPF in relation to the maxil-
14 (70.0)*
the mesial
and distal

6 (30.0)
9 (45.0)
Between

GPF greater palatine foramen, 2 M second molar, 3 M third molar

lary molars, previous studies found different prevalence for

n (%)

the location of the GPF. Some studies found that the most
Table 4  Association between GPF location and facial profiles

prevalent (53% a 87.5%) location was between the mesial

surface of the third molars [12, 13, 21, 28], others between
11 (55.0)*
4 (20.0)

4 (20.0)
Distally

the mesial and distal surfaces of the third molar (38.1% a

to the

n (%)
2M

73%) [4, 23, 25, 26, 29, 30] and one study found that the
most prevalent location was the distal surface of the third
surfaces of
the mesial

molar (78%) [1]. It is worth mentioning that these studies

and distal
Between

the 2 M

0 (0.0)
0 (0.0)
0 (0.0)

were carried out in different populations, which may have

n (%)

*Pearson’s Chi-square test p < 0.05

contributed to such differences in the results.

In the present study, the location of the GPF varied
GPF right
Mesially

according to the facial type. In brachyfacial patients, the

0 (0.0)
0 (0.0)
0 (0.0)
to the

n (%)

GPF was located distally to the third molar (50%), in meso-

2M

facial patients it was located at the distal surface of the sec-

ond molar (55%) and in dolichofacials patients between the
Dolichofacial
Brachyfacial
Mesofacial

mesial and distal surfaces of the third molar (70%). Clini-

cally, this demonstrates the importance of considering the
facial type before surgical and anesthetic procedures in the

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lection or management, data analysis and manuscript writing/editing. 9. Monsour P, Huang T. Morphology of the greater palatine grooves
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editing. review. J Oral Maxillofac Surg. 2019;77:271.e1-271.e9. https://​
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Funding The authors did not receive support from any organization 11. Rapado-González O, Suárez-Quintanilla JA, Otero-Cepeda XL,
for the submitted work. Fernández-Alonso A, Suárez-Cunqueiro MM. Morphometric
study of the greater palatine canal: cone-beam computed tomog-
raphy. Surg Radiol Anat. 2015;37:1217–24. https://​doi.​org/​10.​
Declarations 1007/​s00276-​015-​1511-y.
12. Bahşi İ, Orhan M, Kervancıoğlu P, Yalçın ED. Morphometric
Conflict of interest All authors declare no conflicts of interest. evaluation and clinical implications of the greater palatine fora-
men, greater palatine canal and pterygopalatine fossa on CBCT
Ethics approval All procedures followed were in accordance with the images and review of literature. Surg Radiol Anat. 2019;41:551–
ethical standards of the responsible committee on human experimenta- 67. https://​doi.​org/​10.​1007/​s00276-​019-​02179-x.
tion (Ethics Committee of University Center of Patos, approval date 13. Dave MR, Yagain VK, Anadkat S. A study of the anatomical
and number: 08 July 2016; #69003417.7.0000.5181) and with the Hel- variations in the position of the greater palatine foramen in
sinki Declaration of 1975, as revised in 2008. adult human skulls and its clinical significance. Int J Morphol.
2013;31:578–83. https://​doi.​org/​10.​4067/​S0717-​95022​01300​
Informed consent Not applicable. 02000​36.
14. Hafeez NS, Sondekoppam RV, Ganapathy S, Armstrong JE,
Shimizu M, Johnson M, Merrifield P, Galil KA. Ultrasound-
guided greater palatine nerve block: a case series of ana-
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