|Year : 2021 | Volume
| Issue : 2 | Page : 105-113
Assessment of Position of Posterior Superior Alveolar Artery in Relation to Maxillary Sinus using Cone-Beam Computed Tomography
Manjushri Waingade1, Someshwari Salunkhe1, Raghavendra S Medikeri2
1 Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Periodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Submission||03-Mar-2021|
|Date of Decision||23-Oct-2021|
|Date of Acceptance||01-Nov-2021|
|Date of Web Publication||14-Jan-2022|
Dr. Manjushri Waingade
Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital,Off. Sinhgad Road, SNo 44/1, Vadgaon (Bk), Pune 411051, Maharashtra, Pincode-411041
Source of Support: None, Conflict of Interest: None
Introduction: Posterior superior alveolar artery (PSAA) is branch of the maxillary artery which usually supplies the lateral wall of the sinus and overlying membrane. Evaluation and awareness of the anatomy of maxillary sinus before surgery is crucial to avoid surgical complications. The aim of this study was to examine the position and diameter of PSAA using cone-beam computed tomography (CBCT). Materials and methods: CBCT images of 201 healthy individuals were examined to evaluate the presence, position, and diameter of PSAA. The distances of lower border of the artery to the alveolar crest, bone height below the sinus floor to the ridge crest, distance of the artery to the medial sinus wall were measured; also presence of sinus septa were recorded. Results: The PSAA was detected in 90.04%, and it was located intraosseously and extraosseously in 65.74% and 32.25% of the sample population, respectively. The mean diameter of the PSAA was 0.94 ± 0.46 mm. The mean PSAA to the medial wall distance was 14.56 ± 3.05 mm, PSAA to alveolar crest distance (dentate patients) was 15.92 ± 3.84 mm, respectively. In the maxillary sinuses examined only 7.7% showed the presence of septa. There was no statistically significant difference when position of PSAA was compared with gender and diameter of PSAA was compared with age and gender. Conclusion: The likelihood of detecting the PSAA on CBCT is high; its location is intraosseous or beneath the sinus membrane in most patients. A thorough understanding of the PSAA regarding its location, diameter, and related structures can avoid complications during surgery.
Keywords: Cone-beam computed tomography, maxillary artery, maxillary sinus, position, posterior superior alveolar artery, sinus septa
|How to cite this article:|
Waingade M, Salunkhe S, Medikeri RS. Assessment of Position of Posterior Superior Alveolar Artery in Relation to Maxillary Sinus using Cone-Beam Computed Tomography. J Orofac Sci 2021;13:105-13
|How to cite this URL:|
Waingade M, Salunkhe S, Medikeri RS. Assessment of Position of Posterior Superior Alveolar Artery in Relation to Maxillary Sinus using Cone-Beam Computed Tomography. J Orofac Sci [serial online] 2021 [cited 2022 Jan 18];13:105-13. Available from: https://www.jofs.in/text.asp?2021/13/2/105/335850
| Introduction|| |
Maxillary sinus derives its blood supply from the infraorbital artery (IOA), the greater palatine artery, and the posterior superior alveolar artery (PSAA).,, Several anastomoses of the PSAA and the IOA can be located within the bony lateral wall, which supplies the Schneiderian membrane as well as the epiperiosteal tissues.,
Anatomically, anastomosis between the PSAA and IOA is always found at the lateral wall.,, These vessels should be taken into consideration during sinus augmentation proceduresincluding open sinus lift, Caldwell–Luc surgery, Le Fort I osteotomy, and osteosynthesis for the treatment of maxillary fracture as, damage to these vessel can cause bleeding and lead to perforation of the Schneiderian membrane., In addition, it may obscure the field of vision during surgery, all of which prolong the operation and assessment of the sinus membrane reflection.,
Understanding of regional nutritive arteries helps clinicians to prevent local bone necrosis and also optimizes regional healing via proper vascularization of the graft materials., Conditions such as sinus floor convolutions, sinus septa, and narrow sinuses can complicate membrane elevation and increase the risk of membrane perforation during implant placement.,,
Anatomical limits that may interfere with maxillary sinus bone graft include maxillary sinus septum, maxillary sinus disease, and PSAA invaginated in the lateral wall of the maxillary sinus., The septa cause technical difficulty in working and complicate surgical procedures in this region.,,
Surgeons should be aware of the variations which enable the complications to occur easily, as well as crucial dangerous points while operating. Therefore, the knowledge of location and morphology is essential to recognize anatomical landmarks around the maxillary sinus.,,
The cone-beam computed tomography (CBCT) technology is a prerequisite for the preplanning stages during implant treatment to prevent complications such as hemorrhage, sinus perforations, or associated vascular anomalies. Also in clinical practice, it provides a number of potential advantages such as lower cost, radiation dose, and availability for maxillofacial imaging compared with conventional computed tomography.,,,,
Numerous studies describing the location of PSAA, visibility of the PSAA on the lateral wall of maxillary sinus, diameter of the artery, and its distance from medial wall and floor of maxillary sinus and from alveolar crest vary within wide range.,,,,
This is a cross-sectional observational study to assess the prevalence and position of PSAA in relation to maxillary sinus using CBCT. This study is an attempt to provide clarity on the features of the PSAA in the given population as well as the relevance for clinical applications alongwith prevalence of maxillary sinus septa and its characteristics to assess the necessity for appropriate imaging prior to any surgical procedure.
| Materials and Methods|| |
The CBCT images of 201 healthy individuals (109 males and 92 females) were obtained fromthe archives of Department of Oral Medicine and Radiology. The study protocol was reviewed and approved (SDCH/IEC/2015-16/12) by the Institutional Review Board of Ethics Committee on November 26, 2015. The CBCT images were made using Planmeca ProMax 3D-Mid CBCT unit (voltage of 60–120 kVp, current of 1–12 mAs, time 9–33 seconds, voxel size of 200–600 μm). The CBCT images of individuals aged 20 years or above, which showed the area of right and left maxillary sinus was included in the study. CBCT imageswith any pathology such as cysts, tumors, and osteomyelitis, fractures in the right and/or left maxillary sinus region, or images showing errors and artifacts obscuring visibility of structures in the right and/or left maxillary sinus region were excluded from the study. Each scan was opened in the Romexis software viewer provided by the manufacturer and was analyzed by two investigators. To improve the intra- and interpersonal reliability, investigators were tested for intra- and interexaminer variability. All measurements were analyzed twice by both examiners with an interval of 1 week before the study analysis in between each measurement. If the variability between the two examiners was found to be upto 10%, then the average was considered. However, for the variability more than 10%, reassessment was carried out by another investigator. The measurements were made to the nearest of 0.6 mm with a caliper. The CBCT images were screened and the following parameters were evaluated and measured:
- Presence of PSAA: Each slice of the scan was checked by scrolling it from anterior aspect to posterior aspect. Specifically lateral wall of maxillary sinus was evaluated for radiolucency interrupting the corticated border of the wall. It may appear as a well-defined, corticated, circular radiolucency, or C-shaped curve [Figure 1]a–c.
|Figure 1 (a) Coronal section of cone-beam computed tomography (CBCT) scan showing posterior superior alveolar artery (PSAA) canal on lateral walls of maxillary sinus. (b) Coronal section of CBCT scan showing PSAA canal below Schinderian membrane. (c) Coronal section of CBCT scan showing PSAA canal above the surface.|
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- Position of the PSAA: Intraosseous artery will appear as a well-defined circular radiolucency with corticated border. Extraosseous artery will appear as a C-shaped corticated indentation on lateral wall of maxillary sinus. Extraosseous artery is further classified as artery below the membrane and artery above the surface of sinus [Figure 1]a–c.
- Diameter of the PSAA: The diameter was measured from the outer surface up to the inner surface of the canal. Those with very small diameter which cannot be measured were recorded as less than 0.5 mm (<0.5 mm).
- Distance between the PSAA and the medial sinus wall (PSAA-MW distance): This distance was measured by drawing a straight horizontal line from the lower border of the canal up to the medial wall of maxillary sinus [Figure 2].
|Figure 2 Distance between posterior superior alveolar artery and medial sinus wall.|
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- The distance between the PSAA and the alveolar ridge was measured as follows:
- In case of edentulous sites, the distance was measured from the lower border of canal up to the lowermost point on buccal alveolar ridge (PSAA-AR distance) [Figure 3].
|Figure 3 Distance between posterior superior alveolar artery and alveolar ridge.|
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- In case of dentate, the distance was measured from the lower border of canal up to the crestal bone on buccal cortex (PSAA-AC distance) [Figure 4].
|Figure 4 Distance between posterior superior alveolar artery to the alveolar crest.|
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- If the PSAA canal and ridge are not in a straight line, the distance was measured from the horizontal line passing from PSAA to medial wall of sinus.
- Distance between the sinus floor and alveolar crest/alveolar ridge: The distance was measured from the lowest point on floor of maxillary sinus up to the horizontal line passing from buccal and palatal cortices in case of both dentate and edentulous scans. This distance was denoted as “SF-AC” and “SF-AR distance,” respectively [Figure 5]a,b.
|Figure 5 (a) Distance between sinus floor and alveolar ridge. (b) Distance between sinus floor and alveolar crest.|
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- Presence of sinus septa and its number, location, and height: To check for the presence and number of sinus septa, the whole sinus was examined by scrolling from anterior to posterior and superior to inferior aspect. Depending upon the orientation of the septa, the respective section was opened and height of the septa was measured [Figure 6] and [Figure 7].
Data obtained were compiled on a MS Office Excel Sheet (v 2010) and was subjected to statistical analysis using Statistical Package for Social Sciences (SPSS v 21.0; IBM) (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). Comparison of distances as per gender, sides (right and left), dentulous, or edentulous status has been performed using t test. For all the statistical tests, P<0.05 was considered to be statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study as 80%.
| Results|| |
The CBCT images of 201 healthy individuals (109 males and 92 females) were examined. The mean age of the study population was 37.5 ± 14.08 years. The PSAA was detected in 90.04% of the population studied. Prevalence in males and females was 87.15% and 93.47%, and prevalence on right and left sides was 91.54% and 88.55%, respectively [Table 1].
The PSAA was located intraosseously in 59.20% and extraosseously in 30.84% of the sample population. Intraosseous location of PSAA was reported in 63.58%females and 55.5% males, respectively. Extraosseous location of PSAA (below the membrane) was reported in 29.89% females and 31.19% males, respectively. Extraosseous location (on the cortex) was observed in only 0.24% of total sample. PSAA was absent in 6.52% females and 12.84% males. There was statistically nonsignificant difference when the position of PSAA was compared with the gender (P > 0.05, Chi-squared value = 2.424) [Table 2], Graph 1].
|Table 2 Position of posterior superior alveolar artery in relation to gender|
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The mean diameter of the PSAA in the sample population was 0.94 ± 0.46 mm. The mean diameter in males was 0.95 ± 0.51 and females 0.94 ± 0.42. There was statistically nonsignificant difference when the diameter of PSAA was compared with age and gender (P > 0.05) [Table 3], Graph 2].
|Table 3 Diameter of posterior superior alveolar artery in relation to age and gender|
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The mean PSAA-MW distance was 14.56 ± 3.05 mm. There was statistically nonsignificant difference when PSAA-MW distance was compared with age and gender (P > 0.05; Graph 3).
The mean PSAA-AC distance (dentate patients) was 15.92 ± 3.84 mm. There was statistically nonsignificant difference when the PSAA-AC distance was compared with age (P > 0.05). In dentulous patients, mean of the distance was more in males which was statistically significant (P = 0.001; Graph 3).
The mean PSAA-AR distance (edentulous patients) was 15.42 ± 4.44 mm. There was statistically nonsignificant difference when the PSAA-AR distance was compared with age and gender (P > 0.05; Graph 3).
The mean SF-AC distance was 8.77 ± 3.72 mm and mean SF-AR distance was 7.26 ± 3.31 mm, respectively. There was statistically nonsignificant difference when the SF-AC distance and SF-AR distance was compared with age and gender (P > 0.05, Graph 4).
The visibility of endosseous vascular canal (PSAA) according to the location of teeth showed maximum in second molar region (51.5%) followed by third molar (19.7%), first molar (15.9%), second premolar (2.2%), and first premolar region (0.5%), respectively (Graph 5).
The prevalence of sinus septa in the given population was 7.71%. Males (10.55%) showed higher prevalence of septa than females (4.34%) [Table 4].
Single septum wasreported predominantly followed by two and three septa [Table 5].
The mean height of the septa was 10.78 ± 3.62 mm. There was statistically nonsignificant difference observed when the height and number of septa were compared with gender (P > 0.05).
| Discussion|| |
Understanding of the anatomical location of PSAA is important not only to avoid threats to the neurovascular bundle, but also to avoid mechanical damages. Studies to assess the location and characteristics of PSAA have been carried out in the literature using cadaveric specimens and traditional CT but the benefits of CBCT over these are ease of operation and lower dose of radiation to cover a similar field of view (FOV) with minimum slice thickness and higher resolution, respectively.,,,,
A higher prevalence of PSAA (90.04%) was reported in the present studywhich is in accordance with previous studies reported by Anamali et al. (91%), Ilgüy et al. (89.3%), Tehranchi et al. (87%), and Kurt et al. (78%).,,, Although other authors have reported lower prevalence including studies by Güncü et al. (64.5%), Elian et al. (53%), Mardinger et al. (55%), Kim et al. (52%), and Yang and Kye (32.5%).,,,, This variation could be due to the use of different imaging modality, sample size, and racial differences between study populations.
Cadeveric studies have shown 100% prevalence of PSAA, whereas in CBCT, it is reported to be 47% to 67%.,,,, If the PSAA that is not detected on CBCT or CT scans does not necessarily mean that it is absent. This difference could be explained by the inability of CBCT to show arteries with a diameter less than 0.5 mm, as well as the fact that some alveolar antral arteries are subperiosteal to the Schneiderian membrane and not localized in the bone or also due to anastomosis of the PSAA and IOA as reported in cadaveric specimens.,,,,
A higher prevalence of PSAA was reported in females (93.47%) than males (87.15%) in the present study which is not in accordance with the previous studies, as they found the prevalence was high in males than females; as reported by Park et al. (males 66.7% and females 50%) and Kim et al. (64% males and 40% females), respectively. Few authors reported no difference in prevalence between males and females., Also, we reported no significant difference of PSAA occurrence between right (91.54%) and left (88.55%) sides.
In the present study, we reported the frequency of presence of intraosseous location of PSAA to be 65.74% which is in accordance with that reported in various studies (47–73.2%).,,,, Similarly, the occurrence of extraosseous location was 32.25%, which is in accordance with the previous studies that ranged from 13% to 47%.,, Extraosseous artery is classified as artery below the membrane, which was found to be 30.59% in the present study, which is in accordance with those reported by previous studies., PSAA on the external cortex of the lateral sinus wall have also been reported by various authors ranging from 1% to 6.6%.,,, This study has reported only 0.24% which is the least that is reported in literature. This could be attributed to the anatomic variations in the study population. Also, no significant difference in the prevalence of PSAA was found between males and females was which is in agreement with the previous studies.,,
The mean diameter of PSAA has been reported as <1 mm and >1 mm in the literature.,,,, Larger diameter may suggest severe bleeding resulting in operative and postoperative complications such as perforation of Schniederian membrane, postoperative sinusitis, displacement of graft material, and hematoma of the cheek.,, In the current study, the mean diameter of the PSAA was found to be <1 mm (0.94 ± 0.46 mm) which is similar to the results in the previous studies.,
Contradictory findings have been reported regarding relationship of gender and diameter of PSAA.,,, Few authors have reported that the diameter of PSAA was greater in males than females.,,,, But in the present study, no significant difference in diameter was observed according to gender which is in accordance with the previous research.,
Similarly, contradictory findings regarding relationship of age and diameter of PSAA have been reported.,,, Few authors have reported no relationship which is in accordance with the present study.,,, However, few authors suggested that the canal diameter was directly related to age; the older the patient, wider the diameter., This could be attributed to the variations in the population and use of different imaging modality for the evaluation.
The visibility of the PSAA or detail of the images depends on the voxel size and smaller voxel sizes have higher resolution. Few studies reported voxel size of 0.1 mm3., The CBCT images used in our study have the voxel size of 0.2 mm3 which is in accordance with previous studies.,
In our study, the mean PSAA-MW distance was 14.56 ± 3.05 mm which is in accordance with the previous studies., In addition, we found nonsignificant difference between PSAA-MW distance with age and gender. Few authors reported this distance to be more in males than females., Similarly, Khojastehpour et al. reported that this distance increases with age, whereas Ilgüy et al. reported shorter distance in older patients.
In the present study, the mean PSAA-AC distance in dentate patients was 15.89 ± 3.29 mm which is lesser when compared with those reported in previous studies.,,, In addition, most authors suggest this distance to be more in the premolar than molar region.,
As alveolar ridge level changes depending on the absence of tooth, the maxillary sinus floor also repositions accordingly., Hence, the height of the residual alveolar ridge is an important factor in determining the approximate position of the PSAA and also it helps to decide the proper length of an implant to be placed in edentulous region., The PSAA-AR distance in edentulous patients was found to be 15.09 ± 4.38 mm which is similar than that reported in previous studies.,,,
The visibility of endosseous vascular canal according to the location of teeth showed maximum percentage in second molar region (51.5%) in the present study. This is not in accordance with the previous study by Kurt et al. in which they have reported maximum percentage of 34.9% in first molar and 45.2% in the second premolar region on the left and right sides, respectively.
The most frequent intraoperative complication during implant procedures involving sinus floor elevationis the tearing of the sinus membrane (11–56%), which in turn is correlated to the presence of septa in the maxillary sinus.,,,, Therefore, preoperative imaging is highly clinically relevant for the detection and localization of septa.,,,,
According to our study, the prevalence of sinus septa was 7.71% which is lesser than that reported in previous studies that ranged from 16% to 69%.,,,,, This variability might be attributed to the number of samples, the radiographic techniques used, accuracy of observations, definition in relation to the height and size of septa, and presence or absence of teeth.
The mean height of the septa found in the present study was 10.78 ± 3.62 mm which is similar to that reported in the literature which ranged from 3.5 to 11.7 mm.,,,, This study also showed predominantly single septum within the sinus as reported in previous research.,,,, A higher prevalence of sinus septa was reported in males than females which is in accordance with study by Shen et al., whereas Neugebauer et al. found no such difference.
This study used CBCT to detect PSAA which showed better reproducibility and cost-effectiveness for the detection of the PSAA and so can be recommended as a dose-sparing alternative to conventional CT for maxillofacial imaging.
The limitations of the present study include a smaller sample size with unequal distribution between dentate and edentulous patients and also nonuniform distribution of samples according to age and gender. Thus, we propose further research on larger sample including comparison between dentulous and edentulous patients, considering various age groups and other confounding factors.
| Conclusion|| |
The PSAA prevalence in the given population was 90% with higher prevalence in females (93.47%) than males (87.15%). The frequency of presence of intraosseous PSAA (65.74%) was higher than extraosseous PSAA (32.25%). The diameter of the artery was found to be <1 mm with no difference with respect to gender. In addition, the prevalence of sinus septa was 7.7% with higher prevalence in males than females. Thus, CBCT can be considered as an accurate tool to evaluate important anatomical parameters for implant or grafts or any surgical procedures in and around the floor of the maxillary sinus.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]