A Radiographic Study of the Position and Prevalence of the

Maxillary Arterial Endosseous Anastomosis Using

Cone Beam Computed Tomography
Junho Jung, DMD1/Jin-Hyuk Yim, DMD, MSD2/Yong-Dae Kwon, DMD, MSD, PhD3/Bilal Al-Nawas, Prof Dr Dr4/
Gyu-Tae Kim, DMD, MSD, PhD5/Byung-Joon Choi, DMD, MSD, PhD6/Deok-Won Lee, DMD, MSD, PhD6

Purpose: This study was designed to investigate the prevalence and course of the vascular canals in the
maxillary sinus walls and to measure the distance between the sinus floor, the edentulous alveolar crest, and
the vascular canal using cone beam computed tomography (CBCT). Materials and Methods: The maxillary
sinus CBCT scans of 250 patients scheduled for implant surgery were examined. The vertical and mediolateral
positions of the vascular canals or notches were investigated on the CBCT images. The location of each tooth
was confirmed using a diagnostic template for implant placement. Statistical analyses were performed
to verify whether the mean artery position was significantly different according to each tooth location,
gender, and age. Results: A maxillary arterial endosseous anastomosis was observed in 52.8% of patients. The
mean perpendicular distance from the sinus floor to the vascular canal was shortest in the first molar region
(7.58 ± 3.19 mm) and longest in the first premolar region (9.2 ± 3.22 mm). The mean distance from the alveolar
crest to the vascular canal was shortest in the first molar region (14.79 ± 4.04 mm) and longest in the first
premolar region (18.92 ± 4.86 mm). These distances were significantly different according to tooth position.
The mean distances from the alveolar crest and the sinus floor to the vascular canal did not decrease with age.
The mediolateral position of the canals was also significantly different depending on tooth position. Conclusion:
With this information about the branch of the posterior superior alveolar artery from CBCT, unnecessary
bleeding during implant placement should be more easily preventable. The use of CBCT is recommended as a
routine procedure prior to sinus floor elevation. Int J Oral Maxillofac Implants 2011;26:1273–1278

Key words: cone beam computed tomography, maxillary artery, maxillary sinus, sinus elevation

S inus floor elevation, with grafting through a lateral

maxillary osteotomy, has become a popular and
successful procedure in recent years.1 This procedure
1Resident, Department of Oral and Maxillofacial Surgery,
School of Dentistry, Kyung Hee University, Seoul, Korea.
2PhD candidate, Department of Oral and Maxillofacial Surgery,
School of Dentistry, Kyung Hee University, Seoul, Korea.
3Associate Professor, Department of Oral and Maxillofacial
Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea.
4Professor, Department of Oral and Maxillofacial Surgery,
Johannes Gutenberg University Mainz, Germany.
5Assistant Professor, Department of Oral and Maxillofacial
Radiology, School of Dentistry, Kyung Hee University, Seoul,
Korea.
6Assistant Professor, Department of Oral and Maxillofacial
Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea.
Correspondence to: Dr Yong-Dae Kwon, Department of Oral and
Maxillofacial Surgery, Kyung Hee University School of Dentistry,
Hoegi-Dong 1, Dongdaemun-Gu, Seoul, 130-701, Korea.
Fax: +82-2-966-4572. Email: yongdae.kwon@gmail.com.
Drs Jung and Yim equally contributed to this work.
has proven to be a predictable and relatively safe1
method for increasing the alveolar bone height of the
lateral maxilla.
The maxillary sinus has several anatomic variations
that can undergo many physiologic and pathologic
changes.2 Panoramic radiography is used frequently
in clinical dentistry. However, the anatomy of the
maxillary sinus cannot be assessed accurately with
panoramic radiography only because overlapping
of anatomical structures is inevitable. Some imaging
techniques provide sectional views, such as computed
tomography and cone beam computed tomography
(CBCT). Among those imaging modalities, the relative-
ly recently developed CBCT offers three-dimensional
(3D) images to provide additional and useful informa-
tion about the maxillary sinus structure. Because of this
advantage, CBCT has been widely used for imaging
the oral and maxillofacial area in various s­pecialties,
including implant dentistry.3
Understanding the blood supply system of the
maxillary sinus can be crucial in many instances. The
main arteries nourishing the maxillary sinus are the

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Jung/Yim et al

C a b

A Fig 2   Measurement of the

mediolateral position of en-
B dosseous vascular canal.
(Left) Intrasinus position: un-
der the sinus membrane of
the external wall of the sinus;
(center) intraosseous position:
inside the external wall of the
sinus; (right) superficial posi-
tion: under the periosteum of
the external wall of the sinus.
c
Fig 1   Measurements of the endosseous vascular canal.
A = measurement of the perpendicular distance from the alveo-
lar crest to the lower border of the endosseous vascular canal;
B = measurement from the alveolar crest to the sinus floor;
C = measurement of the perpendicular distance from the sinus
floor to the lower border of the endosseous vascular canal (ob-
tained by subtracting B from A).

posterior superior alveolar artery (PSAA), the infraor-
bital artery (IOA), and the greater palatine artery. The
lateral wall of the maxilla and the sinus membrane are
nourished by branches of the PSSA and the IOA, re-
spectively, which anastomose with each other on the
lateral wall of the maxillary sinus.4 Thus, the PSAA must
be taken into consideration during sinus floor eleva-
tion because of the potential for hemorrhage.
The purpose of this study was to identify the endos-
seous vascular canal of the PSAA and to measure the
perpendicular distance from the sinus floor and the
edentulous alveolar crest to the endosseous vascular
canal using CBCT scans.
Materials and Methods
From June 2005 to June 2009, 250 patients with an
edentulous posterior maxillary segment preparing to
undergo implant surgery had CBCT examinations at the
Department of Oral and Maxillofacial Surgery, Kyung
Hee University Medical Center. Of the 250 patients, 159
were men and 91 were women. The mean age of the
patients was 57.1 years (range, 33 to 83 years). None
of the patients displayed a pathologically destructive
maxillary sinus from a tumor or severe trauma. Images
were collected using a PSR-9000N Dental CT System
(Asahi Roentgen Ind) and then reformatted using On-
Demand3D Application (CyberMed). These reformat-
ted cross-sectional images were used to measure the
positions of the endosseous vascular canals or notches.
The following measurements were made (Fig 1): A,
the perpendicular distance from the lower border of
the endosseous vascular canal to the alveolar crest; B,
the perpendicular distance from the sinus floor to the
alveolar crest; and C, the perpendicular distance from
the lower border of the endosseous vascular canal to
the sinus floor. The location of each tooth was con-
firmed using a diagnostic template that had been de-
signed for implant placement. A and B were measured
at each of the premolars and molars. Measurement C
was obtained by subtracting B from A.
One-way analysis of variance and the Fisher least
significant difference analysis were carried out to de-
termine whether the mean artery heights, according
to the individual tooth location, were statistically sig-
nificantly different. Significance tests for relationships
of the mean height from the sinus floor to the endos-
seous vascular canal with regard to gender and age
were also conducted.

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 Jung/Yim et al

Table 1   Perpendicular Distance of the Table 2   Perpendicular Distance of the
Endosseous Vascular Canal from the Edentulous Alveolar Crest from the Sinus Floor
Edentulous Alveolar Crest (mm) (mm)
Mean Tooth location n Mean SD Range
Location n (mm) SD Range
First premolar 13 9.72a,b 5.45 2.00–15.90
First premolar 13 18.92a 4.86 12.00–24.90
Second premolar 36 9.39a 5.15 1.00–20.80
Second premolar 36 17.46a,c 4.41 10.60–27.60
First molar 101 7.20c 3.92 1.40–18.30
First molar 101 14.79b 4.04 6.50–25.10
Second molar 58 7.42b,c 3.86 1.90–18.10
Second molar 58 16.44c 3.68 8.70–25.30
The same superscript letter indicates statistical insignificance and dif-
The same superscript letter indicates statistical insignificance, and ferent letters indicates statistical significance. P = .810 (P1 vs P2);
different letters indicate statistical significance. P = .267 (P1 vs P2); P = .045 (P1 vs M1); P = .078 (P1 vs M2); P = .008 (P2 vs M1);
P = .001 (P1 vs M1); P = .047 (P1 vs M2); P = .001 (P2 vs M1); P = .236 P = .029 (P2 vs M2); P = .761 (M1 vs M2).
(P2 vs M2); P = .014 (M1 vs M2).

Table 3   Perpendicular Distance of the Table 4   Position of the Endosseous Vascular
Endosseous Vascular Canal from the Sinus Canal in the External Wall of the Sinus
Floor (mm) Tooth location Intrasinus Intraosseous Superficial Total
Tooth location n Mean SD Range First premolar 1 9 3 13
First premolar 13 9.20a 3.22 4.30–17.60 Second premolar 16 12 7 35
Second premolar 36 8.07a,c 2.77 2.20–14.20 First molar 90 11 0 101
First molar 101 7.58b,c 3.19 1.80–14.40 Second molar 25 27 6 58
Second molar 58 9.02a 3.46 2.10–16.60 Total 132 59 16 207
The same superscript letter indicates statistical insignificance, and Chi-square, P = .000.
different letters indicate statistical significance. P = .180 (P1 vs P2);
P = .048 (P1 vs M1); P = .654 (P1 vs M2); P = .438 (P2 vs M1);
P = .162 (P2 vs M2); P = .007 (M1 vs M2).

In addition, the mediolateral position of the endos-
seous vascular canal according to the location of each
tooth was measured in three positions (Fig 2): (1) intra-
sinus position, under the sinus membrane at the lat-
eral wall of the sinus; (2) intraosseous position, inside
the lateral wall of the sinus; and (3) superficial position,
under the periosteum at the lateral wall of the sinus.
Chi-square tests were conducted to discover any
statistically significant differences in the position of
the endosseous vascular canal according to the loca-
tion of each tooth. A P value less than .05 was chosen
to indicate statistical significance.
Results
A maxillary arterial endosseous anastomosis was ob-
served in 52.8% of patients, as determined by the
CBCT scans. A total of 132 patients (83 men, 49 women;
mean age 56.3 years; range, 33 to 83 years) who dem-
onstrated an endosseous anastomosis on CBCT scans
were selected for measurement of the perpendicular
distance of the endosseous vascular canal from neigh-
boring structures. The perpendicular distances of the
endosseous vascular canal on CBCT measurements are
given in Tables 1 to 3. The mean perpendicular distance
(± standard deviation) from the maxillary sinus floor to
the endosseous vascular canal was shortest at the max-
illary first molar region (7.58 ± 3.19 mm) and ­longest
at the first premolar region (9.2 ± 3.22 mm) (Fig 3). The
mean distance from the edentulous alveolar crest to
the endosseous vascular canal was shortest at the first
molar region (14.79 ± 4.04 mm) and longest at the first
premolar region (18.92 ± 4.86 mm) (Fig 3). Both distanc-
es—from the edentulous alveolar crest to the canal and
from the sinus floor to the canal—decreased slightly
from the first premolar to the first molar region but in-
creased to the second molar region. The course of the
endosseous vascular canal resembled a concave arch,
with the lowest point at the first molar area (Fig 3).
According to the statistical analyses, there was a
significant difference in the perpendicular distances to
the canal according to tooth location (P = .018). Statis-
tical differences according to tooth positions are pre-
sented in Tables 1 to 3. The mean height from the sinus
floor to the endosseous vascular canal was not statisti-
cally different according to gender (P = .891); the mean
distance in men was 8.32 ± 3.4 mm and in women it
was 7.94 ± 3.01 mm. The mean distance from the al-
veolar crest to the endosseous vascular canal was also

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Jung/Yim et al
25
20 18.92 Endosseous
17.46
16.44 vascular
Distance (mm)
14.79
canal to alveolar
15 crest (mm)
10 Endosseous
9.2 9.02 vascular
8.07 7.58
5 canal to sinus
floor (mm)
0 B
First Second First Second
premolar premolar molar molar
a
Fig 3   (a) Distance of the PSAA from the alveolar crest and
sinus floor. (b) Schematic 3D reconstruction of the posterior
maxilla showing the average course of PSAA and the sinus floor.
not statistically different according to gender (P = .212)
(men: 15.02 ± 3.8 mm; women: 14.02 ± 4.1 mm). The re-
sults, verified by Pearson correlation, suggest that the
distances from the alveolar crest and the sinus floor to
the endosseous vascular canal did not decrease with
age (P = .063, P = .212, respectively).
The mediolateral position of the endosseous vas-
cular canal in the lateral wall of the sinus showed
significant  differences depending on tooth location
(P = .000). In the first premolar region, only 7.7% (1/13)
of canals were in the intrasinus position. However, the
vascular canal coursed through the intrasinus position
in 45.7% (16/35) of second premolar regions and in
89.1% (90/101) of first molar regions. The prevalence of
an intrasinus position of the vascular canal decreased
to 43.1% (25/58) in the second molar region (Table 4).
These results suggest that the endosseous vascular ca-
nal may run medial to the maxillary lateral wall in the
first molar area but may then run lateral to the max-
illary lateral wall. The overall frequencies of mediolat-
eral position, regardless of tooth location, were 63.8%
(132/207) for the intrasinus position, 28.5% (59/207)
for the intraosseous position, and 7.7% (16/207) for the
superficial position.
Discussion
With the popularity of sinus floor elevation proce-
dures, many dentists without a surgical specialty are
performing the procedure, and occasionally patients
with complications resulting from the procedure are
transferred to referral centers, most often for postop-
erative infection and perioperative bleeding. Excessive
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18.92 mm
16.44 mm A 17.46 mm
14.79 mm
9.72 mm
7.42 mm 9.39 mm
7.20 mm
b
bleeding in particular must be treated immediately.
Therefore, dentists who perform sinus floor elevation
must understand the arterial anatomy and general
blood supply system of the sinus.
With a routine panoramic radiographic exam, the
PSAA is poorly visualized. In agreement with previous
studies, the PSAA was identified in more than half of
the subjects in the current study.5,6 With respect to the
current results, the endosseous vascular canal of the
PSAA is encountered most frequently in the first mo-
lar region during the lateral window technique in the
atrophic posterior maxilla, while it is encountered least
frequently in the first premolar area. Dental implants
are often placed at the first molar region, a frequent
site for sinus elevation. With information regarding the
presence and location of the PSAA gained through
CBCT, greater efforts can be made to prevent surgical
hemorrhage (Fig 4).
Wound healing following sinus floor elevation de-
pends, in part, on the blood supply of the affected
bone. While the maxilla is well vascularized in young
and dentate individuals, the blood supply to the maxil-
lary sinus may be reduced with age, with progressing
atrophy, a decrease in the number of vessels and their
diameters, and a concurrent increase in vessel tortu-
osity.7 Most patients undergoing sinus elevation have
an atrophic maxillary alveolar ridge and a decreased
arterial blood supply. Therefore, it is important to un-
derstand the usual locations of the local arteries and
the overall vascular topography.
There have been previous anatomic studies regard-
ing the maxillary arteries in relation to sinus elevation
and vascularization of the lateral maxilla.4,5,8 Solar et
al4 studied 18 human cadavers and concluded that the

10.5 mm
a sponding to the CBCT image.
vascular supply to the lateral sinus wall originated from
two arteries: the PSAA and the IOA. These arteries also
supply the sinus membrane of the lateral maxillary si-
nus and the local mucoperiosteum as a double arterial
arcade that is composed of extraosseous and intraos-
seous anastomoses. A vestibular anastomosis (extraos-
seous anastomosis) was found in 44% of subjects. The
mean distance between the vestibular anastomosis
and the alveolar ridge was 23 mm. However, an endos-
seous (intraosseous) anastomosis was found in 100% of
subjects, with the mean distance between the endosse-
ous vascular canal and the alveolar ridge being 19 mm.
Therefore, the vestibular anastomosis is located more
cranially than the endosseous anastomosis.­This dis-
tance in this study was very similar to that found in
studies by Mardinger et al9 (mean distance of 16.9 mm)
and Elian et al10 (mean of 16.4 mm), which, however,
used CT scans rather than CBCT scans. This distance was
shortest at the first molar region (14.79 mm) and lon-
gest at the first premolar region (18.92 mm). The per-
pendicular distances from the edentulous alveolar crest
and from the sinus floor to the canal decreased slightly
from the first premolar to the first molar region but in-
creased to the second molar region. The results define a
concave arch course of the endosseous vascular canal,
with the lowest point at the first molar area (Fig 3).
Regarding the mediolateral position of the endos-
seous vascular canal, the canals were mostly circum-
scribed by the lateral wall of the sinus or were positioned
slightly more medially, making a notch on the inside of
the lateral wall. The arterial branch in the canal is usually
masked by the thickness of the osseous wall during the
lateral window preparation; this may increase the risk of
inadvertent injury to the arterial branch.
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Jung/Yim et al
b
Fig 4   (a) CBCT image showing a vascular canal about 10.5 mm
above the alveolar crest in one of the subjects in this study.
(b) Clinical photograph showing an endosseous arterial branch
on the upper margin of the osteotomy of the lateral wall, corre-
Based on the results of this and other studies,9,10
it is recommended that the bony window should be
planned to be elevated no higher than 15 mm above
the alveolar crest. In the extremely atrophied posterior
maxilla, a larger amount of grafting material would be
necessary than for less atrophied cases. Regarding the
location of the osteotomy of the lateral window, the
vascular anastomosis can frequently be severed dur-
ing the lateral window osteotomy, and therefore the
position of the vascular canal should be considered
during window preparation.
In previous radiologic studies, a bony canal was
confirmed in only 53%10 and 55%9 of CT imaging stud-
ies. In the current study, a bony canal was observed in
52.8% of the CBCT scans. However, an anastomosis is
always present anatomically.5 This difference between
the anatomic and radiologic studies was significant.5,9
This discrepancy might be a result of the fact that the
diameter of the canal is frequently too small to be
detected by CBCT scans. The position and the preva-
lence of the endosseous vascular canal are reported
to vary.11 This artery was large enough to be detected
by CBCT scans in more than 50% of the patients in the
present study. If an artery with a significant diameter
is damaged intraoperatively, significant hemorrhage
may result. In comparison, transection of a small arte-
rial branch is not life-threatening, since the bleeding
can be controlled by electrocauterization, although
the resulting brisk bleeding may annoy the surgeon6,12
and the possibility of sinus membrane perforation may
increase during hemostasis. As a result, postoperative
sequelae may be more serious.
In recent years, CBCT scans have been used with
increased frequency as a diagnostic tool in oral and
The International Journal of Oral & Maxillofacial Implants 1277
Jung/Yim et al
maxillofacial surgery. This modality is advantageous
based on cost-effectiveness, shorter radiography time
(< 30 seconds), higher resolution, excellent spatial
resolution, and lower radiation exposure compared
to conventional CT. Of the radiographic methods cur-
rently used in dentistry, several authors suggested that
CBCT is the most accurate method.13–15 The use of the
recently developed CBCT scan is recommended as a
routine exam prior to a sinus floor elevation procedure.
The resulting images provide clinicians and patients
with an intuitive visualization of the sinus anatomy, in-
cluding the position of the endosseous arterial branch.
Conclusion
This study may be beneficial for clinicians to predict the
possible risk of bleeding during sinus floor elevation.
• The mean distance from the alveolar crest to the ar-
terial branch was 14.79 mm, and the arterial branch
may be severed in the atrophic posterior maxilla
during sinus floor elevation.
• Based on the mediolateral position, the arterial
branch is usually masked by the thickness of the os-
seous wall, resulting in possible injury to the arterial
branch during the lateral window preparation.
Intimate knowledge of the anatomy and informa-
tion provided by CBCT scans will prevent intraopera-
tive bleeding, which can cause discomfort to patients
and complicate treatment.
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