|Year : 2019 | Volume
| Issue : 3 | Page : 60-65
Tomographic evaluation of the prevalence of the intraosseous branch of the posterior superior alveolar artery
Eduardo Claudio Lopes de Chaves e Mello Dias, Julia Bellinazzi de Andrade Santos, Khalila Chequer Cotrim, Fabiano Caparo de Brito
Postgraduate Department, São Leopoldo Mandic, Campinas, SP, Brazil
|Date of Submission||13-Nov-2019|
|Date of Decision||26-Dec-2019|
|Date of Acceptance||27-Dec-2019|
|Date of Web Publication||14-Feb-2020|
Eduardo Claudio Lopes de Chaves e Mello Dias
Rua Desembargador Sampaio, 204 sl. 403, Praia do Canto, Vitória, ES 29055-250
Source of Support: None, Conflict of Interest: None
Background: Despite being well documented and relatively safe, sinus lifting procedures can result complications. Aims: This study aimed to evaluate the presence of the intraosseous branch of the posterior superior alveolar artery (ibPSAA) at the surgical access point for maxillary sinus floor elevation procedure. Materials and Methods: A total of 583 tomography slices of 89 patients were analyzed for the presence or absence of this branch. The frequency of the presence of the artery, its diameter, its distance to the maxillary sinus floor, and its distance to the alveolar ridge according to the anatomical region related to the mentioned teeth were also measured. Results: The ibPSAA was visualized using the tomography in 50 patients (56.2%); a total of 583 tomography slices were evaluated and the vessel was identified in 219 slices. The artery had a diameter smaller than 1 mm in 67.9% of the cases and >1 mm in 32.1% of the cases. Conclusion: The present study provides information regarding the anatomy, presence, and most frequent location and size of the ibPSAA and revealed a risk of considerable hemorrhage in 32.1% of the cases, as the ibPSAA had a diameter >1 mm.
Keywords: Anatomy, maxillary sinus, posterior superior alveolar artery, tomography
|How to cite this article:|
Dias EC, Santos JB, Cotrim KC, Brito FC. Tomographic evaluation of the prevalence of the intraosseous branch of the posterior superior alveolar artery. J Oral Maxillofac Radiol 2019;7:60-5
|How to cite this URL:|
Dias EC, Santos JB, Cotrim KC, Brito FC. Tomographic evaluation of the prevalence of the intraosseous branch of the posterior superior alveolar artery. J Oral Maxillofac Radiol [serial online] 2019 [cited 2020 May 29];7:60-5. Available from: http://www.joomr.org/text.asp?2019/7/3/60/278418
| Introduction|| |
The increased pneumatization associated with resorption of the edentulous alveolar ridge and maxillary sinuses occasionally prevents the placement of dental implants.
Currently, maxillary sinus floor elevation is a well-described and widely used technique. It is considered the treatment of choice in cases of posterior maxillary reconstruction owing to a high rate of clinical success. However, despite being well documented and relatively safe, the procedure can result in serious complications if details regarding the vasculature, for example, the presence of the intraosseous branch of the posterior superior alveolar artery (ibPSAA), are neglected.,
Despite the availability of literature on the presence of ibPSAA, this aspect is neglected while planning maxillary sinus floor elevation. In general, the ibPSAA vessel does not influence the dental rehabilitation following treatment involving implants, unless a lateral window approach of the maxillary sinus is required to elevate the maxillary sinus. Thus, a comprehensive knowledge of the maxillary sinus vasculature is critical in such situations.
The PSAA divides into two branches before entering the foramen at the region of the maxillary tuberosity – a gingival branch (extraosseous branch of the PSAA) and the dental branch (ibPSAA). Both branches form an anastomosis with branches of the infraorbital artery, creating a vascular arcade around the anterior wall of the maxillary sinus , [Figure 1]. The intraosseous branch (ibPSAA) has a mean diameter of 0.9 mm (range: 0.4–1.9 mm). However, according to another source, the vessel has a mean diameter of 1.2 mm and can reach up to 2.5 mm.
|Figure 1: Intraosseous branch of the posterior superior alveolar artery at the location related to the surgical access point for the maxillary sinus floor elevation procedure|
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Computed tomography (CT) reveals variability in the visualization of the bone canal with regard to the ibPSAA at the lateral wall of the maxillary sinus. For instance, some studies report visualization in approximately 53% of the cases,, whereas other studies report it to be approximately 64%.,,,,,,, Moreover, some studies even claim the visualization to be as high as 92.7%. In contrast, there exist studies that report a considerably lower visualization (10.5%). Nevertheless, all studies clearly recommend the necessity of performing CT for appropriate surgical planning.
The ibPSAA has been reported to be in close proximity to the maxillary sinus floor in the region of the first molar.
Although CT images reveal different visualization rates, the anatomic dissection shows the anastomosis between the ibPSAA and the infraorbital artery to be always present.
The main objective of the present study was to evaluate the presence of the ibPSAA at the surgical access point for the maxillary sinus floor elevation procedure and to verify the presence or absence of the vessel at the lateral wall of the sinus. Other objectives of the study included measuring the height of this vessel in relation to the sinus floor, determining the location of the vessel in relation to the bone ridge, and evaluating the diameter of the bone canal where the ibPSAA supplies the lateral wall of the maxillary sinus.
| Materials and Methods|| |
The present research was approved by the Ethics Committee of Comitê de Ética em Pesquisa da Centro de Pós Graduação São Leopoldo Mandic (Statement 917.297). Five hundred and eighty-three CT images of the regions corresponding to the premolar and maxillary molar teeth were evaluated for the presence or absence of the ibPSAA [Figure 2]. A total of 89 patients attending the Specialization in Implant Dentistry Clinics at the São Leopoldo Mandic Post-Graduation Center, Campinas, São Paulo, Brazil, for diagnostic purposes before the dental implant treatment or other surgical procedures were selected using the convenience sampling method between July and December 2015. All patients whose scans were evaluated in the present study provided their written signed consent before the treatment for using their data in the research.
|Figure 2: Tomographic slices showing the presence of the intraosseous branch of the posterior superior alveolar artery|
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The sample size was determined using the method of proportion estimation, for which a prevalence of 64% reported by Güncü et al. was used. The acceptable error, that is, the expected precision around the prevalence was set at 10.0% to allow a 95% confidence interval. The minimum sample size required for the study was estimated to be 88 CT scans of patients undergoing treatment with dental implants. A total of 89 cone-beam CT (CBCT) scans were evaluated, including 583 tomographic slices. Any information that could reveal patient's identity was removed to retain patient confidentiality. Only age, gender, and the presence or absence of teeth were registered.
The CT scans were analyzed by a single trained researcher (ED). The reconstructed images were analyzed using i-CAT XoranCat ® software (Imaging Sciences International; Hatfield, Pennsylvania, USA), with transaxial images of 1 mm thickness and 1 mm interval. The measurements performed on each tomographic slice image were entered into a spreadsheet using the Microsoft ® Excel for Mac, version 15.35 (Microsoft, Redmond, Washington, EUA).
The data obtained in the present study were statistically analyzed as absolute (n) and relative (%) frequencies. The association of gender, local dental status (dentate × edentulous area), and the dental region ( first premolars, second premolars, first molars, second molars, and third molars) with the presence of ibPSAA was analyzed using Fisher's exact test and G-test.
The relationship between the patient's age and the distance between the ibPSAA and the crest (ibPSAA–crest) and that between the patient's age and distance between the ibPSAA and the sinus floor (ibPSAA–sinus floor) were investigated using the Pearson's test. To investigate the association between the distance between the ibPSAA and the ridge (ibPSAA–ridge) and the sinus floor (ibPSAA–sinus floor) with the gender, the area (dentate × edentulous), and the site, Student's t- tests and analysis of variance, followed by Tukey's test, were applied.
Statistical calculations were performed using the SPSS version 23 (SPSS Inc., Chicago, IL, USA) and BioEstat 5.0 (Mamirauá Foundation; Belém, PA, Brazil). The statistical significance level was set at 5.0%.
| Results|| |
Of a total of 89 CBCT scans obtained from the patients included in the present study, 18 (20.2%) belonged to males and 71 (79.8%) to females. Patient's whose CT scans were evaluated had a mean age of 51.5 years, with a standard deviation (SD) of 9.3 years (minimum age: 31 years and maximum age: 76 years). Male participants had a mean age of 54.8 years (range: 36–68 years) and a SD of 8.9 years. Among women, the minimum age was 31 years and the maximum was 76 years, with a mean of 50.6 years and a SD of 9.2 years.
The presence of ibPSAA was verified in 50 of the 89 CBCT scans evaluated in the study, indicating a prevalence of 56.2%. Although the results indicated a higher prevalence among male participants (72.2%) as compared to females (52.1%), Fisher's exact test did not show a statistically significant difference between the genders with respect to the prevalence of ibPSAA [Table 1]. We also observed two ibPSAAs in four participants, all of them were females.
|Table 1: Absolute (n) and relative (percentage) frequencies of the presence of intraosseous branch of the posterior superior alveolar artery by gender and a condition of evaluated area|
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The student's t- test showed no statistically significant difference in the age of patients (mean: 51.3 years and SD: 9.0 years) and the presence or absence (mean: 51.7 years and SD: 9. 6 years) of ibPSAA (P = 0.854).
A total of 583 regions were examined in the CBCT scans of 89 patients (tooth 14 and/or 15 and/or 16 and/or 17 and/or 18 and/or 24 and/or 25 and/or 26 and/or 27 and/or 28). Based on the findings, the ibPSAA was found on 219 occasions, indicating the presence of ibPSAA in 37.6% of the total regions examined.
In 574 of the 583 regions (tooth 14 and/or 15 and/or 16 and/or 17 and/or 18 and/or 24 and/or 25 and/or 26 and/or 27 and/or 28) having dentate or edentulous area, ibPSAA was present in 15.7% (90 in 574) and 21.4% (123 in 574) of dentate and edentulous areas, respectively. On the contrary, the ibPSAA was absent in 19.2% (110 of 574) of dentate areas and 43.7% (251 in 574) of edentulous areas. Fisher's exact test was applied at the frequencies described in [Table 1] and revealed a statistically significant difference in the prevalence of ibPSAA for the dentate or edentulous area (P = 0.005). Moreover, it was noted that the presence of ibPSAA was significantly lower among edentulous patients [Table 1].
The G-test showed that the prevalence in the region of second premolars and maxillary first molars was significantly higher – 32.9% and 29.2%, respectively, than that found in the first premolars (16.9%), second molars (20.1%), and third molars (0.9%). In 67.9% of the cases reporting the presence of ibPSAA, the diameter of the vessel was measured to be up to 1 mm, whereas it was >1 mm in the remaining 32.1% of cases.
The Student's t-test revealed that the ibPSAA–crest distance (P = 0.910) and the ibPSAA–sinus floor distance (P = 0.569) were not significantly affected by the patient's gender [Table 2]. On the contrary, the ibPSAA–crest distance was statistically significantly lower in edentulous areas (P < 0.001, [Table 2]). The ibPSAA–sinus floor distance was not significantly affected by the condition of the area (dentate or edentulous, P = 0.095; [Table 2]).
|Table 2: Mean values and standard deviations of the intraosseous branch of the posterior superior alveolar artery-crest and intraosseous branch of the posterior superior alveolar artery-sinus floor distances (mm)|
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The association between the patient's age and the ibPSAA–crest distance was statistically significant, being inversely proportional but extremely weak (P = 0.012; r = −0.167), whereas the age and the ibPSAA–sinus floor distance showed no association (P = 0.112) [Figure 3] and [Figure 4].
|Figure 3: Scatter diagram of the distance intraosseous branch of the posterior superior alveolar artery–crest as a function of the patient's age|
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|Figure 4: Scatter diagram of the distance intraosseous branch of the posterior superior alveolar artery–sinus floor as a function of the patient's age|
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| Discussion|| |
Surgeries involving the maxillary sinus floor are increasingly common in the field of dental implantology. However, bleeding complications associated with dental implant surgery, although infrequent, may prove to be serious. Therefore, extensive knowledge of the varying anatomical possibilities of the sinus vasculature, especially with reference to ibPSAA that is reported to get injured during the procedure, is essential to prevent such hemorrhagic complications. We describe these as possibilities because, despite being present in 100% of the cases,,,, the ibPSAA was visualized using CT only in 56.2% of the cases in the present study. Previous reports describe the visualization of this artery in 50%–65% of cases using CT,,,,,, although there is one report that could identify it in only 10.5% of the cases. Vessels that are smaller than 0.5 mm may not be properly identified using CT, and this may explain the differences in the percentages previously observed. Another possibility for its inconsistent visualization could be that the route of the artery is not constant through the lateral wall of the maxillary sinus. Moreover, its position may be superficial, intraosseous, or intrasinusal.,,
The ibPSAA is usually found in regions where the second and first premolars are located. In the present study, the vessel traveling through the bone canal was more common at first premolar and second molar regions in 19.6% and 20.1% of samples, respectively.
The risk of bleeding during maxillary floor elevation surgery is associated with two factors: proper planning of the surgery with the tomographic evaluation of the case , and the artery diameter., Arteries that are smaller than 0.5 mm in diameter, even if injured, rarely cause severe transoperatory problems. However, 32.1% of the cases in the present study reported the diameter of the ibPSAA to be ≥1 mm, thereby increasing the risk of hemorrhage. Attention is warranted when planning the procedure because numerous studies report arteries with diameters >2 mm to be present on the lateral wall of the maxillary sinus.,,,,,,,,,,,,
The region used for analyzing the bone window mainly depends on the presence or absence of teeth and on how much remaining bone exists in the region. It may be incorrect to say that 15 mm is a safe distance for osteotomy. Despite the mean ibPSAA–crest distance found to be higher than 15 mm [Table 2] in the present study, we observed great variations in it. These results suggest the characteristic curve of the artery with a superior concavity such that the more it distances itself from the bone crest, the more anterior the maxillary region becomes.
We did not find any statistically significant difference regarding the ibPSAA–sinus floor distance, suggesting that the artery followed the shape of the maxillary sinus floor at its anterior region. However, evaluation of the distance from the ibPSAA to the maxillary sinus floor revealed the height stability, implying the degree of resorption of the ridge, and not the artery position, to be a variable factor.
Knowledge of the vascular anatomy of the maxillary sinus, especially a deep understanding of the vessels related to the lateral wall of the sinus, is a fundamental factor that allows the dental surgeons to safely and successfully execute the procedure. The presence of the ibPSAA is of great importance for routine interventions at the implantology clinic, particularly in procedures that use the sinus elevation technique and gain access through the lateral wall of the maxillary sinus for implant placement.
| Conclusions|| |
The present study revealed a risk of considerable hemorrhage in 32.1% of the cases, as the ibPSAA had a diameter >1 mm. Thus, a comprehensive understanding of the vessel anatomy is imperative to avoid hemorrhagic risks and further consequences while performing dental implants.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Pramstraller M, Farina R, Franceschetti G, Pramstraller C, Trombelli L. Ridge dimensions of the edentulous posterior maxilla: A retrospective analysis of a cohort of 127 patients using computerized tomography data. Clin Oral Implants Res 2011;22:54-61.
Lee HW, Lin WS, Morton D. A retrospective study of complications associated with 100 consecutive maxillary sinus augmentations via the lateral window approach. Int J Oral Maxillofac Implants 2013;28:860-8.
Jung J, Yim JH, Kwon YD, Al-Nawas B, Kim GT, Choi BJ, et al
. A radiographic study of the position and prevalence of the maxillary arterial endosseous anastomosis using cone beam computed tomography. Int J Oral Maxillofac Implants 2011;26:1273-8.
Hong YH, Mun SK. A case of massive maxillary sinus bleeding after dental implant. Int J Oral Maxillofac Surg 2011;40:758-60.
Güncü GN, Yildirim YD, Wang HL, Tözüm TF. Location of posterior superior alveolar artery and evaluation of maxillary sinus anatomy with computerized tomography: A clinical study. Clin Oral Implants Res 2011;22:1164-7.
Hur MS, Kim JK, Hu KS, Bae HE, Park HS, Kim HJ. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg 2009;20:551-4.
Kqiku L, Biblekaj R, Weiglein AH, Kqiku X, Städtler P. Arterial blood architecture of the maxillary sinus in dentate specimens. Croat Med J 2013;54:180-4.
Ella B, Sédarat C, Noble Rda C, Normand E, Lauverjat Y, Siberchicot F, et al
. Vascular connections of the lateral wall of the sinus: Surgical effect in sinus augmentation. Int J Oral Maxillofac Implants 2008;23:1047-52.
Kim JH, Ryu JS, Kim KD, Hwang SH, Moon HS. A radiographic study of the posterior superior alveolar artery. Implant Dent 2011;20:306-10.
Elian N, Wallace S, Cho SC, Jalbout ZN, Froum S. Distribution of the maxillary artery as it relates to sinus floor augmentation. Int J Oral Maxillofac Implants 2005;20:784-7.
Kang SJ, Shin SI, Herr Y, Kwon YH, Kim GT, Chung JH. Anatomical structures in the maxillary sinus related to lateral sinus elevation: A cone beam computed tomographic analysis. Clin Oral Implants Res 2013;24 Suppl A100:75-81.
Anamali S, Avila-Ortiz G, Elangovan S, Qian F, Ruprecht A, Finkelstein M, et al
. Prevalence of the posterior superior alveolar canal in cone beam computed tomography scans. Clin Oral Implants Res 2015;26:e8-12.
Traxler H, Windisch A, Geyerhofer U, Surd R, Solar P, Firbas W. Arterial blood supply of the maxillary sinus. Clin Anat 1999;12:417-21.
Lwanga SK, Lemeshow S. Sample Size Determination in Health Studies: A Practical Manual. Geneva: World Health Organization; 1991. Available from: https://apps.who.int/iris/handle/10665/40062
. [Last accessed on 2019 Sep 25].
Rysz M, Ciszek B, Rogowska M, Krajewski R. Arteries of the anterior wall of the maxilla in sinus lift surgery. Int J Oral Maxillofac Surg 2014;43:1127-30.
Mardinger O, Abba M, Hirshberg A, Schwartz-Arad D. Prevalence, diameter and course of the maxillary intraosseous vascular canal with relation to sinus augmentation procedure: A radiographic study. Int J Oral Maxillofac Surg 2007;36:735-8.
Santos German IJ, Buchaim DV, Andreo JC, Shinohara EH, Capelozza AL, Shinohara AL, et al
. Identification of the bony canal of the posterior superior alveolar nerve and artery in the maxillary sinus: Tomographic, radiographic, and macroscopic analyses. ScientificWorldJournal 2015;2015:878205.
Watanabe T, Shiota M, Gao S, Imakita C, Tachikawa N, Kasugai S. Verification of posterior superior alveolar artery distribution in lateral wall of maxillary sinus by location and defect pattern. Quintessence Int 2014;45:673-8.
Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian membrane perforation rate during sinus elevation using piezosurgery: Clinical results of 100 consecutive cases. Int J Periodontics Restorative Dent 2007;27:413-9.
Khojastehpour L, Dehbozorgi M, Tabrizi R, Esfandnia S. Evaluating the anatomical location of the posterior superior alveolar artery in cone beam computed tomography images. Int J Oral Maxillofac Surg 2016;45:354-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]