Dental Tribune India

Discovery of ‘Coronoid Foramen’ by a Bengaluru surgeon Dr Nyer Firdoose could explain pain after LA

By Rajeev Chitguppi, Dental Tribune South Asia
August 16, 2019

Dr Nyer Firdoose Chintamani Subhan, a maxillofacial and cleft surgeon from Bengaluru has published his original work on the unique discovery of ‘coronoid foramina’ bilaterally along with bilateral accessory foramina over the ‘lateral aspect of the ramus of the mandible,’ which has never been seen or documented in the literature so far in a live patient.

Dr Nyer Firdoose Chintamani Subhan was thinking along the lines of D. H. Lawrence “what the eye doesn’t see, and the mind doesn’t know, doesn’t exist," even if it does... while presenting his discovery of ‘foramina on the coronoid process’ and ‘accessory foramina on the lateral aspect of ramus’ of the mandible.

Dr Nyer Firdoose is a Maxillofacial and Cleft surgeon, Department of Oral & Maxillofacial Surgery, East Riyadh Specialized Centre, Saudi Arabia. His friends and colleagues call him a maxillofacial surgeon with an eagle's eye. He is also a researcher fascinated by the intricacies of human anatomy since his graduation days. For over a decade, Dr Nyer has been trying to unravel the mysteries of human anatomy.

What intrigued him the most was why some dental patients complain of pain despite receiving sufficient anaesthesia. His curiosity compelled him to go beyond the thirty-two teeth and look into the surrounding structures. The reason for ineffective anaesthesia or a lower pain threshold in some patients is either an improper technique used or the presence of additional nerves within the foramen. The latter is something that often goes unnoticed and is seldom taught during training years.

His search for the unique anatomic variants resulted in his chance finding in one of his patients - an extra opening in the lower jaw of that patient, not found in all individuals. The extra-opening in the bone, known as a foramen (foramina, plural), was present in the coronoid structure of lower jaw - confirmed by CBCT, facial scans and Steriolithograph models. Dr Nyer named his discovery as “Coronoid Foramen” and published it in the Journal of Surgical and Radiological Anatomy 2018 Feb titled - "Bilateral 'coronoid foramina' with accessory foramina on the 'Lateral aspect of Ramus' of the mandible: An unseen variance discovery in humans."

Dr Nyer says that after this unique finding, the pattern started repeating and he identified the Coronoid Foramen in as many as 30 cases including a few pediatric cases from all over the Middle East and South India. He hopes that his discovery could help the surgeons realise that foramina like these could be responsible for the variations they observe in the spread and aggressiveness of different infections and cancer metastasis. A thorough understanding of the anatomical variations may also help the surgeons to achieve haemostasis effectively in challenging situations.

Click here to watch the CBCT Demonstration of Bilateral "Coronoid Foramen" by Dr Nyer Firdoose.

Dr Nyer, who did his masters from Yenepoya Dental College, Mangalore is an innovator too. His innovation - Nyer-Zetractor, can be used for retraction, reflection and isolation of the surgical site simultaneously.

17 Comments

  • S.Cherie Natasha says:

    what are the specific structures passing through the coronoid foramina?

  • Dr. Nyer Firdoose says:

    The identified foramina are occupied by neurovascular bundle. The confirmed structures are to be debated and need extensive invasive investigations to identify and isolate them.

  • Dr. Nyer Firdoose says:

    These bilateral coronoid foramina along with the accessory foramina on the lateral aspect of ramus of mandible are occupied by neurovascular bundle. The confirmed structures are debatable, also it needs extensive invasive investigations to isolate and identify them.

  • Dr Dannis Brij says:

    Thank you Dr Nyer for widening our knowledge about this anatomic variation.
    Congratulations and best wishes

  • Dr. Ninad jamdade says:

    How much clinical significance does this foramina and associated structures carry during the surgical procedures and in case of pain control?

  • Dr rashid tellawi says:

    Thx dr Nyer for this knowledge its verry important for the dental future .
    God bless you ❤

  • Yak Lindy says:

    Would it be possible to change injection angle to Anesthetize nerves from this Foramen as well?

  • Dr Azhar perveiz says:

    Thanks dr nyyer n best wishes for ur future

  • Prof Puneet Wadhwani says:

    Dr Nyer, is one isolated case on the lateral aspect of coronoid enough to state it as a ground breaking finding?.. If you look at Langlais(1985)classification of bifid inferior alveolar canals, this falls under a Type 4 category (LA MALAMED PG 183) the only difference being present on the lateral aspect of the mandible.. bifid inf alv canals are known to have different origin (openings)on various levels of ramus and are notorious for incomplete anaesthesia because of differential distribution of the the inferior alv nerve bundle.
    My concern is that in todays world everything present on internet is being taken verbatim.

  • Prof. Narayana Kilarkaje says:

    Previously, I reported accessory foramina, including retromolar foramen and canal, and accessory mandibular foramina in mandibles (please see my papers in google). Cortex of mandible has numerous inconstant foramina. The inconstant foramen on ramus may be pierced by some nerve fibers from messeteric nerve after it supplies the masseter. However, these branches do not reach the mandibular teeth as they are far away. When I reviewed this paper, I did not see that discussion. Early branching of IAN in the case of mandible or accessory alveolar nerves in the case of maxilla may be responsible for anesthesia escape theory and the nerve fibers passing through the foramina are unlikely to be the reason.

  • Dr. Nyer Firdoose says:

    @Dr. Ninad jamdade. The clinical significance of any new structure identified or isolated depends on extensive studies on patients having such a feature. Presently we can only give hypothesis based on previous studies. As no such feature is ever been recorded on cadavers or osteology studies so far, we are currently researching on the demographic patterns and environmental factors which may be contributing towards such a feature.

    Pertaining to the pain control its already well established that activation of nerves (small or big) by any stimulus can interfere with signals from pain fibers, thereby inhibiting pain. So it is preferred to anesthetise even accessory nerve fibres for painfree procedures in and around the aforementioned structures.

  • Dr. Nyer Firdoose says:

    @Yak Lindy. Yes maybe, but firstly one has to identify the presence of such a feature before attempting any change in the conventional local anesthesia techniques. 🙂

  • Dr. Nyer Firdoose says:

    @Prof Puneet Wadhwani, Firstly, the first patient to be identified from my series of patients had accessory foramina on the lateral aspect of ramus bilaterally and not the coronoid process. And moreover i have not claimed it a groundbreaking finding all by myself, this script was presented in the international event “World congress of anatomists” held in Gadag in Sep 2017, plus the official journal of clinical anatomy peer review members and the editors suggested to be mentioned it as discovery which is a “never before seen/documented entitiy either in live humans or even in osteology studies”. And a discovery always begins with one isolated case which has now been validated using 3D reconstructed CBCT scans in over 30 such patients (case) globally and counting.

    If it were to be only just an isolated case one can consider it a coincidence but when the same truth keeps repeating itself its hard to pretend its just a coincidence. Moreover once you see a pattern you can’t unsee it.

    Finally the thing about the Langlais 1985 classification of mandibular canal bifurcation, u may be partly right about my pt falling under the category type 4 but not exactly. Moreover my script is not about the mandibular canal bifurcation or its variations rather it mainly about the presence of a huge foramen in the coronoid process bilaterally which is occupied with distinct isolated neurovascular bundle the structures of which remain debatable.

    (https://www.ncbi.nlm.nih.gov/pubmed/29423703) the link to my original script published in Surgical and Radilogical Anatomy dated Feb 2018. Kindly give it a read.

  • Dr. Nyer Firdoose says:

    @Prof. Narayana Kilarkaje, My script is not about foramina on ramus, this was a additional feature. The original script is about a huge isolated foramina in the coronoid process bilaterally which has never been seen or documented in literature until now. And about the discussion part we will surely consider adding your theories in our upcoming scripts on series of such similar patients.

    (https://www.ncbi.nlm.nih.gov/pubmed/29423703) the link to my original script published in Surgical and Radilogical Anatomy dated Feb 2018. Kindly give it a read.

  • Dr.Revathy Mohan says:

    Wow .. that’s amazing..Thank you for discovering and researching on this anatomic variations.This gave me the answers for those rare cases in which IANB not worked perfectly..and this finding helped me to regain my lost confidence while I encountered such cases…👍

  • Pooja ahluwalia sethi says:

    Congratulations commendable work. There are only very few who can see into what others can’t see or accept. Keep up the good work.

  • Shahla nigaar says:

    Excellent observation Dr.Nyer..
    Carry on with the good work.

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