Clinical Implications of the Topography

and Distribution of the Posterior

Superior Alveolar Artery

Jong-Kook Kim

Department of Dentistry

The Graduate School, Yonsei University

Clinical Implications of the Topography

and Distribution of the Posterior

Superior Alveolar Artery

Directed by Professor Hyung-Sik Park

The Doctoral Thesis

submitted to the Department of Dentistry,

the Graduate School of Yonsei University

in partial fulfillment of the requirements for the

degree of Doctor of Philosophy

Jong-Kook Kim

December 2006

ThiscertifiesthattheDoctoralDissertationofJong-KookKim is

approved.

-----------------------------------------ThesisSupervisor:PPPrrrooofff...HHHyyyuuunnnggg---SSSiiikkkPPPaaarrrkkk

-----------------------------------------ThesisCommitteeMember:PPPrrrooofff...DDDooonnnggg---HHHooooooHHHaaannn

-----------------------------------------ThesisCommitteeMember:PPPrrrooofff...JJJaaaeee---HHHaaaYYYoooooo

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-----------------------------------------ThesisCommitteeMember:PPPrrrooofff...HHHeeeeee---JJJiiinnnKKKiiimmm

TheGraduateSchoolYonseiUniversity

December2006

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본 논문이 완성되기까지 용기를 주시고 정성을 다해 지도를 해 주신 지도교수님이신 박형식 교수님께 진심으로 감사드립니다.제 논문의 완성도를 위해 바쁘신 가운데 따뜻한 마음으로 많은 격려와 조언을 해 주신 보철과 한동후 교수님,구강악안면외과학 교실의 유재하 교수님,차인호 교수님께 감사를 드리며,실험과 논문자료의 정리와 편집 및 논문의 구성을 위해애써주신 해부학 교실의 김희진 교수님,허경석 선생님,허미선 선생님께감사의 마음을 드립니다.

이 논문이 완성되기까지 끝없는 사랑으로 저를 지켜주신 부모님과 가족들에게 감사하며 이 작은 결실을 함께 하고자 합니다.

December2006

Jong-KookKim

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Table1.Measurementsoftheheightoftheintraosseousbranch(IObr)oftheposteriorsuperioralveolararteryfrom thecementoenameljunction(CEJ)ofthemaxillaryteethandthemaxillarysinusfloor.·················12

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Figure1.Photographoftheposteriorsuperioralveolarartery(PSAA)anditsextraosseousbranch(EObr)priortoenteringtheposteriorsuperioralveolarforamen,showingslightbulgingandentanglement.································································································································7

Figure2.RunninganddistributionpatternsoftheEObrofthePSAA.···········8Figure3.Photographsofcoronalsectionsofthespecimensshowingthe

coursesoftheintraosseousbranch(IObr)ofthePSAA atthelateralwallofthemaxillarysinus.··········································································9

Figure4.ThreecategoriesofthecoursesoftheIObrofthePSAA.················11Figure5.Schematicindicatingthemeanandrangevaluesoftheheightof

theIObrofthePSAA from thecementoenameljunctionateachmaxillarytooth.·································································································12

Figure6.PhotographsshowingtwodifferentcoursesoftheIObrofthePSAA.··················································································································13

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CCCllliiinnniiicccaaalllIIImmmpppllliiicccaaatttiiiooonnnsssooofffttthhheeeTTTooopppooogggrrraaappphhhyyyaaannndddDDDiiissstttrrriiibbbuuutttiiiooonnnooofffttthhheeePPPooosssttteeerrriiiooorrrSSSuuupppeeerrriiiooorrrAAAlllvvveeeooolllaaarrrAAArrrttteeerrryyy

Jong-KookKim

DepartmentofDentistry,TheGraduateSchool,YonseiUniversity

(DirectedbyProfessorHyung-SikPark,D.D.S.,M.S.D.,Ph.D.)

The posterior superior alveolar artery (PSAA) is one of the terminalbranchesofthethirdportionofthemaxillaryartery,andisdividedbroadlyintotheextraosseousbranch(EObr)andintraosseousbranch(IObr),andcanbe damaged during Le FortIosteotomy and the maxillary sinus graft.The PSAA distributes in the lateralwallofthe maxillary sinus,which

makesitimportanttotheintegrationofthegraftmaterialandwoundhealingafterthemaxillarysinusgraftandcausesintraoperativebleedingoccasionallyduringLeFortIosteotomyandthemaxillarysinusgraft.Theaim ofthisstudy wasto clarify thearrangementoftheanatomic

coursesanddistributionofthePSAA anditsbranchesusingatopographicexaminationfollowedbyadetaileddissection.Thisstudywasalsodesignedtodescribe the anatomicalvariations in the topographic relationships,therebyprovidingcriticaldataforminimizingdamagetothePSAA duringLeFortIosteotomyandthemaxillarysinusgraft.

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The PSAA was examined in 42 hemifaces (19 males,23 females)ofembalmedKoreancadavers(meanage70years,range47-94years).Priortodissection(25cases)andsectioning(10cases),allspecimensweredecalcified.Theremainingsevenspecimenswerenon-decalcified.Theresultswerecomefrom thisstudyasfollows:1.TheanteriorlimitofthedistributionoftheEObrwaswithintheconfines

ofthemaxillaryfirstmolarregionin14(56%)ofthe25dissections.2.TheIObrranthroughthebonygrooveorthebonycanalformedwithin

thelateralcorticalplateofthemaxillarysinus.3.ThecoursesoftheIObrwereclassifiedintothreecategories:straight

(TypeI)wasobservedin24cases(75%).4. In the maxillary first molar region, the mean height from the

cementoenameljunction(CEJ)andthemaxillarysinusfloortotheIObrwere21.1mm (range15.2-29.3mm),10.3mm (2.5-10.4mm),respectively.5.TheexternaldiameteroftheIObrwas0.9mm (0.3-1.9mm)atthe

posterior superior alveolar foramen and 0.8 mm (0.3-1.6 mm) at theinfrazygomaticcrest,respectively.Taking these results together,itis considered thata bilateralmucosal

incisionwithinthemesialaspectofthefirstmolarmayminimizedamagetothe EObr during Le Fort Iosteotomy.Moreover,the anatomic findings(includingthemeasurementdata)inthepresentstudycouldrepresentcrucialinformation for certain surgical procedures. In addition, considering theminimum height and the maximum external diameter of the IObr,thepossibilityofseverebleeding during LeFortIosteotomyandthemaxillarysinusgraftmustbeconsidered.___________________________________________________________________________Keywords:posteriorsuperioralveolarartery,extraosseousbranch,

intraosseousbranch,LeFortIosteotomy,maxillarysinusgraft

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Jong-KookKim,D.D.S.,M.S.D.

DepartmentofDentistryTheGraduateSchool,YonseiUniversity

(DirectedbyProfessorHyung-SikPark,D.D.S.,M.S.D.,Ph.D.)

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Intraoperativeorpostoperativebleeding isoccasionally encountered asthemajorvascularcomplication in Le FortIosteotomy.Among the vascularcomplications,arterialhemorrhagetendstobemorepersistentandmayrecurpostoperatively,whichmakesitmoredifficulttomanage.Themostcommonlyinvolvedvesselsaretheterminalbranchesofthemaxillaryartery,suchasthedescendingpalatineartery,sphenopalatineartery,andposteriorsuperioralveolarartery(PSAA).The PSAA is a branch of the third portion of the maxillary artery

(Woodburneetal,1994;Standringetal,2005;MooreandDalley,2006),andisdivided broadly intotheintraosseousbranch (IObr)supplying themaxillarymolarandthemaxillarysinus,andtheextraosseousbranch(EObr)supplyingtheattachedgingivaandthemucosaofthemaxillaryposteriorteethregion.UsuallythePSAA andinfraorbitalartery(IOA)communicatewitheachotherattheanteriorwallofthemaxilla(Solaretal,1999).

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ThePSAA isoneoftheterminalbranchesofthemaxillaryartery,andcanbedamaged during LeFortIosteotomy.Severepostoperativehemorrhage,falseaneurysm,and arteriovenousfistulahavebeen noted in patientswitheitherpartialorcompletedamagetoamaxillaryarterialbranchsuchasthePSAA afterthisprocedure(Laniganetal,1990,1991).The PSAA distributes in the lateralwallofthe maxillary sinus,which

makesitimportanttotheintegrationofthegraftmaterialandwoundhealingafterthemaxillarysinusgraft(Solaretal,1999).Thesuccessofthemaxillarysinusgraftisdependentonminimaldamagetothisarteryduringthewindowopeningprocedure.Althoughbleedingisrareduetotheabsenceofamajorarteryatthesurgicalareawhenperformingthewindow openingbyalateralapproachduringthemaxillarysinusgraft(vandenBerghetal,2000),severebleeding due to damage to the IObr during the window opening hasoccasionally beenreportedby clinicians(Elian etal,2005).Thishasledtomanymodifiedsurgicaltechniquesbeingsuggestedforminimizingdamagetothemain arterialbranchesduring surgicalproceduresinvolving themaxilla,suchasLeFortIosteotomy(Montgomeryetal,1967;Pearsonetal,1969;Wentges,1974;TurveyandFonseca,1980;Laniganetal,1990,1991;MortonandKahn,1991;Lietal,1996;ChoiandPark,2003)andthemaxillarysinusgraft(Tatum,1986;Summers,1994;MarxandGarg,2002).Despitethisclinicalimportance,therehavebeenfew reportsontheclinicalanatomyofthePSAAbranches(Jones,1939;BrandandIsselhard,1990;Solaretal,1999;Traxleretal,1999).Theaim ofthis study was to clarify thearrangementofthe anatomic

coursesanddistributionofthePSAA anditsbranchesusing atopographicexaminationfollowedbyadetaileddissection.Thisstudywasalsodesignedto

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describe the anatomicalvariations in the topographic relationships,therebyprovidingcriticaldataforminimizingdamagetothePSAA duringLeFortIosteotomyandthemaxillarysinusgraft.

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The PSAA was examined in 42 hemifaces (19 males,23 females) ofembalmedKoreancadavers(meanage70years,range47-94years)withoutanyhistoryoftraumaorsurgicalproceduresonthemiddleportionoftheface.Latex(Neoprene,LotNo.307L146,DuPont,France)witharedcoloringagent(colorantuniversel,Castorama,France)wasinjected into allthespecimensthroughthecommoncarotidarterytoenableobservationofthetopographicrelationshipbetweenthecourseofthePSAA anditssurroundingstructuresofthemaxilla.Priortodissection(25cases)andsectioning(10cases),allspecimenswere

decalcifiedin40lofdecalcificationsolutionfor4-7days.Thedecalcificationsolutionwaspreparedwith7gofaluminum chloridehexahydrate(Al2Cl36H2O),8.5mlof30% hydrochloricacid,and8.5mlof100% formicacid,whichwasthendilutedto100mlwithdistilledwater.Afterdecalcification,thespecimenswereneutralized for2-3daysin aneutralization solution prepared from 5g ofsodium sulfatein100mlofdistilledwater.In the25dissections,aftertheskin andsubcutaneoustissueoftheface

wereremovedfrom thelowereyelidtotheinferiormarginofthemandible,thefacialmuscleattachingthemandible,thezygomaticarchwiththemasticatorymuscles,and the mandible itselfwere removed.A detailed dissection wasperformedonallspecimens,withextremecarebeingtakennottodamagethebranchesofthethirdportionofthemaxillaryartery.Dissectionwasperformedwith a fine rongeurand forceps undera surgicalmicroscope (CarlZeiss,Germany),withspecialattentionpaidtothepreciseoriginandcoursesoftheEObrandIObrofthePSAA anditssmallarterialbranches.AfteradetaileddissectionofthePSAA,themaxillaandsurroundingtissueswereremoveden

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bloc,includingthemaxilla,maxillaryteeth,hardpalate,themainpartofthemaxillarysinus,andthePSAA distributedwithinthemaxillaandsurroundingstructures.Thedecalcified10specimenswerepreparedasexcisedtissueblocksofthe

maxilla thatincluded the maxillary sinus floor,the hard palate,and thealveolarportion ofthe maxilla.The specimens were then sectioned usingautopsyblades(No.170,Feather,Japan)throughthelongaxisofthedentalcrownandroot.Colorimagesofeachsection(includingaruler)werethenobtainedusingacomputerscanner(HP ScanJet6100c,HP,USA),andtheywerestoredinJPEGformatwithhigh-qualitycompression.Intheremainingsevennon-decalcifiedspecimens,themaxillawasseparated

from theskullandthesurroundingsofttissuewasremoved.ThePSAA andIOA were exposed by approaching the maxillary sinus by removing thesuperiorwallofthemaxillarysinusandthelateralwallofthenasalcavitywiththerongeur.The following examinations and measurement were performed on the

dissectedandnon-decalcifiedmaxillaryspecimens:1.DistributionandpreciseextentoftheEObrofthePSAA.2.TopographyanddistributionoftheIObrofthePSAA.3.MeasurementsofthePSAA:a.Heightofthe traveling course ofthe IObrofthe PSAA from the

cementoenameljunction(CEJ)oftheindividualmaxillaryteethandfloorofthemaxillarysinus(from thefirstpremolartothemaxillarytuberosityregion).b.ArterialexternaldiametersoftheEObrandIObrofthePSAA atthe

enteringpointoftheposteriorsuperioralveolarforamenandtheinfrazygomaticcrestregion,respectively.

Inthe10decalcifiedsectionedspecimens,theheightofthetravelingcourse

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oftheIObrofthePSAA from theCEJoftheindividualmaxillaryteethandthemaxillarysinusfloor(from thefirstpremolartothemaxillarytuberosityregion) was measured, respectively, using an image analysis system(Image-Pro® Plus,ver.4.0,Media Cybernetics,USA)after performing astandardcalibration.Nodistinctionwasmadebetweenmaleandfemalecadavers.Allphotographs

anddiagramsinthisarticleareofstructuresviewedfrom therightsideoftheface.

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ThePSAA andIOA werelocatedattheposteriorwallofthemaxilla,andthePSAA enteredthroughtheposteriorsuperioralveolarforamenorforamina.Beforeenteringtheforamenorforamina,thePSAA dividedintotwoarterialbranches:theEObrandIObr.Inthisregion,theexternaldiameteroftheEObrofthePSAA waslarger(1.3±0.8mm,mean±SD;range0.3-2.0mm)thanthatoftheIObr(0.9±0.4mm,0.3-1.9mm).ThiswasreflectedbythePSAA priortoentering theposteriorsuperioralveolarforamenappearing slightly bulgedandentangled(Fig.1).

Fig.1.Photographoftheposteriorsuperioralveolarartery(PSAA)anditsextraosseousbranch (EObr)priortoentering theposteriorsuperioralveolarforamen,showingslightbulgingandentanglement(arrowhead).Buc,buccinatormuscle;IOA,infraorbitalartery;IZC,infrazygomatic crest;MA,maxillaryartery.

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TheEObrofthePSAA wasusually locatedinsubcutaneoustissues,butsomeofarterialbrancheswereembeddedwithintheperiosteallayerofthefacialaspectofthe maxilla.TheEObrran on thedecline toward to thealveolarcrestasitapproachedtothepremolarregion.Thesebranchessuppliedand distributed to the attached gingiva and the mucosa atthe maxillarypremolarandmolarregions.Althoughtheanteriorlimitofthedistributionwaswithintheconfinesofthemaxillaryfirstmolarregionin14(56%)ofthe25dissections,the fine arterialbranches extended to the region between thesecond premolarand thefirstmolar(1case,4%),tothesecond premolarregion(4cases,16%),totheregionbetweenthefirstandsecondpremolars(4cases,16%),and to thefirstpremolarregion (2cases,8%).TheexternaldiameteroftheEObrofthePSAA attheinfrazygomaticcrestregionwas0.9±0.6mm (0.2-1.2mm)(Figs.1,2).

Fig.2.RunninganddistributionpatternsoftheEObr(arrowheads)ofthePSAA.(A)TheEObrofthePSAA formsananastomosiswiththeIOA.(B)TheEObrsuppliesanddistributestotheattachedgingivaandthemucosaatthemaxillarypremolarandmolarregion.FA,facialartery;FV,facialvein.

IncontrasttothecourseoftheEObr,theIObrofthePSAA ranwithinthemaxilla.EveryIObrofthePSAA formedananastomosiswiththeIOA branch,

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namedtheanteriorsuperioralveolarartery.MostoftheIObrranthroughthebonygrooveinsideofthelateralwallofthemaxillarysinus.However,inasmallnumberofthespecimens,theIObrranthroughthebonycanalformedwithin the lateralcorticalplate ofthe maxillary sinus.This pattern wasobservedindifferentregionsofthesamespecimen(Fig.3).

Fig.3.Photographs ofcoronalsections ofthe specimens showing thecoursesoftheintraosseousbranch(IObr)ofthePSAA atthelateralwallofthemaxillarysinus.(A)MostoftheIObrofthePSAA ranthroughthebonygroove (arrow) inside ofthe lateralwallofthe maxillary sinus in themaxillaryfirstmolarregion.(B)TheIObrofthePSAA locatedatthebonycanal(arrowhead)formed within the lateralcorticalplate ofthe maxillarysinusinthemaxillarysecondmolarregion.B,buccalaspect;P,palatalaspect;MS,maxillarysinus;NC,nasalcavity.

ThecoursesoftheIObrofthePSAA wereclassifiedintothreecategories:straight(typeI),U-shaped(typeII),anddownstep(typeIII).TypeIwasthemostcommon(24cases,75%),typeIIwasobservedin7cases(21.9%),and typeIIIwasfound in only 1case(3.1%)(Fig.4).In thecasesthatexhibitedaslightcurveinthecourseoftheartery,thechangeindirection

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occurredattheregionbetweenthefirstandsecondpremolarsorbetweenthesecondpremolarandthefirstmolar.TheexternaldiameteroftheIObrofthePSAA was0.8±0.3mm (0.3-1.6mm)attheinfrazygomaticcrestregion.The heights of the IObr of the PSAA based on the topographic

measurementsaregiveninTable1andFig.5.TheshortestdistancebetweentheCEJandtheIObrofthePSAA was21.1mm (15.2-29.3mm),andthisoccurredinthemaxillaryfirstmolarregion.However,theIObrofthePSAAin the maxillary firstpremolarregion tended to run atthe highestlevelcomparedtotheotherregions(26.9mm,22.5-34.6mm)(Table1,Fig.5,6).ComparedtothemeasurementoftheheightoftheIObrofthePSAA from

thereferencetotheCEJ,theheightfrom themaxillarysinusfloortotheIObrofthePSAA was9.5mm (2.4-16.8mm)inthemaxillarytuberosityregion.Inthemaxillaryfirstmolarregion,theheightbetweentheIObrofthePSAA andthemaxillarysinusfloorwas10.3mm (2.5-19.4mm).TheIObrofthePSAAranatthelowestlevelfrom themaxillarysinusfloorinthefirstpremolarregion(9.4mm,4.5-17.4mm)(Table1).

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Fig.4.Threecategories ofthe courses ofthe IObrofthe PSAA:(A)straight(typeI),(B)U-shaped(typeII),and(C)downstep(typeIII).EObr,extraosseousbranch;IObr,intraosseousbranch;IOA,infraorbitalartery;MA,maxillaryartery.

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Table1.Measurementsoftheheightoftheintraosseousbranch(IObr)oftheposteriorsuperioralveolararteryfrom thecementoenameljunction(CEJ)ofthemaxillaryteethandthemaxillarysinusfloor.

n=42,unit:mm

Fig.5.SchematicindicatingthemeanandrangevaluesoftheheightoftheIObrofthePSAA from thecementoenameljunctionateachmaxillarytooth.Max,maximum;Min,minimum.Unit:mm.

Region FirstPremolar

SecondPremolar

FirstMolar

SecondMolar

Maxillarytuberosity

From CEJtoIObrMean 26.9 24.1 21.1 22.4 23.3SD 4.9 4.6 4.8 3.7 2.3

Maximum 34.6 32.4 29.3 28.1 27.3Minimum 22.5 16.3 15.2 15.4 19.1From maxillarysinusfloortoIObrMean 9.4 9.7 10.3 9.6 9.5SD 3.6 4.3 4.2 4.0 4.0

Maximum 17.4 18.3 19.4 17.3 16.8Minimum 4.5 3.6 2.5 2.9 2.4

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Fig.6.PhotographsshowingtwodifferentcoursesoftheIObrofthePSAA.(A)TheIObrofthePSAA locatedatthehighestpositionofthemaxillaattheleveloftherootoftheinfrazygomaticcrestwithreferencetothemaxillaryteethandthemaxillarysinusfloor.(B)TheIObrofthePSAA runningataninferolateralaspectofthemaxillanearthemaxillarysinusflooratthelowestlevelwithreferencetothemaxillaryteethandthemaxillarysinusfloor.EObr,extraosseousbranch;IObr,intraosseousbranch;MA,maxillaryartery.

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Therearefourarterialbranchessupplyingthemaxillaandmaxillarysinus:thePSAA,IOA,greaterpalatineartery,andsphenopalatineartery (van denBerghetal,2000;Flanagan,2005).ThePSAA isofgreatclinicalimportancewhen performing surgicalproceduressuch asLeFortIosteotomy andthemaxillarysinusgraft.Inaddition,complicationscanbeencounteredduringtheposteriorsuperioralveolarnerveblockanesthesia,includingtheformationofahematomasecondarytoneedle-inducedPSAA trauma(Harnetal,2002).Accordingtothepresentstudy,alltheextraosseousbranchesdistributedto

theattached gingivaand themucosa atthemaxillary premolarand molarregions.PreservingtheEObrandIObrofthePSAA iscrucialtopreventingsurgicalcomplicationsin LeFortIosteotomy.In particular,considering theanteriorlimitofthe distribution and course ofthe EObr(Fig.1,2),theincisionlineduringLeFortIosteotomyshouldbemade4-5mm abovethemucogingivaljunction,anditshouldnotpassposteriorly beyondthemesialaspectofthefirstmolar.Thissurgicalprocedurediffersfrom thatin theliterature(Bell,1992),inwhichtheincisionismadewithinthebilateralfirstpremolarregion.Basedon thepresentresults,an incision madewithin thebilateralmesialaspectsofthefirstmolarwillresultinawidersurgicalfieldandminimizedamagetotheEObrofthePSAA.The maxillary sinus is an air-filled space ofpyramidalshape thatis

surroundedbyfourwalls.Itiswellknownthatthemorphologyandsizeofthemaxillary sinusvary significantly between individuals(McGowan etal,1993;Standringetal,2005).Thetopographyofthemaxillarysinusfloorwiththe maxillary root apices varies with the age,the size and degree ofpneumatizationofthemaxillarysinus,andthestateofdentalretention(Kwak

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etal,2004).Inparticular,themaxillarysinusvolumeisreportedlycorrelatedwith the interzygomatic buttress distance (Kim et al, 2002). However,malocclusion,thestateofthedentition,andgenderdonotinfluencethesizeofthemaxillary sinus,with genderbeing asignificantfactoronly in Angle’sclassIImalocclusion(Oktayetal,1992;Arijietal,1994).Forthesereasons,thepresentstudydidnotconsidervariationsinthemaxillarysinusdimensionswiththedentitionstateandmalocclusion.InthisstudytheheightoftheIObrofthePSAA wasmeasuredwiththe

referencesoftheCEJofthemaxillary teeth andthemaxillary sinusfloor.These were considered more reliable than using the alveolarridge as areference(Solaretal,1999;Traxleretal,1999),becausethisreferencecanvarywiththepresenceofteethandtheperiodontalpathologiccondition.WhenperformingLeFortIosteotomy,theosteotomylineisgenerallyplaced

throughahigherlevelfrom thepyriform apertureto4–5mm abovetherootapexofthemaxillarymolar.Thatis,consideringthelengthofthemolarroot,theosteotomylineisusuallydetermined15mm from theCEJofthemolarinthemaxillarymolarregion.ThisincreasestheriskofdamagetotheIObrofthePSAA duringtheosteotomybecausetheminimum heightoftheIObrofthePSAA from theCEJofthefirstmolarwasfoundtobeabout15mm inthepresentstudy.Themaxillarysinusgraftisusuallyperformedwhenmorethan4mm of

bonegraftisrequiredduringimplantplacementinthemaxillarymolararea.Thehingeosteotomy,whichinvolvesthewindow opening2-3mm abovethemaxillary sinus floor,is preferred forpreventing the leakage ofthe graftmaterialandforbetterhealingandremodeling.Solaretal(1999)reportedthattheIObrofthePSAA runshalfwayupthe

lateralwallofthemaxillary sinus,approximately 19mm from thealveolarmargin,whichinrarecasesresultsinbleedingduringthewindow opening.In

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thepresentstudyitwasfoundthattheshortestdistancefrom themaxillarysinusfloortothefirstmolarwas2.5mm.Therefore,theIObrofthePSAAcan bedamagedwhen performing thewindow opening abovethemaxillarysinusfloor.ItisreportedthattheIObrofthePSAA isdamagedduringthewindow openinginabout20% ofcases,duetoitslocation(Elianetal,2005).SincethediameteroftheIObrofthePSAA islessthan thoseofthe

descending palatineartery (Lanigan,1990),theposteriorlateralnasalartery(Flanagan,2005),andthemaxillaryartery(ChoiandPark,2003),bleedingdueto damage inflicted during the window opening procedure has notbeenconsideredtobeaseriousproblem.However,thepresentstudyfoundthatthemaximum externaldiameteroftheIObrofthePSAA wasapproximately 2mm at the posterior superior alveolar foramen and 1.6 mm at theinfrazygomaticcrest.Thesemeasurements-indicatingthemoderatediameterofthisarterialbranch-suggestthatseverebleedingcouldoccurwhenthearteryisdamaged.Summarizing theresults,itisconsideredthatabilateralmucosalincision

withinthemesialaspectofthefirstmolarmayminimizedamagetotheEObrofthePSAA duringLeFortIosteotomy.Inaddition,consideringtheminimumheightand themaximum externaldiameteroftheIObrofthePSAA,thepossibilityofseverebleeding during LeFortIosteotomyandthemaxillarysinusgraftmustbeconsidered.

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Theaim ofthisstudy wastoclarify thearrangementoftheanatomiccoursesanddistributionofthePSAA anditsbranchesusing atopographicexaminationfollowedbyadetaileddissectionin42hemifaces(19males,23females)ofembalmed Korean cadavers.This study was also designed todescribe the anatomicalvariations in the topographic relationships,therebyprovidingcriticaldataforminimizingdamagetothePSAA duringLeFortIosteotomyandthemaxillarysinusgraft.Theresultswerecomefrom thisstudyasfollows:1.TheanteriorlimitofthedistributionoftheEObrwaswithintheconfines

ofthemaxillaryfirstmolarregionin14(56%)ofthe25dissections.2.TheIObrranthroughthebonygrooveorthebonycanalformedwithin

thelateralcorticalplateofthemaxillarysinus.3.ThecoursesoftheIObrwereclassifiedintothreecategories:straight

(TypeI)wasobservedin24cases(75%).4.Inthemaxillaryfirstmolarregion,themeanheightfrom theCEJandthe

maxillary sinusfloorto theIObrwere21.1mm (15.2-29.3mm),10.3mm(2.5-10.4mm),respectively.5.TheexternaldiameteroftheIObrwas0.9mm (0.3-1.9mm)atthe

posterior superior alveolar foramen and 0.8 mm (0.3-1.6 mm) at theinfrazygomaticcrest,respectively.

Astheresultsofthisstudy,itisconsideredthatabilateralmucosalincisionwithinthemesialaspectofthefirstmolarmayminimizedamagetotheEObrduring LeFortIosteotomy.Moreover,theanatomicfindings(including themeasurementdata)inthepresentstudycouldrepresentcrucialinformationfor

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certainsurgicalprocedures.Inaddition,considering theminimum heightandthemaximum externaldiameteroftheIObr,thepossibilityofseverebleedingduringLeFortIosteotomyandthemaxillarysinusgraftmustbeconsidered.

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RRReeefffeeerrreeennnccceeesss

1.ArijiY,KurokiT,MoriguchiS,ArijiE,KandaS:Agechangesin thevolume of the human maxillary sinus: a study using computedtomography.DentomaxillofacRadiol23:163-168,1994

2.BellWH:Modernpracticeinorthognathicandreconstructivesurgery.vol3.1798-1801,1992

3.BrandRW,IsselhardDE:Anatomyoforofacialstrucrures(ed4).St.Louis,C.V.Mosby,171-177,1990

4.ChoiJH,ParkHS:TheClinicalAnatomyoftheMaxillaryArteryinthePterygopalatineFossa.JOralMaxillofacSurg61:72-78,2003

5.Elian N,WallaceS,Cho SC,JalboutZn,Froum S:Distribution ofthemaxillary artery as itrelates to sinus flooraugmentation.IntJ OralMaxillofacImplants20:784-787,2005

6.FlanaganD:ArterialSupplyofMaxillarySinusandPotentialforBleedingComplicationDuring LateralApproachSinusElevation.ImplantDent14:336-339,2005

7.JonesFW:Theanteriorsuperioralveolarnerveand vessels.JAnt73:583-591,1939

8.HarnSD,Durham TM,CallahanBP,KentDK:Thetriangleofsafety:Amodified posterior superior alveolar injection technique based on theanatomyofthePSA artery.GenDent50:554-557,2002

9.Kim HJ,YoonHR,Kim KD,KangMK,KwakHH,ParkHD,ParkCS:Personal-computer-based three-dimensionalreconstruction and simulationofmaxillarysinus.SurgRadiolAnat24:393-399,2002

10.KwakHH,ParkHD,YoonHR,KangMK,KohKS,Kim HJ:Topographicanatomy ofthemaxillary sinusfloorin Koreans.IntJOralMaxillofac

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Surg33:382-388,200411. Lanigan DT,Hey JH, West RA: Major vascualr complications of

orthognathicsurgery:falseaneurysmsandarteriovenousfistulasfollowingorthognathicsurgery.JOralMaxillofacSurg49:571-577,1991

12. Lanigan DT,Hey JH, West RA: Major vascular complications oforthognathicsurgery:HemorrhageassociatedwithLeFortIosteotomies.JOralMaxillofacSurg48:561,1990

13.LiKK,MearaJG,AlexanderA:LocationofthedescendingpalatinearteryinrelationtotheLeFortIosteotomy.JOralMaxillofacSurg 54:822,1996

14.McGowanDA,BaxterPW,JamesJ:Themaxillarysinusanditsdentalimplications(ed1).Wright,London,1-25,1993

15.MarxRE,GargAK:A novelaidtoelevationofthesinusmembraneforthesinusliftprocedure.ImplantDent11:268-271,2002

16.Montgomery WW,Katz R,Gamble JF:Anatomy and surgery ofthepterygomaxillaryfossa.AnnOtolRhinolLaryngol79:606,1967

17. Moore KL, Dalley AF: Head. Clinically oriented anatomy (ed 5).Philadelphia:LippincottWilliams& Wilkins,982,2006

18. Morton AL, Khan A: Internal maxillary artery variability in thepterygopalatinefossa.OtolaryngolHeadNeckSurg104:204,1991

19.OktayH:Thestudyofthemaxillarysinusareasindifferentorthodonticmalocclusions.Am JOrthodDentofac102:143-145,1992

20.Pearson BW,Mackenzie RG,Goodman WS:The anatomic basis oftransantral ligation of the maxillary artery in severe epistaxis.Laryngoscope79:969,1969

21.SolarP,GeyerhoferU,TraxlerH,WindischA,Ulm C,WatzeaG:Bloodsupplytothemaxillarysinusrelevanttosinusfloorelevationprocedures.ClinOralImplRes10:34-44,1999

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22.Standring S:Nose,nasalcavity,paranasalsinuses,and pterygopaltinefossa.Gray'sanatomy(ed39).Edinburgh,NY:Elsevier,572-579,2005

23.SummersRB:New conceptinmaxillaryimplantsurgery:Theosteotomestechnique.Compendium.vol15,152-156,1994

24.Tatum OH:Maxillaryandsinusimplantreconstructions.DentClinNorthAm 30:207-229,1986

25.TraxlerH,Windisch A,GeyerhrhoferU,Surd R,SolarP,Firbas W:ArterialBloodSupplyoftheMaxillarySinus.ClinAnat12:417-421,1999

26.TurveyTA,FonsecaRJ:Theanatomyoftheinternalmaxillaryarteryinthepterygopalatinefossa:Itsrelationshiptomaxillarysurgery.JOralSurg38:92,1980

27.van den Bergh JPA,ten Bruggenkate CM,Disch FJM,Tuinzing DB:Anatomicalaspects ofsinus floor elevations.Clin OralImplRes 11:256-265,2000

28.WentgesRT:Surgicalanatomy ofthepterygopalatinefossa.JLaryngolOtol89:35,1974

29.WoodburneRT,BurkelWE:EssentialsofHumanAnatomy(ed9).NewYorkOxfordUniversityPress,269,1994

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AAABBBSSSTTTRRRAAACCCTTT IIINNN KKKOOORRREEEAAANNN

뒤뒤뒤위위위이이이틀틀틀동동동맥맥맥의의의 분분분포포포와와와 임임임상상상적적적 적적적용용용에에에 관관관한한한 연연연구구구

뒤위이틀동맥 (posteriorsuperioralveolarartery)은 위턱동맥 (maxillaryartery)의 셋째부분에서 일어나 뼈밖가지 (extraosseousbranch)와 뼈속가지 (intraosseousbranch)로 나뉘어져 위턱굴 (maxillarysinus)과 점막,부착치은 및 치아에 분포한다.그러나 뒤위이틀동맥의 형태와 변이에 관한 임상해부학적 지식이 충분하게 알려져 있지 않아,LeFortI뼈절단술을 하거나 상악동거상술 (maxillary sinusgraft)시 창 (window)을 형성할 때 뼈속가지를 손상시켜 출혈이 발생하는 경우가있다.이 연구의 목적은 뒤위이틀동맥의 정확한 국소해부학적 위치와 분포를 밝혀악교정수술이나 상악동거상술 시 출혈을 최소로 하는데 도움을 주고자 함이다.연구재료로 한국 성인 시신 42쪽 (남자 19쪽,여자 23쪽)을 사용하였다.그중 25

쪽은 latex를 주입하여 탈회 후 해부하였고,10쪽은 탈회 후 관상절단하여 뼈속가지가 달리는 양상을 관찰하였다.나머지 7쪽은 탈회하지 않고 위턱뼈를 머리뼈에서 분리하여 주위 물렁조직을 제거 후 관찰하였다.뒤위이틀동맥의 뼈밖가지는 눈확아래동맥 (infraorbitalartery)과 연결되었으며,

뒤위이틀구멍 (posteriorsuperioralveolarforamen)부위에서 대체로 부풀은 고리형태를 보였다.뒤위이틀동맥 뼈밖가지의 분포범위는 첫째큰어금니까지 분포하는경우 (56%),둘째작은어금니와 첫째큰어금니 사이까지 분포하는 경우 (4%),둘째작은어금니 부위까지 분포하는 경우 (16%),첫째와 둘째작은어금니 사이까지 분포하는 경우 (16%),첫째작은어금니까지 분포하는 경우 (8%)등 다양하였다.따라서LeFortI뼈절단술 시 수평절개선은 지금까지 추천된 종래의 안내와 달리 본 연구에 의하면 좌우측 위턱 첫째큰어금니의 근심면까지 보다 광범위하게 함으로써수술시야를 확보하고 뼈밖가지의 손상을 최소로 할 수 있다고 생각한다.뒤위이틀동맥 뼈속가지가 위턱뼈 속을 달리는 형태는 곧은형이 75.0%,U자형이

21.9%,계단형이 3.1%로 곧게 수평으로 달리는 경우가 가장 많았으며,위턱뼈 관

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상단면에서 뒤위이틀동맥의 뼈속가지가 위턱굴 외측방벽을 달리는 양상을 관찰한결과 대부분의 경우 외측방벽 안쪽면에서 고랑으로 지나갔고,일부는 뼈판 속에서관 형태를 이루며 지나갔다.이 두 형태는 한 예의 다른 부위에서 관찰되는 경우도 있었다.뒤위이틀동맥 뼈속가지의 주행 높이는 치아목선 (cementoenameljunction)에서

뼈속가지와의 거리를 계측하였으며 치아목선과 뒤위이틀동맥의 뼈속가지 사이의평균거리는 20mm 상방이었으며 첫째작은어금니에서 26.9(22.5-34.6)mm,둘째작은어금니에서 24.1(16.3-32.4)mm,첫째큰어금니에서 21.1(15.2-29.3)mm,둘째큰어금니에서 22.4(15.4-28.1)mm,위턱뼈융기에서 23.3(19.1-27.3)mm였다.따라서 LeFortI뼈절단술 시 지금까지 추천되어온 뼈절단선이 위턱 첫째큰어금니의 치아목선에서 대략 15mm 상방이어서 이 연구결과에 의하면 위턱 첫째큰어금니의 치아목선에서 뼈속가지의 최소거리가 대략 15mm로 뼈절단술 시 뼈속가지의 손상의 위험이 있을 수 있다고 생각한다.또한 뒤위이틀동맥의 뼈속가지의 거리를 위턱굴바닥 (maxillarysinusfloor)으

로부터 계측한 결과 평균거리는 10mm 내외로 첫째작은어금니에서 9.4(4.5-17.4)mm,둘째작은어금니에서 9.7 (3.6-18.3)mm,첫째큰어금니에서 10.3 (2.5-19.4)mm,둘째큰어금니에서 9.6(2.9-17.3)mm,위턱뼈융기에서 9.5(2.4-16.8)mm로뒤위이틀동맥의 뼈속가지가 달리는 높이는 다양하게 관찰되었으며 뼈속가지가 높게 위치하는 경우는 광대돌기 (zygomaticprocess)깊숙히 달렸고 뼈속가지가 낮게 위치하는 경우는 위턱뼈의 아래가쪽면을 따라 위턱굴바닥 가까이 지나갔다.따라서 상악동거상술 시 창 형성은 위턱굴바닥 2-3mm 상방에서 형성하는데 본 연구결과에 의하면 위턱 첫째큰어금니에서 위턱굴바닥에서 뼈속가지의 최소거리가2.5mm로 창 형성 시 뼈속가지의 손상이 있을 수 있다고 생각한다.뒤위이틀동맥 뼈속가지의 평균 혈관두께는 뒤위이틀구멍에서 0.9(0.4-1.9)mm,

광대아래능선 (infrazygomaticcrest)에서 0.8(0.3-1.6)mm였으며,뼈밖가지의 평균 혈관두께는 뒤위이틀구멍에서 1.3 (0.8-2.0) mm, 광대아래능선에서 0.9(0.6-1.2)mm로 뼈속가지의 최대 혈관 두께는 대략 2mm로 손상 시 심한 출혈이발생할 수 있다.

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이상의 결과를 종합하면,LeFortI 뼈절단술 시 수평절개선은 좌우측 위턱 첫째큰어금니의 근심면까지 형성하여도 뒤위이틀동맥의 뼈밖가지의 손상이 최소화될 것이며 LeFortI뼈절단술이나 상악동거상술 시행 시 본 연구에서 계측한 뒤위이틀동맥 뼈속가지의 평균거리에서는 술식을 시행하는데 있어서 뼈속가지의 손상의 위험이 없으나 최소 거리와 최대 혈관두께를 고려하면 뼈속가지의 손상에의한 심한 출혈도 고려해야 된다고 생각한다.

핵심되는 말:뒤위이틀동맥,뼈밖가지,뼈속가지,LeFortI뼈절단술,상악동거상술