Localization of the position of vital anatomical structures in the lateral wall of maxillary sinus during different surgical intervention using cone beam computed tomography

Background : Proper information about the anatomy of the maxillary sinus is required to avoid any unexpected complications that may arise due to the close relation between the maxillary sinus and posterior superior alveolar artery. Objective: To the current study used cone beam computed tomography CBCT imaging to assess the position of the posterior superior alveolar artery (PSAA) in relationship to the alveolar ridge and the flour of maxillary sinus. Patients and Methods: A number of 95 Iraqi patients participated in this prospective study (53 females, 42 males; age range 20-49 years). From January 2021 to February 2022, attended a 2nd specialised dentistry institution in Baquba city for CBCT scanning for numerous diagnostic and management purposes. Results: According to our study, we detected the presences of artery in (83.68%) of the sample. females showed higher PSAA prevalence than men on both sides, and the difference was significant overall, Also, the existence of artery for each side and total in the intramembranous locating in females is greater than that in males, which may demonstrate that the probability of Bleeding and other side effects is higher in males, since the existence of artery in the intramembranous area in females will reduce the likelihood of traumatic injury throughout any surgical treatment. Conclusion: This research used CBCT to determine the precise location of PSAA in the Iraqi population. This data could assist in decreasing the likelihood of hemorrhage as well as other complications which may happen throughout any surgical treatment, such as dental implant placement, ridge expansion.As well as other surgical interventions in this region


Introduction
In order to The maxillary artery, supplies blood to the lateral sinus walls and sinus floor membrane,via a branch known as the posterior superior alveolar artery(PSAA) [1].Pre surgical radiographic assessment to detect and identify the precise position of the artery during any surgical intervention to prevent injuring these arteries and consequent perioperative bleeding [2].For craniofacial imaging, cone beam computed tomography (CBCT) is suitable.It produces accurate views of highly contrast structures; it is also appropriate imaging of bone [3,4].Furthermore, the practical use of the CBCT approach offers various potential benefits for "maxillofacial imaging," including X-ray beam limitation, imaging accuracy, dosage reduction, and short scan time [5].
Sinus floor elevation can be considered as a surgical operation method for increasing the volume of bone in the vertical dimension for dental implant insertion [6].Nonetheless, the complication should be avoided during surgery and afterwards during sinus floor elevation.A blood vessel disruption caused by these complications may result in serious hemorrhage [7].
The posterior superior alveolar artery, shenopalatine artery, larger palatine artery, and infraorbital artery supply the maxillary sinuses.The infraorbital artery and PSAA are maxillary artery branches that nourish the schneiderian membrane and the lateral wall of the sinus.Extraosseous and intraosseous branches of the PSAA and infraorbital artery may anastomose.The PSA artery travels laterally, outside of the maxillary bone, to the convexity of the maxillary tuberosity, and is in direct contact to the bone and the periosteum [8,9].
Knowledge of the anatomy of the maxillary sinus is required to avoid any unexpected complications that may arise due to the tight interaction between the maxillary sinus and PSAA [10,11].Scanning techniques that exposed the patient to radiation exposure must provide as much necessary details as feasible, and the clinician must acquire as much valuable information as possible.When compared to traditional medical computed tomography (MDCT) scans in maxillofacial imaging, cone beam computed tomography (CBCT) is more helpful with the option of low dosage [12].The actual dosage from a conventional dental protocol scan with MDCT is 1.5 to 12.3 times higher than that from equivalent medium-field of view dental CBCT scans (International Committee on Radiological Protection -ICRP 2007).
[13,14].Hence, CBCT is used before any treatments in the alveolar ridge and maxillary sinus in patients who require dental implants.CBCT is well appropriate for craniofacial area imaging.It shows precise images of well-contrasted structures; it is also suitable for bone imaging [15].
The current study used CBCT imaging to assess the connection and position of the posterior superior alveolar artery in relationship to the alveolar ridge and the flour of maxillary sinus.

Patients and Methods
A number of 95 Iraqi patients participated in this prospective trial (53 females, 42 males; age range 20-49 years).From January 2021 to February 2022, attended a 2 nd specialised dentistry institution in Baquba city for CBCT scanning for numerous diagnostic purposes.For all views, the same radiographic apparatus was used: "Tomographic pictures were taken with a CBCT scanner (NewTom VGi)TM."Some of the scanning settings were as follows: "Voltage =110 kilovolts, exposure period =24 seconds, electrical charge =5.7 mA, voxel size =0.5 mm, viewable field of view =16 cm ×14 cm" Oral and maxillofacial radiologists performed the measurements and analysis.The test was carried out on 10 selected randomly Iraqi individuals in order to determine the reliability and repeatability of the link between PSAA and maxillary sinus wall using cone beam computed tomography."

Inter examiner calibration
This calibration was executed by contrasting the study's observation of a randomised chosen ten sample to the observation of another well-trained oral and maxillofacial radiologist.There wasn't a significant difference (p>0.05) when the paired t-test was employed to compare the two measures.

Intra examiner calibration
The calibration was accomplished by the investigator repeating the evaluation of a randomized chosen ten CBCT images 2 weeks after the initial measurement.When the two readings were compared using a paired t-test, the difference was not significant (p>0.05).Findings in Table (3) show that distance from artery to sinus floor is higher in extraosseous from other two locations in each side with significant difference between location.Results in Table (6) show that females represent with more artery presence than males in each side and in the total with significant result in the left side and in the total while not significant in the right side.Findings in Table (7) show that presence of artery in each side and in the total in the intramembranous find in females more than that in males while in the extra osseous, artery find to be higher in males than that in females, in the intra osseous, artery find to be higher in males more than that of females in the right side and in the total while in the left side, this result is higher in females more than that in males, but all these results are not significant.

Discussion
Cone Beam Computed Tomography is an ideal choice for maxillofacial scanning.It produces crisp pictures of highly contrast features; it is also appropriate for skeletal scanning [16,17].Furthermore, the practical use of the CBCT approach offers various potential benefits for "maxillofacial imaging," including X-ray beam limitation, picture accuracy, dosage minimization, and short scan time [5].
The objective of this investigation was to determine the connection and position of the PSAA in relation to the alveolar bone ridge and floor of maxillary sinus.The accurate identification of PSAA position is crucial.Nevertheless, because no study has been conducted within the Iraqi population, only analogous studies in other groups can be used to examine how the variable PSAA location varies by ethnic background.
According to a study done on the Turkish population, the artery was found in 89.3 percentage points of the sinuses and was predominantly intraosseous (71.1%percentage), [18].In this study, we detected the artery in (83.68%percentage).The artery detecting performance was greater than that reported by Güncü et al. [ [22], a comparable study conducted by Cruz ILA et al on a Mexican population revealed the presence (90%) [23] the difference in percentage of PSAA detection may be due to techniques and ethnic variances, because these studies were conducted in different regions of the world .
Females showed higher PSAA prevalence than men on both sides, and the difference was significant overall, which agrees with Kim et al, but disagrees with Lee et al. [24], and Rahpeyma et al [25].This disparity may be attributable to a difference in the male to female ratio of responders.
Also, the existence of artery for each side and total in the intramembranous locating in females is greater than that in males, which may demonstrate that the probability of Bleeding and other side effects is higher in males, which must be taken into account when expelling bone for surgical treatment in this region, since the existence of artery in the intramembranous area in females will reduce the likelihood of traumatic injury throughout any surgical treatment.
Males show a greater distance from the artery to the alveolar crest and a greater distance from the artery to the sinus floor than females, which is consistent with the findings of Fayek et al [26] Güncü et al. [13] and Mardinger et al. [27], however they disagree with Ilgüy et al [18] This disparity might be attributed to differences in number of respondents or technique .The limitation of present study was we use the CBCT to detect both the hard tissue (lateral wall of maxillary sinus) and soft tissue (PSAA and schneiderian membrane ) which may be better to detected by magnetic resonance imaging devices because it show better quality for imaging of soft tissue.

Conclusions
This research used CBCT to determine the precise location of PSAA in the Iraqi population.This data could assist in decreasing the likelihood of hemorrhage as well as other complications which may happen throughout any surgical treatment, such as dental implant placement, ridge expansion, as well as other surgical interventions in this region.

Recommendations
Evaluating the same variable with sample size larger than used in this study also doing comparison of the variable used in this study in varied races.

Source of funding:
The current study was funded by our charges with no any other funding sources elsewhere.
of any deciduous teeth in the region of interest.-Radiographyrevealed the existence of pathological alteration in the region of interest.-Apreexisting incidence of surgery and/or trauma to the target location.Included criteria:Each teeth in the designated target should have been available and permanent.

Figures ( 1
Figures (1):(A,B and C) depict coronal view of CBCT used to determine the location of the PSAA A intramembranous(inside the Schneiderian membrane of maxillary sinus), B intraosseous(inside the bone of lateral wall of maxillary sinus) and C (outside the extraosseous bone of lateral wall of maxillary sinus)

Table ( 1
With the Statistical Package for Social Science (SPSS version -22, Chicago, Illinois, USA), minimum, maximum, mean, standard deviation (SD), and standard error (SE), cluster chart bars, frequency, and percent Shapiro Wilk test, Levene test, Two independent Sample T test, One Way Analysis Of Variance (ANOVA) with Games-Howell posthoc test, and Pearson Chi square are examples of inferential statistics.The acceptable threshold of relevance is 0.05.): Association between artery and tooth presence

Table ( 2
): Descriptive and statistical test of Alveolar crest among locations

Table ( 3
): Descriptive and statistical test of Sinus floor among location *=significant at p<0.05

Table ( 5
): Descriptive and statistical test of Alveolar crest and sinus floor among gender

Table ( 7
): Association between location and gender