Int. J. Oral Maxillofac. Surg.

2007; 36: 735–738

doi:10.1016/j.ijom.2007.05.005, available online at http://www.sciencedirect.com

Research Paper
Pre-Implant Surgery

Prevalence, diameter and O. Mardinger1, M. Abba2,

A. Hirshberg3, D. Schwartz-Arad4
1
Tel-Aviv University Savion, Israel; 2Tel-Aviv
University, Israel; 3Department of Oral
course of the maxillary Medicine and Pathology, The Maurice and
Gabriela Goldschleger Dental School, Tel-
Aviv University, Israel; 4Department of Oral

intraosseous vascular canal and Maxillofacial Surgery, The Maurice and

Gabriela Goldschleger School of Dental
Medicine, Tel-Aviv University, Israel

with relation to sinus

augmentation procedure: a
radiographic study
O. Mardinger, M. Abba, A. Hirshberg, D. Schwartz-Arad: 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: 735–738. # 2007 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of the study was to characterize the prevalence, diameter and
course of intraosseous anastomosis between the posterior superior alveolar
artery and the infraorbital artery (bony canal) involved in the sinus floor
augmentation procedure. Data from 208 sinuses were analyzed from
reconstructed computed tomography (CT) images. The presence of the intraosseous
anastomosis in the lateral antral wall was detected using sagittal plane
sections, in addition, the intraosseous course and the diameter of the bony
canal were examined. The bony canal was identified in 114 (55%) of the
208 maxillary sinuses, with a mean distance of 16.9 mm from the alveolar ridge.
Key words: sinus floor augmentation; CT scan;
From the examined canals, in 7% the diameter was 2–3 mm wide, in 22% 1–2 mm
posterior superior alveolar artery; infraorbital
and in 26% it was less than 1 mm wide. Because only in 50% of cases the vessel artery; complications; bleeding.
was large enough to be detected by a CT scan, it is recommended, to place
the superior border of the osteotomy up to 15 mm from the alveolar crest in Accepted for publication 2 May 2007
A to C type ridges to avoid penetration of the artery. Available online 12 July 2007

Sinus augmentation has evolved into a placement of dental implants4. Sinus floor the blood supply of the maxillary sinus is
predictable surgical modality for increas- augmentation is a relative safe procedure8, mandatory to avoid unnecessary compli-
ing the existing height with bone of suffi- but severe haemorrhage may occur as a cations11,3. The blood supply to both the
cient quality to allow successful result of arterial injury1,7. Knowledge of lateral wall of the maxillary sinus and the

0901-5027/080735 + 04 $30.00/0 # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
736 Mardinger et al.

overlying Schneiderian membrane origi-

nates from the posterior superior alveolar
artery (PSAA) and the infraorbital artery
(IOA). Both vessels anastomose to a com-
mon vessel at the lateral antral bony wall,
18.9–19.6 mm from the alveolar mar-
gin9,10,12. The common vessel runs in a
canal which can be easily damaged whilst
preparing the bony window for sinus aug-
mentation. Transecting this vessel can
cause minor to intense bleeding that
may obscure vision and lead to perforation
of the Schneiderian membrane. When the
intra-bony course of the vessels is known,
the osteotomy can be properly planned to
avoid damage to the vessels and to main-
tain perfusion of the entire bone segment9.
Anatomically, anastamosis between the
PSAA and IOA is always found at the
lateral antral wall10. Whilst examining
computed tomography (CT) scans of the Fig. 1. CT images examined for the presence of bony canal in the lateral antral wall using para-
maxillary sinus, ELIAN et al. detected the axial plane sections and divided into four categories. Category no. 2: diameter less than 1 mm.
bony canal in only 53% of cases2. They
based the results on only 50 cases; the
diameter and course of the canal as well as
relations to neighbouring structures were
not studied.
The purpose of the present study was to
characterize the prevalence, diameter and
course of the intraosseous vascular canal
(the anastamosing PSAA and IOA) and to
discuss its importance in the sinus floor
augmentation procedure.

Patients and methods

The study group consisted of 104 CT scans
from patients scheduled for implant-sup-
ported restorations in the posterior eden-
tulous maxilla. Of the 104 patients, 69
were women and 35 men, age ranging
from 24 to 76 years (mean 52.9 years).
In the examined area, 66% were edentu-
lous and 33% were partially edentulous.
Only maxillary reconstructed high-
quality computerized images (CT) were
included in the study; excluded were
images of low quality such as scattering
or inferior level of window exposure. For
each case, both right and left maxillary
sinuses were analysed. The CT scans were
performed on an ELITE 2400 scanner
(Elscint Co. Ltd., Haifa, Israel) operated
at 120 kV and 33 mA. According to the
manufacturer’s instructions this is a highly
accurate scan with less than 1 mm devia-
tion. Overlapping 1.2-mm axial cuts at
1 mm intervals and the axial images were
reconstructed into cross sections (para-
axial). The protocol used 2-mm-thick
reconstruction algorithms.
CT images were examined for the pre-
sence of a bony canal in the lateral antral
wall using para-axial sections (Figs. 1–3).
Fig. 2. Category no. 2: diameter less than 1 mm.
The measurements were done on the film
using a caliper. The CT scans were
divided according to the presence of the
canal and its diameter into four cate-
gories: 1, no identification of bony canal;
2, diameter less than 1 mm; 3, diameter 1–
2 mm; and 4, diameter 2–3 mm. The
course of the canal was measured verti-
cally from the alveolar crest in each sagit-
tal reconstruction. The residual bony
ridges were classified according to
LEKHOLM & ZARB5 and the vertical heights
measured. The position of the canal
antero-posteriorly (A-P) was measured
from the lateral nasal wall. This distance
(A-P) was divided into four sections
according to tooth location, first and sec-
ond premolars and first and second
molars. The diameter of the canal was Fig. 3. Category no.4: diameter 2–3 mm.

analysed with regard to age, gender, site
(right or left) and the presence of teeth.
Mean values and standard deviations
were calculated. Statistical analysis was
performed using the Pearson correlation
test.
Results
A total of 208 CT images were examined
of which the bony canal was identified in
114 (55%). The course of the bony canal
formed a concave arch, with the most
inferior site in the first molar area
(Table 1, Fig. 4).
The diameter of the canal was less than
1 mm (category 2) in 26% of the cases, 1–
2 mm (category 3) in 22.1% and 2–3 mm
(category 4) in 6.7%. The diameter of the
canal was constant throughout its course
from the lateral nasal wall to the posterior
antral wall. The vertical measurements
related to residual bony height and the
ridge classification are summarized in
Table 2. The canal diameter was directly
related to age: the older the patient, the
wider the diameter (p = 0.031). No corre-
lation was found with gender, presence of
teeth and sinus site (right or left).
Discussion
According to the present study, an
intraosseous vascular canal at the lateral
antral wall has been identified in over 50%
of examined CT images. The results cor-
relate well with previous studies2. In an
anatomic study, TRAXLER et al.10 found
intraosseous anastamosis between PSAA
and IOA in all examined specimens. This
contradiction means that an undetected
intra-bony canal in a CT radiograph does
not exclude its existence but merely that it
Table 1. Distance of the bony canal from the alveolar crest related to tooth area
Minimum
Tooth area N (mm)
First premolar 50 10.00
Second premolar 41 6.00
First molar 37 5.00
Second molar 37 11.50
Table 2. Vertical measurements related to residual bony height and ridge classification*
A+B (mm) C (mm)
Distance, crest to vessel
Mean 21.25
Range 17–27
Ridge height
Mean 12.56
Range 9–20
*
LEKHOLM & ZARB5.
Intraosseous distribution of maxillary artery 737
Fig. 4. Course of the canal A-P related to mean distance from the alveolar crest (mm).
is not visible, because of its small dia- ridge appears to play a significant role in
meter. the location of the vessel: in classes A, B
Sinus floor augmentation procedures are and C (LEKHOLM & ZARB classification5)
mostly performed in the maxillary first and the vessel was found >15 mm from the
second premolars and first molar areas. In alveolar crest, whilst in classes D and E at
the present study, as well as in the anatomic >7 mm (mean 10.4 mm). It is recom-
study of TRAXLER et al.10, the anastamosis mended, therefore, to place the superior
formed a concave arch, with the first molar border of the osteotomy up to 15 mm from
area being the lowest point of the bony the alveolar crest in classes A, B and C
canal arch course. The distance of the canal which is sufficient for sinus exposure and
from the alveolar ridge ranged between 5 placement of long dental implants. In
and 29 mm (mean 16.9 mm); similar severely atrophic ridges, classes D and
results were published by ELIAN et al.2, E, where the surgeon has a tendency to
who found a mean distance of 16.4 mm. place the osteotomy of the sinus wall too
These results are somewhat shorter than far cranially, there is a high probability of
previously reported by SOLAR et al.9 in an transecting the vessel.
anatomic study; they found distances to be Damage of the bony vessel can cause
between 17 and 23 mm (mean 18.9 mm). intense bleeding1, obscuring of vision and
The differences are probably because of the may lead to perforation of the Schneider-
small number of cases examined compared ian membrane, which prolongs the opera-
to the present study. tion and assessment of the sinus
There is a high probability of transect- membrane reflection. On the CT scans,
ing the vessel whilst preparing the bony in 71% of the sinuses the bony canal
window. The height of the residual bony was either missing or smaller than 1 mm
(categories 1 and 2). In these cases, blood
supply to the bone and graft is negligible
and will not cause a surgical obstacle if
Maximum Mean transected. In 29% of the cases the canals
(mm) (mm) SD were over 1 mm and therefore at risk of
34.00 22.5480 5.49796 bleeding (categories 3 and 4).
30.25 19.0541 4.60333 Variations exist in the position and dia-
29.00 16.9221 4.45531 meter of the canal; only in 50% of cases the
27.00 18.8802 3.86095 vessel was large enough to be detected by a
CT scan. A dental CT scan is recom-
mended, therefore, as an essential part of
the pre-surgical evaluation and treatment
plan for severely atrophic ridges, in order to
D (mm) E (mm)
avoid the occurrence of considerable arter-
ial bleeding especially under local anaes-
16 11.08 9.6 thesia. CT is the most accurate tool to
15–18 8–15 7–12
evaluate important anatomic parameters,
such as the existence of a large diameter
8 4.8 2.1 anastamosis, the width of the lateral antral
5–10 3–7 1–4 wall and pathology of the Schneiderian
membrane and sinus septa12,6.
738 Mardinger et al.
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Address:
Ofer Mardinger
Tel-Aviv University Savion
Israel
E-mail: oferanat1@isdn.net.il