Radiological Classification of Palatal Vascular Anatomy for Periodontal Surgery: Insights from 3D-RA

Radiological Classification of Palatal Vascular Anatomy for Periodontal Surgery: Insights from 3D-RA | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Radiological Classification of Palatal Vascular Anatomy for Periodontal Surgery: Insights from 3D-RA Ahmet Aydogdu, Evrim Bozay OZ, Ibrahim Ilker OZ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6775834/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Objective: This study aimed to comprehensively evaluate the anatomical variations and detailed vascular anatomy of the palatal mucosa, emphasizing the greater palatine artery (GPA) and lesser palatine artery (LPA), through the use of three-dimensional rotational angiography (3D-RA). This detailed vascular analysis aims to inform clinical decisions and reduce the risk of vascular injury during palatal graft harvesting procedures. Methods: A retrospective analysis of radiological data was conducted on 80 consecutive patients who underwent cerebral or carotid digital subtraction angiography (DSA) incorporating 3D-RA imaging. Detailed measurements were obtained for the GPA, descending palatine artery (DPA), and LPA, including arterial diameters, branching patterns, and their spatial relationships with palatal mucosal thickness and vault morphology. Based on GPA and LPA branching patterns, the vascular supply to the hard palate was classified. Results: The GPA was classified into three branching patterns, with Type I (absence of medial branch) being most prevalent (65%), typically accompanied by the presence of LPA contributions to the medial hard palate. The mean diameter of the GPA was 0.99 ± 0.16 mm, while DPA was significantly larger in males (p = 0.036). The GPA’s lateral branch narrowed anteriorly, with the smallest mucosal-to-vessel distance measured at the first premolar region (2.55 ± 1.11 mm), indicating a heightened risk for surgical injury. No significant relationship was found between palatal vault morphology and mucosal thickness. Conclusion: Significant anatomical variability exists within the palatal vasculature. The understanding of the branching patterns of GPA and LPA can greatly assist in planning for surgeries and make mucogingival graft procedures safer by reducing the risk of vascular complications. greater palatine artery lesser palatine artery palatal vault palatal mucosa cone beam computer tomography Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The palatal mucosa has been widely utilized as an autogenous donor site for subepithelial connective tissue and free gingival grafts (FGG) in mucogingival surgical procedures, particularly for the management of soft tissue deficiencies around teeth and dental implants [1,2]. Harvesting of FGG is commonly performed from the region extending from the distal aspect of the maxillary canine to the mid-palatal area of the first molar [3]. Anatomical variations in this region significantly influence the size of the graft that can be obtained [4]. The primary morphological constraints include the limited thickness of the mucosa and the proximity of vital vascular structures, both of which pose challenges to graft harvesting and increase the risk of surgical complications [5,6]. Among these complications, injury to the Greater Palatine Artery (GPA) is the most critical, frequently leading to severe haemorrhage [7,8]. The GPA, a terminal branch of the descending palatine artery (DPA), originates from the maxillary artery (MA). Additionally, the lesser palatine artery (LPA), arising as a side branch of the DPA, has been demonstrated in cadaveric studies to predominantly supply the soft palate, while the GPA primarily nourishes the hard palate [9-11]. Anatomical investigations have revealed considerable variability in the course and branching pattern of the LPA after passing through the greater palatine foramen (GPF), with reports suggesting possible anastomoses between the LPA and GPA [10,12,13]. However, due to inherent challenges associated with the dissection of the pterygopalatine canal (PPC) in cadaveric studies and non-contrast radiological studies, precise vascular variations within this canal remain difficult to ascertain. The studies on the vascularization of the palatal mucosa are limited, with only two significant studies investigating vascular variations within the PPC through cadaveric and radiological analyses [10,14]. However, neither study specifically examined branching variations of the LPA after emergence from the GPF. English-language literature generally accepts that the primary vascular supply to the palatal mucosa is derived from branches of the GPA, yet potential variations in the LPA have not been adequately explored. Consequently, classifications regarding the vascularization of the palatal mucosa may be incomplete or imprecise, potentially affecting clinical applications in periodontal and implant surgery. Several radiological studies utilizing Cone Beam Computed Tomography (CBCT) have evaluated the anatomical features of the GPA, the Greater Palatine Canal (GPC), and the Pterygopalatine Canal (PPC) [15-17]. Although CBCT provides valuable anatomical information about bone structures, a principal limitation is the inability to distinctly differentiate vascular structures from adjacent tissues due to the absence of contrast enhancement [7,15]. This technical constraint significantly impairs the accurate identification of vascular structures traversing foramina and canals of the hard palate. To overcome these limitations, the present study utilizes three-dimensional rotational angiography (3D-RA), an advanced imaging technique that allows for simultaneous acquisition of high-resolution, thin-section CBCT images during conventional angiography. By integrating advantages of both traditional angiography and CBCT, this method facilitates detailed visualization of vascular structures in three dimensions, enabling a more precise assessment of anatomical relationships within the PPC. The aim of this study is to provide a comprehensive understanding of the vascularization of the palatal mucosa and to investigate potential associations between vascular structures and anatomical features of the maxillary region. Furthermore, this study seeks to elucidate branching variations of the LPA within the PPC. By offering a more precise vascular mapping of the palatal region, findings from this study are expected to contribute to improved surgical planning and enhanced safety in periodontal and mucogingival procedures, ultimately reducing the risk of vascular complications during graft harvesting. Materials and Methods Study Population This retrospective study was approved by the institutional ethics committee (E-54022451-050.05.04-22084), and written informed consent was obtained from all participants. Between June 2020 and May 2021, consecutive adult patients who underwent cerebral or carotid artery digital subtraction angiography (DSA) with unilateral or bilateral 3D-RA via common carotid artery injection in the Interventional Radiology Department were included. Retrospective radiological image analysis was performed to evaluate the DPA and its branches, palatal vault morphology, and mucosal thickness using 3D-RA images from a total of 80 patients. 3D-RA and CBCT Imaging Protocols All imaging was performed using Philips FD20 (Philips Medical Systems, Netherlands) with the Cerebral Prop Scan acquisition protocol under default manufacturer settings. Raw data were acquired with a diagnostic catheter placed in the common carotid artery. A contrast medium (300 mg I/mL) was injected at a rate of 4 mL/s for 6 seconds (total volume: 24 mL) with a 2-second imaging delay. Post-processing of the raw data was conducted using Allura 3D-RA 6.4.6 and XperCT Dual 3.2.6 (Philips Medical Systems, Netherlands) on a workstation. High-resolution CBCT reconstructions were generated with a slice thickness ranging from 0.14 mm to 0.36 mm, enabling detailed visualization of vascular structures. Image Analysis CBCT image analysis was performed in consensus by a radiologist and a periodontologist using Allura 3D-RA 6.4.6 on a dedicated workstation. Image manipulation was permitted to enhance visualization of vascular structures and optimize morphological assessments. Arterial structures were evaluated using maximum intensity projection (MIP) images with a slice thickness of 10–20 mm. For standardization, measurements were performed on multiplanar reconstruction (MPR) images (Figure 1), using consistent anatomical landmarks: Axial images: A reference line was drawn parallel to the incisive fossa and posterior nasal spine. Sagittal images: A second reference line was positioned parallel to the nasal floor. Coronal images: A third line was aligned parallel to the hard palate. Diameters of the DPA and LPA were measured on sagittal reformatted images at the level of the PPC. The GPA diameter was assessed on coronal reformatted images at the level of the GPF, following previously established methods [18,19].The labial branch of the GPA, its terminal branch, was measured at the levels of the first and second molars and premolars. The medial and lateral branches of the GPA were evaluated at the level of the palatal spine. Based on previous studies, the branching pattern of the GPA and the arterial supply of the hard palate were analysed. Palatal Morphology and Mucosal Thickness Measurements Palatal width and depth were assessed using coronal reformatted images, with modifications based on the descriptions by Klosek et. al [20]. The palatal width (PW7) was defined as the distance between the alveolar bone crests of the maxillary second molars. The GPF-A distance was measured from the centre of the GPF to the median sagittal plane. For vertical measurements, the reference point was the alveolar bone crest at the level of the maxillary first premolar and second molar: Total palatal vault depth (TPVD): Measured vertically from the alveolar crest to the palatal sagittal midline. Greater palatine sulcus rim depth (GPSRD): Measured from the alveolar crest to the external rim of the sulcus. Greater palatine sulcus alveolar slope depth (GPSRAS): Measured along the slope of the maxillary alveolar process. Greater palatine sulcus vault depth (GPSVD): Measured vertically to the deepest point of the sulcus. Mucosal thickness was assessed on coronal images at multiple distances from the gingival margin (Figure 2): 3 mm from the gingival margin 6 mm from the gingival margin 9 mm from the gingival margin 12 mm from the gingival margin Distance from the mucosa to the GPA Statistical Analysis Statistical analysis was conducted using SPSS software (version 21.0 for Windows; SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented as mean, standard deviation, median, minimum, and maximum values for continuous variables, while categorical variables were reported as frequency and percentage. The Shapiro-Wilk test was applied to assess normality of data distribution. Independent samples t-tests were performed for two-group comparisons of normally distributed variables. For non-normally distributed variables, the Kruskal-Wallis test was used for independent group comparisons, followed by the Bonferroni-corrected Mann-Whitney U test for post-hoc analysis. A p-value <0.05 was considered statistically significant in all analyses. Results Demographic Findings A total of 80 consecutive patients (24 males and 56 females; mean age: 50.63 ± 13.53 years) meeting the inclusion criteria were included in the study. Measurements were conducted regardless of dental status (dentate or edentulous). Among the participants, 72 patients had at least three teeth in the molar and premolar regions, while eight patients were completely edentulous. Arterial Measurements and Morphological Findings In all cases, the GPA gave rise to the lateral branch (LB) as the terminal branch. The mean GPA diameter was 0.99 ± 0.16 mm, with no statistically significant difference between genders (male: 1.04 ± 0.15 mm, female: 0.97 ± 0.16 mm; p = 0.089). The LB was the dominant trunk of the GPA and exhibited the largest diameter at all measured levels (0.87 ± 0.14 mm). However, LB progressively narrowed anteriorly, reaching its smallest diameter (0.52 ± 0.09 mm) at the canine region. MB was found 28/80 (35%) of the patients and there were no statistically significant gender differences in LB and MB (p > 0.05; Table 1). Conversely, measurements of the DPA at the PPC level revealed a statistically significant difference between genders (p = 0.036). Findings related to the LPA are also presented in Table 1. The GPA branching pattern was classified into three types based on the course of the medial branch (MB) (Figure 3): Type I: No MB arises from the GPA. Type II: The MB of the GPA courses anterior to the palatal spine. Type III: The MB courses posterior to the palatal spine. The most prevalent branching pattern was Type I, observed in 52 patients (65%), all of whom exhibited one or more LPA branches supplying the hard palate. Type II, characterized by the MB coursing anterior to the palatal spine, was identified in 19 patients (23.75%). Type III was present in 9 patients (11.25%) and they have at least one LPA branches supplying the hard palate. In five patients (6.25%), at least one LPA was not observed; in all of these cases, the MB was present and originated anteriorly. In all remaining patients, at least one LPA contributed to the vascularization of the hard palate. Palatal Vault Measurements The median TPVD was 39.26 mm. Although male patients exhibited a wider vault (40.97 mm) compared to female patients (38.34 mm), the gender difference was not statistically significant (p = 0.186, p = 0.869). Other palatal vault measurements are provided in Table 3, with no statistically significant gender differences observed. Mucosal Findings The thickness of the palatal mucosa was assessed at five dental levels (M2, M1, P2, P1, C) and at four measurement points (a-d) extending 3 mm from the radiological gingival margin. A gradual increase in mucosal thickness was observed from coronal to apical regions, with the thickest mucosa at the maxillary first molar (M1) and the thinnest at the first premolar (P1) (Table 2). The distance between the palatal mucosa and the LB of the GPA was greatest at the M1 level (5.68 ± 2.53 mm), whereas the shortest distance was recorded at the P1 level (2.55 ± 1.11 mm) (Table 3). There were no statistically significant gender differences in palatal mucosal thickness. However, in general, female patients exhibited thicker palatal mucosa across all measurement points, except for the palatal midline mucosa (PMM), though these differences were not statistically significant. The PMM was found to be thicker from the canine to the P1 in male patients, whereas it was thicker from the second premolar (P2) to the P2 in female patients, although this trend was not statistically significant (Table 3). No significant correlations were found between palatal vault measurements and mucosal thickness (Table 4). Discussion Arterial Measurements and Morphological Findings After emerging from the GPF, the terminal branch of the DPA is known as the GPA. The LPA displays more variability in both origin and branching patterns. Yu et al. classified all arterial structures arising from the GPF as GPA and its branches. However, this approach did not account for the role of LPA in hard palate vascularization or the morphological diversity of GPA branching. This study reclassified GPA branching patterns and provided a detailed categorization of hard palate arterial supply. In the study of Yu et al., the origin of LPA or its role in palatal blood supply was not examined, creating an important gap in the understanding of arterial variations pertinent to mucogingival surgery. Similarly, the literature review by Tavelli et al. did not evaluate GPA and LPA variations concurrently [7]. In this analysis, GPA branching patterns and hard palate vascularization were described separately, offering anatomical data useful for reducing vascular complications during mucogingival procedures. This study showed that in 76.25% of cases, GPA and LPA originated simultaneously from the GPF (Figure 4). In 93.75% of the cases, at least one LPA branches supplied the medial hard palate. GPA was classified into three types based on the presence of a MB, with Type 1 being the most common. In 65% of cases, no MB was observed, and LPA supplied the medial hard palate. Comparison with the study of Yu et al. suggests that the MB described in Type 2 is likely LPA, due to the difficulty of identifying DPA branching in cadaver studies [4]. Griffin et al. reported lower necrosis rates in the palatal region than in upper first molar and premolar regions, where vascular injury risk was 5.7% [21]. Anastomoses between GPA, anterior palatine artery, nasopalatine artery, and LPA likely provide vascular redundancy that reduces necrosis risk. This anatomical framework supports future research exploring whether submucosal anaesthetic injections at contralateral palatal foramina reduce intraoperative bleeding during graft harvesting or sinus lift procedures. Newly identified contralateral anastomoses suggest that bilateral connective tissue grafting may impair palatal blood supply and increase necrosis risk. GPA measurements in this study align with findings from Kim et al., who used intra-arterial latex injections. Klosek et al. reported larger GPA diameters, possibly because latex coating was not applied [20]. No studies have used contrast-enhanced radiology to measure GPA diameters. Radiological imaging in living subjects could improve accuracy in submillimetre measurements compared to cadaver studies. Mucosal Findings Palatal mucosal thickness was measured from the radiological gingival margin. This was preferred over the cementoenamel junction to avoid errors in edentulous cases or those with gingival recession. Mucosal thickness values were similar to those reported by Kim et al., based on sectional palatal images [18]. Compared to Song et al., the measurements were higher that may be attributed to the reduced spatial resolution caused by the 2 mm slice thickness used in the 512x512 matrix, which reduces edge sharpness and inflates measurements [22]. Mucosal thickness and the distance between the mucosal surface and vascular structures directly affect graft survival. Grafts must allow adequate nutrient diffusion without increasing necrosis or vascular injury risk. Literature recommends a graft thickness between 1.0- and 1.5-mm [22]. Excessive thickness reduces integration potential, while thin grafts risk necrosis. Tavelli et al. described a "safety zone" width ranging from 10.9 mm in molars to 5 mm in the canine region [7]. Zucchelli et al. reported mean graft thicknesses of 1.34±0.26 mm and 1.32±0.16 mm, yet primary flap necrosis occurred in 28% of the test group during the first week [23]. This study found 29% of mucosal thickness measurements below the 1.5 mm threshold, suggesting higher vascular injury risk. LB passed closest to the mucosa at the first premolar level, differing from findings by Kim et al. [18]. This variation may be attributed to reduced spatial resolution caused by increased section thickness. Average LB-to-mucosa distance at this level was 2.55 mm, with the closest measurement recorded at 0.85 mm. The increased use of palatal mini-screw anchorage in orthodontics raises concern about vascular injury. Palatal arteries are also at risk during cleft repair, maxillary surgeries, and orthognathic procedures. In situations where collateral circulation is limited, palatal artery injury could cause significant complications. Insufficient mucosal thickness increases risks of necrosis, delayed healing, and postoperative pain. Damage to blood vessels during incision heightens these risks. Necrosis of palatal mucosa and hard tissue is possible. GPA, along with labial and canine branches, plays a central role in palatal blood supply. No correlation was observed between bony prominence and GPA branching patterns, confirming Yu et al.'s findings [4]. Palatal vault measurements matched previous studies, showing no relationship with GPA morphology. These observations suggest that predicting vascular injury in the hard palate based solely on topographic data remains unreliable. Current imaging technologies do not fully visualize the relationship between neurovascular structures, mucosa, and bone. Future advancements may allow detailed three-dimensional mapping of palatal anatomy, enabling replacement of cadaver studies with large digital anatomical databases. Conclusion The study refines GPA classification, emphasizes the role of LPA in hard palate vascularization, and highlights variations in mucosal thickness and vascular proximity. These anatomical insights are essential for minimizing risks during mucogingival surgeries, graft harvesting, and other palatal procedures. Continued advancements in imaging technologies are expected to improve anatomical mapping and surgical planning in this complex anatomical region. Declarations Author Contribution A Aydogdu: Protocol/project development, Data analysis, Data collection or management, Manuscript writing/editing E. Bozay OZ: Data collection or management, Data analysis, Manuscript writing/editing II OZ: Data collection or management, Data analysis, Manuscript writing/editing CRediT author statement Ibrahim Ilker OZ: Conceptualization, Methodology, Writing- Original draft preparation, Writing- Reviewing and Editing. Ahmet Aydogdu: Validation, Data curation, Formal analysis, Software, Writing- Reviewing and Editing. Evrim Bozay Oz: Visualization, Investigation, Resources, Writing- Reviewing and Editing. Funding None. Ethics declarations Ethical approval and consent to participate The Bezmialem Vakif University Ethics Committee approved the imaging study (number of approval: E-54022451-050.05.04-22084). The research was conducted ethically following the Code of Ethics of the World Medical Association (Declaration of Helsinki). Competing Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare no competing interests. References Monnet-Corti V, Santini A, Glise JM, Fouque-Deruelle C, Dillier FL, Liébart MF, Borghetti A (2006) Connective tissue graft for gingival recession treatment: assessment of the maximum graft dimensions at the palatal vault as a donor site. J Periodontol 77(5):899–902. 10.1902/jop.2006.050047 Reiser GM, Bruno JF, Mahan PE, Larkin LH (1996) The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Periodontics Restor Dent 16(2):130–137 Sullivan HC, Atkins JH (1968) Free autogenous gingival grafts. 3. Utilization of grafts in the treatment of gingival recession. 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J Clin Periodontol 37(8):728–738. 10.1111/j.1600-051X.2010.01550.x Tables Table 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Jun, 2025 Reviews received at journal 09 Jun, 2025 Reviews received at journal 07 Jun, 2025 Reviews received at journal 05 Jun, 2025 Reviewers agreed at journal 02 Jun, 2025 Reviewers agreed at journal 02 Jun, 2025 Reviews received at journal 02 Jun, 2025 Reviewers agreed at journal 02 Jun, 2025 Reviews received at journal 01 Jun, 2025 Reviewers agreed at journal 01 Jun, 2025 Reviewers agreed at journal 01 Jun, 2025 Reviewers invited by journal 01 Jun, 2025 Editor assigned by journal 30 May, 2025 Submission checks completed at journal 29 May, 2025 First submitted to journal 29 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6775834","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":465371271,"identity":"66f89cb3-c23a-400a-b14a-1c68c04b83ec","order_by":0,"name":"Ahmet Aydogdu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYDACCQaGAwkV/+VA7AMPiNTC+ODDGWZjsJYEIrUwG85sYU5sAHGI0sI/uztNmreBLX1+2OGHQFvs5HQbCFly5+w2ad4dPLkbb6cZALUkG5sdIGTNjVygljMSuRtnJ4C0HEjcRkiLPFhLm0G64ez0D8RpMbiRu9lwZltCgrx0DpG2GN7I3QgM5AOGG6RzCg4kGBDhF7kbuRuAUXlAXn52+uYPHyrs5Ah7H+5CsEoDYpWDgHwDKapHwSgYBaNgRAEATHxMObr6sp0AAAAASUVORK5CYII=","orcid":"","institution":"Galati Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Ahmet","middleName":"","lastName":"Aydogdu","suffix":""},{"id":465371272,"identity":"40c96ad9-430e-43af-8b33-85600b007f83","order_by":1,"name":"Evrim Bozay OZ","email":"","orcid":"","institution":"Marmara University","correspondingAuthor":false,"prefix":"","firstName":"Evrim","middleName":"Bozay","lastName":"OZ","suffix":""},{"id":465371273,"identity":"a37e1e36-6044-4910-8aeb-8ed1f9383734","order_by":2,"name":"Ibrahim Ilker OZ","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Ilker","lastName":"OZ","suffix":""}],"badges":[],"createdAt":"2025-05-29 10:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6775834/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6775834/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83905458,"identity":"ade82bb5-0a97-4d9c-a049-e111d01c65b8","added_by":"auto","created_at":"2025-06-04 10:13:52","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":709294,"visible":true,"origin":"","legend":"\u003cp\u003eMulti-planar maximum intensity projection reconstruction used for anatomical standardization. (a) Axial images: a reference line was drawn parallel to the incisive foramen and posterior nasal spine. (b) Sagittal images: a second reference line was aligned parallel to the nasal floor. (c) Coronal images: a third line was set parallel to the hard palate.\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6775834/v1/33ade59450fa78d30b352ca1.jpeg"},{"id":83905462,"identity":"9fcc6333-3846-446a-8fcf-faaf9fcca3d6","added_by":"auto","created_at":"2025-06-04 10:13:52","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1093380,"visible":true,"origin":"","legend":"\u003cp\u003eOn the coronal reformatted images, mucosal thickness was assessed at multiple distances from the gingival margin, measured at 3-mm intervals.\u003c/p\u003e","description":"","filename":"image2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6775834/v1/1150423679117df92f65b13c.jpeg"},{"id":83905982,"identity":"94da60a2-f74a-4dcd-9b2d-e65201b4c99a","added_by":"auto","created_at":"2025-06-04 10:21:52","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1267458,"visible":true,"origin":"","legend":"\u003cp\u003eThe branching pattern of the Greater Palatine Artery (GPA) was classified into three types based on the course of the medial branch (MB): Type I, in which no MB arises from the GPA (a); Type II, in which the medial branch courses anterior to the palatal spine* (b); and Type III, in which the MB courses posterior to the palatal spine* (c). (LPA: lesser palatine artery, LB: lateral branch)\u003c/p\u003e","description":"","filename":"image3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6775834/v1/a88eccd29dfeae88f34f8dcd.jpg"},{"id":83905461,"identity":"a523c425-3529-45be-821a-c3083fb147b9","added_by":"auto","created_at":"2025-06-04 10:13:52","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1437464,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal (a), sagittal (b), and axial (c) maximum intensity projection reconstruction images demonstrating the simultaneous origin of one Greater Palatine Artery (GPA) and multiple Lesser Palatine Arteries (LPAs) from the greater palatine foramen (GPF). Additionally, multiple LPAs are observed arising as side branches from the descending palatine artery (DPA) within the greater palatine canal. (IMA: internal maxillary artery)\u003c/p\u003e","description":"","filename":"image4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6775834/v1/fbd59ef0ded8c5856beea26b.jpg"},{"id":83905983,"identity":"6a84c0cd-16b7-4b2f-adeb-5af06f91b1f1","added_by":"auto","created_at":"2025-06-04 10:21:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5038153,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6775834/v1/791faa4c-5ef8-4fdd-9902-0bb106d6e30c.pdf"},{"id":83905456,"identity":"ddc52d30-179e-4735-a96c-15874be24241","added_by":"auto","created_at":"2025-06-04 10:13:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":43600,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6775834/v1/2871ee4663a921584c3403f2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Radiological Classification of Palatal Vascular Anatomy for Periodontal Surgery: Insights from 3D-RA","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe palatal mucosa has been widely utilized as an autogenous donor site for subepithelial connective tissue and free gingival grafts (FGG) in mucogingival surgical procedures, particularly for the management of soft tissue deficiencies around teeth and dental implants [1,2]. Harvesting of FGG is commonly performed from the region extending from the distal aspect of the maxillary canine to the mid-palatal area of the first molar [3]. Anatomical variations in this region significantly influence the size of the graft that can be obtained [4]. The primary morphological constraints include the limited thickness of the mucosa and the proximity of vital vascular structures, both of which \u003cu\u003epose\u003c/u\u003e challenges to graft harvesting and increase the risk of surgical complications [5,6].\u003c/p\u003e\n\u003cp\u003eAmong these complications, injury to the Greater Palatine Artery (GPA) is the most critical, frequently leading to severe haemorrhage [7,8]. The GPA, a terminal branch of the descending palatine artery (DPA), originates from the maxillary artery (MA). Additionally, the lesser palatine artery (LPA), arising as a side branch of the DPA, has been demonstrated in cadaveric studies to predominantly supply the soft palate, while the GPA primarily nourishes the hard palate [9-11]. Anatomical investigations have revealed considerable variability in the course and branching pattern of the LPA after passing through the greater palatine foramen (GPF), with reports suggesting possible anastomoses between the LPA and GPA [10,12,13]. However, due to inherent challenges associated with the dissection of the pterygopalatine canal (PPC) in cadaveric studies and non-contrast radiological studies, precise vascular variations within this canal remain difficult to ascertain.\u003c/p\u003e\n\u003cp\u003eThe studies on the vascularization of the palatal mucosa are limited, with only two significant studies investigating vascular variations within the PPC through cadaveric and radiological analyses [10,14]. However, neither study specifically examined branching variations of the LPA after emergence from the GPF. English-language literature generally accepts that the primary vascular supply to the palatal mucosa is derived from branches of the GPA, yet potential variations in the LPA have not been adequately explored. Consequently, classifications regarding the vascularization of the palatal mucosa may be incomplete or imprecise, potentially affecting clinical applications in periodontal and implant surgery.\u003c/p\u003e\n\u003cp\u003eSeveral radiological studies utilizing Cone Beam Computed Tomography (CBCT) have evaluated the anatomical features of the GPA, the Greater Palatine Canal (GPC), and the Pterygopalatine Canal (PPC) [15-17]. Although CBCT provides valuable anatomical information about bone structures, a principal limitation is the inability to distinctly differentiate vascular structures from adjacent tissues due to the absence of contrast enhancement [7,15]. This technical constraint significantly impairs the accurate identification of vascular structures traversing foramina and canals of the hard palate.\u003c/p\u003e\n\u003cp\u003eTo overcome these limitations, the present study utilizes three-dimensional rotational angiography (3D-RA), an advanced imaging technique that allows for simultaneous acquisition of high-resolution, thin-section CBCT images during conventional angiography. By integrating advantages of both traditional angiography and CBCT, this method facilitates detailed visualization of vascular structures in three dimensions, enabling a more precise assessment of anatomical relationships within the PPC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to provide a comprehensive understanding of the vascularization of the palatal mucosa and to investigate potential associations between vascular structures and anatomical features of the maxillary region. Furthermore, this study seeks to elucidate branching variations of the LPA within the PPC. By offering a more precise vascular mapping of the palatal region, findings from this study are expected to contribute to improved surgical planning and enhanced safety in periodontal and mucogingival procedures, ultimately reducing the risk of vascular complications during graft harvesting.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003ch4\u003e\u003cem\u003eStudy Population\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eThis retrospective study was approved by the institutional ethics committee (E-54022451-050.05.04-22084), and written informed consent was obtained from all participants. Between June 2020 and May 2021, consecutive adult patients who underwent cerebral or carotid artery digital subtraction angiography (DSA) with unilateral or bilateral 3D-RA via common carotid artery injection in the Interventional Radiology Department were included. Retrospective radiological image analysis was performed to evaluate the DPA and its branches, palatal vault morphology, and mucosal thickness using 3D-RA images from a total of 80 patients.\u003c/p\u003e\n\u003ch4\u003e\u003cem\u003e3D-RA and CBCT Imaging Protocols\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eAll imaging was performed using Philips FD20 (Philips Medical Systems, Netherlands) with the Cerebral Prop Scan acquisition protocol under default manufacturer settings. Raw data were acquired with a diagnostic catheter placed in the common carotid artery. A contrast medium (300 mg I/mL) was injected at a rate of 4 mL/s for 6 seconds (total volume: 24 mL) with a 2-second imaging delay.\u003c/p\u003e\n\u003cp\u003ePost-processing of the raw data was conducted using Allura 3D-RA 6.4.6 and XperCT Dual 3.2.6 (Philips Medical Systems, Netherlands) on a workstation. High-resolution CBCT reconstructions were generated with a slice thickness ranging from 0.14 mm to 0.36 mm, enabling detailed visualization of vascular structures.\u003c/p\u003e\n\u003ch4\u003e\u003cem\u003eImage Analysis\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eCBCT image analysis was performed in consensus by a radiologist and a periodontologist using Allura 3D-RA 6.4.6 on a dedicated workstation. Image manipulation was permitted to enhance visualization of vascular structures and optimize morphological assessments. Arterial structures were evaluated using maximum intensity projection (MIP) images with a slice thickness of 10\u0026ndash;20 mm.\u003c/p\u003e\n\u003cp\u003eFor standardization, measurements were performed on multiplanar reconstruction (MPR) images (Figure 1), using consistent anatomical landmarks:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eAxial images:\u003c/em\u003e A reference line was drawn parallel to the incisive fossa and posterior nasal spine.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eSagittal images:\u003c/em\u003e A second reference line was positioned parallel to the nasal floor.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCoronal images:\u003c/em\u003e A third line was aligned parallel to the hard palate.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDiameters of the DPA and LPA were measured on sagittal reformatted images at the level of the PPC. The GPA diameter was assessed on coronal reformatted images at the level of the GPF, following previously established methods [18,19].The labial branch of the GPA, its terminal branch, was measured at the levels of the first and second molars and premolars. The medial and lateral branches of the GPA were evaluated at the level of the palatal spine. Based on previous studies, the branching pattern of the GPA and the arterial supply of the hard palate were analysed.\u003c/p\u003e\n\u003ch4\u003e\u003cem\u003ePalatal Morphology and Mucosal Thickness Measurements\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003ePalatal width and depth were assessed using coronal reformatted images, with modifications based on the descriptions by Klosek et. al [20]. The palatal width (PW7) was defined as the distance between the alveolar bone crests of the maxillary second molars. The GPF-A distance was measured from the centre of the GPF to the median sagittal plane.\u003c/p\u003e\n\u003cp\u003eFor vertical measurements, the reference point was the alveolar bone crest at the level of the maxillary first premolar and second molar:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eTotal palatal vault depth (TPVD):\u003c/em\u003e Measured vertically from the alveolar crest to the palatal sagittal midline.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eGreater palatine sulcus rim depth (GPSRD):\u003c/em\u003e Measured from the alveolar crest to the external rim of the sulcus.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eGreater palatine sulcus alveolar slope depth (GPSRAS):\u0026nbsp;\u003c/em\u003eMeasured along the slope of the maxillary alveolar process.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eGreater palatine sulcus vault depth (GPSVD):\u003c/em\u003e Measured vertically to the deepest point of the sulcus.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMucosal thickness was assessed on coronal images at multiple distances from the gingival margin (Figure 2):\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e3 mm from the gingival margin\u003c/li\u003e\n \u003cli\u003e6 mm from the gingival margin\u003c/li\u003e\n \u003cli\u003e9 mm from the gingival margin\u003c/li\u003e\n \u003cli\u003e12 mm from the gingival margin\u003c/li\u003e\n \u003cli\u003eDistance from the mucosa to the GPA\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eStatistical analysis was conducted using SPSS software (version 21.0 for Windows; SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented as mean, standard deviation, median, minimum, and maximum values for continuous variables, while categorical variables were reported as frequency and percentage.\u003c/p\u003e\n\u003cp\u003eThe Shapiro-Wilk test was applied to assess normality of data distribution. Independent samples t-tests were performed for two-group comparisons of normally distributed variables. For non-normally distributed variables, the Kruskal-Wallis test was used for independent group comparisons, followed by the Bonferroni-corrected Mann-Whitney U test for post-hoc analysis. A p-value \u0026lt;0.05 was considered statistically significant in all analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003ch4\u003e\u003cem\u003eDemographic Findings\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eA total of 80 consecutive patients (24 males and 56 females; mean age: 50.63 \u0026plusmn; 13.53 years) meeting the inclusion criteria were included in the study. Measurements were conducted regardless of dental status (dentate or edentulous). Among the participants, 72 patients had at least three teeth in the molar and premolar regions, while eight patients were completely edentulous.\u003c/p\u003e\n\u003ch4\u003e\u003cem\u003eArterial Measurements and Morphological Findings\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eIn all cases, the GPA gave rise to the lateral branch (LB) as the terminal branch. The mean GPA diameter was 0.99 \u0026plusmn; 0.16 mm, with no statistically significant difference between genders (male: 1.04 \u0026plusmn; 0.15 mm, female: 0.97 \u0026plusmn; 0.16 mm; p = 0.089). The LB was the dominant trunk of the GPA and exhibited the largest diameter at all measured levels (0.87 \u0026plusmn; 0.14 mm). However, LB progressively narrowed anteriorly, reaching its smallest diameter (0.52 \u0026plusmn; 0.09 mm) at the canine region. MB was found 28/80 (35%) of the patients and there were no statistically significant gender differences in LB and MB (p \u0026gt; 0.05; Table 1). Conversely, measurements of the DPA at the PPC level revealed a statistically significant difference between genders (p = 0.036). Findings related to the LPA are also presented in Table 1.\u003c/p\u003e\n\u003cp\u003eThe GPA branching pattern was classified into three types based on the course of the medial branch (MB) (Figure 3):\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eType I: No MB arises from the GPA.\u003c/li\u003e\n \u003cli\u003eType II: The MB of the GPA courses anterior to the palatal spine.\u003c/li\u003e\n \u003cli\u003eType III: The MB courses posterior to the palatal spine.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe most prevalent branching pattern was Type I, observed in 52 patients (65%), all of whom exhibited one or more LPA branches supplying the hard palate. Type II, characterized by the MB coursing anterior to the palatal spine, was identified in 19 patients (23.75%). Type III was present in 9 patients (11.25%) and they have at least one LPA branches supplying the hard palate. In five patients (6.25%), at least one LPA was not observed; in all of these cases, the MB was present and originated anteriorly. In all remaining patients, at least one LPA contributed to the vascularization of the hard palate.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePalatal Vault Measurements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe median TPVD was 39.26 mm. Although male patients exhibited a wider vault (40.97 mm) compared to female patients (38.34 mm), the gender difference was not statistically significant (p = 0.186, p = 0.869). Other palatal vault measurements are provided in Table 3, with no statistically significant gender differences observed.\u003c/p\u003e\n\u003ch4\u003e\u003cem\u003eMucosal Findings\u003c/em\u003e\u003c/h4\u003e\n\u003cp\u003eThe thickness of the palatal mucosa was assessed at five dental levels (M2, M1, P2, P1, C) and at four measurement points (a-d) extending 3 mm from the radiological gingival margin. A gradual increase in mucosal thickness was observed from coronal to apical regions, with the thickest mucosa at the maxillary first molar (M1) and the thinnest at the first premolar (P1) (Table 2).\u003c/p\u003e\n\u003cp\u003eThe distance between the palatal mucosa and the LB of the GPA was greatest at the M1 level (5.68 \u0026plusmn; 2.53 mm), whereas the shortest distance was recorded at the P1 level (2.55 \u0026plusmn; 1.11 mm) (Table 3).\u003c/p\u003e\n\u003cp\u003eThere were no statistically significant gender differences in palatal mucosal thickness. However, in general, female patients exhibited thicker palatal mucosa across all measurement points, except for the palatal midline mucosa (PMM), though these differences were not statistically significant. The PMM was found to be thicker from the canine to the P1 in male patients, whereas it was thicker from the second premolar (P2) to the P2 in female patients, although this trend was not statistically significant (Table 3). No significant correlations were found between palatal vault measurements and mucosal thickness (Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch3\u003e\u003cem\u003eArterial Measurements and Morphological Findings\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eAfter emerging from the GPF, the terminal branch of the DPA is known as the GPA. The LPA displays more variability in both origin and branching patterns. Yu et al. classified all arterial structures arising from the GPF as GPA and its branches. However, this approach did not account for the role of LPA in hard palate vascularization or the morphological diversity of GPA branching.\u003c/p\u003e\n\u003cp\u003eThis study reclassified GPA branching patterns and provided a detailed categorization of hard palate arterial supply. In the study of Yu et al., the origin of LPA or its role in palatal blood supply was not examined, creating an important gap in the understanding of arterial variations pertinent to mucogingival surgery. Similarly, the literature review by Tavelli et al. did not evaluate GPA and LPA variations concurrently [7]. In this analysis, GPA branching patterns and hard palate vascularization were described separately, offering anatomical data useful for reducing vascular complications during mucogingival procedures.\u003c/p\u003e\n\u003cp\u003eThis study showed that in 76.25% of cases, GPA and LPA originated simultaneously from the GPF (Figure 4). In 93.75% of the cases, at least one LPA branches supplied the medial hard palate. GPA was classified into three types based on the presence of a MB, with Type 1 being the most common. In 65% of cases, no MB was observed, and LPA supplied the medial hard palate. Comparison with the study of Yu et al. suggests that the MB described in Type 2 is likely LPA, due to the difficulty of identifying DPA branching in cadaver studies [4].\u003c/p\u003e\n\u003cp\u003eGriffin et al. reported lower necrosis rates in the palatal region than in upper first molar and premolar regions, where vascular injury risk was 5.7% [21]. Anastomoses between GPA, anterior palatine artery, nasopalatine artery, and LPA likely provide vascular redundancy that reduces necrosis risk. This anatomical framework supports future research exploring whether submucosal anaesthetic injections at contralateral palatal foramina reduce intraoperative bleeding during graft harvesting or sinus lift procedures. Newly identified contralateral anastomoses suggest that bilateral connective tissue grafting may impair palatal blood supply and increase necrosis risk.\u003c/p\u003e\n\u003cp\u003eGPA measurements in this study align with findings from Kim et al., who used intra-arterial latex injections. Klosek et al. reported larger GPA diameters, possibly because latex coating was not applied [20]. No studies have used contrast-enhanced radiology to measure GPA diameters. Radiological imaging in living subjects could improve accuracy in submillimetre measurements compared to cadaver studies.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eMucosal Findings\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003ePalatal mucosal thickness was measured from the radiological gingival margin. This was preferred over the cementoenamel junction to avoid errors in edentulous cases or those with gingival recession. Mucosal thickness values were similar to those reported by Kim et al., based on sectional palatal images [18]. Compared to Song et al., the measurements were higher that may be attributed to the reduced spatial resolution caused by the 2 mm slice thickness used in the 512x512 matrix, which reduces edge sharpness and inflates measurements [22]. Mucosal thickness and the distance between the mucosal surface and vascular structures directly affect graft survival. Grafts must allow adequate nutrient diffusion without increasing necrosis or vascular injury risk. Literature recommends a graft thickness between 1.0- and 1.5-mm [22]. Excessive thickness reduces integration potential, while thin grafts risk necrosis. Tavelli et al. described a \u0026quot;safety zone\u0026quot; width ranging from 10.9 mm in molars to 5 mm in the canine region [7]. Zucchelli et al. reported mean graft thicknesses of 1.34\u0026plusmn;0.26 mm and 1.32\u0026plusmn;0.16 mm, yet primary flap necrosis occurred in 28% of the test group during the first week [23]. This study found 29% of mucosal thickness measurements below the 1.5 mm threshold, suggesting higher vascular injury risk. LB passed closest to the mucosa at the first premolar level, differing from findings by Kim et al. [18]. This variation may be attributed to reduced spatial resolution caused by increased section thickness. Average LB-to-mucosa distance at this level was 2.55 mm, with the closest measurement recorded at 0.85 mm.\u003c/p\u003e\n\u003cp\u003eThe increased use of palatal mini-screw anchorage in orthodontics raises concern about vascular injury. Palatal arteries are also at risk during cleft repair, maxillary surgeries, and orthognathic procedures. In situations where collateral circulation is limited, palatal artery injury could cause significant complications. Insufficient mucosal thickness increases risks of necrosis, delayed healing, and postoperative pain. Damage to blood vessels during incision heightens these risks. Necrosis of palatal mucosa and hard tissue is possible. GPA, along with labial and canine branches, plays a central role in palatal blood supply.\u003c/p\u003e\n\u003cp\u003eNo correlation was observed between bony prominence and GPA branching patterns, confirming Yu et al.\u0026apos;s findings [4]. Palatal vault measurements matched previous studies, showing no relationship with GPA morphology. These observations suggest that predicting vascular injury in the hard palate based solely on topographic data remains unreliable.\u003c/p\u003e\n\u003cp\u003eCurrent imaging technologies do not fully visualize the relationship between neurovascular structures, mucosa, and bone. Future advancements may allow detailed three-dimensional mapping of palatal anatomy, enabling replacement of cadaver studies with large digital anatomical databases.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study refines GPA classification, emphasizes the role of LPA in hard palate vascularization, and highlights variations in mucosal thickness and vascular proximity. These anatomical insights are essential for minimizing risks during mucogingival surgeries, graft harvesting, and other palatal procedures. Continued advancements in imaging technologies are expected to improve anatomical mapping and surgical planning in this complex anatomical region.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Aydogdu:\u0026nbsp;Protocol/project development, Data analysis, Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eE. Bozay OZ:\u0026nbsp;Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eII OZ: Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT author statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIbrahim Ilker OZ: Conceptualization, Methodology, Writing- Original draft preparation, Writing- Reviewing and Editing. Ahmet Aydogdu: Validation, Data curation, Formal analysis, Software, Writing- Reviewing and Editing. Evrim Bozay Oz: Visualization, Investigation, Resources, Writing- Reviewing and Editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Bezmialem Vakif \u0026nbsp;University Ethics Committee approved the imaging study (number of approval: E-54022451-050.05.04-22084). The research was conducted ethically following the Code of Ethics of the World Medical Association (Declaration of Helsinki).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 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J Periodontol 79(3):406\u0026ndash;412. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1902/jop.2008.070302\u003c/span\u003e\u003cspan address=\"10.1902/jop.2008.070302\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZucchelli G, Mele M, Stefanini M, Mazzotti C, Marzadori M, Montebugnoli L, de Sanctis M (2010) Patient morbidity and root coverage outcome after subepithelial connective tissue and de-epithelialized grafts: a comparative randomized-controlled clinical trial. J Clin Periodontol 37(8):728\u0026ndash;738. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1600-051X.2010.01550.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-051X.2010.01550.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"greater palatine artery, lesser palatine artery, palatal vault, palatal mucosa, cone beam computer tomography","lastPublishedDoi":"10.21203/rs.3.rs-6775834/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6775834/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: This study aimed to comprehensively evaluate the anatomical variations and detailed vascular anatomy of the palatal mucosa, emphasizing the greater palatine artery (GPA) and lesser palatine artery (LPA), through the use of three-dimensional rotational angiography (3D-RA). This detailed vascular analysis aims to inform clinical decisions and reduce the risk of vascular injury during palatal graft harvesting procedures.\u003c/p\u003e\n\u003cp\u003eMethods: A retrospective analysis of radiological data was conducted on 80 consecutive patients who underwent cerebral or carotid digital subtraction angiography (DSA) incorporating 3D-RA imaging. Detailed measurements were obtained for the GPA, descending palatine artery (DPA), and LPA, including arterial diameters, branching patterns, and their spatial relationships with palatal mucosal thickness and vault morphology. Based on GPA and LPA branching patterns, the vascular supply to the hard palate was classified.\u003c/p\u003e\n\u003cp\u003eResults: The GPA was classified into three branching patterns, with Type I (absence of medial branch) being most prevalent (65%), typically accompanied by the presence of LPA contributions to the medial hard palate. The mean diameter of the GPA was 0.99 ± 0.16 mm, while DPA was significantly larger in males (p = 0.036). The GPA’s lateral branch narrowed anteriorly, with the smallest mucosal-to-vessel distance measured at the first premolar region (2.55 ± 1.11 mm), indicating a heightened risk for surgical injury. No significant relationship was found between palatal vault morphology and mucosal thickness.\u003c/p\u003e\n\u003cp\u003eConclusion: Significant anatomical variability exists within the palatal vasculature. The understanding of the branching patterns of GPA and LPA can greatly assist in planning for surgeries and make mucogingival graft procedures safer by reducing the risk of vascular complications.\u003c/p\u003e","manuscriptTitle":"Radiological Classification of Palatal Vascular Anatomy for Periodontal Surgery: Insights from 3D-RA","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-04 10:13:47","doi":"10.21203/rs.3.rs-6775834/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-09T19:41:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-09T13:09:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-07T11:31:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T05:30:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313362779415190244482007523774967933719","date":"2025-06-02T15:38:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263979891320248163737780822795812610308","date":"2025-06-02T10:33:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-02T09:15:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222623464327699814396775906074223743511","date":"2025-06-02T07:51:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-01T21:18:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53794344922086979937864507202181220052","date":"2025-06-01T21:13:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59644562657407735487937768042312948657","date":"2025-06-01T20:41:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-01T20:38:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-30T07:50:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-29T13:32:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Surgical and Radiologic Anatomy","date":"2025-05-29T10:51:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e21c514d-6cd7-445b-8ca0-6d0ea941292e","owner":[],"postedDate":"June 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-25T13:53:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-04 10:13:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6775834","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6775834","identity":"rs-6775834","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}