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Silvio Taschieri
Jean-François Gaudy
relation to sinus lift surgery
Tommaso Weinstein
Massimo Del Fabbro
Authors’ affiliations: Key words: haemorrhage risk, maxillary sinus vascularisation, sinus lift surgery
Gabriele Rosano, Silvio Taschieri, Tommaso Weinstein,
Massimo Del Fabbro, Dental Clinic, Department of
Health Technologies, Galeazzi Orthopaedic Institute, Abstract
University of Milan, Milan, Italy Objectives: To investigate the prevalence, location, size and course of the anastomosis between the
Jean-François Gaudy, Department of Cranial dental branch of the posterior superior alveolar artery (PSAA), known as alveolar antral artery (AAA),
Cervicofacial Anatomy, Faculty of Medicine,
University René Descartes – Paris 5, Paris, France and the infraorbital artery (IOA).
Material and methods: The first part of the study was performed on 30 maxillary sinuses deriving from
Corresponding author: 15 human cadaver heads. In order to visualize such anastomosis, the vascular network afferent to the
Dr Gabriele Rosano
Università degli Studi di Milano sinus was injected with liquid latex mixed with green India ink through the external carotid artery. The
Dipartimento di Tecnologie per la Salute second part of the study consisted of 100 CT scans from patients scheduled for sinus lift surgery.
IRCCS Istituto Ortopedico Galeazzi
Results: An anastomosis between the AAA and the IOA was found by dissection in the context of the
Via R. Galeazzi, 4
20161 – Milano sinus anterolateral wall in 100% of cases, while a well-defined bony canal was detected
Italy radiographically in 94 out of 200 sinuses (47% of cases).
Tel.: þ 39 02 50319950
The mean vertical distance from the lowest point of this bony canal to the alveolar crest was
Fax: þ 39 02 50319960
e-mail: gabriele.rosano@unimi.it 11.25 2.99 mm (SD) in maxillae examined by CT. The canal diameter was o1 mm in 55.3% of cases,
1–2 mm in 40.4% of cases and 2–3 mm in 4.3% of cases.
In 100% of cases, the AAA was found to be partially intra-osseous, that is between the Schneiderian
membrane and the lateral bony wall of the sinus, in the area selected for sinus antrostomy.
Conclusions: A sound knowledge of the maxillary sinus vascular anatomy and its careful analysis by CT
scan is essential to prevent complications during surgical interventions involving this region.
Sinus augmentation using autogenous bone or 2003; Rosano et al. 2009), and the infraorbital
bone substitutes is a safe procedure with high artery (IOA).
predictability (Wallace & Froum 2003; Aghaloo Such anastomosis, although radiographically
& Moy 2007; Del Fabbro et al. 2008; Pjetursson evident in almost 50% of cases (Elian et al.
et al. 2008) for the rehabilitation of severely 2005; Mardinger et al. 2007), courses intra-os-
atrophic posterior maxillae. seously halfway up the lateral sinus wall and is
However, given the extensiveness of the max- reported in the width of the cortical bone of the
illary vascular network, it is not infrequent to run lateral wall of the maxillary sinus in 100% of
into vascular complications that may compro- cases (Solar et al. 1999; Traxler et al. 1999;
mise the outcome of surgery. For example, severe Rosano et al. 2009).
haemorrhage may occur as a result of arterial The AAA, whose reported diameter is up to
injury (Chanavaz 1996). 2.5–3 mm (Mardinger et al. 2007; Ella et al.
A sound knowledge of the arterial supply of the 2008), supplies the sinus membrane and the
maxillary sinus is mandatory for surgical proce- antero-lateral wall of the sinus, and as a
dures involving this area, such as sinus floor consequence, has the potential to cause bleeding
elevation and implantation of grafting materials. complications during lateral window osteo-
The vascularization of the antero-lateral wall of tomies.
Date: the sinus, which is involved in sinus lift surgery Even if the transection of such artery is not life
Accepted 7 July 2010
when the lateral approach is carried out, is threatening because its haemorrhage mostly re-
To cite this article: characterized by the presence of an intra-osseous solves itself owing to a reactive contraction
Rosano G, Taschieri S, Gaudy J-F, Weinstein T, Del Fabbro
M. Maxillary sinus vascular anatomy and its relation to sinus anastomosis between the dental branch of the (Rosano et al. 2009), impairment in visualization
lift surgery.
Clin. Oral Impl. Res. 22, 2011; 711–715.
posterior superior alveolar artery (PSAA), also of the Schneiderian membrane may occur,
doi: 10.1111/j.1600-0501.2010.02045.x known as alveolar antral artery (AAA) (Gaudy especially when the AAA diameter is relevant,
712 | Clin. Oral Impl. Res. 22, 2011 / 711–715 c 2010 John Wiley & Sons A/S
Rosano et al Haemorrhage risk during sinus surgery
sinusal or sub-periosteal) in the maxillary tuber- Discussion teeth play a relevant role in determining the
osity area. location of the vessel.
The vertical distance from the lowest point of The anastomosis between PSAA and IOA pro- In the present study, the average distance of the
the vessel, corresponding to the first molar area, vides blood supply to the sinus membrane, to the AAA from the alveolar ridge in atrophic maxillae
to the alveolar crest averaged 11.25 2.99 (SD) periosteal tissues, and especially, to the antero- of Cawood & Howell class V and VI was
mm (range between 7.2 and 17.7 mm). lateral wall of the sinus (Solar et al. 1999; Rosano 11.25 mm. For the most atrophic cases, in which
The residual ridge height ranged from 0.7 to et al. 2009). the ridge height is inferior to 3 mm, such a
5.1 mm (mean height 3.60 1.28 mm). A slight The scientific literature reports that this vessel distance was significantly lower with respect to
positive correlation between such a distance and is located at an average distance of 19 mm (Solar lesser atrophic cases. This would confirm that
the ridge height was observed (r ¼ 0.38). When et al. 1999; Traxler et al. 1999), 16.4 mm (Elian the more resorbed the bone crest, the higher the
considering a threshold of 3 mm for the residual et al. 2005) and 16.9 mm (Mardinger et al. 2007) risk of violation of such a vessel during sinus
ridge height, the AAA-to-alveolar crest distance from the alveolar crest of the posterior maxilla. augmentation procedure.
averaged 9.33 2.41 (n ¼ 39) and 12.45 2.71 Nevertheless, such data can be misleading These results are substantially in agreement
(n ¼ 55) for cases with ridge height o3 mm and because the height of the residual bony ridge, with the study by Mardinger et al. (2007), which
3 mm, respectively. the maxillary atrophy class and the presence of found that this vessel was located at a mean
distance of 10.9 mm from the crest in classes
D, E (Lekholm & Zarb 1985) and at a distance
greater than 15 mm in classes A, B and C.
Differences concerning the mean distance from
the vessel to the crest, with the studies by Solar
et al. (1999), Traxler et al. (1999) and Elian et al.
(2005) are probably due to the more strict inclu-
sion criteria considered in the present study,
where only highly atrophic ridges have been
examined.
Moreover, because a well-distinguished bony
wall between the intra-osseous maxillary anasto-
Fig. 3. Internal view of the maxillary sinus: the arrow A shows the alveolar antral artery, the endosseous branch of the
mosis and the maxillary sinus has never been
posterior superior alveolar artery (PSAA), partially encased in the lateral sinus wall, while the arrow B shows the infraorbital found by anatomic dissection (Fig. 1), it could be
artery deriving from the maxillary artery and forming a vascular arcade with the PSAA. speculated that the lowest border of such a vessel
Fig. 4. Computed tomography scan transversal views of the anterior lateral wall of a sinus where it is possible to evidence the course of the alveolar antral artery from the infraorbital artery (1)
to the posterior superior alveolar artery (2): completely intra-osseous at its extremities, between the Schneiderian membrane and the bony wall in the sinus antrostomy area, sub-periosteal in
the maxillary tuberosity area.
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