{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T13:38:32Z","timestamp":1793108312799,"version":"4.5.0"},"reference-count":49,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T00:00:00Z","timestamp":1751241600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background\/Objectives: Variations in the course of the maxillary artery (MA) relative to the lateral pterygoid muscle (LPM) pose critical challenges in surgical, anesthetic, and interventional procedures involving the infratemporal fossa (ITF). These variations can increase the risk of hemorrhage, nerve injury, or incomplete anesthesia. The present study aimed to elucidate the topographic relationship between the MA and LPM by combining high-resolution radiological imaging with a comprehensive analysis of anatomical literature. Materials and Methods: A retrospective review of 250 brain computed tomography angiographies (CTAs), totaling 500 sides, was conducted to classify the MA course as lateral (superficial), medial (deep), or intramuscular. Additionally, a systematic review and meta-analysis of 32 eligible studies\u2014including 5938 arteries\u2014was performed following PRISMA 2020 and Evidence-Based Anatomy (EBA) guidelines. Study quality and risk of bias were assessed using the Anatomical Quality Assurance (AQUA) tool. Results: In the imaging cohort, the MA coursed lateral to the LPM in 64.2% of sides, medial in 29.6%, and through the muscle fibers in 6.2%. A rare temporalis-traversing variant was identified in 3.0% of cases. Bilateral symmetry was observed in 77.6% of patients. Meta-analytic findings indicated a pooled prevalence of 79.6% for the lateral course, 19.9% for the medial course, and 0.01% for the intramuscular course. Cadaveric studies and Asian populations showed a higher incidence of lateral variants, while imaging-based studies more frequently detected medial and transmuscular paths. Conclusions: While the MA most often follows a lateral course relative to the LPM, clinically significant variation\u2014including medial, intramuscular, and temporalis-traversing routes\u2014exists. These variants complicate access during maxillofacial surgery, TMJ procedures, and regional anesthesia. Findings emphasize the importance of individualized preoperative vascular mapping to improve procedural safety and outcomes in the ITF.<\/jats:p>","DOI":"10.3390\/medicina61071201","type":"journal-article","created":{"date-parts":[[2025,7,1]],"date-time":"2025-07-01T04:04:22Z","timestamp":1751342662000},"page":"1201","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Mapping the Maxillary Artery and Lateral Pterygoid Muscle Relationship: Insights from Radiological and Meta-Analytic Evidence"],"prefix":"10.3390","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4831-8005","authenticated-orcid":false,"given":"Maria","family":"Piagkou","sequence":"first","affiliation":[{"name":"Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece"},{"name":"\u201cVARIANTIS\u201d Research Laboratory, Department of Clinical Anatomy, Masovian Academy in P\u0142ock, 90 402 P\u0142ock, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0122-2436","authenticated-orcid":false,"given":"George","family":"Triantafyllou","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece"},{"name":"\u201cVARIANTIS\u201d Research Laboratory, Department of Clinical Anatomy, Masovian Academy in P\u0142ock, 90 402 P\u0142ock, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-5662-8354","authenticated-orcid":false,"given":"Panagiotis","family":"Papadopoulos-Manolarakis","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece"},{"name":"Department of Neurosurgery, General Hospital of Nikaia-Piraeus, 18454 Nikaia, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-5974-0599","authenticated-orcid":false,"given":"Fotis","family":"Demetriou","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8559-8969","authenticated-orcid":false,"given":"George","family":"Tsakotos","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Faculty of Health Sciences, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6414-9504","authenticated-orcid":false,"given":"\u0141ukasz","family":"Olewnik","sequence":"additional","affiliation":[{"name":"\u201cVARIANTIS\u201d Research Laboratory, Department of Clinical Anatomy, Masovian Academy in P\u0142ock, 90 402 P\u0142ock, Poland"},{"name":"Department of Clinical Anatomy, Masovian Academy in P\u0142ock, 90 402 P\u0142ock, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7131-7692","authenticated-orcid":false,"given":"Fabrice","family":"Duparc","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Faculty of Medicine-Pharmacy, University of Rouen-Normandy, 76183 Rouen, France"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,30]]},"reference":[{"key":"ref_1","unstructured":"Standring, S., Anand, N., Birch, R., Collins, P., Crossman, A., Gleeson, M., Jawaheer, G., Smith, A., Spratt, J., and Stringer, M. (2016). Gray\u2019s Anatomy: The Anatomical Basis of Clinical Practice, Elsevier. [41st ed.]."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Tubbs, R.S., Shoja, M.M., and Loukas, M. (2016). Bergman\u2019s Comprehensive Encyclopedia of Human Anatomic Variation, John Wiley & Sons.","DOI":"10.1002\/9781118430309"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1875","DOI":"10.1007\/s00276-021-02825-3","article-title":"Systematic Review and Meta-Analysis of the Anatomy of the Maxillary Artery Using the Anatomical Quality Assurance (AQUA) Checklist","volume":"43","author":"Ottone","year":"2021","journal-title":"Surg. Radiol. Anat."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"152387","DOI":"10.1016\/j.aanat.2025.152387","article-title":"Beyond Two Heads: An Imaging-Based Analysis of the Lateral Pterygoid Muscle\u2019s Heads","volume":"259","author":"Albu","year":"2025","journal-title":"Ann. Anat. Anat. Anz."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.aanat.2015.12.002","article-title":"Methods of Evidence-Based Anatomy: A Guide to Conducting Systematic Reviews and Meta-Analysis of Anatomical Studies","volume":"205","author":"Henry","year":"2016","journal-title":"Ann. Anat."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1002\/ca.22799","article-title":"Development of the Anatomical Quality Assessment (AQUA) Tool for the Quality Assessment of Anatomical Studies Included in Meta-Analyses and Systematic Reviews","volume":"30","author":"Henry","year":"2017","journal-title":"Clin. Anat."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1097\/XEB.0000000000000141","article-title":"A New Improved Graphical and Quantitative Method for Detecting Bias in Meta-Analysis","volume":"16","author":"Barendregt","year":"2018","journal-title":"Int. J. Evid. Based Healthc."},{"key":"ref_9","first-page":"89","article-title":"Report of the Committee of Collective Investigation of the Anatomical Society of Great Britain and Ireland for the Year 1889\u201390","volume":"25","author":"Thomson","year":"1891","journal-title":"J. Anat. Physiol."},{"key":"ref_10","unstructured":"Adachi, B. (1928). Adachi, B. A Maxillaris Interna. Das Arterinsystem der Japaner, Maruzen."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"250","DOI":"10.5357\/koubyou1927.6.4_250","article-title":"Ueber Einen Fall von Beiderseitig Medial Vom N. Mandibularis Verlaufender A. Maxillaries Interna, Nebst Einer Statistikder Verlaufsvariatioon Der Arterie","volume":"6","author":"Fujita","year":"1932","journal-title":"J. Stomatol. Soc. Jpn."},{"key":"ref_12","first-page":"71","article-title":"On Distribution of the Artery over the Mandibular-Joint","volume":"10","author":"Kijima","year":"1932","journal-title":"Med. J. Kagoshima Univ."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1159\/000140210","article-title":"On the Topographical Anatomy of the Internal Maxillary Artery","volume":"2","author":"Lurje","year":"1947","journal-title":"Acta Anat."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1002\/ar.1091090109","article-title":"The Position of the Internal Maxillary Artery and Its Questionable Relation to the Cephalic Index","volume":"109","author":"Lasker","year":"1951","journal-title":"Anat. Rec."},{"key":"ref_15","first-page":"1","article-title":"Anatomical Studies on the Maxillary Artery","volume":"53","author":"Takarada","year":"1958","journal-title":"J. Tokyo Dent. Coll. Soc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1159\/000141629","article-title":"Beirtraege Zur Deskriptiven Und Topographischen Anatomie der A. Maxillaris","volume":"41","year":"1960","journal-title":"Acta Anat."},{"key":"ref_17","first-page":"91","article-title":"On the Origin Course and Distribution of the Maxillary Artery in Japanese","volume":"18","author":"Ikakura","year":"1961","journal-title":"Kouku Kaibou Kenkyu"},{"key":"ref_18","first-page":"534","article-title":"Ueber Die Varialitaet Im Verlauf Der a.Maxillaris","volume":"123","author":"Skopakoff","year":"1968","journal-title":"Anat. Anz."},{"key":"ref_19","first-page":"449","article-title":"Variability of the Course of External Carotid Artery and Its Rami in Man in the Light of Anatomical and Radiological Studies","volume":"40","author":"Czerwinski","year":"1981","journal-title":"Folia Morphol."},{"key":"ref_20","first-page":"75","article-title":"Some Variations in the Course of the Maxillary Artery","volume":"6","author":"Iwamoto","year":"1981","journal-title":"J. Natl. Def. Med. Coll."},{"key":"ref_21","first-page":"817","article-title":"X-Ray Anatomy of the Maxillary Artery","volume":"16","author":"Sashi","year":"1989","journal-title":"Akita J. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"303","DOI":"10.2535\/ofaj1936.67.5_303","article-title":"On the Arteria Maxillaris Which Passes Medial to the Pterygoideus Lateralis Muscle of the Japanese Patterns of Origin of the Inferior Alveolar, the Masseteric and the Posterior Temporal Arteries","volume":"67","author":"Suwa","year":"1990","journal-title":"Okajimas Folia Anat. Jpn."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1159\/000147203","article-title":"The Human Maxillary Artery Reinvestigated: I. Topographical Relations in the Infratemporal Fossa","volume":"142","author":"Pretterklieber","year":"1991","journal-title":"Cells Tissues Organs"},{"key":"ref_24","first-page":"188","article-title":"Three-Dimensional Analysis of Arteriographs of the Maxillary Artery in Man\u2014Part 1: The Maxillary Artery and Its Branches","volume":"11","author":"Tsuda","year":"1991","journal-title":"J. Jpn. PRS"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1016\/j.joms.2005.11.009","article-title":"Anatomical Study of the Complications of Intraoral Vertico-Sagittal Ramus Osteotomy","volume":"64","author":"Fujimura","year":"2006","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1055\/s-2007-985193","article-title":"Microanatomy and Surgical Approaches to the Infratemporal Fossa: An Anaglyphic Three-Dimensional Stereoscopic Printing Study","volume":"17","author":"Isolan","year":"2007","journal-title":"Skull Base"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1865","DOI":"10.1097\/01.prs.0000287137.72674.3c","article-title":"Maxillary Artery: Anatomical Landmarks and Relationship with the Mandibular Subcondyle","volume":"120","author":"Orbay","year":"2007","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.tripleo.2007.04.010","article-title":"Relationship of the Maxillary Artery and Lateral Pterygoid Muscle in a Caucasian Sample","volume":"105","author":"Hussain","year":"2008","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e26","DOI":"10.1016\/j.tripleo.2009.07.029","article-title":"The Maxillary Artery and the Lateral Pterygoid Muscle: The New Zealand Story","volume":"108","author":"Dennison","year":"2009","journal-title":"Oral Surg. Oral Med. Oral Pathol Oral Radiol. Endodontol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1055\/s-0039-1697825","article-title":"A Morphometric Study of the Maxillary Artery and Lingula in Relation to Mandibular Ramus Osteotomies and TMJ Surgery","volume":"4","author":"Balcioglu","year":"2010","journal-title":"Eur. J. Dent."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"155","DOI":"10.2535\/ofaj.87.155","article-title":"Clinical Anatomy of the Maxillary Artery","volume":"87","author":"Otake","year":"2011","journal-title":"Okajimas Folia Anat. Jpn."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1465","DOI":"10.1097\/SCS.0b013e3182575793","article-title":"Radiologic Assessment of the Relationship Between the Maxillary Artery and the Lateral Pterygoid Muscle","volume":"23","author":"Gulses","year":"2012","journal-title":"J. Craniofac. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1007\/s12565-012-0146-x","article-title":"Variations in the Course of the Maxillary Artery in Japanese Adults","volume":"87","author":"Maeda","year":"2012","journal-title":"Anat. Sci. Int."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1002\/ca.22202","article-title":"Microsurgical Anatomy of the Infratemporal Fossa","volume":"26","author":"Joo","year":"2013","journal-title":"Clin. Anat."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1002\/ca.22329","article-title":"Proximity of the Maxillary Artery to the Mandibular Ramus: An Anatomic Study Using Three-dimensional Reconstruction of Computer Tomography","volume":"27","year":"2014","journal-title":"Clin. Anat."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1007\/s00701-017-3092-5","article-title":"The Maxillary Artery and Its Variants: An Anatomical Study with Neurosurgical Applications","volume":"159","author":"Alvernia","year":"2017","journal-title":"Acta Neurochir."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2075","DOI":"10.4314\/aja.v11i1.7","article-title":"Relationship of the Neurovascular Structures of the Infratemporal Fossae in Black Zimbabweans: A Cadaveric Study","volume":"11","author":"Makosa","year":"2022","journal-title":"Anat. J. Afr."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1007\/s10006-021-00960-0","article-title":"Proximity of the Middle Meningeal Artery and Maxillary Artery to the Mandibular Head and Mandibular Neck as Revealed by Three-Dimensional Time-of-Flight Magnetic Resonance Angiography","volume":"26","author":"Ferrari","year":"2022","journal-title":"Oral Maxillofac. Surg."},{"key":"ref_39","first-page":"859","article-title":"Musculus Pterygoideus Proprius: A Meta-analysis","volume":"37","author":"Mandal","year":"2023","journal-title":"Clin. Anat."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Rusu, M.C., Toader, C., Tudose, R.C., and Grigori\u0163\u0103, L.O. (2024). Debate on the Morphological Variability of the Lateral Pterygoid Muscle\u2014Discrepancies, Speculations and New Original Anatomical Samples. Medicina, 60.","DOI":"10.3390\/medicina60121913"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1007\/s00276-019-02305-9","article-title":"Prevalence, Morphology, and Morphometry of the Pterygospinous Bar: A Meta-Analysis","volume":"42","author":"Henry","year":"2020","journal-title":"Surg. Radiol. Anat."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1535","DOI":"10.1016\/j.jcms.2017.06.019","article-title":"The Pterygoalar Bar: A Meta-Analysis of Its Prevalence, Morphology and Morphometry","volume":"45","author":"Henry","year":"2017","journal-title":"J. Cranio-Maxillofac. Surg."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1007\/s12565-025-00826-5","article-title":"Foramen Ovale Morphology and Relationship with the Lateral Pterygoid Process Plate: Proposal for a New Classification System","volume":"100","author":"Triantafyllou","year":"2025","journal-title":"Anat. Sci. Int."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1002\/ca.21089","article-title":"Functional Anatomy of the Mandibular Nerve: Consequences of Nerve Injury and Entrapment","volume":"24","author":"Piagkou","year":"2011","journal-title":"Clin. Anat."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1002\/ar.23943","article-title":"Masticatory Muscles and Branches of Mandibular Nerve: Positional Relationships Between Various Muscle Bundles and Their Innervating Branches","volume":"302","author":"Akita","year":"2019","journal-title":"Anat. Rec."},{"key":"ref_46","first-page":"e273","article-title":"Maxillary Artery Traversing Through the Temporal Muscle","volume":"35","author":"Dumitru","year":"2024","journal-title":"J. Craniofac. Surg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1007\/s00276-013-1181-6","article-title":"Unique Variation in the Course of Maxillary Artery in Infratemporal Fossa: A Case Report","volume":"36","author":"Verma","year":"2014","journal-title":"Surg. Radiol. Anat."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1007\/s12565-015-0289-7","article-title":"Divided Maxillary Artery in Relation to the Lateral Pterygoid Muscle","volume":"91","author":"Aland","year":"2016","journal-title":"Anat. Sci. Int."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"e861","DOI":"10.1097\/SCS.0000000000008788","article-title":"Fenestrated Maxillary Artery","volume":"33","author":"Rusu","year":"2022","journal-title":"J. Craniofac. Surg."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/7\/1201\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:01:59Z","timestamp":1760032919000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/7\/1201"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,30]]},"references-count":49,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["medicina61071201"],"URL":"https:\/\/doi.org\/10.3390\/medicina61071201","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,30]]}}}