Journal of Oral Biosciences xxx (xxxx) xxx

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Journal of Oral Biosciences

journal homepage: www.elsevier.com/locate/job

Review

Importance of anatomy in dental implant surgery

Ikuo Kageyama*, Shingo Maeda, Kojiro Takezawa
Department of Anatomy, School of Life Dentistry, Nippon Dental University, Niigata

a r t i c l e i n f o a b s t r a c t

Article history: Background: The knowledge of nerves and vessels in the maxillofacial region, particularly the anatomical
Received 9 November 2020 structures in the maxilla, mandible, tongue muscles, and salivary glands, is essential for dental surgeons.
Received in revised form In addition, the structures in the mandibular canal, palate, and maxillary sinus should be understood
7 January 2021
well.
Accepted 7 January 2021
Available online xxx
Highlight: The arteries and nerves in the maxillofacial region were observed in this study. Some varia-
tions in the origin of the inferior alveolar artery were found. Notably, the variations in the origin of the
inferior alveolar artery from that of the external carotid artery and a double origin of the inferior alveolar
Keywords:
Dental implant surgery
artery were observed. Thus, the maxillary artery may originate from the external carotid and stapedial
Maxillofacial region arteries. The following points are important. (1)The greater palatine artery is always located deeper than
Anatomical knowledge the greater palatine nerve. (2)The posterior superior alveolar artery often runs through the compact bone
Dental anatomy of the maxilla. Using CT scans, the canal of the artery can be observed. (3)Variations in origins of the
inferior alveolar artery have been observed. The origin of the inferior alveolar nerve may differ
depending on the course of the maxillary artery.
Conclusions: Dental practitioners should, therefore, have a comprehensive knowledge of the anatomy of
the maxillofacial region and its variations. Without this knowledge, they should not operate on patients.
© 2021 Japanese Association for Oral Biology. Published by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.1. Important arteries and nerves in the maxillofacial region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.1.1. The greater palatine artery and nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.1.2. The posterior superior alveolar artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.1.3. The inferior alveolar artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Author Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Abbreviations: AMM, Accessory middle meningeal artery; AMMB, Accessory

middle meningeal branch; ATN, Auriculotemporal nerve; Bc, Buccinator; CC, 1. Introduction
Common carotid artery; EC, External carotid artery; F, Facial artery; IA, Inferior
alveolar artery; IAN, Inferior alveolar nerve; IC, Internal carotid artery; L, Lingual
artery; LN, Lingual nerve; LP, Lateral pterygoid; MM, Middle meningeal artery; Mx,
Dental implant surgery is a minor maxillofacial surgical pro-
Maxillary artery; ST, Superficial temporal artery; St, Stapedial artery; Tm, Temporal cedure that differs remarkably from prosthodontic and conserva-
muscle; MP, Medial pterygoid. tive dental treatments. The knowledge of the nerves and vessels in
* Corresponding author. Department of Anatomy, School of Life Dentistry at the maxillofacial region, particularly the anatomical structures in
Niigata, The Nippon Dental University, 1-8 Hamaura-cho, Chuo-ku, Niigata-city,
the maxilla and mandible including tongue musculature and sali-
951-8580, Japan. Fax: þ81 25-267-1134.
E-mail address: kageyama@ngt.ndu.ac.jp (I. Kageyama). vary glands, is essential. In addition, the details of structures in the

https://doi.org/10.1016/j.job.2021.01.002
1349-0079/© 2021 Japanese Association for Oral Biology. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Please cite this article as: I. Kageyama, S. Maeda and K. Takezawa, Importance of anatomy in dental implant surgery, Journal of Oral Biosciences,
https://doi.org/10.1016/j.job.2021.01.002
I. Kageyama, S. Maeda and K. Takezawa
Fig. 1. Left palate (superior view) with greater palatine artery (red) and nerve (yellow).
(For interpretation of the references to colour in this figure legend, the reader is
referred to the Web version of this article.)
mandibular canal, palate, and maxillary sinus should be understood
thoroughly. All dental practitioners use their knowledge of anat-
omy when they operate on patients. Although numerous anatomy
textbooks with standard anatomical illustrations and information
are available, practitioners often encounter considerable variations
in the nerves, vessels, and anomalies of the teeth in daily practice.
One hundred patients may demonstrate 100 anatomic variations in
nerve and vessel distributions. Dental practitioners should,
2
Journal of Oral Biosciences xxx (xxxx) xxx
Fig. 2. Right palate (superior view) with greater palatine artery (red) and nerve
(yellow). (For interpretation of the references to colour in this figure legend, the reader
is referred to the Web version of this article.)
therefore, have a comprehensive knowledge of the anatomy, of the
maxillofacial region and its variations.
1.1. Important arteries and nerves in the maxillofacial region
1.1.1. The greater palatine artery and nerve
The greater palatine artery arises from the pterygopalatine
region of the maxillary artery; it exits the greater palatine fora-
men and runs forward to the mucous membrane of the hard
palate. Conventionally, the nerves and arteries are described
systemically. The greater palatine nerve is part of the nervous
I. Kageyama, S. Maeda and K. Takezawa
Fig. 3. Left palate (superior view) with greater palatine artery (red) and nerve (yellow).
(For interpretation of the references to colour in this figure legend, the reader is
referred to the Web version of this article.)
system. However, the nerve, artery, vein, glands, and the palatal
mucosal membrane have complex relationships in the palate. The
order of the layers of the nerve and artery is also important for
surgical procedures. When practitioners make an incision into the
superficial layer of the mucous membrane, they should consider
the structures that can be severed. The greater palatine nerves are
always located superficially to the greater palatine arteries. The
greater palatine artery runs close to the palatal process of the
maxilla and horizontal plate of the palatine bone. As shown in
Figs. 1e4, after the removal of the palatal structures, the sections
were carefully dissected and the distribution of the nerves and
arteries were illustrated. The greater palatine artery can bifurcate
3
Journal of Oral Biosciences xxx (xxxx) xxx
Fig. 4. Right palate (superior view) with greater palatine artery (red) and nerve
(yellow). (For interpretation of the references to colour in this figure legend, the reader
is referred to the Web version of this article.)
into the lateral and medial branches. The arteries were located
deeper than the greater palatine nerve (Fig. 1, 2). Alternatively,
one large greater palatine artery can be present without any
branches, and it may be located deeper than and lateral to the
artery (Fig. 3). In some cases, an anastomosis between the lateral
and medial branches of the artery has been observed (Fig. 4). The
greater palatine arteries were universally located deeper than the
greater palatine nerve. Furthermore, a bony groove and bridge
I. Kageyama, S. Maeda and K. Takezawa
Fig. 5. The bony groove in the hard palate of the skull.
Fig. 6. The bony bridge in the hard palate of the skull.
were observed in the hard palate of the skulls. The knowledge of
the anatomy of the greater palatine nerve and artery is important
in dental implant surgery, when taking connective tissue grafts
from the palate and when placing pterygoid and zygomatic im-
plants (Figs. 5 and 6).
1.1.2. The posterior superior alveolar artery
The posterior superior alveolar artery arises from the pter-
ygopalatine part of the maxillary artery. It bifurcates near the
maxillary tuberosity, enters the alveolar foramen, and runs
through the alveolar canals to reach the maxillary molars; it
surrounds the gingiva and buccal mucosal membrane. The alve-
olar canals were present in the bony wall of the maxilla between
the foramen and the molars. This canal can be detected in CT
scans (Fig. 7). When placing pterygoid implants or harvesting
hard and soft tissue from the maxillary tuberosity, special
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Journal of Oral Biosciences xxx (xxxx) xxx
Fig. 7. The alveolar canal was found via CT scans.
attention is needed during implant procedures. To avoid severing
the main trunk of the artery, information from CT images can be
very useful during implant procedures (Figs. 8 and 9). This artery
also supplies the lateral wall of the maxillary sinus. As such,
careful attention is required during sinus lift procedures.
1.1.3. The inferior alveolar artery
The inferior alveolar artery arises from the mandibular part of
the maxillary artery, enters the mandibular foramen, and runs
through the mandibular canal. Regarding the branching pattern of
the maxillary artery, the middle meningeal artery (MMA) generally
arises proximally to the inferior alveolar artery (IA) in Japanese
individuals (proximal: the MMA, distal: IA). The maxillary artery
runs superficially along the lateral pterygoid muscle in most cases
(90%) (Fig. 10). On the other hand, the inferior alveolar artery arises
proximally to the middle meningeal artery in cases where the
maxillary artery runs deeply along the lateral pterygoid muscle. The
superficial trunk and deep trunk of the maxillary artery reunited to
form a complete loop near the crossing of the maxillary artery at
the anterior margin of the lateral pterygoid (Fig. 11). In this case, the
middle meningeal and the accessory middle meningeal arteries
arose from the deep trunk, and the inferior alveolar artery origi-
nated from the superficial trunk. Furthermore, we observed cases
of the inferior alveolar artery with different origins:
1) The inferior alveolar artery arose from the external carotid ar-
tery (Fig. 12).
2) The inferior alveolar artery originated from the middle menin-
geal artery (Fig. 13).
3) The inferior alveolar artery had double origins (Figs. 14 and 15).
2. Discussion
The variations of the maxillary artery have been studied by
many investigators [21,1,4,8,12,10,19,9,5,17,3,6,16,22,14,13]. There
I. Kageyama, S. Maeda and K. Takezawa Journal of Oral Biosciences xxx (xxxx) xxx

Fig. 8. The posterior superior alveolar artery enters into the alveolar foramen and runs through the alveolar canals.

Fig. 9. The posterior superior alveolar artery.

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I. Kageyama, S. Maeda and K. Takezawa Journal of Oral Biosciences xxx (xxxx) xxx

Middle meningeal artery

Lingual nerve

Inferior alveolar artery

Inferior alveolar nerve

Lingual artery

Fig. 10. The maxillary artery runs superficially along the lateral pterygoid muscle.

are differences between the frequencies of the medial course of
the maxillary artery in Caucasoids and Japanese individuals
(Mongoloids) (Table 1). The frequency of the medial type in the
present study is comparable with that reported by other Japanese
authors (Table 1). However, the frequency of the medial type
tended to be significantly higher in Caucasoids than in Japanese
individuals (Mongoloids).
The middle meningeal artery originated from the deep trunk
of the maxillary artery, and the inferior alveolar artery arose from
the superficial trunk [1]. Therefore, a part of the deep trunk, in
this case, may be equivalent to the trunk of the medial type of the
maxillary artery (Figs. 16 and 17).
Claire et al. [2] reported a case of a divided and reunited
maxillary artery in the infratemporal region. According to Claire's
study, the maxillary artery bifurcated into the deep and superfi-
cial branches at the distal part of the divergence of the anterior
tympanic artery. The deep and superficial branches reunited to
form a complete loop in the infratemporal region. The courses of
the maxillary artery converged at the anterior margin of the
infratemporal fossa in that case. In the previous descriptions of
divided maxillary arteries, the two branches did not reunite
[11,18].
Padget [15] reported that the internal maxillary branch (the
maxillary artery) of the external carotid artery established a

Complete loop

Fig. 11. The superficial trunk and a deep trunk of the maxillary artery reunited to form a complete loop near the point of the maxillary artery crossing the anterior margin of the
lateral pterygoid.

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I. Kageyama, S. Maeda and K. Takezawa Journal of Oral Biosciences xxx (xxxx) xxx

Table 1
Frequencies of different types of maxillary artery.

Japanese (Mongoloids)

Authors (year) Cases Lateral Type Medial Type

Adachi (1928) 331 310 (93.7%) 21 (6.3%)

Fujita (1932) 119 107 (89.9%) 12 (10.1%)
Kijima (1932) 20 19 (95.0%) 1 (5.0%)
Takarada (1958) 120 109 (90.8%) 11 (9.2%)
Ikakura (1961) 160 145 (90.6%) 15 (9.4%)
Iwamoto et al. (1981) 158 147 (93.0%) 11 (7.0%)
Sashi (1989) 100 93 (93.0%) 7 (7.0%)
Tsuda (1991) 339 317 (93.5%) 22 (6.5%)
Otake et al. (2011) 28 27 (96.4%) 1 (3.6%)
Maeda et al. (2012) 208 188 (90.4%) 20 (9.6%)
Total 1583 1462 (92.4%) 121 (7.6%)

Caucasoids

Authors (Year) Cases Lateral Type Medial Type

Thomson (1891) 447 243 (54.4%) 200 (44.7%)

Lurje (1947) 152 103 (67.8%) 49 (32.2%)
Lasker et al. (1951) 147 80 (54.4%) 67 (45.6%)
Krizan (1960) 200 132 (66.0%) 68 (34.0%)
Skopakoff (1968) 180 125 (69.4%) 55 (30.6%)
Czerwinski (1981) 240 158 (65.8%) 82 (34.2%)
Total 1366 841 (61.6%) 521 (38.0%)

Fig. 12. The inferior alveolar artery arose from the external carotid artery.

connection with the lower division of the stapedial artery at the
junction of its maxillary and mandibular branches (the inferior
alveolar artery). As soon as the common trunk of the max-
illomandibular division of the stapedial artery becomes sur-
rounded by the auriculotemporal nerve, the part of this trunk that
lies above the recently completed anastomosis with the internal
maxillary artery (the maxillary artery) becomes recognizable as
the stem of the middle meningeal artery. This suggests that the
mechanism of the formation of the maxillary artery may not be
simple.
Conventionally, the inferior alveolar artery may be the
extension of the middle meningeal artery; therefore, the inferior
alveolar artery may be considered as the third branch of the
stapedial artery [20,15]. According to Tandler [20] and Padget
[15], the inferior alveolar artery was formed by the third branch of
the stapedial artery.
Furthermore, we observed that the inferior alveolar artery
arose from different origins; it arose from the external carotid
artery and, middle meningeal artery, and it sometimes had dou-
ble origins [7]. Therefore, we suggest that the inferior alveolar
artery does not only originate from the extension of the third
branch of the stapedial artery but also other possible arteries. We
speculated that during the fetal period, the arterial loop sur-
rounds the lateral pterygoid muscle, but the underlying portion of
the loop disappears, leaving only the superficial part of the loop in

7
I. Kageyama, S. Maeda and K. Takezawa Journal of Oral Biosciences xxx (xxxx) xxx

Fig. 13. The inferior alveolar artery originated from the middle meningeal artery.

Middle meningeal artery

Inferior alveolar
artery (A)

Inferioralveolar
Inferior alveolarB
artery (B)

Lingual Nerve

Inferior alveolar N

Lingual Artery

Fig. 14. Double inferior alveolar arteries have been observed proximal and distal to the origin of the middle meningeal artery.

8
I. Kageyama, S. Maeda and K. Takezawa Journal of Oral Biosciences xxx (xxxx) xxx

Fig. 15. The inferior alveolar artery had double origins.

9
I. Kageyama, S. Maeda and K. Takezawa Journal of Oral Biosciences xxx (xxxx) xxx

practice. One hundred patients may demonstrate 100 different

Superficial trunk anatomic variations in their nerve and vessel distributions.
MM Dental practitioners should, therefore, have a comprehensive
knowledge of the anatomy, of the maxillofacial region and its
St variations. Without this knowledge, they should not operate on
patients. Careful pre-operative planning and cone-beam CT
IC scanning are recommended.
The greater palatine artery and nerve, posterior superior alve-
EC olar artery, lingual artery and nerve, and inferior alveolar artery and
nerve may all require special attention for implant surgery. The
F following points are important:

Deep trunk
IA 1) The greater palatine artery is always located deeper than the
L greater palatine nerve.
2) The posterior superior alveolar artery often runs through the
compact bone of the maxilla. Using CT scans, the canal of the
artery can be observed.
CC 3) Variations in origins of the inferior alveolar artery have been
observed. The origin of the inferior alveolar nerve may differ
depending on the course of the maxillary artery.

Fig. 16. Developing stages of the maxillary artery.

Fig. 17. Developing stages of the maxillary artery.

most cases. However, further studies on the morphogenesis of the
inferior alveolar artery are needed.
3. Conclusions
For dental surgeons, the knowledge of the nerves and vessels
in the maxillofacial region, particularly the anatomical structures
in the maxilla and mandible, tongue muscles, and salivary
glands, is essential. In addition, the structures in the mandibular
canal, palate, and maxillary sinus should be understood well. All
dental practitioners should have detailed anatomical knowledge
when they operate on patients, and although numerous anatomy
textbooks with standard anatomical illustrations and information
are available, practitioners often encounter considerable varia-
tions in the nerves, vessels, and anomalies of teeth in daily
Author Statement
All dental practitioners use anatomical knowledge when they
operate on patients and although numerous anatomy textbooks
with standard anatomical illustrations and information are avail-
able, practitioners often encounter considerable variations in
nerves and vessels just as anomalous teeth can be encountered in
daily practice. Indeed, 100 patients might exhibit 100 anatomic
variations in nerve and vessel distribution. Dental practitioners
must therefore have a comprehensive knowledge of the anatomy,
and its variations, in the maxillofacial region.
Conflicts of interest
The authors declare no conflicts of interest.

10
I. Kageyama, S. Maeda and K. Takezawa
Acknowledgements
The authors are greatly indebted to Dr. Neil Patel from the
University of Manchester and Prof. Zac Morse from the Auckland
University of Technology for their review of this manuscript.
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