PRENATAL MORPHOMETRIC ANALYSIS OF SUPRAORBITAL, INFRAORBITAL AND MENTAL FORAMINA IN HUMAN FOETUSES AND THEIR CLINICAL CORRELATIONS TO ANAESTHESIA AND SURGICAL PROCEDURE

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Int J Anat Res 2014, 2(2):446-50. ISSN 2321-4287

Original Article

PREN ATAL M ORPHOM ETRIC AN ALYSIS OF SUPRAORBITAL,

INFRAORBITAL AND M ENTAL FORAM INA IN HUM AN FOETUSES

AND THEIR CLINICAL CORRELATIONS TO ANAESTHESIA AND

SURGICAL PROCEDURE

Fazal Ur Rehman.

ABSTRACT

Address for Correspondence: Dr. Fazal Ur Rehman, Depart ment of Anat omy, Jawahar Lal Nehru M edical College, Aligarh M uslim Universit y, Aligarh-202002. M ob.: +919045545139.

E-M ail: [email protected]

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Depart ment of Anat omy, Jawahar Lal Nehru M edical College, Aligarh M uslim Universit y, India.

M odern surgical procedures, anest hesia, acupunct ure and ot her invasive procedures on t he face requir e a m ore precise understanding of t he anat omy of im portant landm arks t o prevent subsequent neurovascular com plicat ions in t he f ront al region, upper jaw and low er jaw. St udies on bilat eral locat ional relat ionship of SOF, IOF and m ent al foram en in foetal skull are st ill lacking, so aim of our st udy w as 1) t o exam ine t he various m or phom et ric variat ions (t he locat ion and shape) of SOF, IOF and m ental foram ina of t he facial skelet on in hum an foet uses at different age of gestat ion 2) t o establish w het her or not , t he locat ion of t hese foram ina get changed as t he foet us m at ures and 3) t o establish t he patt ern of grow t h of aforesaid foram ina. For t hese 40 for m alin-fixed foet uses bet w een 17 and 32 w eeks of gestat ion w ere st udied for SOF, IOF and m ental foram ina. Foet uses w ere divided int o t w o groups according t o age. It w as int erest ing t o not e t hat supra-orbital and m en-tal foram ina w ere placed in t he sam e sagiten-tal plane on bot h sides of t he m idline. Inf ra-or bien-tal foram en w as locat ed lat eral t o sagittal plane for supra-or bital and m ental foram ina. The shape of SOF w as recorded as a not ch or rarely a foram en, w hereas t he shape of IOF and m ental foram en w ere det erm ined as a circular and an oval opening respect ively.

KEYW ORDS:Supraor bital not ch/ foram en, infraorbit al foram en, m ental foram en, surgical landm ark, hum an foet uses.

INTRODUCTION

Int J Anat Res 2014, Vol 2(2):446-50. ISSN 2321- 4287

Received: 11 M ay 2014

Peer Review : 11 M ay 2014 Published (O):30 June 2014 Accepted: 18 June 2014 Published (P):30 June 2014 Internat ional Journal of Anat omy and Research

ISSN 2321-4287 w w w.ijmhr.org/ ijar.ht m

The sup r aor b i t al , i n f rao r bi t al an d m ent al foramina are t he important landm arks on t he face. M odern surgical procedures, anest hesia and acupunct ure require a more precise under-st an din g of t h e sur ro und in g anat o m y [ 1] . Supraorbital notch/ foramen is sit uated at t he junct ion of lateral 2/3rd_{and medial1/3}rd_{of t he}

supraorbital margin. Infraorbital foramen is an opening located below t he infraorbital margin bilaterally on t he maxilla, giving passage t o t he infraorbital nerves and vessels. Infra orbital

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ship of t he supraorbital notch or foramen and infraorbital and mental foramina in adult s [2, 3]. No st udy has been recorded on supraorbit al foramen in foet uses t ill dat e. Few st udies on infraorbital foramen w ere conducted in human foetal skull [4]. St udies on format ion and early prenatal locat ion of t he human mental foramen [5] and horizontal migrat ion of pre- and post na-tal menna-tal foramen [6] in human foet uses have also been st udied in past . St udies on bilateral locat ional relat ionship of t hese foramina in foetal skull are st ill lacking. Such finding w ill be of great importance for forensic, anaest het ic and surgical procedures. In adult s t he SON or SOF is considered t o be reliably constant in t heir locat ion. SON/ SOF t ransmit s supraorbital nerve and vessels. The supraorbital nerve is one of t he main cutaneous nerves supplying t he forehead and scalp region, may be injured during various invasive procedures. This nerve is t he larger terminal branch of t he frontal nerve, and after exit t hrough t he SON/ SOF divides int o medial and lateral branches t o supply t he upper eyelid (as palpebral filament s), conjunct iva and skin of t he scalp u p t o t he l am bd oi d su t u re. Th e su pr ao r b i t al n er v e b l o ck s ar e co m m on l y performed in t he region of supraorbital foramen during procedures like closure of facial w ounds, biopsies, and scar revisions, as absolute but temporary t reat ment for supraorbital neuralgia and ot her cosm et ic cut aneous procedures. Effect ive and precise analgesia can be achieved only if one is aware of t he most frequent loca-t ion of exiloca-t of loca-t he nerve in loca-t his region. Know l-edge of t he locat ion of supraorbital nerve is also essent ial during various endoscopic procedures, w hich are increasingly being used for cosmet ic facial surgery [7, 8]. How ever, cosmet ic surgeons are generally reluctant t o perform brow lift s and ot her open, as w ell as endoscopic surgical procedures in t his region for fear of injuring t he supraorbital nerve and subsequent sensory loss [9, 10]. Excessive dissect ion and ret raction close t o such neurovascular bundles can cause scar-ring, w hich may lead t o ent rapment neuropa-t hies and painful neuralgias [11, 12]. Supraor-bital artery, a branch of opht halmic artery, leaves t he orbit t hrough t he SON/ SOF, divides int o su-perficial and deep branches t o supply t he skin and muscles of t he upper eyelid, forehead and scalp.

Aim of the study

1. To exam ine t h e var iou s m or p hom et r ic variat ions (t he locat ion and shape) of SOF, IOF and M ent al foram ina of t he facial skelet on in human foet uses at different age of gestat ion.

2. To establish w het her or not , t he locat ion of t hese foramina get changed as t he foet us mat ures.

3. To establish t he pattern of grow th of aforesaid foramina.

M ATERIALS AND M ETHODS

40 formalin-fixed foet uses bet w een 17 and 32 w eeks of gest at ion w ere invest igat ed in t his st udy and facial areas of skull w ere st udied for SOF, IOF and M ental foramina. Foet uses w ere divided int o t w o groups according t o age (Table I). These foet uses w ere collect ed f rom t he museum of Anat omy, facult y of medicine, AM U, Ali gar h. So f t t issue an d p er i ost eu m w er e removed carefully under magnifying glasses t o visualize t he supra-orbit al, infra-orbit al, and mental foramina. M easurement s w ere taken t o an al y ze t h e l o cat i on an d sh ap e of t hese f or am in a. Al l m easu r em en t s w ere m ad e bilaterally by a single observer and variat ions w ere evaluated in t w o groups. Locat ion of t hese foram ina t o cer t ain r eference point s w ere measured by Vernier calliper. To find out t he gr ow t h b et w een ad j acen t f o et al gr o up s, St udent ’s t ’ test was used. The follow ing met ric measurement s w ere recorded:

1. Distance bet w een SOF & M F

2. Distance bet w een IOF & M F

3. Distance bet w een SOF & IOF

4. Distance bet w een low er border of mandible & M F

5. Distance bet w een symphysis ment i & M F

6. Distance of IOF from vert ical line bet w een SOF & M F

7. Distance of IOF from infraorbital margin

Follow ing morphological observat ions were also made,

1. Shape of t he SOF

2. Shape of t he IOF

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RESULTS

The supraorbital notch was frequent ly observed t h an t he su pr aor bit al for am en i n gro up II foet uses, w hile t he same was difficult t o identify in group I foet uses. The mean distance bet w een SOF and mental foramen w ere 24.85±5.93 and 32.25±1.07 in group I and group II respect ively. The mean distance bet w een IOF and mental foramen were 13.05±4.69 and 19.35±1.63 in tw o groups respect ively. The mean distance of t he IOF from t he m idline w as 8.5±0.94 m m and 12.8±2.85 m m r esp ect i v el y. Th e av erage distance bet w een SOF and IOF foramen w ere 12.35±0.93 and 15.45±2.74 in t w o foetal groups respectively. The average length from t he inferior margin of mandible t o t he cent re of t he mental

foramen was 3.95±0.604 and 6.80±0.95 in 1st_and

2nd_{groups respect ively.}

The mean distance bet w een symphysis ment i and M F in group I and II fet uses w ere 6.9±0.94 m m and 9.8±2.85 m m r espect ively. It w as interest ing t o note t hat supra-orbital and mental foramina w ere placed in t he same sagittal plane on bo t h sides of t he m id line. Inf ra-or bit al foramen was located lateral t o sagittal plane for supra-orbital and mental foramina.

The average lengt hs of infra-orbit al foram ina f ro m afo r em ent io n ed sagit t al p l an e w er e 1.7±0.57 mm and 3.4±0.82mm in group I and gr oup II f et u ses on b ot h si des. The m ean distance of t he IOF from t he inferior orbital

Table 1: Grouping of Hum an Foet uses.

I 13-24 w eeks (2nd t rim est er) 20

II >24 w eek (3rd t rim ester) 20

Groups Age in w e eks No. of foe tuse s

Table 2: Right sided SOF, supra-or bital foram en; IOF, infra-orbit al foram en; M F, m ental foram en in hum an foet uses.

No. of

cases M eans ±SD (mm) No. of

cases

M eans ±SD (mm)

4 Distance between lower

border of mandible & M F 20 3.95±0.60 20 6.80±0.951 0 5 Distance between symphysis

menti & M F 20 8.40± 0.94 20 12.80±2.85 0 6 Distance of IOF from ve rtical

line between SOF & M F 20 1.70±0.57 20 3.40±0.82 0 7 Distance of IOF from

infraorbital margin 20 2.47±0.54 20 3.40± 0.88 0 13.05±4.69 20 19.35±1.63 0 1 Distance between SOF & M F 20 24.85±5.93 20 32.25±1.07

P Value

0 Parameters

S.NO

Group II Group I

3 Distance between SOF & IOF 20 12.35±0.93 20 15.45±2.74 0

2 Distance between IOF & M F 20

margin was about 2.47±0.547 mm in group I and 3.40±0.882 mm in group II. The shape of SOF was recorded as a notch or rarely a foram en, w hereas t he shape of IOF and mental foramen w ere det er m ined as a circular and an oval opening respect ively.

Table 3: Lef t sided SOF, supra-orbital foram en; IOF, in-fra-orbital foram en; M F, m ental foram en in hum an foe-t uses.

No. of cases

M eans±SD (mm)

4 Distance betw een lower

border of mandible & M F 20 3.95±0.60 20 6.80±0.951 0

5 Distance betw een symphysis

menti & M F 20 8.40± 0.94 20 12.80±2.85 0

6 Distance of IOF from vertical

line between SOF & M F 20 1.70±0.57 20 3.44±0.705 0

7 Distance of IOF from

infraorbital margin 20 2.47±0.54 20 3.46±0.810 0

19.55±1.39 0

1 Distance betw een SOF & M F 20 24.85±5.93 20 32.6±1.04

2 Distance betw een IOF & M F 20 13.05±4.69 20

0

S.NO Parameters

Group I Group II P Value

3 Distance betw een SOF & IOF 20 12.35±0.93 20 15.45±2.79 0

Table 4: Bi l at er al var i at i o n s i n d i st an ce b et w een supraor bit al foram en and m ent al foram en in hum an foet uses.

Group I 20 24.85±5.93 20 24.85±5.93 Nil

Group II 20 32.25±1.04 20 32.60±1.04 Nil

Groups

Right side Left side

Per-cent difference

Table 5: Bi l at er al var i at i o n s i n d i st an ce b et w een inf raor bit al foram en and m ent al foram en in hum an foet uses.

No. of

cases

M eans±SD

(mm)

No. of

cases

M eans±SD

(mm)

Group I 20 13.05±4.69 20 13.05±4.69 Nil

Group II 20 19.35±1.63 20 19.55±1.39 Nil

Groups Per-cent

difference

Table 6: Bi l at er al var i at i o n s i n d i st an ce b et w een supraorbital foram en and infraorbital foram en in hum an foet uses.

Group I 20 12.35±0.93 20 12.35±0.93 Nil

Group II 20 15.45±2.79 20 15.45±2.79 Nil

Groups

Table 7: Bilat eral var iat ions in dist ance bet w een low er border of m andible & M F in hum an foet uses.

N o. of cases

Group I 20 3.95±0.604 20 3.95±0.604 Nil

Group II 20 6.80±0.95 20 6.80±0.95 Nil

Groups Per-cent

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Table 8: Bi l at er al var i at i o n s i n d i st an ce b et w een sym physis m ent i & M F in hum an foet uses.

M eans±SD (mm) Group I 20 8.40±0.94 20 8.40±0.94 Nil

Group II 20 12.80±2.85 20 12.80±2.85 Nil

Groups

Table 9: Bilat eral variat ions in distance of IOF from t he ver t ical line bet w een SOF & M F in hum an foet uses.

Group II 20 3.40±0.82 20 3.44±0.70 Nil

Groups

Table 10: Bi lat eral variat ions in dist ance of IOF from inf raor bital m argin in hum an foet uses.

Group II 20 3.40±0.88 20 3.46±0.81 Nil

Groups

Table 11: Shape of SOF/ Not ch, IOF & M F in hum an foet uses.

DISCUSSION

Group I Group II

1 Supraorbital foramen / Notch Diff icult to identif y Wide notch

2 Infraorbital foramen Circular Circular

3 M ental foramen Oval Oval

Shape

S. No Foramen

The posit ions of SON/ F, IOF and M F vary among racial groups and genders [14-17]. Despite t he significance of t he SON/ F, IOF and M F, lit t le at tent ion has been given t o t he st udy of t he morphology, locat ions of t hese foram ina and t heir associated anat omic characterist ics in t he human foet uses. M ost of t hese studies are done i n ad ul t ’s h u m an sku l l. The f req u en cy o f occurrence of a Supraorbit al not ch/ foram en varies in different populat ions. Chung et al. (1995) r ep or t ed t h at a SON (69.9%) w as observed more frequent ly t han a SOF (28.9%) w hereas Saylam et al. (2003) [18] reported t hat t he frequencies of a notch, foramen or double p assage w er e 71.6%, 26.6%, an d 1.8%, respect ively. The frequency of SOF ranged from 8% t o 51% depending upon t he st udy samples. St udy by Berry and Berry (1967) [19] in w hich skulls from Nort hern India (Punjab) show ed SOF in only 12.3% of cases. Anat omical locat ion of t he supraorbital passages is a reliable landmark f or t he cor r esp o n di n g n er ve exi t . Th e supraorbital nerves are prone t o injury during

CONCLUSION

procedures involving dissect ion of t he scalp. M any cosmet ic surgeons m ay be reluctant in performing brow lift s and ot her open as w ell as endoscopic surgical procedures in t his region for fear of inj ur ing t he supraor bit al nerve and subsequent sensory loss (Rosenberg, 1998; Erdogmus and Govsa, 2007) [20, 21].

In adult s t he IOF has been variably reported t o lie bet w een 4 m m t o 10 m m inferior t o t he inferior orbital margin (Zide and Sw ift , 1998; Aziz et al., 2000) [22, 23]. In t his foetal st udy, t he mean distance of the IOF from t he inferior orbital margin w as found t o be bet w een 2.47—3.40 mm.

Congenital abnormalit ies t hat can be repaired prenatally occur in a small percent age of full-term birt hs. Surgical intervent ion is considered w hen a foet us present s w it h a congenital lesion t hat can compromise or dist urb vital funct ion or cause severe post nat al m or bidit y. Neonat al invasive congenital heart surgery has become an important area of interest [24]. After advances in imaging t echniques like ult rasound, CT and M RI m any congenit al abnorm alit ies such as

hyd r o cep h al u s, m eni n gom yelo co el e,

diaphragmat ic hernia, facial hypoplasia and cleft palate t hat can be diagnosed in utero and are amenable t o intervent ion. Plast ic surgeon w ill b e ab l e t o d eal w i t h var i o u s co ngen it al deformities w ith reconstruct ive surgeries, aimed at rest oring funct ion, correct ing disfigurement and t o avoid furt her complicat ions.

In o u r st u dy all t h e SOF an d M F ar e symmet rically located on bot h side of midline in sam e sagit t al plane w hi le t he IOF is placed slight ly lateral t o aforement ioned sagittal plane.

This locat ional relat ionship w ould be helpful clinical ly t o det er m in e t he locat ion of t he infraorbital and mental foramina, by palpat ion of t he supraorbital notch in foetal anaest hesia and in foetal surgery.

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How to cite this article

:

Fazal Ur Rehm an. PRENATAL M ORPHOM ETRIC ANALYSIS OF SUPRAORBITAL, INFRAORBITAL AND M ENTAL FORAM INA IN HUM AN FOETUSES AND THEIR CLINICAL CORRELATIONS TO ANAESTHESIA AND SURGICAL PROCEDURE. Int J Anat Res 2014;2(2):446-50.

Conflicts of Interests: None

REFERENCES

t hree foramina in t he majorit y of st udied foetal skulls. We can ascertain t hat in our st udy t his zone on average w ill extend from 8 mm t o 12 m m from t he m id line and can be used for providing regional nerve blocks and performing foetal surgery.

Source of Funding: Self

[11]. Hw ang K, Han JY, Batt uvshin D, Kim DJ, Chung IH. Com m unicat ion of inf raor bital ner ve and facial ner ve: anat om ic and hist ologic st udy. J Craniofac

Surg. 2004;15:88–91.

[ 12] .Karakas P, Bozkir M G, Oguz O. M or ph om et r i c m easurem ent s from various reference point s in t he o r b i t o f m al e Cau casi an s. Su r g Rad i o l

Anat. 2003;24:358–362.

[ 13] .Radw an IA, Sait o S, Got o F. High-concent rat ion t et racain e f or t he m an agem ent o f t r i gem i nal neur algia: q uan t i t at ive assessm en t of sen so r y f u n ct i o n af t er p er i p h er al n er ve b l o ck. Cl i n J

Pain.2001;17:323–326.

[14]. Kim ura K. Foram ina and notches on t he supraorbital m argin in som e racial groups. Kai bogaku Zasshi 1977; 52: 203-9.

[15]. Green RM . The posit ion of t he m ental foram en: a com par ison bet w een t he sout hern (Hong Kong) Chinese and ot her et hnic and racial groups. Oral Surg Oral M ed Oral Pat hol 1987; 63: 287-90. [16]. Sant ini A, Land M . A com parison of t he posit ion of

t h e m e n t al f o r am e n i n Ch i n ese an d Br i t i sh m andibles. Acta Anat (Basel) 1990; 137: 208-12. [ 17 ] .Cu t r i gh t B, Qu i l l o p a N, Sch u b e r t W. An

ant hropom et ric analysis of t he key foram ina for m axillofacial surgery. J Oral M axillofac Surg 2003; 61: 354-7.

[ 18] . Saylam C, Ozer M A, Ozek C, Gur l er T. 2003. An at o m i cal var i at i o n s o f t h e f r o n t al an d supraorbital t ranscranial passages. J Craniofac Surg 14:10–12.

[19]. Berry AC, Berry RJ. 1967. Epigenet ic variat ion in hum an cranium . J Anat 101:361–379.

[20]. Rosenberg GJ. 1998. The subperiost eal endoscopic laser for eh ead (SELF) lif t . Plast Reco nst r Su rg 102:493–501.

[ 21] . Er d o gm u s S, Go vsa F. 2007. An at o m y o f t h e supraor bital region and t he evaluat ion of it for t he reconst ruct ion of facial defect s. J Craniofac Surg 18:104–112.

[22]. Zide BM , Sw ift R. 1998. How t o block and tackle t he face. Plast Reconst r Surg 101:840–851. [23]. Aziz SR, M archena JM , Puran A. 2000. Anat om ic

char act er i st i cs of t h e i n f r aor b it al f or am en : A cadaver st udy. J Oral M axillofac Surg 58:992–996. [24]. W itt kope M M . Int ervent ional fetal cardiac t herapy-possi ble perspect ives and current short com ings. Ult rasound Obst et Gynecol. 2002;20:527–531. [ 1] . W i l li am s PL, W ar w ick R, Dyso n M , Ban ni st er

LH. Gray’s anatomy. 37th ed. New York: Churchill

Livingst one; 1989.

[2] . Chung M S, Kim HJ, Kang HS, Chung IH. Locat ional relat ionship of t he supraor bital notch or foram en an d i n f r ao r b i t al an d m en t al f o r am i n a i n

Koreans. Acta Anat (Basel) 1995; 154: 162–166.

[3] . M acedo VC, Cabrini RR, Faig-Leit e H. Infraorbital f o ram en lo cat io n i n d r y hu m an sku l ls. Br az J M or phol Sci. 2009;26: 35–38.

[ 4 ] . Far u q i e t . al . Bi l at er al var i at i o n an d sexu al d i m o r p h i sm i n m o r p h o m et r i c p ar am et er s o f i nf raor bi t al f or am en in h um an fet u ses. In t . j . m or phol.,27(2):475-480, 2009.

[5] . Kjaer I. form at ion and early prenatal locat ion of t he hum an m ental foram en. Sc J Dent Res.1989; 97:1-7.

[6]. Huseyin Avni Balcioglu, Cenk Kilic, M esut Akyol and Ayca Tuba Ulusoy. Horizontal m igrat ion of pre- and post nat al m ent al foram en: An anat om ic st udy. Int ernat ional jour nal of pediat r ic ot orhinology 75 (2011) 1436-1441.

[7] . M acedo VC, Cabrini RR, Faig-Leit e H. Infraorbital f o ram en lo cat io n i n d r y hu m an sku l ls. Br az J M or phol Sci. 2009;26:35–38.

[8] . Esper RS, Yara J, Yam am ura Y, Cricent i SV. Relações anat ôm icas do pont o de acupunt ura E-2 (Sibai) l o cal i zad o n o f o r am e i n f r ao r b i t al . Rev Pau l

Acupunt. 1998;4:19–21.

[9] . Du Tolt DF, Nor t jé C. The m axillae: int egrat ed and ap p l i ed an at o m y r el e van t t o

dentistry. SADJ.2003;58:325–330.

[ 10] .Zide BM , Sw if t R. How t o block and t ackle t he