J Clin Periodontol 2014; 41: 908914 doi: 10.1111/jcpe.

12288

Topographical relationship of the 1

Sun-KyoungYu , Myoung-Hwa Lee ,
Byung Sun Park1, Yong Hyun Jeon2,
1

greater palatine artery and the

2
Yoon Young Chung and Heung-
1
Joong Kim
1
Department of Anatomy and Orofacial

palatal spine. Significance for Development, School of Dentistry, Chosun

2
University, Gwangju, Korea; Department of
anatomy, School of Medicine, Chosun

periodontal surgery.
University, Gwangju, Korea

Yu S-K, Lee M-H, Park BS, Jeon YH, Chung YY, Kim H-J. Topographical
relationship of the greater palatine artery and the palatal spine. Significance for
periodontal surgery. J Clin Periodontol 2014; 41: 908913. doi: 10.1111/jcpe.12288.

Abstract
Aim: The aims of this study were to (1) identify the branching pattern and course
of the greater palatine artery (GPA), (2) carry out a morphological analysis of
the palatal bony prominence that divides the medial and lateral grooves and (3)
characterize the topographical relationships between these two structures.
Methods: Thirty-six hemimaxillae were studied with the aid of a surgical micro-
scope to elucidate the GPA. A further 25 dry skulls were examined to establish
the morphology of the palatal spine.
Results: The most common GPA branching pattern was type I (41.7%, 15 sides),
which gave off the medial and canine branches after the bony prominence. The
distances from the CEJ to the lateral branch of the GPA were 9.04 2.93 mm
(canine), 11.12 1.89 mm (first premolar), 13.51 2.08 mm (second premolar),
13.76 2.86 mm (first molar) and 13.91 2.20 mm (second molar). The palatal
spine was frequently observed as the bony prominence (66.3%, 57 sides), and was
located at 6.49 1.76 mm from the greater palatine foramen, with a length of
10.42 2.45 mm. There was no a correlation between the bony prominence
shape and the GPA branching pattern. Key words: greater palatine artery; lateral
Conclusions: These results could provide the reference data regarding the topog- groove; palatal spine; periodontal surgery
raphy of the GPA for periodontal surgery.
Accepted for publication 7 February 2014

Conflict of interest and source of
funding statement
The authors declare that there are no
conflicts of interest in this study.
This research was supported by Basic
Science Research Program through
the National Research Foundation of
Korea (NRF) funded by the Ministry
of Education (NRF-2013R1A1A205
9176).
908
Similar to the gingiva, the mucosa of
the hard palate comprises three parts
histologically: a keratinized epithe-
lium, a dense lamina propria which
is important for vascularization and
resistance to functional stress in the
graft and can determine the pheno-
types of oral epithelium, and a sub-
mucosa located below these two
structures (Sullivan & Atkins 1968,
Hsieh et al. 2010). While Sharpeys
fibres in the submucosa hold the
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
lamina propria tightly to the perios-
teum, it is still possible to separate
the dense connective tissue from the
periosteum via the adipose and glan-
dular tissues (McMinn 1990, Wearne
et al. 2001). Because of the histologi-
cal similarities and characteristics
between the gingiva and the mucosa
of the hard palate, the palatal
mucosa is used widely as an autoge-
nous donor site for periodontal
mucogingival surgery.
 Topography of greater palatine artery 141

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
142 Yu et al. aspect of GPN 4 l tional 25
In root of 1996). In Further
general, the first this the in more, the , s dry skulls
the distal molar, context, upper the neurovascu (50 sides)
regions of the an third form of lar bundle R a were
the canine greater accurate molar, to the runs e n evaluated
to palatine under- reach the neurova anteriorly i d to elucidate
midpalata foramen standing hard scular within the s the
l aspects in the of the palate bun- dle bilateral e M morphol-
of the first pos- location (Li et al. have longitudina r e ogy of the
molar in terior and 1996, been l grooves t palatal
the hard region course of Methathr describe of the bony e h bony
palate are of the the GPA athip et d only palate t o prominence
recommen first is needed al. vaguely (Hassanali d . These
ded as molar, to enable 2005). At in the & a s cadavers
the donor the clini- cians the hard literatur Mwaniki l The GPA and dry
site greater to develop palate, e 1984), and . and the skulls had
because palatine a pre- the GPA, (Netter the palatal palatal been
of the neurova operative together 1987, bony 1 bony prepared
presence scular plan so with the Putz & promi- 9 prominenc for
of a uni- bun- that they GPN, Pabst nence 9 e of the educational
formly dle can courses 2000, divides 6 hard pur- poses
thick [which determine and Drake these ) palate and
mucosa, comprise the sends et grooves, . were donated to
which can s the amount of out al. forming The examined the
pro- vide greater donor branches 2010 the aims of in 24 Depart-
a pal- tissue that anteriorly, , margins this embalmed ment of
maximum atine can be in close Schu between study Korean Anatomy,
tissue artery harvested, contact enke the medial were to cadavers School of
graft (GPA) while with the et and (1) (36 Medicine,
length of and the simultane alveolar al. lateral identify the hemimaxil Chosun
31.7 mm greater ously ridge 2010 sides branching lae; 18 University.
(Monnet- palatine reducing between ). (Jeyaseelan patterns males and This study
Corti et nerve the the & Gupta and courses six followed the
al. (GPN)] potential junction 1988). of the GPA females). Declaration
2006, and the risk of of the Clinicians in the hard The mean of Helsinki
Song et pala- damag- maxil- can pal- age at on medical
al. 2008). tine ing the lary therefore ate, (2) death protocol
However, rugae in GPA. alveolar esti- carry out a of these and ethics.
because the The ridge and mate the morphologi cadavers Latex
of anterior GPA the course of cal analysis was (Neopren
variations region originates horizon- the of the 60.8 years e,
in the of the from the tal plate neurovascu palatal (range Lot
anatomy canine descendin of the lar bundle bony 2990 no.
of the distal g maxilla, and reduce promi- years). 307L146,
hard (Morm palatine and then the risk of nence that All of DuPont,
palate ann et artery of enters divides the Barsac,
dam- them had
al. the nasal France)
between the aging by medial more than
patients, 1981, maxillary cavity and lateral containing
palpation three
Greenste superiorl a red
particular artery in of this grooves poster- ior
care must in et al. the y and (3) colouring
prominent teeth or
be taken 2008). pterygopa through determine agent
bony were
during Thus, la- the the (Colorant
structure treated
donor the tine fossa, incisive topographi Universal,
during with a
height, foramen Castorama,
tissue passes periodonta cal den- tal
harvesting length through (Reiser et relationship Templemars
l prosthesis
and al. 1996, , France)
not to the surgery and between for
dam- thickness pteryg- Drake et these two was
when missing
age of the opalatine al. 2010). parameters. injected
injecting teeth;
structures available canal and Thus through the
local therefore,
such as donor emerges far, the pterygopala
anaesthetic M all
the thin tissue from branching tine canal
(Hassanali a hemimaxil
mucosa will vary the greater patterns of all
& t lae could
that exists between palatine and specimens
Mwaniki e provide a
close to patients foramen courses to reveal
1 r tooth
the bulky (Reiser in the of the the course
9 i location.
palatal et al. palatal GPA and of
8 a
2014 John Wiley & Sons A/S. Published
An addi-
by John Wiley & Sons Ltd
the GPA in After s was branching periodo d Topography of greater palatine artery 143
the palatal exposing identified, patterns ntal hemimaxi
neurovascu the and then of the probe llae and
lar bundle. neurova the GPN GPA (Hu 25 dry
The scular was were Frie- skulls.
epithelium bundle, removed. then dy, The
and the The classified Chicago shape of
subepi- specime distribu into four , IL, the
thelial ns were tion types USA) palatal
connective immerse patterns according with a bony
tissue were d in of the to the rubber prominen
then guanidin GPA courses stopper. ce was
carefully e were of these The classified
removed hydroch categorize three measure into
so as not loride d common d three
to dam- (0.2 M) according branches values types:
age the for 1 to the (Fig. 1). on the 1 Spine
palatal month, origins of The probe type,
neurovascu and its three topograp were in
lar bundle. then branches: hic taken which
treated course of using the
1 The
with the lateral digital promi-
lateral
ultrasoni branch ver- nier nence
branch
c of the calipers formed
(and
cleaner GPA (Mituto a spine
main
for 2 h from the yo, that
trunk
to second Kawasa clearly
of the
soften molar ki, separat
GPA)
the to the Japan) ed the
emerge
dense canine to an medial
d from
connecti the was accurac and
ve greater examined. y of lateral
tissue palatine The 0.01 groove
around foramen vertical mm s.
it (Hur and ran distance (
et al. anteriorl from the F
2013). y cementoe i
The toward namel g
GPA the junction .
and the anterior (CEJ) at
GPN teeth. the 1
were 2 The central )
dissecte medial point of .
d branch each The
meticulo coursed canine morpho
usly toward and logical
with the the premolars variatio
aid of a (correspo ns of
midpal
surgical nding the
atal
microsc to the palatal
suture.
ope meeting bony
3 The
(OPMI- point promine
canine
FC, between nce
branch
Carl the that
emerged
Zeiss, lingual divides
from
Oberkoc groove the
the
hen, and the medial
lateral
German CEJ of and
branch
y). The the lateral
and
topogra molars) palatal
ascende
phic to the grooves
d to the
relation- lateral were
canine
ship branch investig
region.
between was ated in
the two measured the 36
The
structure using a dissecte
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
144 Yu et al.

2 Bridge type, in which the bony

prominence was shaped like a
canal linked by bony or fibrous
ligaments.
3 Smooth type, in which the bony
prominence was rarely revealed.

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 premolar; M1, firstTopography
molar; of greater palatine artery
A morphometric of
145
M2, second molar. analysis of the bony statistical
prominence was then significanc
con- ducted using e
digital vernier calipers; w
(1) start and end a
points of the bony s
prominence relative to
(a) (b) specific tooth sites, (2) s
distance from the e
Fig. 1. Diagram showing the parameters of the greater anterior margin of the t
palatine artery (GPA) and the palatal bony prominence greater palatine fora-
that were measured. (a) Branches of the GPA and the men to the start point a
vari- ous distances measured. The arrows indicate the
and (3) length of the t
distance between the lateral branch of the GPA from
the cementoenamel junction. (b) Morphometric analysis bony prominence (Fig.
of the bony prominences: a, start point of the bony 1). p
prominence relative to the tooth site; b, end point of All measurements
the bony prominence relative to the tooth site; c were repeated by two <
(arrow), distance from the anterior margin of the investigators based
greater palatine foramen to the start point of the bony on the 0
promi- nence; d (arrow), length of the bony same standard. The .
prominence. CB, canine branch; GPF, greater palatine intra-observer 0
foramen; IC, incisive foramen; LB, lateral branch;
MB, medial branch; PS, palatal spine; C, canine; P1, analysis did not show a 5
first premolar; P2, second premolar; M1, first molar; significant difference .
M2, second molar. (p > 0.05); the
second
R
measurement value of
e
each investiga- tor was s
used for final data. u
The l
inter-observer t
differences and differ- s
ences between
measurements made The main
on the right and left trunk of
sides were anal- ysed the GPA
by one-way ANOVA was the
using lateral
SPSS (version 12.0, branch,
SPSS, Chicago, IL, and the
USA). Since there were subsequen
no signif- t GPA
icant inter-observer branching
differences pattern
(p = 0.842), the mean was
of the mea- classi- fied
surements from into four
individual observers types
was used as final according
measurement. The to the
correlation between location
the branching of the
Fig. 2. Illustrations of the four branching patterns of origins of
the GPA. In type I, the lateral branch ran anteriorly patterns of the GPA
and the shape of the the
in the lateral groove of the bony prominence from the
palatal bony medial
greater palatine foramen, and then gave off a medial
and a canine branch after the bony prominence. In prominences was and
type II, a medial branch was given off from the lateral analysed using Pearson canine
branch before the bony prominence, and ran in the correlation coefficients. branches.
medial groove of the bony prominence. In type III, the No distinctions In type
lateral branch gave off a canine branch immediately were I, which
after passing through the greater palatine foramen. In
made with regard to was the
type IV, a medial branch, which arose from the most
lateral branch before the bony prominence, ran in the either age or gender.
All measurements are prevalent
lateral groove of the bony prominence along with the (41.7%, n
lateral branch. CB, canine branch; GPF, greater palatine pre-
sented as mean SD = 15), the
foramen; LB, lateral branch; MB, medial branch; PS,
palatal spine; C, canine; P1, first premolar; P2, second values, and the level lateral
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 146 ranYu anteriorly
branch et al. in the lateral groove of
the bony prominence from the greater palatine
foramen, and gave off a medial and a canine
branch after the bony prominence. In type II
(33.3%, n = 12), the medial branch arose
from the lateral branch before reaching the
bony promi- nence, and ran in the medial
groove

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Topography of greater palatine artery 147

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
148 Yu et al.
Table 1. Distances between the lateral branch of the greater palatine artery and the ce- difference between the left and right
mentoenamel junction at different tooth sites sides of approximately 1.5 mm was
Left Right Total p* not statistically significantly, with

C, canine; P1, first premolar; P2, second premolar; M1, first molar; M2, second molar. groove through which the palatal
The data (in mm) are mean SD values. neurovascular bundle passes into the
*p values represent the difference between the right and left sides at each tooth site using
one-way ANOVA (p < 0.05 is significant).
medial and lateral grooves. For the
bridge type (19.8%, n = 17), the two
crests of which were linked by bony
or fibrous ligaments that covered the
neurovascular bundle, there was no
bony canal (Fig. 3). The smooth
type occurred infrequently (13.9%,
n = 12) in this study. In addition,
both the spine and bridge types fre-
quently appeared 6.49 1.76 mm
from the anterior margin of the
greater palatine foramen at the sec-
ond molar, with a length of
10.42 2.45 mm, mostly disappear-
ing at the first molar (Table 2).
While the GPA and GPN
(a) (b) which make up the palatal neurovas-
cular bundle and supply blood and
Fig. 3. Photographs showing the bridge-shaped bony prominence in the bony palate sensation to the hard palate had a
(a) and the dissected GPA (b). The solid arrows indicate the bridge. The dashed line similar course, the main trunks of
encircles the fibrous ligament in the lateral groove of the bridge. The GPN was this artery and nerve did not appear
reflected bilaterally to reveal the fibrous ligament. GPA, greater palatine artery; GPF, to run together. The lateral (main)
greater palatine foramen; GPN, greater palatine nerve; gr., groove. branch of the GPA lay deeper than
the GPN, the main trunk of which
was located more medially and
of the bony prominence. In type III glands and adipose tissue in the mid- superficially closer to the oral
(16.7%, n = 6), the lateral branch palatal suture region. In all, except mucosa than that of the GPA
gave off a canine branch immedi- the type III branching pattern, the (Fig. 4). There was no correlation
ately after passing through the tooth site from which the canine between the branching pattern of the
greater palatine foramen. Finally, in branch arose from the lateral branch GPA and the shape of the palatal
type IV, which was the rarest of the was distributed similarly: 30% arose bony prominence (r = 0.060).
four types (8.3%, n = 3), the medial from around the first premolar,
branch arose from the lateral branch 33.3% from around the second pre- Discussion
before it reached the bony promi- molar and 36.7% from around the
nence, and ran together with the lat- first molar. The GPA is the main artery that
eral branch in the lateral groove of The distances between the lateral passes through the greater palatine
the bony prominence (Fig. 2). branch of the GPA and the CEJ foramen in the hard palate and dis-
The main, lateral branch coursed were 9.04 2.93 mm (canine), tributes its branches over the gingi-
tortuously and was the main supplier 11.12 1.89 mm (first premolar), val tissue, the palatine glands and
of blood to the hard palate. The 13.51 2.08 mm (second premolar), the mucous membrane of the hard
canine branch spread out over the 13.76 2.86 mm (first molar) and palate (Klosek & Rungruang 2009).
palatal gingiva adjacent to the canine 13.91 2.20 mm (second molar), Accurate and safe administration of
and premolar teeth, and the medial decreasing sharply at the first premo- local anaesthesia and periodontal
branch spread out over the palatine lar. However, for the canine the surgery require estimation of the

Table 2. Start and end points of the bony prominence relative to the greater palatine foramen at different tooth sites
M3 M3-M2 M2 M2-M1 M1 M1-P2 P2 P2-P1 P1

Start point 1 (1.7%) 2 (3.4%) 38 (64.4%) 11 (18.6%) 7 (11.9%)

End point 2 (3.4%) 1 (1.7%) 22 (37.3%) 11 (18.6%) 14 (23.7%) 8 (13.6%) 1 (1.7%)

Data are n (%) values at each tooth site.

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

(a)
Fig. 4. (a, b) Photographs showing the GPA and GPN. In (b), the GPN was reflected
bilaterally to reveal the GPA. The main trunk of the GPN was located more medial
and superficial (closer to the oral mucosa) than the GPA. CB, canine branch; GPA,
greater palatine artery; GPF, greater palatine foramen; GPN, greater palatine nerve;
LB, lateral branch; MB, medial branch; PS, palatal spine; C, canine; P1, first premo-
lar; P2, second premolar; M1, first molar; M2, second molar.
location and course of the GPA
through easily identifiable and palpa-
ble structures, such as the molar
teeth, the midpalatal suture and the
posterior border of the hard palate
(Hassanali & Mwaniki 1984, Metha-
thrathip et al. 2005, Klosek & Run-
gruang 2009).
The GPA and GPN together
form the neurovascular bundle.
Benninger et al. (2012) reported that
the main trunk of the artery tra-
verses the lateral palatal groove and
the main trunk of the nerve traverses
the medial palatal groove. Similarly,
in this study, the main trunks of the
artery and nerve ran different
courses. However, the main trunk of
the GPN, instead of traversing the
medial groove, was located more
superficially (i.e. closer to the oral
mucosa) than the GPA. In addition,
it was more medially in the area of
the posterior teeth, turned direction
of the course toward the anterior
teeth and had a similar course with
the lateral branch of the GPA more
laterally.
While the GPA sends branches
to all areas of the hard palate, they
are more prevalent on the side of
the alveolar process particularly in
the premolar region, compared to
the midpalatal suture (Klosek &
Rungruang 2009). The type I
branching pattern was the most
common in this study, whereby the
medial and canine branches arose
after the bony prominence. In the
(b)
case of the type III branching pat-
tern, the canine branch was observed
immediately passing through the
greater palatine foramen. Although
the canine branch is not the main
trunk of the GPA, unexpected bleed-
ing could occur on incision since it
is located closer to the CEJ. For the
type IV branching pattern, both the
lateral and medial branches tra-
versed in the lateral groove, more
attention should therefore be paid to
this type because the lateral branch
is located closer to the CEJ than for
the other types. Furthermore, an
anastomosis has been observed
between the GPA and the ascending
palatine artery at the posterior bor-
der of the hard palate (Mercer &
MacCarthy 1995, Gauthier et al.
2002). Additional studies are thus
needed to determine the topography
of the branches of the GPA in the
posterior region of the hard palate.
The GPA is 717 mm from the
CEJ, is located at 77% of the palatal
height and courses close to the CEJ
from the distal surface of the canine
(Reiser et al. 1996, Benninger et al.
2012). However, according to the
finding of a discrepancy between the
estimated location of the greater pal-
atine neurovascular bundle on mod-
els and the true location on the
cadavers, the height in most of the
participants tended to be underesti-
mated by about 4 mm (Fu et al.
2011). It is clear then that it is neces-
sary to establish the average distance
with respect to the course of the
GPA. The previous studies report
that the GPA has a positive correla-
tion with the palatal vault height,
and the average of palatal vault
height is about 14 mm (Reiser et al.
1996, Fu et al. 2011). On an average
palatal height, the greater palatal
groove rim from the CEJ is
decreased from 7.9 mm at the sec-
ond molar to 5.7 mm at the first pre-
molar, and the greater palatal
neurovascular bundle is also
decreased from 13.1 mm at the first
molar to 12.2 mm at the first premo-
lar (Klosek & Rungruang 2009, Fu
et al. 2011). In this study, the dis-
tance from the CEJ to lateral GPA
branch was about 13 mm at the sec-
ond molar, and decreased sharply to
11 mm at the first premolar. In addi-
tion, the canine branch arose from
lateral branch at a right angle, near
the premolar region. Therefore,
when the height of donor tissue is
determined in the recommended
area, which is from the distal regions
of canine to the midpalatal aspects
of the first molar, the location of the
GPA should be evaluated particu-
larly carefully at the first premolar.
The palatal bony prominence,
together with the greater palatine
neurovascular bundle, has been stud-
ied with reference to anthropometry
and dental prosthetics (Zivanovi c
1980, Hassanali & Mwaniki 1984,
Lee et al. 2001). In this study, the
spine type prominence, which has a
long and sharp shape, was similar to
that described elsewhere as a ridge
or crest and was also the most com-
mon type (66.3%) (Hassanali &
Mwaniki 1984, Jeyaseelan & Gupta
1988, Lee et al. 2001). This spine
appears to exist regardless of the
presence (or lack) of a tooth, and
the clinician can usually palpate it
because it forms the margins of the
grooves at both sides (Reiser et al.
1996, Benninger et al. 2012). The
bridge type, which is characterized
by a short, blunt and distinct bony
prominence, was found to be formed
by incomplete canals linked by a
fibrous band. The presence of bony
or incomplete fibrous bridges may
cause problems when infiltrating the
GPN for local anaesthesia (Hassa-
nali & Mwaniki 1984, Jeyaseelan &
Gupta 1988).
There was no correlation between
the branching patterns of the GPA
and the shape of the bony promi-
nence. It was not possible to define
the branching type of the GPA by
palpation of the palatal bony promi-
nence. However, the GPA could
have a predictable course because a
palatal spine or bridge could be
observed in most people between the
second and first molars, anteroposte-
riorly, with a length of 10 mm. Like
this, it is important to understand
surrogate parameters for providing a
helpful tip for surgery. The crown
form of the central maxillary incisor
may indicate the positive correlation
of a buccal gingiva thickness and a
buccal alveolar bone thickness (Stein
et al. 2013). Thus, to provide a pre-
dictor for the location of the GPA,
further studies are needed to deter-
mine the correlation of the buccal
gingival thickness with the connec-
tive tissue thickness above the GPA
in hard palate.
In conclusion, the GPA was
found to run in the lateral groove of
the bony prominence and commonly
to divide into a lateral, a medial and
a canine branch after passing the
palatal spine. The lateral branch
mostly spread out over the palatal
gingiva adjacent to the teeth, and
the medial branch mostly spread out
over the palatine glands and adipose
tissue. These anatomical findings
could provide the clinician with ref-
erence data for periodontal surgery
regarding the location and course of
the GPA.
Acknowledgements
We would like to express our
thanks to Ms. Myoung Jin Ro and
Gee Young Park, students of School
of Dentistry, Chosun University, for
manuscript review and editing.
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Address:
Heung-Joong Kim
Department of Anatomy and Orofacial
Development
School of Dentistry, Chosun University
309 Pilmun-daero, Dong-gu, Gwangju 501-
759, Korea
E-mail: hjbkim@chosun.ac.kr
groove of the palatal spine, which
was located between the first and
second molars with a length of
10 mm. Thus, the clinician could
predict the course of the greater
palatine artery by palpating the
palatal spine.