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Arterial Supply of Maxillary Sinus and Potential for Bleeding Complication During Lateral Approach Sinus Elevation

Flanagan, Dennis DDS*

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doi: 10.1097/01.id.0000188437.66363.7c
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Abstract

The maxillary sinuses (antra of Highmore) are frequently encountered by the dental implant surgeon. Their enlargement of these by pneumatization results in a decrease of available bone for implant placement. The bone volume can be surgically augmented by a lateral or inferior approach. The arteries that supply the sinuses that may be encountered during sinus surgery are relatively small, but they are branches of more important, larger vessels. The 2 maxillary sinuses are located bilaterally in the maxilla. In each, there is an ostium for drainage, located in 80% of the cases in the superior portion of the medial wall. In most anatomies, it is canal-like because of mucosal thickness that leads into the nasal cavity via the ethmoid infundibulum. Drainage primarily is accomplished by action of cilia. This ciliary action is so efficient that it even supercedes an inferior surgically created opening for gravity drainage.1 There may be a second, smaller ostium present, usually in the middle meatus posterior to the main ostium. These additionally acquired ostia may occur from breakdown of the mucous membrane.2

The bone walls of the sinuses are very thin so that transillumination can show traversing vessels and nerves that are contained supraosseously and intraosseously. The thin walls can be easily penetrated surgically. The average capacity of the maxillary sinus varies from 9.5 to 20 mL and averages 14.75 mL. Average dimensions are 3.75 cm vertically, 2.5 cm mediolaterally, and 2.5 cm anteroposteriorly. The volume of the sinus may extend into the zygoma.1

An enlarged, pneumatized, antrum may cause an attenuated bone volume in the maxillary alveolus, precluding dental implant placement. Augmentation of the bone at the inferior aspect of the sinus (sinus elevation) may be performed to provide adequate bone to accept dental implants. During this surgical procedure, especially from the lateral approach, there is the theoretical potential to sever a small artery that supplies the sinus.

Arterial Supply of the Antrum

There are 3 primary arterial suppliers to the maxillary sinus: the posterior superior alveolar artery, infraorbital artery, and posterior lateral nasal.3,4 The posterior superior and infraorbital are direct branches of the third (pterygopalatine) portion of the maxillary artery, which in turn emanates from the external carotid artery. The posterior lateral nasal is a branch of the sphenopalatine artery that also comes off the maxillary artery. The ramifications of these arteries form a network located in and below the mucous membrane lining of the nasal cavity and sinuses, and also can course intraosseously.

Posterior Superior Alveolar Artery

This artery branches from the maxillary artery just as it passes into the pterygopalatine fossa. This branch descends on the maxillary tuberosity and gives off numerous branches that enter the alveolar process to supply the lining of the antrum, posterior teeth, and other superficial branches to supply the maxillary gingivae. This artery can be encountered while aspirating during an infiltration of the maxillary second or third molar because it runs near the tuberosity.

Infraorbital Artery

The infraorbital can be a continuation of the internal maxillary artery but also can occur with the posterior superior alveolar artery. It courses along in the infraorbital groove and canal along with the infraorbital nerve, under the orbit and through the infraorbital foramen on the facial aspect of the maxilla. Anterior superior alveolar branches of the infraorbital artery occur in the infraorbital canal and descend through alveolar nutrient canals to supply the anterior teeth and lining of the antrum.

Posterior Lateral Nasal Artery

The sphenopalatine artery branches from the third or pterygopalatine portion of the maxillary artery and enters the nasal cavity via the sphenopalatine foramen located at the posterior of the superior meatus (Fig. 1). The artery here courses with the pterygopalatine nerves. After passing through the foramen, it divides into the posterior lateral and posterior septal ends. The posterior lateral nasal artery can be found close to, or within, the lateral wall of the nasal cavity (medial wall of the antrum). As it proceeds anteriorly, it increases in diameter, which may indicate anastomoses with the terminals of the facial artery or other nasal arteries, the anterior and posterior ethmoidal arteries.5 The posterior lateral branch also ramifies, and these spread over the conchae, meatus, and supply the sinuses of that side, including the posterior and medial wall of the antrum.6

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Fig. 1.:
View of the arterial supply of the lateral wall of nasal cavity. The lateral wall of the nasal cavity is the medial wall of the maxillary sinus. The posterior lateral nasal artery can be located intraosseously. A vigorous curettage of the medial wall of the sinus, during a lateral approach sinus elevation, can perforate the thin bone and lacerate this artery, initiating a potentially serious hemorrhage. This area is well vascularized. The posterior lateral nasal artery is a branch of the sphenopalatine artery, a direct branch of the maxillary artery. 1, Posterior lateral nasal artery. 2, Palate. 3, Nares. 4, Lateral nasal branches of facial artery. 5, Lateral nasal branches of the anterior ethmoidal artery. 6, Lateral branches of the posterior ethmoidal artery. 7, Sphenopalatine artery. 8, Sphenoid air sinus. *Reprinted with permission from LifeArt image, ©2003, Lippincott Williams & Wilkins. All rights reserved.

Discussion

The 3 arteries that supply the maxillary sinus occur ultimately from the maxillary artery. By the time they reach the sinus, they are of a relatively small diameter. A surgical severance of 1 of these may not be a life-threatening event but may complicate the procedure. However, endoscopically guided sinus surgery has been known to be fatal and be complicated with severe bleeding.7

A terminus of the infraorbital artery is remote from the maxillary artery and probably would not produce significant bleeding. The posterior superior alveolar artery breaks into multiple small ends that again would probably not produce significant bleeding. However, the posterior lateral nasal is relatively close to the sphenopalatine artery, and may anastomose with the facial or other nasal arteries and may produce a problematic flow of blood if severed.

Bleeding may be controlled with head elevation, tamponade, an intranasal balloon catheter, ice, electrocautery, diathermy, or percutaneous arterial embolization. If bleeding from the posterior lateral nasal artery is indeed severe, then endoscopic ligation or diathermy of the severed artery or the sphenopalatine artery may be indicated.8–11 However, endoscopic ligation may be the most effective and least traumatic method, with fewer risks than packing, diathermy, or electrocautery, which may engender a complication rate of 25%.12,13

Head Elevation Can Decrease Nasal Mucosal Blood Flow by 38%14

It may be possible that a severed small intraosseous artery in the medial wall of the antrum may be occluded by placing fine particulate bone graft material into the lacerated bone with a small amalgam carrier or graft carrier, pressing it into place, and gently compressing and burnishing so as not to push through the thin bone wall. The most expedient in-office method for bleeding control may be electrocautery.

Conclusions

There are 3 arteries, all ultimate branches of the maxillary artery, that supply the maxillary sinus. The posterior superior lateral nasal artery is relatively close to the sphenopalatine artery and may anastomose with the facial or other nasal arteries. It can course intraosseously in the medial wall of the sinus. This effect presents the theoretical potential for a significant bleeding complication during lateral approach sinus elevation surgery. Given that the posterior lateral nasal artery or its branches can be intraosseous, it may be possible to sever this artery or a branch during elevation of the sinus lining at the medial posterior wall by vigorous curettage of the thin bone. Bleeding from this artery may be controlled with electrosurgery or an endoscopic ligation of the artery, or the sphenopalatine artery. Endoscopic ligation by an appropriately trained surgeon may be indicated. Elevation of the head can decrease nasal blood flow. In-office electrocautery may be the most effective method of the bleeding control of a small arteriole.

Disclosure

The author claims to have no financial interest in any company or any of the products mentioned in this article.

References

1. Hollinshead WH. The nose and paranasal sinuses. In: Hollinshead WH, ed. Anatomy for Surgeons The Head and Neck. Philadelphia, PA: Lippincott Williams & Wilkins; 1982:259–263.
2. Grant JCB. Accessory maxillary orifices, head and neck. In: An Atlas of Anatomy. 5th ed. Baltimore, MD: Williams and Wilkins; 1962:613.
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4. Goss CM, ed. Upper respiratory tract. In: Anatomy of the Human Body by Henry Gray. Philadelphia, PA: Lea & Fibiger; 1967:1123–1125.
5. Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of the arterial supply to the inferior turbinates. J R Soc Med. 1991;84:728–730.
6. Lee HY, Kim HU, Son EJ, et al. Surgical anatomy of the sphenopalatine artery in lateral nasal wall. Laryngoscope. 2002;112:1813–1818.
7. Castillo L, Verschuur HP, Poissonnet G, et al. Complications of endoscopically guided surgery. Rhinology. 1996;34:215–218.
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9. Voegels RL, Thome DC, Iturralde PP, et al. Endoscopic ligature of the sphenopalatine artery for severe posterior epistaxis. Otolaryngol Head Neck Surg. 2001;124:464–467.
10. Srinivasan V, Sherman IW, O’Sullivan G. Surgical management of intractable epistaxis: Audit of results. J Laryngol Otol. 2000;114:697–700.
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12. O’Flynn PE, Shadaba A. Management of posterior epistaxis by endoscopic clipping of the sphenopalatine artery. Clin Otolaryngol. 2000;25:374–377.
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Abstract Translations [German, Spanish, Portugese, Japanese]

AUTOR: Dennis Flanagan, DDS*. *Privat praktizierender Arzt. Schriftverkehr: DennisFlanagan, DDS, 1671 West Main Street, Willimantic, CT 06226. Telefon: 860-456-3153 Fax: 860-456-3251, eMail:[email protected]

Die arterielle Versorgung des Oberkiefersinus und mögliche Quellen für Komplikationen durch Blutungen während einer mittels lateralem Ansatz durchgeführten Sinusanhebung

ZUSAMMENFASSUNG: Insgesamt drei Arterien versorgen den Oberkiefersinus mit Blut. Jede von diesen Versorgungsadern kann während einer mittels lateralem Ansatz durchgeführten Sinusanhebung chirurgisch verletzt werden. Bei diesen Arterien handelt es sich um die letzten Verzweigungen der Oberkieferarterie. Obwohl bislang darüber an keiner Stelle berichtet wurde, besteht doch die theoretische Möglichkeit die im Knochengewebe eingelagerte Arterie während einer intensiven Kürettage zur Anhebung der Sinusauskleidung in der hinteren medialen Wand des Sinus zu verletzen. Es werden unterschiedliche Techniken zur Stoppung von Blutungen vorgestellt, so zum Beispiel die Elektrokauterisation sowie die endoskopische Ligatur. Eine Anhebung des Kopfes kann den Blutfluss in den betreffenden Bereich maβgeblich verringern.

SCHLÜSSELWÖRTER: Sinusanhebung, Kürettage, Zahnimplantate, chirurgische Knochengewebsanreicherung

AUTOR: Dennis Flanagan, DDS*. *Práctica Privada. Correspondencia a: Dennis Flanagan, DDS, 1671 West Main Street, Willimantic, CT 06226. Teléfono: 860-456-3153, Fax: 860-456-3251. Correo electrónico:[email protected]

Suministro arterial del seno maxilar y potencial de complicaciones por pérdida de sangre durante una elevación del seno con método lateral

ABSTRACTO: Hay tres arterias que suministran al seno maxilar, cualquiera de las cuales puede encontrarse durante una operación para elevar el seno con método lateral. Estas arterias son las ramas finales de la arteria maxilar. A pesar de que no se ha informado, existe el potencial teorético de cortar una arteria ubicada en el interior del hueso durante un curetaje vigoroso para la elevación del recubrimiento del seno en la pared medial posterior del seno. Se explican las técnicas para interrumpir la pérdida de sangre tales como electrocauterización y ligación endoscópica. La elevación de la cabeza puede reducir significativamente el flujo de sangre hacia el lugar.

PALABRAS CLAVES: elevación del seno, curetaje, implantes dentales, cirugía para el aumento del hueso.

AUTOR: Dennis Flanagan, Cirurgião-Dentista*. *Clínica Particular. Correspondência para: Dennis Flanagan, DDS, 1671 West Main Street, Willimantic, CT 06226. Telefone: 860-456-3153, Fax: 860-456-3251, E-mail:[email protected]

Abastecimento Arterial da Cavidade Maxilar e Potencial para Complicação por Sangramento Durante Elevação da Cavidade na Abordagem Lateral

RESUMO: Há três artérias que abastecem a cavidade maxilar, qualquer uma das quais pode ser encontrada durante a cirurgia de elevação da cavidade na abordagem lateral. Estas artérias são ramos posteriores da artéria maxilar. Embora não tenha sido relatado, há um potencial teórico para seccionar uma artéria intra-óssea durante uma curetagem vigorosa para elevação do revestimento da cavidade na parede medial posterior da cavidade. Técnicas para cessação de sangramento são discutidas, como eletro-cautério e ligação endoscópica. A elevação da cabeça pode diminuir significativamente o fluxo de sangue para a área.

PALAVRAS-CHAVE: Elevação da cavidade, curetagem, implantes dentários, cirurgia de aumento do osso.

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Figure
Keywords:

Sinus elevation; curettage; dental implants; bone augmentation surgery; antrum

© 2005 Lippincott Williams & Wilkins, Inc.