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Bilateral nasopalatine ducts of the premaxilla
Reconstructivesurgery
Bilateral nasopalatine ducts of the premaxilla
B a r r y L. Eppley and John J. Delfino st. John's Mercy Medical Center, Department
of OraI-Maxillofaeial Surgery, 621 South New Ballas Road, St. Louis, Missouri 63141, USA
B.L. Eppley and J.J. Delfino: Bilateral Nasopalatine ducts of the premaxilla. Int. J. Maxillofac. Surg. 1988; 17: 360-362. Abstract. An unusual case involving the development of patency of the nasopalatine ducts after orthopedic expansion of the premaxilla in a young child is described. The embryogenesis, clinical presentation and surgical repair is discussed.
The premaxilla contains a midline incisive canal which serves as a passageway from the nasal cavity to the oral cavity through which the terminal branches of the descending palatine and sphenopalatine arteries and the nasopalatine nerve course. The nasopalatine duct, or remnants thereof, may be found within or adjacent to this canal. This association is secondary to their embryological development in which, at the 6th to 8th week of fetal life, the median palatine processes of the maxilla grow medially along the inferior borders of the primitive choanae until they unite, with the exception of a small area in the midline o f the premaxilla,-where a nasopalatine canal persists 18,s0. Thus, communication between the nose and m o u t h endures and marks the position o f the incisive fossa. The nasopalatine duct is lined with respiratory epithelium as well as mucous glands. In m a n y lower mammals, the ducts remain patent in postnatal life and connect the oral cavity with the vomeronasal organs of Jacobson along the anterior septum which serve as accessory olfactory organs ~8. In man, however, the nasopalatine ducts m a y remain patent in the fetus 3, 7, ~9 but degenerate and are obliterated by mucous membrane at their terminal ends prior to parturition or within the first postnatal year 3,6,12,14 Thus, only v'estigal epithelial remnants and/or blind oral and nasal cul-de-sacs may be found which can be associated with the pathogenesis of rnidline maxillary cysts 1, 5, 16. They have rarely been reported beyond the neonatal period and their presentation is that of a single or bilateral opening adjacent to the palatine papilla which may have a patent communication to the nasal cavity 2, 4, 211, 13,15
Case report
A nine-year-old male patient in good health was seen for evaluation of a 3-month history of the development of occasional passage of liquids into the nose while drinking, and a 'whistling' deformity. Neither of these symptoms had existed previously. The patient's medical history was non-contributory with the exception of a fall sustained a t age 6 years with the resultant loss of all permanent maxillary incisors. Secondary to this loss, the remaining teeth had collapsed into the resultant space giving rise to a constricted anterior maxilla. Subsequently, the patient underwent orthodontic expansion at age 8½ years with the development of the aforementioned symptoms near the conclusion of the anterior uprighting and expansion of the premaxilla. Clinical examination revealed a normal exterior facial appearance with bilateral intraoral openings, approximately 2 mm in diameter, adjacent to the palatine papillae. (Fig.
Fig. 1.
Key words: nasopalatine duct. Accepted for publication 18 June 1988
1) These openings had unimpeded communication with the nasal cavity as seen on radiographs (Fig. 2). The patient could voluntarily force fluid into the nose as well as produce a high pitched whistle with the mouth closed. Due to these symptoms, the patient elected surgical closure of the oronasal ducts. Intraoperatively, both ducts were simultaneously cannulated and radiopaque contrast was injected, delineating the outline of the communications. (Fig.3) The ducts and surrounding tissue were elliptically incised including the periosteum, from a palatal approach. Both osseous openings were easily located and found to have a mucosal lining. The duct mucosa was inverted and due to their small size the long ducts (< lmm) were occluded with bone wax, rather than grafted. The denuded premaxilla was then closed by rotating a posteriorly pedicled palatal flap, leaving the donor site to heal secondarily. After 4 weeks, the flap was well healed with complete granulation of the donor defect. After 1 year, there
Nasopalatine ducts o f the premaxilla
361
munication between the 2 cavities, their narrow dimensions did not permit clinical symptoms prior to orthopedic movement. This suggests that nasopalatine ducts may be more c o m m o n than the few reports which document their existence, but go unrecognized due to their asymptomatic nature s, 13. While nasopalatine duct symptoms are usually minor, surgical repair may be requested. Simple mucosal excision of the palatal duct orifice(s) may not be sufficient, as the osseous canal persists which may lead to re-opening. It is recommended that not only the palatal soft tissue duct be excised, but the osseous c o m p o n e n t located and obliterated. The use of both autogenous or alloplastic bone grafts is acceptable, based on their successful use in alveolar cleft repair, but may be unnecessary if the osseous canal is very small. This procedure, combined with full-thickness palatal tissue, will provide adequate coverage that is unlikely to reopen. Manipulation o f the nasal side of the ducts is difficult due to access, and is moreover unneccessary. Periodic radiographic follow-up, however, should be maintained as the resultant nasal culde-sac (blind end) may be a stimulus for cyst formation 1,5, 16
Fig. 2.
References
Fig. 3.
has been no recurrence of the nasopalatine ducts. Discussion
This case illustrates a rare phenomenon, but is the first report of such an occur-
rence after active expansion of the anterior maxilla. It is assumed that widening of the midline suture, in conjunction with lateral osseous movement, had opened pre-existant nasopalatine ducts. While the ducts probably had com-
1. Abrams, A.M., Howell, F.V. & Bullock, W.K.: Nasopalatine cysts. Oral Surg. 1963: 16: 306-332. 2. Allard, R.H.B., de Vries, K. & Van der Kwast, A.M.: Persisting bilateral nasopalatine ducts. Oral Surg. 1982: 53: 24-26. 3. Bellous, A.: Observations on the incisive canaculi and nasopalatine ducts. Br. Dent. J. 1951: 91: 281-283. 4. Buchner, A. & Mlinek, A.: Palatal opening of nasopalatine duct. Oral Surg. 1972: 34: 440-444. 5. Burket, L.W.: Nasopalatine duct structures and peculiar bony pattern observed in anterior maxillary region. Arch. Path. 1937: 23: 793-800. 6. Cohen, M.M.: Incisive canal cysts. Am. J. Orthodont. Oral Surg. 1941: 27: 670-674. 7. Fry, J.C.: Two cases of a sinus in the incisive canal Br. Dent J. 1932: 53: 528-529. 8. Goebel, W.M.: Bilateral patent nasopalatine ducts. J. Oral Med. 1975: 30: 96-98. 9. Grohs, R.: Epithelial rests in the region of the palatine papilla of the upper jaw. J. Dent. Res. 1934: 14: 187-188. 10 Hill, W.C.O. & Darlow, H.M.: Bilateral perforate nasopalatine communication in the human adult. J. Laryngol. Otol. 1945: 60: 160-165.
362
Eppley & DelJ~no
11. MacGregor, A.J.: Patent nasopalatine canal. Oral Surg. 1964: 18: 285-292. 12. Meyer, A.W.: Median anterior maxillary cysts. JADA 1931: 18:1851 1877. 13. Moskow, B.S.: Bilateral congenital nasopalatine communication Oral Surg. 1982: 53: 458~460. 14. Noyes, H.J.: Nasopalatine duct and Jacobson's organ in newborn infants. J. Dent. Res. 1935: 15: 155-156. 15. Roper-Hall, H.T.: Patent incisive canal. Br. Dent. J. 1941: 71: 306-308.
16. Rosenburger, H.C.: Fissural cysts. Arch. Otolaryngol. 1944: 40: 288-290. 17 Rydzek, A.: Uber den vorderen Gaumenschluss beim Menschen. Arch. Mikr. Anat. 1923: 97: 486-506. 18. Stern, I.B.: Orban's oral histology and embryology. Bhaskar, SN (ed). C.V. Mosby Company, St. Louis, 1976, p. 279. 19. Stones, H.H.: Oral and dental diseases. E & S Livingstone, London, 1954, pp. 822-823. 20. Ten Cate, A.R.: Oral histology - develop-
ment, structure, and function. C.V. Mosby Company, St. Louis, 1980, pp. 420424.
Address: B.L. Eppley St. John's Mercy Medical Center Department of Oral-Maxillofacial Surgery 621 South New Bullas Road St. Louis, Missouri 63141 USA
Bilateral nasopalatine ducts of the premaxilla
B a r r y L. Eppley and John J. Delfino st. John's Mercy Medical Center, Department
of OraI-Maxillofaeial Surgery, 621 South New Ballas Road, St. Louis, Missouri 63141, USA
B.L. Eppley and J.J. Delfino: Bilateral Nasopalatine ducts of the premaxilla. Int. J. Maxillofac. Surg. 1988; 17: 360-362. Abstract. An unusual case involving the development of patency of the nasopalatine ducts after orthopedic expansion of the premaxilla in a young child is described. The embryogenesis, clinical presentation and surgical repair is discussed.
The premaxilla contains a midline incisive canal which serves as a passageway from the nasal cavity to the oral cavity through which the terminal branches of the descending palatine and sphenopalatine arteries and the nasopalatine nerve course. The nasopalatine duct, or remnants thereof, may be found within or adjacent to this canal. This association is secondary to their embryological development in which, at the 6th to 8th week of fetal life, the median palatine processes of the maxilla grow medially along the inferior borders of the primitive choanae until they unite, with the exception of a small area in the midline o f the premaxilla,-where a nasopalatine canal persists 18,s0. Thus, communication between the nose and m o u t h endures and marks the position o f the incisive fossa. The nasopalatine duct is lined with respiratory epithelium as well as mucous glands. In m a n y lower mammals, the ducts remain patent in postnatal life and connect the oral cavity with the vomeronasal organs of Jacobson along the anterior septum which serve as accessory olfactory organs ~8. In man, however, the nasopalatine ducts m a y remain patent in the fetus 3, 7, ~9 but degenerate and are obliterated by mucous membrane at their terminal ends prior to parturition or within the first postnatal year 3,6,12,14 Thus, only v'estigal epithelial remnants and/or blind oral and nasal cul-de-sacs may be found which can be associated with the pathogenesis of rnidline maxillary cysts 1, 5, 16. They have rarely been reported beyond the neonatal period and their presentation is that of a single or bilateral opening adjacent to the palatine papilla which may have a patent communication to the nasal cavity 2, 4, 211, 13,15
Case report
A nine-year-old male patient in good health was seen for evaluation of a 3-month history of the development of occasional passage of liquids into the nose while drinking, and a 'whistling' deformity. Neither of these symptoms had existed previously. The patient's medical history was non-contributory with the exception of a fall sustained a t age 6 years with the resultant loss of all permanent maxillary incisors. Secondary to this loss, the remaining teeth had collapsed into the resultant space giving rise to a constricted anterior maxilla. Subsequently, the patient underwent orthodontic expansion at age 8½ years with the development of the aforementioned symptoms near the conclusion of the anterior uprighting and expansion of the premaxilla. Clinical examination revealed a normal exterior facial appearance with bilateral intraoral openings, approximately 2 mm in diameter, adjacent to the palatine papillae. (Fig.
Fig. 1.
Key words: nasopalatine duct. Accepted for publication 18 June 1988
1) These openings had unimpeded communication with the nasal cavity as seen on radiographs (Fig. 2). The patient could voluntarily force fluid into the nose as well as produce a high pitched whistle with the mouth closed. Due to these symptoms, the patient elected surgical closure of the oronasal ducts. Intraoperatively, both ducts were simultaneously cannulated and radiopaque contrast was injected, delineating the outline of the communications. (Fig.3) The ducts and surrounding tissue were elliptically incised including the periosteum, from a palatal approach. Both osseous openings were easily located and found to have a mucosal lining. The duct mucosa was inverted and due to their small size the long ducts (< lmm) were occluded with bone wax, rather than grafted. The denuded premaxilla was then closed by rotating a posteriorly pedicled palatal flap, leaving the donor site to heal secondarily. After 4 weeks, the flap was well healed with complete granulation of the donor defect. After 1 year, there
Nasopalatine ducts o f the premaxilla
361
munication between the 2 cavities, their narrow dimensions did not permit clinical symptoms prior to orthopedic movement. This suggests that nasopalatine ducts may be more c o m m o n than the few reports which document their existence, but go unrecognized due to their asymptomatic nature s, 13. While nasopalatine duct symptoms are usually minor, surgical repair may be requested. Simple mucosal excision of the palatal duct orifice(s) may not be sufficient, as the osseous canal persists which may lead to re-opening. It is recommended that not only the palatal soft tissue duct be excised, but the osseous c o m p o n e n t located and obliterated. The use of both autogenous or alloplastic bone grafts is acceptable, based on their successful use in alveolar cleft repair, but may be unnecessary if the osseous canal is very small. This procedure, combined with full-thickness palatal tissue, will provide adequate coverage that is unlikely to reopen. Manipulation o f the nasal side of the ducts is difficult due to access, and is moreover unneccessary. Periodic radiographic follow-up, however, should be maintained as the resultant nasal culde-sac (blind end) may be a stimulus for cyst formation 1,5, 16
Fig. 2.
References
Fig. 3.
has been no recurrence of the nasopalatine ducts. Discussion
This case illustrates a rare phenomenon, but is the first report of such an occur-
rence after active expansion of the anterior maxilla. It is assumed that widening of the midline suture, in conjunction with lateral osseous movement, had opened pre-existant nasopalatine ducts. While the ducts probably had com-
1. Abrams, A.M., Howell, F.V. & Bullock, W.K.: Nasopalatine cysts. Oral Surg. 1963: 16: 306-332. 2. Allard, R.H.B., de Vries, K. & Van der Kwast, A.M.: Persisting bilateral nasopalatine ducts. Oral Surg. 1982: 53: 24-26. 3. Bellous, A.: Observations on the incisive canaculi and nasopalatine ducts. Br. Dent. J. 1951: 91: 281-283. 4. Buchner, A. & Mlinek, A.: Palatal opening of nasopalatine duct. Oral Surg. 1972: 34: 440-444. 5. Burket, L.W.: Nasopalatine duct structures and peculiar bony pattern observed in anterior maxillary region. Arch. Path. 1937: 23: 793-800. 6. Cohen, M.M.: Incisive canal cysts. Am. J. Orthodont. Oral Surg. 1941: 27: 670-674. 7. Fry, J.C.: Two cases of a sinus in the incisive canal Br. Dent J. 1932: 53: 528-529. 8. Goebel, W.M.: Bilateral patent nasopalatine ducts. J. Oral Med. 1975: 30: 96-98. 9. Grohs, R.: Epithelial rests in the region of the palatine papilla of the upper jaw. J. Dent. Res. 1934: 14: 187-188. 10 Hill, W.C.O. & Darlow, H.M.: Bilateral perforate nasopalatine communication in the human adult. J. Laryngol. Otol. 1945: 60: 160-165.
362
Eppley & DelJ~no
11. MacGregor, A.J.: Patent nasopalatine canal. Oral Surg. 1964: 18: 285-292. 12. Meyer, A.W.: Median anterior maxillary cysts. JADA 1931: 18:1851 1877. 13. Moskow, B.S.: Bilateral congenital nasopalatine communication Oral Surg. 1982: 53: 458~460. 14. Noyes, H.J.: Nasopalatine duct and Jacobson's organ in newborn infants. J. Dent. Res. 1935: 15: 155-156. 15. Roper-Hall, H.T.: Patent incisive canal. Br. Dent. J. 1941: 71: 306-308.
16. Rosenburger, H.C.: Fissural cysts. Arch. Otolaryngol. 1944: 40: 288-290. 17 Rydzek, A.: Uber den vorderen Gaumenschluss beim Menschen. Arch. Mikr. Anat. 1923: 97: 486-506. 18. Stern, I.B.: Orban's oral histology and embryology. Bhaskar, SN (ed). C.V. Mosby Company, St. Louis, 1976, p. 279. 19. Stones, H.H.: Oral and dental diseases. E & S Livingstone, London, 1954, pp. 822-823. 20. Ten Cate, A.R.: Oral histology - develop-
ment, structure, and function. C.V. Mosby Company, St. Louis, 1980, pp. 420424.
Address: B.L. Eppley St. John's Mercy Medical Center Department of Oral-Maxillofacial Surgery 621 South New Bullas Road St. Louis, Missouri 63141 USA