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The Superior Alveolar Nerves: Their Topographical Relationship and Distribution to the Maxillary Sinus in Human Adults

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The Superior Alveolar Nerves: Their Topographical Relationship and Distribution to the Maxillary Sinus in Human Adults Okajimas Folia Anat. Jpn., 70(6): 319-328, March, 1994 The Superior Alveolar Nerves: Their Topographical Relationship and Distribution to the Maxillary Sinus in Human Adults By Gen MURAKAMI, Kenji OHTSUKA, Iwao SATO, Hiroshi MORIYAMA, Kazuyuki SHIMADA and Hiroshi TOMITA Department of Anatomy, Nihon University School of Medicine, Tokyo, Japan (G.M.), Department of Otorhinolaryngology, Nihon University School of Medicine, Tokyo, Japan (K.O., H.T.), Department of Anatomy, Nippon Dental University, School of Dentistry at Tokyo, Tokyo, Japan (I.S), Department of Anatomy, Showa University School of Medicine, Tokyo, Japan (H.M., K.S.). - Received for Publication, January 31, 1994-— Key Words: Human anatomy, Maxillary sinus, Superior alveolar nerves, Superior dental plexus, Whole-mount silver impregnation Summary: The superior alveolar nerves in human adults were investigated macroscopically using whole-mount silver impregnation, paying special attention to their topographical relationship and distribution to the mucous membrane of the maxillary sinus. In addition, the fiber composition of the alveolar nerves was analysed in order to estimate their contribution to teeth innervation. The posterior superior alveolar nerve (PSAN) ran through canaliculi in the lateral wall of the sinus (23 of 37 cases, 62.2%) or under the mucous membrane of the sinus (14 of 37 cases, 37.8%). Moreover, the PSAN gave off many fine twigs to make complex plexus under the mucous membrane of the sinus before joining the superior dental plexus. The plexus of the maxillary sinus was separated from the superior dental plexus by the bony wall of the sinus. After the above gross observations, the perimeter compositions of myelinated fibers of the plexus, PSAN and the anterior alveolar nerve were analysed in the same specimen. The plexus was composed of myelinated fibers of less than 27μm in circumference perimeter (mean; 14.3μm) and numerous unmyelinated fibers. The fiber composition suggested that few fibers in the plexus of the maxillary sinus contribute to the formation of the superior dental plexus. The superior dental plexus, innervating the upper teeth, was located in the thick alveolar process of the maxilla, and not on the maxillary sinus wall. The clinical importance of these results was discussed in relation to nerve injury during antrostomy of the maxillary sinus. The maxillary sinus is innervated by several textbooks (Plate I). According to some (Piersol, 1913; branches of the maxillary nerve, and especially Cryer, 1916; Toldt, 1919; Schaeffer, 1953; Anson, by the superior alveolar nerves (Warwick, 1976; 1966; Romanes, 1981; Liebgott, 1982, Leonhardt Paparella and Shumrick, 1980; Cummings, 1986; et al., 1988), the posterior superior alveolar nerve Kerr and Groves, 1987; McMinn, 1990). However, (PSAN) runs along (superficial to) the zygomatic previous descriptions of the superior alveolar nerve surface of the maxilla and joins the superior dental have concentrated on its contribution to the superior plexus outside the maxillary bone (Plate IA). dental plexus which innervates the upper teeth Takayama (1959) also described the outside course (Kopsch, 1955; Williams and Warwick, 1980; of PSAN in his study. In contrast, others (Spalteholz, Clemente, 1985). In fact, some textbooks (Hyrtl, 1922; Shapiro, 1954; Nishi, 1974; Hollinshead, 1982; 1866; Schaffer et al. , 1909; Spitzka, 1913; Rouviere, Lang, 1985; DuBrul, 1988; McMinn, 1990) claim 1974) refer to this nerve as the superior "dental" that the PSAN runs under the mucous membrane of nerve. In contrast to the innervation of the upper the maxillary sinus and that the superior dental teeth, the nerve supply to the mucous membrane of plexus is also located under the mucous membrane the maxillary sinus has not yet been investigated in (Plate IB). detail. The aim of this study was to clarify the course of Moreover, descriptions of the course of the the superior alveolar nerve and the location of the superior alveolar nerve and the location of the superior dental plexus relative to the wall of the superior dental plexus have differed among anatomy maxillary sinus, and to clarify the main nerve supply- Address correspondence to Dr. Gen Murakami M. D., Ph.D., Department of Anatomy , Nihon University School of Medicine, Ohyaguchi-kamimachi 30, Itabashi-ku, Tokyo 173, Japan 319 320 G. Murakami et al. ing the lateral and posterior walls of the sinus, in arose from the base of the infraorbital nerve in the order to obtain basic data useful for prevention of pterygopalatine fossa and ran downwards and for- nerve injury during antrostomy of the maxillary sinus wards to pierce the zygomatic surface of the maxilla. (Killey and Kay, 1975). The PSAN usually arose by a single trunk (31 of 37 cases, 83.8%), but sometimes arose from a thick nerve and 1-3 thin nerves (6 cases, 16.2%). One or Materials and Methods two branches, which arose from the origin of the PSAN, ran downwards outside the maxilla to the Thirty-seven specimens of the head region from posterior palate. After piercing the zygomatic surface cadavers of 37 adults, aged 51-75 years, of which of the maxilla, the PSAN frequently (23 cases, the nerves had been stained by whole-mount 62.2%) passed through a canaliculus in the postero- silver impregnation, were examined grossly and lateral wall of the sinus (Plate II). Sometimes, how- histologically. ever, the PSAN (14 cases, 37.8%) ran beneath the The specimens, which had been fixed by perfusion mucous membrane of the sinus (Plate III), and not with 10% formol solution from the femoral artery, through a bony canaliculus. In the latter 14 cases, were viewed from the medial side for gross obser- the PSAN was always closely accompanied by a vation. The medial wall of the maxillary sinus was branch of the posterior superior alveolar artery. In partly removed, and the major branches of the this study, we did not find a single case in which the maxillary nerve were identified. Each specimen was main trunk of the PSAN passed outside (superficial then decalcified for minute dissection in 3N hydro- to) the zygomatic surface of the maxilla. cloric acid for 2-5 days at room temperature, then Along its course close to the maxillary sinus, rinsed with tap-water for 3 days and with distiled PSAN did not give off branches to the palate and water for another 3 days (6 changes in all). Then, the teeth, except at its anterior and posterior ends. At whole specimen block was immersed in 0.7% silver the anterior end of its course, the PSAN divided into nitrate (Kanto kagaku) solution for 12-24 h at room a few branches leading to the posterior part of the temperature under dark conditions in a modification superior dental plexus (Plate II). At the posterior end of the whole-mount silver impregnation method of its course, the PSAN gave off 2-3 branches of Kimura and Takahashi (1985) for staining of leading to the posterior palate, which communicated cutaneous nerves. After rinsing in distiled water for with branches of the greater palatine nerve. 3 days (with 6 changes), the specimen was preserved Many twigs from the PSAN formed a nerve plexus in 50% ethanol solution under dark conditions. under (outside) the mucous membrane of the maxil- After macroscopic observations of the silver- lary sinus (Plates III, IV), irrespective of whether the impregnated specimens, the mucous membrane of nerve passed through a bony canaliculus or under the maxillary sinus, including its accessory nerves, the mucous membrane (see above). In the nerve was removed from the maxillary bone, re-fixed in plexus, relatively large twigs accompanied small PBS-buffered 10% formol solution (ph 7.4), dehy- vessels, while small twigs ran independently away drated and embedded in paraffin, and cut into semi- from vessels. The PSAN was located in the central serial sections 10 [tm thick. These sections were portion of the nerve plexus. The plexus was not stained with luxol fast blue solution (Kliiver and observed clearly on the upper and lower walls of the Barrera, 1953) and van Gieson's picro-fuchsin sol- sinus. The gross morphology of the plexus was similar ution (Lillie, 1965), after removal of impregnated in both dentate and edentulos specimens. silver particles by rinsing in 4N hydrocloric acid for 2h. Using histological sections, the circumference b. Histology perimeter of myelinated fibers was measured Myelinated fibers were observed in nerve twigs and analysed with an optical electron planimeter which formed the plexus (Plate IV). Most of the (Digiplan, Kontron Co). The reduction in size during myelinated fibers (82.8%) of the plexus were less the histological preparation procedure was estimated than 201[A,min circumference perimeter and all were to be about 15% . less than 27 [Am. On the other hand, in the anterior superior alveolar nerve and PSAN, larger fibers were more frequently observed. In particular, large Results myelinated fibers were observed in 4.2% of the anterior superior alveolar nerve (Table 1). Numerous 1. Posterior superior alveolar nerve and the unmyelinated fibers were also present both in the nerve plexus of the maxillary sinus plexus and superior alveolar nerves. a. Gross observation The posterior superior alveolar nerve (PSAN) Superior Alveolar Nerves and Maxillary Sinus 321 Table 1. Perimeter composition of myelinated fibers in the maxilla, but inside the maxilla. posterior and anterior superior alveolar nerves and the We also demonstrated that numerous twigs from nerve plexus of the maxillary sinus*. the PSAN form a nerve plexus under the mucous membrane of the maxillary sinus. This plexus, "the nerve plexus of the maxillary sinus", was located mainly at the lateral and posterior walls of the sinus, along the course of the PSAN. In contrast, the major part of the superior dental plexus was located in the thick bony part of the maxilla, the alveolar process, * In total, 1502fibers of the posteriorsuperior alveolar nerve although previously the superior dental plexus had (PSAN), 1308fibers of the anterior superioralveolar nerve often been described as lying just beneath the mucous (ASAN)and 64 fibersof the nerveplexus of the maxillarysinus membrane of the sinus (Spalteholz, 1972; Nishi, weremeasured and analysed.
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