ORIGINAL ARTICLE Anatomical Variability of the Maxillary Artery Findings From 100 Asian Cadaveric Dissections Jin Kook Kim, MD; Jae Hoon Cho, MD; Yeo-Jin Lee, MD; Chang-Hoon Kim, MD; Jung Ho Bae, MD; Jeung-Gweon Lee, MD; Joo-Heon Yoon, MD Objective: To describe the anatomical variability of the Results: The first and second sections of the maxillary ar- maxillary artery. tery most commonly traveled through the lateral aspect of the lateral pterygoid muscle, with the inferior alveolar nerve, Design: Anatomical study. lingualnerve,andbuccalnerveonthemedialsideofthemax- illary artery (61.0%). The course and branching type of the Setting: Academic institution. third section of the maxillary artery were classified into 3 patterns: loop (61.0%), bifurcated (19.0%), and straight Subjects: One hundred midsagittal sections of ran- (18.0%).Inmostcases(62.0%),thedivisionpointofthemax- domly selected adult cadaver heads with intact maxil- illary artery was located on the superior and medial thirds lary sinuses, pterygopalatine fossa, and surrounding of the posterior wall of the maxilla. structures. Conclusion: This study provides detailed information con- Main Outcome Measures: The location of the cerning the anatomical variability of the maxillary artery, proximal portion of the maxillary artery in relation to which we hope will help prevent the arterial bleeding that the lateral pterygoid muscle, the branches of the man- may occur during mandibular or maxillary osteotomy or dibular division of the trigeminal nerve, and the maxillectomy for ligation of the sphenopalatine artery. branching patterns of the third section of the maxil- lary artery. Arch Otolaryngol Head Neck Surg. 2010;136(8):813-818 HE MAXILLARY ARTERY IS THE the maxillary artery is necessary to re- largestterminalbranchofthe duce intraoperative bleeding.3,4 external carotid artery. It is The third section of the maxillary artery, divided into 3 sections based in the pterygopalatine fossa, is related to the on its relationship to the lat- maxilla and nasal cavity.2 During maxillary Teralpterygoidmuscle:(1)themandibularsec- (Le Fort I, II, or III) or midfacial osteotomy, tion, which is posterior to the lower border profuse bleeding is possible and complica- of the lateral pterygoid muscle; (2) the ptery- tionssuchaspostoperativehemorrhage,false goid section, which may take a course deep aneurysm, and arteriovenous fistula have 5-7 Author Affiliations: or superficial to the lateral pterygoid muscle; beenreported. Italsohasbeenreportedthat Department of and (3) the pterygopalatine section, which the main vessel most commonly damaged af- Otorhinolaryngology–Head and is in the pterygopalatine fossa. This artery is ter maxillectomy is the maxillary artery and Neck Surgery, Konkuk widely distributed to the mandible, maxilla, its branches. In cases of intractable posteri- University School of Medicine teeth, muscles of mastication, palate, nose, or epistaxis, if posterior nasal packing fails, (Drs J. K. Kim, Cho, and and cranial dura mater.1,2 ligation of the sphenopalatine artery (SPA) Y.-J. Lee); Department The first and second sections of the or maxillary artery is necessary.8,9 of Otorhinolaryngology maxillary artery are related to the man- Despitetheclinicalimportanceofthemax- (Drs C.-H. Kim, J.-G. Lee, and Yoon), the Airway Mucus dibular condyle and pterygoid muscle re- illary artery, reports describing it in its en- 1 Institute (Drs C.-H. Kim and gion. Therefore, internal fixation of the tirety are few because of its anatomical com- Yoon), the Research Center for condyle or subcondylar fracture of the plexityandvulnerability,especiallyinthefirst Human Natural Defense System mandible and surgical procedures such as 2sections.Withincreasinguseofendoscopic (Dr Yoon), and the BK21 mandibular osteotomy and temporoman- approaches to the pterygopalatine fossa, the Project for Medical Science dibular joint arthroplasty may induce in- recent literature has defined the anatomy of (Dr Yoon), Yonsei University tractable bleeding, which is difficult to con- thefossainrelationtoendoscopiclandmarks. College of Medicine; and trol and may recur.1 In case of bleeding that Unfortunately, consistent landmarks to lo- Department of Otorhinolaryngology, Ewha is difficult to control, ligation of the ex- catethevariousstructuresinthepterygopala- 10 Womans University School ternal carotid artery may be necessary. In tine fossa have not been described. of Medicine (Dr Bae), addition, during total or radical maxillec- To perform mandibular osteotomy safely Seoul, Korea. tomy, ligation of the proximal section of and to reduce intraoperative bleeding during (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 8), AUG 2010 WWW.ARCHOTO.COM 813 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 ond, the course of the third section of the maxillary ar- A B tery and its branching patterns were determined from the viewpoint of the posterior wall of the maxilla. Finally, the branching types of the maxillary artery, which are di- 8 vided into the SPA and the descending palatine artery (DPA) in the pterygopalatine fossa, were analyzed and the locations of the division points were recorded. 1 7 2 METHODS 4 3 56 One hundred midsagittal sections from adult cadaver head speci- mens with intact maxillary sinuses and surrounding struc- tures were injected with red latex through the external carotid artery. To identify the first and the second sections of the max- C D illary artery, the mandibular ramus and condyle were re- moved to expose the pterygomaxillary fissure through the lat- eral infratemporal fossa. The lateral pterygoid muscle was resected, and the maxillary artery was dissected up to the ter- minal branches in the pterygopalatine fossa. The course of the maxillary artery in relation to the lateral pterygoid muscle, in- ferior alveolar nerve, buccal nerve, and lingual nerve were re- corded. To investigate the third section of the maxillary ar- tery, the posterior wall of the maxillary sinus and the adipose tissue in the pterygopalatine fossa were removed to expose the maxillary artery under an operating microscope (original mag- nification, ϫ6). After identifying the location where the max- illary artery exited the pterygopalatine fossa, microscissors, fine forceps, and a pick were used to investigate the fine branches and to dissect up to the sphenopalatine foramen. E F FIRST AND SECOND PARTS OF THE MAXILLARY ARTERY The maxillary artery is divided into 3 main sections. We in- vestigated the courses of the first and second sections and cat- egorized their types in relation to the lateral pterygoid muscle and the mandibular nerve. BRANCHING PATTERNS OF THE THIRD SECTION OF THE MAXILLARY ARTERY We also investigated the course of the third section of the maxil- Figure 1. The 6 types of relationships of the first and second sections of the lary artery from the viewpoint of the posterior wall of the maxilla maxillary artery to the lateral pterygoid muscle and mandibular nerve. and classified its patterns in relation to the branches. The termi- A, Type A (21.0%). B, Type B (61.0%). C, Type C (7.0%). D, Type D (4.0%). E, Type E (6.0%). F, Type F (1.0%). 1 indicates lingual nerve; 2, inferior nal branches of the third section of the maxillary artery were di- alveolar nerve; 3, external carotid artery; 4, maxillary artery; 5, medial vided into the SPA and the DPA in the pterygopalatine fossa and pterygoid muscle; 6, buccinator muscle; 7, buccal nerve; and 8, lateral were classified as 1 of 5 types according to the classification by Mor- pterygoid muscle. See the “Courses of the First and Second Sections of the ton and Khan.2 We measured the distance from the highest point Maxillary Artery” subsection of the “Results” section for a description of to the lowest point of the posterior wall of the maxilla and the dis- each type. tance from the most medial point to the most lateral point. We di- vided the height and width into 3 equal lengths, thereby compart- radicalmaxillectomy,theanatomicalorientationoftheproxi- mentalizing the posterior wall of the maxilla into 9 sections. The mal section of the maxillary artery is important. To prevent terminal division point, where the maxillary artery divided into the SPA and DPA, was recorded for the imaginary 9 sections. complications after maxillary osteotomy due to bleeding, an accurate understanding is necessary of the courses of the maxillaryarteryanditsbranchesinthepterygopalatinefossa. RESULTS For ligation of the SPA in intractable cases of posterior epi- staxis, surgical landmarks in relation to the SPA in the ptery- COURSES OF THE FIRST AND SECOND gopalatine fossa are essential to otorhinolarygologists. SECTIONS OF THE MAXILLARY ARTERY Therefore, in this study we investigated the surgical anatomy of the maxillary artery. First, the courses of the We found large anatomical variations in the courses of first and second sections of the maxillary artery and their the first and second sections of the maxillary artery. A relationship to the lateral pterygoid muscle and man- total of 6 pattern types were noted around the mandible dibular nerve were studied via the lateral approach. Sec- and the pterygoid muscle (Figure 1). Twenty-one (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 8), AUG 2010 WWW.ARCHOTO.COM 814 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 A B C SPA IOA SPA IOA DPA IOA SPA DPA MA DPA PSAA PSAA MA Nasal MA PSAA