Global anatomical variability of the posterior superior alveolar artery: a CBCT-based systematic review with AI-assisted risk stratification.

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Abstract

The posterior superior alveolar artery (PSAA) is a clinically important anatomical landmark in the maxilla and is frequently encountered during surgical procedures such as maxillary sinus augmentation and posterior dental implant placement. Owing to considerable anatomical variations in its course, diameter, branching pattern, and position, accurate preoperative assessment is essential to minimize the risk of intraoperative bleeding and vascular injury. The present systematic review analyzed data extracted from 49 published studies, including cone-beam computed tomography (CBCT), computed tomography (CT), cadaveric, anatomical, and clinical investigations, to comprehensively evaluate the global anatomical variability of the PSAA. Exploratory artificial intelligence (AI)-assisted analyses were performed using pooled study-level variables to support evidence synthesis and population-level anatomical risk stratification. The reviewed studies demonstrated that the reported detection rate of the PSAA ranged from 50% to 91.6%. The intraosseous course was the most frequently observed anatomical pattern, while the mean arterial diameter generally ranged from 1.0 to 1.2 mm and the mean distance from the sinus floor ranged from 8 to 11 mm. Traditional statistical analyses, together with exploratory AI-assisted methods including logistic regression, random forest analysis, principal component analysis (PCA), and K-means clustering, identified an intraosseous course, arterial diameter greater than 1 mm, reduced sinus-floor distance, and increased branching complexity as the principal anatomical characteristics associated with higher surgical risk. Exploratory clustering analysis further identified study populations from Malaysia, South Korea, Italy, Türkiye, and India as having relatively higher anatomical risk characteristics based on the pooled literature-derived variables. These findings indicate that PSAA anatomy exhibits substantial anatomical variability across different populations, emphasizing the importance of routine preoperative CBCT evaluation before sinus augmentation and posterior maxillary implant surgery. AI-assisted exploratory analysis provides a structured framework for anatomical evidence synthesis and population-level risk stratification and should be interpreted as a supportive analytical approach rather than a validated patient-level predictive model.

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