Clin Onil Impl Ro IWV: /(): 34-44Primed in Denmark • All righis reserved

Clip 111;,' 11: Munksgaarsi 1999

CLINICAL ORALIMPLANTS RESEARCH

ISSNOW5-7I61

Blood supply to the maxillary sinus relevant tosinus floor elevation procedures

Solar P, Geyerhofer U. Traxler H, Windisch A. Ulm C. Watzek G. Bloodsupply to the maxilUiry sinus relevant to sinus floor elevation procedures.Clin Oral Impl Res 1999: 10: 34^44. © Munksgaard 1999.

The niaxilUiry blood supply is essential for preserving the vitality oftheaffected maxillary region, integration ofthe grafting material, andwound healing such as following sinus floor elevation. Although it Is wellestablished that edentulous maxillae demonstrate a decreasing vascularityas bone resorption progresses, the vascular conditions relevant to sinusfloor elevation procedures have not been investigated yet. This studydeals with maxillary arteries relevant to sinus floor elevation surgery andexamines the vascularization ofthe lateral maxilla after tooth loss.The vessels of the lateral maxilla of 18 maxillary specimens (10 male. 8female, mean age 67 years) were prepared anatomically and the localmain arteries, the number of macroscopically discernible branches andanastomoses, their calibers, and the distance between the caudal mainbranches and the alveolar ridge recorded. The lateral maxilla is suppliedby branches of the posterior superior alveolar artery (PSAA) and theinfraorbital artery (IOA) that form an anastomosis in the bony lateralanlral wall, which also supplies the Schneidcrian membrane. This in-traosseous anastomosis was found in all ofthe specimens. Eight of 18also showed an extraosseous anastomosis between PSAA and IOA. vestibu-lar to the antral wail, giving off an average of 3 branches cranially and 5branches caudally. The two anastomoses form a double arterial arcadeto supply the lateral antral wall and. partly, the alveolar process. ThePSAA had a mean caliber of 1.6 mm and exhibited an average of 2endosseous and 1 extraosseous branches. The IOA had a mean diameterof 1.6 mm and showed an average of I endosseous and 3 extraosseousbranches. The mean distance between the intraosseous anastomosis andthe alveolar ridge was 19 mm in 2 defined measuring sites. Its meanlength was 44.6 mm. The epiperiosteal vestibular anastomosis was situ-ated further cranially. at a mean distance of 23 to 26 mm from the alveolarridge and had a mean length of 46 mm. The rather huge caliber ofthevessels supplying the lateral antral wall seems to be crucial to the fact thatthe periosteal blood supply is maintained even In severe maxillary atrophyand after complete disappearance of the centro-medullary vessels.

Peter Solar\Ursula Geyerhofer\Hannes Traxler ,̂Alfred Windisch^Christian Ulm\ Georg Watzek̂

^ Department of Oral Surgery, DentalSchool, University of Vienna;^Anatomical Institute, First Department,University of Vienna, Austria

Key words: sinus floor elevation -maxillary artery - posterior superioralveolar artery - infraorbital artery -biood supply

Peter Solar, MD, DMD, Department ofOral Surgery, Dental School, Universityof Vienna, Waehringerstrasse 25a,A-1090, Vienna, AustriaTel.: ++431 40181 2500Fax: 4-+431 40181 2807

Accepted for publication 8 June 1998

Internal augmentation of the antral floor for thecreation of an adequate implant host site is verywell documented from the clinical point of view(Boyne & James 1980; Watzek 1996; Nishibori etal, 1994; Jensen et al. 1994; Hurzeler et al. 1996;Haas et al. 1998a. b). A variety of techniques havebeen proposed concerning the grafting materialand reports on autografts (Jensen & Sindet-Peders-en 199I;Caloneetal. 1992; Raghoebar et al, 1993;

Nishibori et al. 1994; Jensen et al. 1994; William-son 1996; Block & Kent 1997; Daelemans et al.1997; Neyt et al. 1997; Lorenzetti et al, 1998),homologous grafts (GaRey et al. 1991; Leder et al.1993; Nishibori et al. 1994; Zinner & Small 1996;Wheeler 1997) and xenografts (GaRey et al, 1991;Moy et al. 1993; Wheeler et al. 1996; Quinones etal. 1997; Haas et al, 1998a; Valentini et al. 1998)have been published. However, one aspect that has

34

Blood supply to the maxillary sinus

Fig. I. Photograph of the lateral antral vi'all; tnedial view. Themaxillary sinus becomes visible when the bony septum betweenthe nasal cavity and the maxillary sinus, including the nasalconchae. are removed. The course of the intraosseous anasto-mosis between PSAA and IOA is discernible in tbe transmittedlight (^) .

Fig. 3. View of a right maxilla from lateral: Posterior surfaceof the body of the maxilla and pterygopalatine fossa. ThePSAA gives off 3 branches into bone (—*) and courses antero-caudally (*) below the zygomatic process (ZP), maintainingclose contact with bone. (PP: pierygoid process.)

Fig. 2. View ofa left maxilla. PSAA and IOA originate from themaxillary artery (MA) in a common trunk. The IOA coursescranially, to the floor of the orbita, and gives off I branch lat-erally (X)- The PSAA descends along the maxillary tuberosity,gives off I branch into bone, and forms a tortuous anastomosis(EA) with a terminal branch of the IOA (observed in 44% ofthe specimens).

Fig. 4. Antero-latera! view of a left maxilla. The IOA emergesfrom the infraorbital foramen together with the nerve of thesame name. It gives off 2 branches anteriorly and passes caud-aliy along the canine fossa, below the zygomatic process, toform an anastomosis with the PSAA. It supplies the periosteumof the anterior antral wall and the vestibular gingiva in thecanine/premolar region via 2 to 3 branches on average. Thearterial arcade supplying ihe lateral antra! wall comes from thePSAA and the IOA. The gingival branches of this anastomosisare discernible as well. They are located at a mean distance of22.8 to 26 mm from the alveolar margin.

been barely investigated so far is the local arterialsupply, on which the vitality of local bone, vascu-larization of the grafting material, and the healingbehavior of the oral mucous membranes depend.

While the maxilla is very densely vascularized inyoung and dentate subjects {Staudt et al. 1977;

Braun et al. 1985; Marx 1994; Bell et al. 1995), theblood supply to bone is permanently reduced withage and progressing atrophy and the number of ves-sels and their diameter decrease, while tortuosity in-creases (Staudt et al. 1977; Soikkonen et al. 1991).Atrophy and vascular reduction trigger a vicious

35

Solar et al.

Figs 5 and 6. Photographs of the lateral antriil wall, medial view. The maxillary sinus becomes visible, when the bone septumbetween the nasal cavity and the maxillary sinus, including the nasal conchae. is removed using a chisel. The course of the intraosse-ous anastomosis between PSAA and IOA is discernible in the transmitted light (—•). A second iotraosseous branch of the PSAA isvisible in Fig. 6 (*). which also participates in the anastomosis.

circle within the bone in that atrophy aggravatesvascular reduction and vice versa (Shibayama et al.1993). Microvascular defects (Burkhardt et al.1987), stenotic changes (McGregor & MacDonaid1989), a reduction of intramedullary blood flow, in-hibition of osteoblastic activity, a delay in bone min-eralization (Kobayashi 1982), and. therefore, a re-duction in cancellous bone (Demmler et al. 1983)occur.

Gradual reduction of thecancellous portion ofthealveolar ridge that is supplied by both centro-medul-lary and periosteal vessels (Chanavaz 1995) often re-duces the antral floor to no more than a paper-thin la-mella of compact bone (Watzek et al. 1993; Ulm et al.1995). This lamella can no longer be supplied by cen-tro-medullary vessels because of its small cross sec-

Fig. 7. Schematic representation ofthe left maxilla, lateral view,with blood vessels. The lateral bone wall with the zygomaticprocess has been removed. The IOA and the extraosseous anas-tomosis (EA) are marked by a continuous line and the intraos-seous vessels (IA) of the lateral antral wall by a broken line.

tion, so that the remaining cortical bone must be sup-plied purely periosteally Sound knowledge of thevessels supplying the local periosteum which will beaffected during grafting procedures to augment thesinus floor volume is therefore essential from the sur-gical-technical point of view.

The literature concerning the course of the ves-sels supplying this region is limited to anatomicaltextbooks (Sicher & Du Brul 1970; Lang et a l1985: Gray's Anatomy 1989; Sobotta 1989;Brand & Isselhard 1990). Some studies describevascular topography under different aspects (Sko-pakoff 1968; Bell & Levy 1975; Lang & Urban

MA

Fig. 8. Schematic representation of a left maxilla, divided me-dian-sagitta!ly. medial view, offering a good view of the maxil-lary sinus after removal of the wall between the nasal cavityand the maxillary sinus, including the nasal conchae. Thedouble arterial arcade formed by PSAA and IOA is marked.The extraosseous anastomosis (EA) is situated approximately 3to 7 mm further cranially than the intraosseous one (IA).

36

Blood supply to the maxillary sinus

Fig. 9. Schematic representation of the maxillary sinus, cranialview, after removal of the floor of the orbita.

PSAA IOA

Fig. 10. Schematic representation of the maxillary sinus, pos-terior view, after removal of the posterior antral wall. The IOAenters into the infraorbital canal (IC) and gives off the anteriorsuperior alveolar artery (ASAA) before emerging from the ca-nal. The vascular stumps of the PSAA left after removal of theposterior antral wall are marked.

1977; Navarro et al. 1982; Schumacher et al. 1988;Morton & Khan 1991; Pretterklieber et al. 1991;Kasey et al. 1996). No specific studies are availableregarding the sinus floor elevation procedure.

The aim of this study was to investigate theblood supply to the lateral and caudal antral wall.

Materials and methodsA total of 18 maxillary segments were obtainedfrom cadavers used for dissection during grossanatomy courses for medical students. Thecadavers were of both sexes (10 male and 8 female)with a mean age of 67 years (min 55 years, max 75years). Sixteen specimens were completely edentu-lous and 2 dentate from the first incisor to the can-ine. The specimens exhibited Class 2 and Class 3resorption of the alveolar process according to Ca-wood & Howell's classification of alveolar resorp-tion (1988). Nine specimens were primarily fixedin formalin/phenol, while latex, Prontobario®, andpigment were injected into the vessels of the 9 re-maining specimens before fixation. After fixation,the skulls were divided into 2 halves sagittally.Only 1 skull half was used for the examination

Fig. II. Photograph ofa frontal section through tbe maxillarysinus and the alveolar process. The bone canal in the buccalantral wall, housing the intraosseous vascular anastomosis be-tween PSAA and IOA, is clearly discernible i-^). Its meanheight in relation to the alveolar ridge is 18.9 to 19.6 mm.

Fig. 12. Intraoperative photograph of the bony window pre-pared in the lateral antral wall during a sinus floor elevation.The intraosseous anastomosis is discernible (->).

37

Solar et al.

Table 1, Results o! the topographic measuremenis of Ihe posterior superior alveolar

artery

Mean SD Min. Max.

Full length (mm) 8.17

Numbef of branches (endosseous and extra- 2.56

osseous)

Number of endosseous branches 1,55

Number oi extraosseous branches 1.1

Caliber (external diameter at the exit trom the 1.59

maxillary artery)' (mm)

3.620.98

0.980.320,21

4I

111, 3

165

422.0

'Comparative vaiues of the maxillary ariery: mean vaiue 2.6, standard deviation 0,33:

min. 2.2, max- 3.2.

Table 2, Results of the topographic measurements of Ihe Inlraorbital artery

/7=18

Number of endosseous branches [along the por-

tion of ttie artery coursing within the infraorbital

canai, before the artery emerges from ttie infra-

orbitai foramen)

Number of extraosseous branchesCaliber (exiernai diameter at the exit from the

maxillary artery) [mm)

Mean

1,44

2.671.64

SD

0,51

0,97

0,48

Min

1

11,2

Max

2

42,7

(left: /?=I0; right: n=%) since the other half wasused for the students' anatomy courses.

First, the maxilla was separated from the re-sidual skull and the soft tissue removed. The zygo-matic arch was then removed using a chisel andthe vessels were dissected. To gain access to themaxillary sinus, the nasal conchae were removedand the lateral wall of the nasal cavity fenestratedusing a sharp chisel. The maxillary artery and its2 branches extending to the maxillary sinus, theposterior superior alveolar artery (PSAA) and theinfraorbital artery (IOA), was exposed. The vesselswere prepared under an operating microscope,starting from the maxillary artery to the terminalbranches of the posterior superior alveolar arteryand the infraorbital artery.

The following examinations and measurementswere carried out:1) The PSAA was located and its topography,

anastomoses, and number of branches were re-corded.

2) The IOA was located and its topography, ana-

stomoses, and number of branches were re-corded.

3) The caliber of both PSAA and IOA was meas-ured at the exit from the maxillary artery (usinga caliper rule calibrated to 0.02 mm).

4) The following distances were measured:- the distance from the alveolar margin to the

exit of the anastomosing artery branching offfrom the IOA;

- the distance from the alveolar margin to theexit ofthe anastomosing artery branching ofTfrom the PSAA;

- the length ofthe anastomosis between the ex-its of the 2 anastomosing vessels of PSAAand IOA.

The mean values and standard deviations of themeasuring results were calculated.

ResultsThe posterior superior alveolar artery (PSAA)runs caudally, on the outside of the convexity ofthe maxillary tuberosity, and is in close contactwith bone and periosteum (Figs 2 & 3). The PSAAhas a mean caliber of 2 mm at its origin and di-vides into 2 branches after 8 mm. A terminalbranch (^gingival branch) passes along the out-side of the bone and supplies the mucoperiosteumin the premolar/molar region. This terminalbranch anastomoses with the extraosseous ter-minal branch of the IOA in 8 of 18 of the speci-mens, coursing at a mean height of 23 to 26 mmfrom the alveolar margin.

The second branch ofthe PSAA (dental branch)also forms an anastomosis with the IOA, which,however, courses endosseously, halfway up the buc-cal antral wall, at a distance of 18.9 to 19.6 mmfrom the alveolar margin (Figs II, 12). This anas-tomosis was found in all specimens examined.

The infraorbital artery (IOA) originates from themaxillary artery, very close to the PSAA, in 12 ofthe 18 specimens and from a common trunk in 6 of18 (Fig. 2). It has a mean caliber of 2 mm at its ori-gin. The IOA emerges from the orbit, entering themaxillary sinus through the infraorbital fissure at avery high level. The artery runs in the infraorbitalgroove, through the infraorbital canal where it sup-plies the anterior and superior branches. It is situ-

Tabla 3 Height and lengtii of the vestibular anastomosis between ttie PSAA and the IOA

Mean

mm 22.75

Height

SD

1,49

1

Min.

21

Max.

25

Mean

26

Height

SD

6.09

2

Min,

16

Max.

37

Mean

47,25

Lengih

SD Min.

2,87 45

Max,

52

T?ie vestibuiar anastomosis was lound In 44% ot the specimens (n=8).

38

Table 4. Height an(j length ot Ihe intraosseous anastomosis between PSAA and IOA

Blood supply to the maxillary sinus

n=8

mm

Mean

19.56

Height

SD

3.67

1

Min.

14

Max.

25

Mean

18.9

Height

SD

2.82

1

Min.

M

Max.

23

Mean

44.5

Lengtfi

SD Min,

4.72 37

Max.

50

Ttie endosseous anastomosis was found in 100% ot ttie specimens {n=18).

ated at the transition from the roof of the maxillarysinus to the vertical bone septum between the maxil-lary sinus and the nasal cavity. Before emergingfrom the infraorbital foramen, the IOA gives off 1or 2 branches that course caudally along the an-terior antral wall in a bone canal; the anterior andthe middle superior alveolar arteries. One of thesevessels anastomoses with the dental branch of thePSAA which also runs endosseously. This anasto-mosis vascularizes the Schneiderian membrane onthe buccal side from anterior to posterior and themembrane at the lateral and caudal antral walls(Figs I, 5, 6).

The oral mucoperiosteum is supplied by the ves-tibular anastomosis (Fig. 4) as well as by an aver-age of 8 branches emerging directly from either thePSAA or the IOA or the anastomosis. Threebranches extend cranially and 5 caudally on av-erage.

The mean values, standard deviations, and mini-mum and maximum values are shown in Tables 1to 5.

DiscussionThe vessels described in this study are only brieflytouched upon in classical textbooks. Sicher & DuBrul (1970) mention an endosseous anastomosisbetween the PSAA and the IOA. However, mosttextbooks only briefly mention the endosseousbranches of the PSAA and the IOA which supplythe teeth in one short sentence (Lang et al. 1985;Gray's Anatomy 1989; Sobotta 1989; Brand & Is-selhard 1990). None of the above textbooks refersto an extraosseous anastomosis. Furthermore,none of the common anatomy textbooks containsexplicit illustrations of the blood supply to themaxillary sinus (Figs 7-10).

Table 5. Number of branches given oft by the vestibular anastomosis and vestibuiarvesseis emerging trom the PSAA and the iOA

Mean

3.1

Cranial

SD Min,

1.0 1

Max.

5

Mean

4.9

Caudai

SD Min.

1.5 3

Max.

8

The results of this study indicate that vasculariz-ation of the grafting material placed in sinus floorelevation occurs via 3 routes: the endosseous vascu-lar anastomosis, the extraosseous anastomosis, andthe vessels of the Schneiderian membrane. TheSchneiderian membrane at the lateral antral wall issupplied by the PSAA. the IOA. and their intraosse-ous branches and anastomoses. The middle portionof the Schneiderian membrane is supplied by thesphenopalatine artery, the terminal branch of themaxillary artery (Ranga & Andronescu 1968; Sich-er & Du Brul 1970). The maxillary sinus exhibits adistinctly sparser vascular network than the nasalcavity (Ranga & Andronescu 1968), which is situ-ated in the deepest layer ofthe lamina propria thatrests directly on the periosteum (Selden 1974). Al-though most of its branches are dichotomous, thereare also numerous recurrent branches, the ramifi-cations sometimes being fascicular. The meshes ofthe capillary network are larger, the further awaythe area to be supplied is situated from the vasculartrunk (Ranga & Andronescu 1968). However, some-times the sinus floor can completely lack the laminapropria with its vessels (Selden 1974). A study inanimals has revealed perfusion ofthe Schneiderianmembrane of 0.09 ml to 0.99 ml/min/g body weight.In comparison, a cardiac output of 146±36 ml/min/g has been observed (Kumlien et al. 1985).

A vestibular extraosseous anastomosis coursesbelow the zygomatic process and is located at amean distance of 23 mm from the alveolar ridge atits most caudal point. Even when no anastomosisis formed between the PSAA and the IOA, themain branches are located at this level in mostcases. The vessels are in close contact with bone,the anastomosis being situated very closely to themucoperiosteal region that has to be prepared asa flap to gain access to the maxillary sinus in sinusfloor elevation procedures. Vertical mucosal in-cisions should therefore extend as little cranially aspossible and the periosteum should be preparedwith utmost care to minimize the vascular traumaand to prevent damage to the extraosseous anasto-mosis. Furthermore, the vertical incisions shouldbe made at a great distance from each other tocreate as large a flap as possible, so that the tissuecan be supplied by other branches of the PSAA.

39

Solar et al.

Fig. 13. (a. b) Schematic representation of a possible soft tissueincision. The vertical incisions should be made at great distancefrom each other to create as large a flap as possible ( ), sothat the tissue can be supplied by other branches of (he PSAA.This possibility and the number of branches is reduced when asmall flap is prepared (•••)- Vertical mucosal incisions shouldextend as little cranially as possible to minimize the vasculartrauma and tc prevent damage to the extraosseous anasto-mosis.

This possibility and the number of branches is re-duced, when a small flap is prepared (Fig. 13).

Careful soft tissue preparation plays a crucialrole in sinus floor elevation surgery since pro-gressing atrophy of the alveolar ridge results inconsiderable changes in the blood supply to thetissue: bone scleroses as a result of resorption(Watzek et al. 1993; Ulm et al. 1995). its bloodsupply is reduced (Staudt et al. 1977; Kobayashi1982; Demmler et al. 1983; Burkhardt et al. 1987;Bert et al. 1989; McGregor & MacDonaid 1989;Shibayama et al. 1993). and the originally com-bined centro-medullary/mucoperiosteal circulation(Chanavaz 1995; You et al. 1991a) gradually turnsinto a purely mucoperiosteal one. The use of anadequate surgical technique therefore gains in-creasing importance in progressing atrophy toavoid a deficit in blood supply to local bone.

The horizontal soft tissue incision should be car-ried out slightly palatally as this not only offers abetter view of the alveolar ridge but also allowsinclusion of the palatine blood vessels in the

wound healing process. Cohen (1994) describedthe formation of a partial-thickness flap, an in-cision through the palatine periosteum at a dis-tance of approximately 15 mm from the alveolarridge, elevation of the palatine periosteum fromthe alveolar ridge, and repositioning of the flapafter impiant placement.

However, when a 2-stage procedure is planned,the periosteal blood supply is interrupted twicewhen this type of incision is used. In this case, it isrecommended to carry out the incision vestibularto the alveolar ridge in the first procedure, i.e.. theacttial sinus floor elevation procedure, and to usea palatal incision in the second procedure, i.e.,when the implants are placed.

Osteotomy linesIn the specimens examined in this study, the endos-seous anastomosis was situated at a smaller dis-tance from the alveolar ridge than the extraosseousanastomosis, the mean distance at the most caudalsite measuring 18.9 mm. As far as the type ofosteotomy lines to be used in sinus floor elevationsurgery is concerned, the findings of this study in-dicate that the bony window, through which thegrafting material will be placed, should be as smallas possible so that the vascular stumps of the en-dosseous anastomosis extend as close to the centerof the graft as possible.

Damage to the periosteum leads to bone ne-crosis as a result of ischemia and to partial re-generation of the underlying bone (Chanavaz1995). The range of variability ofthe threshold fora decrease in vascular supply to the maxilla thatwill result in aseptic necrosis is unknown (Lanigan1995). So far no studies are available describingthe fate of local maxillary bone after periosteal de-nudation, vascularization of the graft, and re-vascularization of local tissue after sinus liftsurgery. By taking into account that sinus lift pro-cedures involve considerably less severe tissuetraumatization than Le Fort I osteotomy, this isthe only comparable surgical technique thoroughlyinvestigated concerning maxillary blood supply(Nelson et al. 1977; Epker 1984; Yeo et al. 1989;Lanigan etal. 1990; You etal. 1990. 1991a. b; Bell etal. 1995; Berding etal. 1995; Geylikmanet al. 1995;Yang et al. 1995; Dodson et al. 1997). In the mildlyresorbed alveolar process, bone receives blood fromboth centro-medullary and mucoperiosteal vessels,while increasing resorption gradually results in apurely mucoperiosteal vascularization. It is rec-ommended to carry out a necessary sinus floor elev-ation as early as possible in order to forestall the on-set of atrophy-related vascular reduction.

40

Blood supply to the maxillary sinus

ConclusionThe findings of this study indicate that the vascularsupply to the buccal antral portions relevant to si-nus floor elevation surgery occurs via 2 arteries;the posterior superior alveolar artery (PSAA) andthe infraorbital artery (IOA). These arteries alsovascularize the Schneiderian membrane of the lat-eral maxillary sinus and the local mucoperiosteumas a double arterial arcade.

The rather large diameter of the vessels supply-ing the lateral antral wall seems to be crucialto the fact that the periosteal supply to local bonecan be maintained even in severe maxillary atrophyand after complete disappearance of the cen-tro-medullary vessels. Especially in the severelyatrophic maxilla, the alveolar ridge should be de-nuded from its periosteum as little, as carefully,and as briefly as possible to minimize the impair-ment of blood flow.

According to the findings of this study, it can beassumed that the periphery of the placed graftingmaterial is supplied by vessels of the Schneiderianmembrane and by intraosseous vascular bundles,while its center receives blood from collateralbranches of the endosseous anastomosis, whichshould therefore extend as far into the center ofthe graft as possible, and from the periosteum ofthe repositioned mucoperiosteal flap. The endosse-ous anastomosis should therefore be transectedonly minimally, which might mean that the antero-posterior dimensions of the bony window shouldbe as small as possible.

AoknowledgementsThe authors wish to thank Ulla Arnold for making the graphicrepresentations and Hedwig Rutschek. Bettina Maani, and thelaboratory assistants ofthe Anatomical Institute ofthe Univer-sity of Vienna for their inestimable assistance in preparing thismanuscript.

ResumeL'alimentation sanguine maxillaire est essentielle pour preserverla vitalite des regions maxillaires affectees, l'integration du ma-teriel greffe et la guerison suite a toute operation d'epaississe-ment du plancher sinusal. Bien qu'il soit etabli que les maxillai-res edentes aient une vascularisation diminuee avec la pro-gression de la resorption osseuse, les conditions vasculairesdurant les techniques d'epaississement du sinus n'ont pas en-core vraiment ete explorees. Cette etude observe les arteresmaxillaires importantes pour la chirurgie de I'epaississement dusinus et examine la vascularisation du maxillaire lateral apr^sla perte dentaire. Les vaJsseaux du maxillaire lateral de 18maxillaires (dix hommes. huit femmes, moyenne d'age de 67ans) ont ete prepares anatomiquement et les arteres locales, lenombre de branches observables macroscopiquement ainsi queles anastomoses, leurs calibres et la distance entre la partie infe-rieure des branche principales et le rebord alveolaire ont etenotes. Le maxillaire lateral est irrigue par des branches de Tar-

tere alveolaire superieure posterieure (PSSA) et I'artire infraor-bitale (IOA) qui forment une anastomose dans la paroi de I'an-tre lateral osseux qui irrigue egalement la membrane de Schnei-derian. Cette anastomose tntraosseuse a ete trouvee dans tousles specimens. Huit des 18 echantillons montraient egalementune anastomose extraosseuse entre PSAA et IOA. en vestibulai-re de la paroi de I'antre, donnant en moyenne trois branchescraniennes et cinq branches inferieures. Les deux anastomosesforment une arcade arterielle double qui irrigue la paroi de I'an-tre lateral et. en partie. le proces alveolaire. La PSAA a un calibremoyen de 1,6 mm et possede le plus souvent deux branches endo-osseuses et une extra-osseuse. L'lOA a un diametre moyen de 1,6mm et possede normalement une branche endo-osseuse et troisextra-osseuses. La distance moyenne entre l'anastomose intra-osseuse et Ie rebord alveolaire etait de 19 mm dans deux sites me-sures. La longueur moyenne etait de 44,6 mm. L'anastomose ves-tibulaire epiperiosteale etait situee plus cranialement a une dis-tance moyenne de 23 a 26 mm du rebord alveolaire et avait unelongueur moyenne de 46 mm. Le calibre relativement importantdes vaisseaux irriguant la paroi de Tantre lateral semble etre tresimportant par le fait que Tirriguation sanguine periosteale estmaintenue meme dans les cas d'atrophie maxillaire severes et ap-res disparition complete des vaisseaux centro-mfedullaires.

ZusammonfassungDie Blutversorgung des Oberkiefers stellt im Rahmen von Si-nusboden-Elevationen einen wesentiichen Aspekt filr die Vital-erhaltung der betroffenen Kieferregion. fUr das Einheilen desAugmentates und fiir das Abheilen der Operationswunde dar.Obwohl sich die Vaskularisation des Oberkieferknochens mitfortschreitender Atrophie reduziert. wurde die nutritive Aus-gangssituation bei Sinusliftoperationen bisher noch nicht unter-sucht. Die vorliegende Studie befaOt sich mit der arteriellenVersorgung des Oberkiefers im Hinblick auf die Sinusliftopera-tion und untersucht. aus welchen Quellen die Ernahrung deslateralen Oberkiefers nach Zahnverlust erfolgt. An 18 Oberkie-ferpr^paraten wurden die GefaBe der lateralen Maxilla anato-misch-praparatorisch dargestellt. Die lokalen Hauptarterien,die Anzahl ihrer makroskopisch darstellbaren Aste und Anas-tomosen. ihre Kaliber sowie die Distanz der caudal verlaufen-den Hauptaste zum Kieferkamm wurden registriert und ver-messen. Die Blutversorgung dieser Region erfolgt aus Asten derArteria atveolaris superior posterior (AASP) und der Arteriainfraorbitalis (AI). Aste dieser beiden GefaBe anastomosierenim Knoehen der lateralen Wand des Sinus maxillaris. verzwei-gen sich sehr dicht und versorgen damit auch die Kieferhohlen-schleimhaut. Diese intraossare Anastomose war in 100"/. desUntersuchungsgutes nachweisbar. In 44% konnte auch eine ex-traossare, vestibular der Kieferhohlenwand verlaufende Anas-tomose zwischen der AASP und der AI festgestellt werden.Diese GefaBanastomose versorgt die orale Schleimhaut vestibu-ISr der Kieferh6hle mit durchschnittlich 3,1 Asten nach cranialund 4.9 Asten nach kaudal. Die beiden Anastomosen bildeneine doppelte arterielie Arkade zur Versorgung der lateralenKieferhohlenwand und beteiligen sich an der Versorgung desProcessus alveolaris. Die AASP hatte ein durchschnittlichesKaliber von 1,59 mm (min 1,3; max 2.0), hatte durchschnittlich1,6 enossale Aste (min I; max 4) und 1,1 extraossSre (min 1;max 2). Das durchschnittliche Kaliber der AI betrug 1,64 mm(min 1.2; max 2.7), sie hatte durchschnittlich 1,4 enossale Aste(min 1; max 2) und 2.7 extraossSre (min 2; max 4). Die durch-schtiittliche Distanz der intraossaren Anastomose zum Kiefer-kamm betrug 18,9 bzw. 19.6 mm an zwei definierten MeBstellen(min 14; max 25). Ihre mittlere Lange betragt 44,6 mm (min 37;max 50). Die epiperiostal verlaufende vestibuUre GefaBanasto-mose liegt etwas weiter kranial mit durchschnittlich 23 bis 23.5mm Distanz zum Kieferkamm (min 16; max 37). Sie verlauftiiber eine Strecke von 46 mm (min 45; max 52). Die Vaskularisa-

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tion der lateralen KieferhohJenwand mit relativ groBkalibrigenGefiiBen dtlrfte eine wesentliche Rolle dabei spielen. daB auchbei hochgradiger Kieferatrophie und vcilligem Verschwindender zeniromedullaren Vaskularisaiion die periostale Ernahrungdes lokalen Knoehen aufrecht erhallen werden kann.

ResumenEl ijportc sanguineo en cl maxilar es esenciai para preservar lavitalidad de la region maxilar afectada para la integracion delmaterial de injerto y la cicatrizacion de la herida tras la eleva-cion del suelo del seno. Aunque esta bien establecido que elmaxilar edentulo demuestra una vascularidad decreciente a me-dida que la reabsorcion progresa. las condiciones vascularestras la elevacion del sueto del seno aiin no han sido investiga-das. Este estudio esta relacionado con las arterias maxilarespertenecientes conccrnientes a la cirugia dc elevacion del suelodel seno y exaniina la vascularizacion del maxilar lateral tras laperdida del diente. Los vasos de maxilar lateral de 18 especime-nes maxilares (10 machos. 8 hembras, edad media 67 aftos) seprepararon anatomicameiUe y se registraron las arterias localesprincipales, el ntimero de ramas y anastomosis discernibles ma-croscopicamente. su calibre y la distancia entre las ramas cau-dalcs principales y le borde alveolar. El maxilar lateral se abas-tecc por ramas de la arteria alveolar posterior superior (PSAA)y la arteria infraorbital (IOA) que forman una anastomosis enla pared osea antral lateral que tambien abastece a la membra-na de Schneider. Esta anastomosis inlraosea se encontro en to-dos los especimenes. Ocho de dieciocho tambien mostraron unaanastomosis extraosea entre PSAA c IOA, por vestibular de lapared'antral. dando una media de tres ramas craneales y cincoramas caudales. Las dos anastomosis forman una dobic arcadaarterial para abasiecer la pared antral laleral y, parcialmente,el proceso alveolar. El PSAA tubo un calibre medio de 1.6 mmy mostro una media dc 2 ramas endoosea una extraosea. ElIOA lubo un diameiro medio de 1,6 mm y mostro una mediadc una rama endoosea y tres extraosea. La distancia media en-tre la anastomosis intraosea y la cresta alveolar fue de 19 mmen dos lugares definidos dc mediacion. Su longitud media fuede 44.6 mm. La anastomosis epiperiostea veslibular se situomas cranealmente y a una distancia media de 23 a 26 mm dela cresta alveolar y tubo una longitud media de 46 mm. El relati-vamente gran calibre de tos vasos que abastecen la pared antrallateral parece ser crucial al hecho de que el suministro de sangreperiosteo se mantiene incluso en la atrofia maxilar severa y trasla completa desaparicion de los vasos centro-medulares.

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