Research Article - (2022) Volume 9, Issue 6
Received: Mar 08, 2022, Manuscript No. JEBMH-21-50871; Editor assigned: Mar 11, 2022, Pre QC No. JEBMH-21-50871(PQ); Reviewed: Mar 25, 2022, QC No. JEBMH-21-50871; Revised: Mar 30, 2022, Manuscript No. JEBMH-21-50871(R); Published: Apr 05, 2022, DOI: 10.18410/jebmh/2022/09.06.25
Citation: Sneha, Ravichandran V, Narayan V. Retrospective Analysis of Ponticulus Posticus in Orthodontic Patients Visiting a Private Dental College in Chennai. J Evid Based Med Healthc 2022;9(06):25.
Introduction: Ponticulus posticus is an anomaly located on the first cervical vertebrae which can be appreciated on the lateral cephalogram that is mostly neglected by the dentist. Ponticulus posticus is seen commonly in the lower primates. The aim of this study is to assess the prevalence of ponticulus posticus and its relation with Gender.
Material and Methods: A sample of 100 patients Lateral cephalogram were retrieved, Each digital radiograph was inspected for the presence and absence of ponticulus posticus and the results were statistically analysed..
Result: Among the 100 patients, 35 % were Male and 65 % were Female, 33 % were less than 15 years old, 54 % were 15 to 25 years old, 12 5 were 25 to 5 years old and 1 % were more than 35 years old. The ponticulus posticus was partially present in 16 % patients and absent in 84 % patients.
Conclusion: Ponticulus posticus is not an uncommon anomaly. If such an anomaly is discovered or suspected, it must be recorded in the patient's medical record and a professional consultation sought. As a result, the lateral cephalogram should be considered one of the primary screening tools for finding abnormalities and pathology in the cervical spine. therefore lateral cephalogram should be carefully examined to check for the presence of this anomaly before screw placement in the lateral mask of the atlas to avoid vertebral artery injury.
Ponticulus, Cervical vertebrae, Vertebral artery
In clinical orthodontics, the lateral cephalogram is the most common diagnostic radiograph. Cephalometric tracings, on the other hand, typically omit the cervical spine area shown in lateral cephalograms. Although the cervical vertebrae maturation evaluation and its modified version, the Cervical Vertebrae Maturation Index (CVMI), are now widely used to interpret the development potential of young children.1 In order to detect pathology, insufficient attention is made to the radiological anatomy of this region. A routine lateral cephalogram can reveal significant cervical spine pathology.2,3 Because "the eye sees what the mind understands," one of the goals of this article is to teach physicians and radiologists how to "see" the cervical spine and recognise deviations from normal structure. Ponticulus posticus is a defective bony bridge between the posterior section of the superior articular process and the posterolateral region of the superior edge of the posterior arch of the atlas. Its Latin name means "small posterior bridge." The normal atlas is a ring-shaped structure made up of two lateral masses linked by a short anterior arc and a longer posterior arch. It is the widest cervical vertebrae with its anterior arch approximately half The laminae of other vertebrae correlate to the posterior arch. A broad groove for the vertebral artery and the first cervical nerve can be found on its upper side. A bony arch may grow in 1 – 15 percent of the population, transforming this groove into a foramen through which these structures travel. The ponticulus posticus is the name for this bony arch.4 Ponticulus posticus has been called pons posticus, arcuate foramen, foramen arcuale, retroarticular vertebral artery ring, Kimmerle abnormality, foramen atlantoideum, foramen sagitale, canalis arteriae vertebralis, and retroarticular canal of the atlas in the past5-8 as long as the posterior arch. Because the majority of people with ponticulus posticus are asymptomatic, the clinical importance of this diagnosis is debatable.9 According to several studies, patients with ponticulus posticus have a low risk of having negative effects following cervical modifications due to its presence.10 Migraine without aura,11 chronic tension type headache,12 vertigo, diplopia, and neck pain are among symptoms that may be connected with ponticulus posticus.13 Monticules posticus has even been linked to vertebral artery compression, vertebro-basilar insufficiency, and even vertebral artery dissection. It must also be considered when the cervical spine is immobilised with lateral mass fixation in C1. During C1 lateral mass screw implantation, Young et al. observed that mistaken the ponticulus posticus for a broad posterior arch of the atlas could result in vertebral artery damage.14
Although we are not directly involved in the treatment of cervical spine anomalies, we do have a responsibility as healthcare providers to document any such discoveries that may be relevant to the patient's overall health. We need to study the morphological aspects and the prevalence of this aberration because of its growing clinical importance. The lateral cephalogram is an effective screening technique for this condition.
Many studies have shown an association of ponticulus posticus with migraine. Because ponticulus posticus is intimately related to the atlanto. Occipital membrane and this membrane, in turn is attached to the dura mater, small tensions exerted on the dura causing posterior circulation is chanier and cervicogenic headache, which in turn results in excruciating pain in migraine. Its prevalence has been reported to be between 5.14 and 37.83 % in the western population. Radiographically, have classified ponticulus posticus into three types:
Full type - complete bony ring.
Incomplete type - some portions of bony ring are defective.
Calcified type - linear or amorphous calcification.
Our team has extensive knowledge and research experience that has translate into high quality publications.15-34
There appear to be very few studies on the prevalence or morphological characteristics of ponticulus posticus in an Indian population. With this background, the present study was intended to investigate the prevalence and morphological features of ponticulus posticus and to identify any possible gender and age predominance with the prevalence of ponticulus posticus in an Indian population comprising patients reporting to private dental college in Chennai.
The study was done in Saveetha Dental College, Chennai. The study was approved by the ethical committee of the institution and it was carried out in the Department of Oral Medicine and Radiology. All the procedures were in accordance with ethical standards. Lateral cephalograms were retrieved from the archives and examined for monticules posticus. The study population was Indian (Dravidian) in origin belonging to Tamilnadu. Lateral cephalograms with poor visualization of the posterior arch of the atlas due to overlapping of the mastoid process or the occiput were excluded. Patients who reported congenital anomalies such as cleft lip and palate were not included in the study. Patients with other syndrome conditions involving the craniofacial region were also excluded. The images were viewed on a flat screen TFTLCD monitor (Thin Film Transistor-Liquid Crystal Display) with a resolution of 2906 x 2304 pixels in JPEG (Joint Photographic Experts Group) format with 24 - bit grayscale. Each radiograph was carefully inspected for the presence of a monticules posticus and whether it was complete or partial. During initial examination, all lateral cephalograms were observed independently by two of the authors. All the data were entered in Microsoft Excel 2007 and subjected to statistical analysis. Chi square test was used to analyze the differences between males and females regarding the presence of monticules posticus. 100 lateral cephalograms were analysed.
Among the total 100 patients 35 % were male and 65 % were Female. 33 % were less than 15 years old, 54 % were 15 to 25 years old, 12 % were 25 to 35 years old and 1 % was more than 35 years old.
The monticules posticus was partially found in 16 % of cases and absent in 84 % of patients (Graphs 1- 5).
Graph 1. The Bar Graph represents the Gender of the Patients. The Horizontal Axis represents the Gender of the Participants and the Vertical Axis Represents the no. of Patients.
Graph 2. The Bar Graph represents the Age Group of the Patients. The Horizontal Axis represents the Age Group of the Participants and the Vertical Axis represents the no. of Patients.
Graph 3. The Bar Graph represents the Presence of Anomaly [Monticules Posticus]. The Horizontal Axis represents the Partial Presence or Absence of Monticules Posticus and the Vertical Axis represents the No. of Patients.
Graph 4. . The Bar Graph represents the Comparison of Gender of the Patients and the presence of Anomaly [Monticules Posticus]. The Horizontal Axis represents the Gender of the patients and the Vertical Axis represents the Number of Patients. The Colour Blue represents the Partial Presence of Monticules Posticus and the Colour Green represents the Absence of Monticules Posticus.
Graph 5. The Bar Graph represents the Comparison of Age of the Patients and the Presence of Anomaly [Monticules Posticus]. The Horizontal Axis represents the Age Group of the Patients and the Vertical Axis represents the Number of Patients. The Colour Blue represents the Partial presence of Monticules Posticus and the Colour Green represents the Absence of Monticules Posticus.
The prevalence of monticules posticus has been estimated to be between 5.1 % and 37.8 % in the western population.14,35 In radiological investigations, complete monticules posticus was found to be between 2.6 % and 14.3 %, and in ontological research, it was shown to be between 3.4 % and 15 %.36 In our study, 2.95 % of the participants had entire monticules posticus. Female predominance.37 has been described more frequently, and our analysis shows a similar pattern. Cervical spine anomalies are more common in cleft lip and palate patients, according to numerous researches.
V Sharma et al.38 identified a prevalence of complete monticules posticus of 4.3 % in Indian Orthodontic patients, which is greater than ours (2.95 %), and they also showed male (5.33 %) predominance over female (3.76 %) in the population research. Complete monticules posticus was found in 2.8 % of males and 3.1 % of females in our study. The disparity could be explained by the fact that the populations in both research came from different places (Graph 5).
The results showed that the majority of the patients were Female and 15 to 25 years old. 6 % of Male patients have partial monticules posticus and 10 % of Female patients have partial monticules posticus. The monticules posticus was absent in 29 % Male and 55 % Female. The chi - square p value was statistically significant.
6 % of patients less than 15 years old have partial monticules posticus, 7 % of patients 15 to 25 years old, 3 % of patients 25 to 35 years old also have partial monticules posticus. The chi - square p value was statistically significant.
The prevalence of monticules posticus was reported to be around 15.8 % in a study done on Caucasians by Kendrick et al,39 which is slightly higher than ours. This disparity could be attributable to the study groups' ethnic diversity. Given the serious consequences of neglecting this defect during cervical spine surgery and other cervical spine procedures, as well as the ease with which it can be prevented if diagnosed correctly, the monticules posticus should be found on routine lateral cephalograms.
Leonardo R et al.40 recently published a study that found that calcification of the Atlanta-occipital ligament should be considered one of the key criteria for diagnosing nevoid basal cell carcinoma syndrome. Furthermore, because there is a link between migraine, chronic tension headache, and the presence of the monticules posticus, both of these or facial pain syndromes are considered as comorbid with TMJ disorders.41,42
Monticules posticus is not an uncommon anomaly; therefore lateral cephalograms should be carefully examined to check for the presence of this anomaly before screw placement in the lateral mass of the Atlas to avoid vertebral artery injury. If this anomaly in lateral cephalograms is detected / suspected, a three dimensional imaging modality such as CBCT or CT scan is needed for that purpose.
In conclusion, the study revealed that monticules posticus is a prevalent ailment among Indians. Because this aberration has been linked to or facial pain, such as migraine, more research should be done on diverse populations with bigger sample numbers, particularly on symptomatic patients, to confirm this link. If monticules posticus is discovered during routine radiography evaluation, it should be documented in the patient's health record, and if the patient is symptomatic, additional study should be sought.
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