Surgical and Radiologic Anatomy (2021) 43:219–224

https://doi.org/10.1007/s00276-020-02582-9

ANATOMIC BASES OF MEDICAL, RADIOLOGICAL AND SURGICAL TECHNIQUES

CBCT study on the positional relationship between marginal points

of pterygomaxillary junction and anterior nasal spine
Xin Chen1,3 · Jiadong Zhu2 · Songsong Guo1 · Yong Hu2 · Hongbing Jiang1,3

Received: 12 July 2020 / Accepted: 15 September 2020 / Published online: 24 September 2020
© Springer-Verlag France SAS, part of Springer Nature 2020

Abstract
Purpose This study aimed to locate the inferior end (Pti) and the superior end (Pts) of pterygomaxillary junction (PMJ)
relative to anterior nasal spine (ANS) so as to provide references for pterygomaxillary separation.
Methods The study was based on CBCT images of 109 Chinese patients. We projected Pti and Pts to the frontal plane and
measured the distance as well as the positional relationship between the projection points and ANS via three-dimensional
reconstruction image.
Results On average, the ANS was 5.18 mm above the Pti and the horizontal distance between the Pti and ANS was 21.86 mm.
The horizontal and vertical distances between Pts and ANS was 20.41 mm and 10.91 mm, respectively. The vertical height
of PMJ was 16.09 mm. Scatter plots diagrammatic centered on ANS showed that 73% (160/218) Pti and 64% (140/218) Pts
appeared in a 45° fan shape ranged from 20 to 25 mm radius in bilateral inferior and superior quadrant, respectively. There
was no significant difference in the distance between both sides (P > 0.05).
Conclusion During the pterygomaxillary disjunction, it exists a risk of injuring neurovascular bundle of the pterygopala-
tine fossa 16.09 mm above the lowest border of the pterygomaxillary junction. The region within a 45° fan shape ranged in
20–25 mm radius in inferior quadrant centered on ANS might be suitable for the osteotome position. The positional rela-
tionship especially between the ANS and Pti found in this study provides a reference for surgeons during pterygomaxillary
disjunction.

Keywords Cone-beam computed tomography · Osteotomy · Le Fort · Maxillary bone

Introduction

Le Fort I osteotomy is a widely-used surgical technique

Xin Chen and Jiadong Zhu contributed equally to this work.
Electronic supplementary material The online version of this
article (https​://doi.org/10.1007/s0027​6-020-02582​-9) contains
supplementary material, which is available to authorized users.
* Hongbing Jiang
jhb@njmu.edu.cn
1
Department of Oral and Maxillofacial Surgery, Affiliated
Stomatological Hospital of Nanjing Medical University, No.
136, Hanzhong Road, Nanjing 210029, Jiangsu, China
2
Department of Stomatology, Affiliated Suzhou Science
and Technology Town Hospital of Nanjing Medical
University, Nanjing 210029, Jiangsu, China
3
Jiangsu Key Laboratory of Oral Diseases, Nanjing Medical
University, Nanjing 210029, Jiangsu, China
for treatment of the skeletal malocclusion, trauma or even
the tumors in the skull base [8, 11]. The pterygomaxillary
disjunction is performed in this osteotomy to separate the
maxilla from the pterygoid process and the palatal bone
[4]. However, many complications could occur from the
unfavorable disjunction, including hemorrhage, inadvertent
iatrogenic fractures and cranial nerve injury [12, 16, 17], as
pterygomaxillary junction (PMJ) lies behind the maxilla and
is not directly visible [4].
Thus, an obvious and distinguishable anatomic site is
necessary for the location of PMJ [7]. Only one available
study in this field has investigated the relationship between
the distal aspect of maxillary second molar and PMJ [7].
However, dental structures could be easily displaced by pre-
operative orthodontics or even the eruption of third molars
[13]. Anterior nasal spine (ANS) is such a more stable bony

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projection as it is always exposed and kept intact during Le
Fort I osteotomy [9]. The inferior end (Pti) and the supe-
rior end (Pts) of PMJ are extremely important points as the
former determines the ideal position of bone chisel during
separation and the latter supports the neurovascular bundle
of the pterygopalatine fossa [3].
The purpose of our study was to locate the Pti and Pts
relative to ANS, providing more convenient location of the
PMJ during Le Fort I osteotomy.
Methods
We collected 109 patients’ craniofacial CBCT images from
October 2018 to October 2019. The inclusion criteria for all
participants were as follows: high-qualified and complete
written records and CBCT images; age range from 20 to
25 years; absence of any systemic disease, facial trauma,
or a temporomandibular joint disorder, or noticeable peri-
odontal disease and open bite; without history of maxillo-
facial surgery. All participants had been informed that their
CBCT data would be collected for the study and they all
approved. The CBCT examinations were performed by one
professional imaging specialist following a standardized
protocol, using the same machine (NewTom 5G, QR s.r.l.,
Verona, Italy) with a uniform parameter setting (110 kVp).
All available data was measured by Mimics 15.0 software in
the department of radiology of the Affiliated Stomatological
Hospital of Nanjing Medical University.
Before measurements taken, the axial plane was adjusted
parallel to the Frankfort horizontal plane (FH plane). The
sagittal plane was set perpendicular to FH plane and passed
through the ANS. The coronal plane was positioned perpen-
dicular to both defined reference planes. The inferior end
and the superior end of the pterygomaxillary junction were
recorded as Pti and Pts, respectively (Fig. 1). The Pti and Pts
were projected to the coronal plane passing through anterior
nasal spine (ANS) by Mimics 15.0 software. The horizontal
distance from the frontal projection point of Pti and Pts to
ANS was calculated as “w1” and “w2”, which indicated the
width of both points. The vertical distance from the frontal
projection point of Pti and Pts to the anterior nasal spine
(ANS) was calculated as “h1” and “h2”, respectively, indi-
cating the height of marginal points of PMJ (Fig. 2). The
vertical height PMJ was calculated as the sum of h1 and h2.
Radiographic examination was conducted by two inde-
pendent radiologists with over 5 years working experi-
ence. To rule out the intra-observer variation, each opera-
tor repeated the measurements of 30% randomly selected
samples after 1-month interval. Another 30% subjects that
were randomly selected were measured to determine inter-
observer variability using intraclass correlation coefficient
(ICC). The inter-observer reproducibility (ICC ≥ 0.923,
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Surgical and Radiologic Anatomy (2021) 43:219–224
P < 0.001) and intra-observer reproducibility (ICC ≥ 0.931,
P < 0.001) of each value were excellent (Supplement
Tables 1, 2). We adopted the average of two repeated meas-
urements from two operators. The measurements were per-
formed on both sides and all values were compared between
the left and right side with the use of paired t tests. Paired
t test was also adopted to analyze the width difference
between Pti and Pts. Independent sample t test was applied
for male–female comparison and the confidence interval was
set at 95%. All statistical calculations were performed using
Statistical Package for Social Sciences, version 19.0 (SPSS
Inc, Chicago, IL, USA). The significance level for all statisti-
cal tests was set at 0.05.
Results
A total of 109 subjects (53 men, 56 women) with a mean
age of 22 years were collected. A total of 10 Pti (4 left, 6
right) appeared above the ANS (4.58%) and 208 Pti was
below the ANS (95.42%) (Table 1). On average, the ANS
was 5.18 mm above the Pti and the horizontal distance
between the Pti and ANS was 21.86 mm. The horizontal
and vertical distances between Pts and ANS was 20.41 mm
and 10.91 mm, respectively. The vertical height of PMJ was
calculated as 16.09 mm. Men showed 1.31 mm broader
width of Pti (95% confidence interval [CI], 0.74–1.88 mm,
P = 0.000) and 0.66 mm larger width of Pts (95% confi-
dence interval [CI], 0.07–1.25 mm, P = 0.029) relative to
ANS than women but not the height (Table 2). The width
of Pti was 1.45 mm larger than that of Pts (95% confidence
interval [CI], 1.26–1.65 mm, P = 0.000) (Table 3). There
was no significant difference in the distance between both
sides (P > 0.05). Scatter plots diagrammatic centered on the
ANS showed that Pti and Pts both lied in a 45° fan shape in
bilateral superior and inferior quadrant, respectively (Fig. 3).
More specifically, 73% (160/218) Pti and 64% (140/218)
Pts appeared in a 45° fan shape ranged in 20–25 mm radius
(Fig. 3).
Discussion
Pterygomaxillary disjunction is one of the key steps in Le
Fort I surgeries. There exist many anatomy studies on PMJ
covering the thickness, width, height, the distance between
PMJ and maxillary artery or greater palatine foramen and
angulations of osteotomy cuts through PMJ [2, 7, 14]. How-
ever, separation of PMJ could not be carried out under totally
exposed situation [12] and a visible structure such as ANS
would be of guiding significance for this clinical procedure.
Interestingly, a little part of Pti (4.58%) had a higher posi-
tion above ANS. This could not be the difference of patients’
Surgical and Radiologic Anatomy (2021) 43:219–224
Fig. 1  Location of the inferior end (Pti) and superior end (Pts) of the pterygomaxillary junction
head position when taking CBCT as all the reconstructed
data was reviewed and repositioned parallel to FH plane. We
thus doubt the necessity and the extent of pterygomaxillary
disjunction for this group of patients undergoing Le Fort
I osteotomy. Thus, CBCT is necessary for comparing the
osteotomy line and the inferior point of PMJ before surgery
to avoid excessive bone damage for those subjects with high
position of Pti.
The vertical distance of PMJ was 16.09 mm in our study,
which was consistent with that in Kenyans (17.4 mm) [12]
and Thai (15.1 mm) [1] but slightly higher when compared
to 12.1 mm found in Chinese [6]. The main difference could
possibly be due to the measurement methods as the authors
obtain the relative value in a lateral vertical plane [6]. We
221
suggested that it exists a risk of injuring neurovascular bun-
dle of the pterygopalatine fossa 16.09 mm above the lowest
border of the pterygomaxillary junction when performing
PMJ separation. A similar study based on the 92 patients
CT aimed to measure the position of maxillary artery in
relation to pterygomaxillary junction [2]. They concluded
that 18 mm above the inferior extremity of the PMJ was the
limitation for preventing hemorrhage during PMJ separation
[2]. The risk of hemorrhage from the pterygopalatine fossa is
rather high except when the conventional curved pterygoid
osteotome is kept low [7]. Considering the difficulty of PMJ
visibility and the height of Pts (10.91 mm above the ANS),
we suggested that the edge of the osteotomy should be less
than 10.91 mm above the ANS.
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222 Surgical and Radiologic Anatomy (2021) 43:219–224

Table 3  The width of the inferior end of the pterygomaxillary junc-

tion (Pti) and the superior end of the pterygomaxillary junction (Pts)
relative to anterior nasal spine (ANS)
Pti Pts Mean 95% CI P value
differ-
ence

Width 21.86 ± 2.23 20.41 ± 2.23 1.45 1.26, 1.65 0.000

(mm)

The width and height of both points were presented as mean ± stand-
ard deviation (SD); paired t test was also adopted to analyze the width
difference
CI confidence interval

Fig. 2  The measurement diagram. The width (w1) and height (h1)
of the inferior end of the pterygomaxillary junction (Pti) to the ante-
rior nasal spine (ANS) on the frontal projection; the width (w2) and
height (h2) of the superior end of the pterygomaxillary junction (Pts)
to the ANS on the frontal projection
Table 1  Proportion of vertical position relationship of the frontal pro-
jection of the inferior end of the pterygomaxillary junction (Pti) and
anterior nasal spine (ANS) as well as the superior end of the ptery-
gomaxillary junction (Pts) and the ANS
Above the ANS Below the ANS
Pti 10 (4.58%) 208 (95.42%)
Pts 218 (100.00%) 0 (0.00%)
Bendrihem and Vacher [2] measured the highest height of
PMJ on parasagittal CT scanner section through the lateral
surface and found no gender difference (18.5 mm in men,
17.8 mm in women). A similar result in our study was that
the height relative to ANS of Pti and Pts both showed no
gender difference, which indicated that the recommended
vertical safe distance is suitable for both men and women.
However, Neema et al. [12] performed a study of posterior
maxilla on 63 subjects and showed gender difference in the
height and the width of PMJ. This might be attributed to the
small samples and ranged age (18–90 years) in their study
[12]. In our study, men presented with 1.31 mm wider width
of Pti relative to ANS than women. However, its clinical
significance is questionable as the pterygoid osteotome is
always placed closely against the lateral marginal of PMJ
before separation [7].
The long axis of PMJ tends to incline inward as the hori-
zontal distance from Pti to ANS was 1.45 mm longer than
that from Pts to ANS. The optimal separation line starts from
the pterygomaxillary groove and progresses along the PMJ.
The buccolingual course of PMJ separation is unpredictable
because of the variants in PMJ anatomy and the direction
and extent of force [7]. A few available studies calculated
the osteotome angulation between the median line through
the widest PMJ on the horizontal plane and the sagittal plane
and the value was around 100° [1, 7]. When performing PMJ
separation perpendicular to the long axis, the angle created
by the junction relative to the sagittal plane was 95° in our
study (data not shown). All the above evidence challenged
the previous recommendation that the curved osteotome
should be placed in approximately 90° relative to the sagittal
plane [5, 10]. An osteotome angulation over 90° seems more
mechanical and reasonable, however, it might not be easy
to evaluate the angulation of the instrument during opera-
tion and the post-operative effects still need to be proved via
clinical trials.
One of the main challenges during Le Fort I osteotomy
is precise location of PMJ without direct vision [7]. To have

Table 2  The width and height Male Female Mean difference 95% CI P value
of the inferior end of the
pterygomaxillary junction (Pti) Pti
and the superior end of the
Width (mm) 22.53 ± 2.21 21.22 ± 2.07 1.31 0.73, 1.88 0.000
pterygomaxillary junction (Pts)
relative to anterior nasal spine Height (mm) 5.56 ± 3.63 4.83 ± 2.94 0.73 − 0.15, 1.61 0.102
(ANS) in men and women Pts
Width (mm) 20.74 ± 2.39* 20.09 ± 2.02 0.65 0.07, 1.25 0.029
Height (mm) 11.14 ± 4.22 10.69 ± 3.57 0.45 − 0.59, 1.49 0.397

The width and height of both points were presented as mean ± standard deviation (SD); independent sam-
ple t test was applied for gender comparison
CI confidence interval

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Surgical and Radiologic Anatomy (2021) 43:219–224
Fig. 3  The positional relationship between marginal points of pterygomaxillary junction and anterior nasal spine (ANS). a, b Scatter plot of the
inferior end (Pti) and the superior end (Pts) of the pterygomaxillary junction relative to the ANS on the frontal projection
an idea of the location, we next made a scatter plots dia-
gram centered on the ANS. We selected ANS as a landmark
because it is the most prominent identifiable hard structure
in the surgical field and always kept intact. In accordance
with the above finding, the axis between Pti and Pts seemed
was inclined to the sagittal plane. Both Pti and Pts appeared
in a 45° fan shape in bilateral superior and inferior quadrant,
indicating that the line between the pterygoid osteotome
and ANS might not exceed 45° from FH plane. Following
the principle of safety as the osteotome put down, the most
suitable for osteotome position was the region occupied by
the majority of Pti, which was the 45° fan shape ranged in
20–25 mm radius in the inferior quadrant.
Our data were based on apparently normal samples.
Patients with dentofacial deformities are the main audi-
ence for the Le Fort I osteotomy. Such subjects might have
variants in maxilla including maxillary retrusion, protrusion
or even cleft palate [15], and a further study is needed. In
addition, Pti and Pts are just reference points for probable
placement of osteotome without direct contact. The anatomy
of PMJ lateral border deserves analysis and classification.
Conclusion
During the pterygomaxillary separation, there is a risk of
injuring the neurovascular bundle of the pterygopalatine
fossa 16.09 mm above the inferior border of the ptery-
gomaxillary junction. The region within a 45° fan shape
ranged in 20–25 mm radius in inferior quadrant centered
223
on ANS might be suitable for the osteotome position. The
positional relationship especially between the ANS and
Pti could provide a reference for surgeons during Le Fort
I osteotomy.
Acknowledgements This work was supported by the Key Research
and Development Program of Jiangsu Province (BE2017732) and the
Priority Academic Program Development of Jiangsu Higher Education
Institutions (PAPD, 2018-87).
Author contributions XC and JZ carried out the measurements and
drafted the manuscript; XC and YH collected data, analyzed and inter-
preted the results; XC and SG were involved in the statistical analy-
sis; HJ managed the measurement design, reviewed the manuscript
and provided funding support. All authors read and approved the final
manuscript.
Funding This work was supported by the Key Research and Devel-
opment Program of Jiangsu Province (BE2017732) and the Priority
Academic Program Development of Jiangsu Higher Education Institu-
tions (PAPD, 2018-87).
Data availability All data generated or analyzed during this study are
included in this published article.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
This study was approved by the local ethics committee (No: PJ2017-
048-001) of the Affiliated Stomatological Hospital of Nanjing Medical
University.
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