Assessment of prevalence of anatomical variations and pathosis of the maxillary sinuses using cone-beam computed tomography in a sample of the population of Saudi Arabia

Lama Alzain; Sama Alzain; Fatma Badr; Linah M Ashy; Ibrahim Yamany; Wael Y Elias; Dania F Bogari; Turki Y Alhazzazi

doi:10.4103/jomr.jomr_27_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 6 | Issue : 3 | Page : 45-50

Assessment of prevalence of anatomical variations and pathosis of the maxillary sinuses using cone-beam computed tomography in a sample of the population of Saudi Arabia

Lama Alzain¹, Sama Alzain², Fatma Badr³, Linah M Ashy⁴, Ibrahim Yamany³, Wael Y Elias³, Dania F Bogari⁵, Turki Y Alhazzazi⁶
¹ Centers-Le Chateau Center, Jeddah, Saudi Arabia
² Internship Training Program, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
³ Department of Diagnostic Oral Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
⁴ Department of Prosthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
⁵ Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
⁶ Department of Oral Biology, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication

1-Feb-2019

Correspondence Address:
Turki Y Alhazzazi
Department of Oral Biology, Faculty of Dentistry, King Abdulaziz University, Jeddah
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jomr.jomr_27_18

Abstract

Background: Cone-beam computed tomography (CBCT) technology has been a useful tool for decreasing dental treatment complications and ensuring more predictable treatment outcomes. Objectives: This study aimed to assess the prevalence of maxillary sinuses status in regard to anatomical variations and pathosis using CBCT as a diagnostic tool, in asymptomatic patients who are willing to receive dental implants at King Abdulaziz University Dental Hospital in Jeddah, Saudi Arabia. Materials and Methods: Both sinuses in 263 patients (140 females and 96 males) were evaluated using iCAT Classic scanner to acquire the total of 526 CBCT images. Two calibrated dental radiology consultants evaluated the CBCT of the maxillary sinuses images using the Vision software (Imaging Sciences International, Hatfield, PA, USA) for the following finding: number of teeth in intimate relation with the maxillary sinus and the presence of septa (as anatomical variations) and the presence, extent, and configuration of mucosal thickening (MT) as sign of pathosis (mucositis). Results: The highest prevalence of dental proximity to the sinus wall was between the first left premolars and the anterior sinus wall (57.14%) followed by the second right premolars (56.14%). The presence of septa in both right and left maxillary sinuses was 54.37% and 57.41%, respectively. The prevalence of sinus pathosis was 52.7%. Interestingly, 87.07% of the MT cases were due to nonodontogenic origin compared to 12.93% of odontogenic-related pathosis. Conclusions: Preoperative radiographic assessment using CBCT is highly recommended before dental implant placement in our population due to the high anatomical variations and pathosis rates, to allow proper assessment and diagnosis of maxillary sinus disease, if present. The assessment of maxillary sinus disease before surgical intervention will provide a higher standard of care and decrease the risk of complications and failures of dental implants.

Keywords: Cone-beam computed tomography, maxillary mucositis, maxillary sinuses, septa

How to cite this article:
Alzain L, Alzain S, Badr F, Ashy LM, Yamany I, Elias WY, Bogari DF, Alhazzazi TY. Assessment of prevalence of anatomical variations and pathosis of the maxillary sinuses using cone-beam computed tomography in a sample of the population of Saudi Arabia. J Oral Maxillofac Radiol 2018;6:45-50

How to cite this URL:
Alzain L, Alzain S, Badr F, Ashy LM, Yamany I, Elias WY, Bogari DF, Alhazzazi TY. Assessment of prevalence of anatomical variations and pathosis of the maxillary sinuses using cone-beam computed tomography in a sample of the population of Saudi Arabia. J Oral Maxillofac Radiol [serial online] 2018 [cited 2023 Mar 28];6:45-50. Available from: https://www.joomr.org/text.asp?2018/6/3/45/251374

Introduction

Maxillary sinuses are one pair of the paranasal pneumatic sinuses in the head-and-neck region that are lined by a thin respiratory mucous membrane called Schneiderian membrane.^[1] Under normal physiologic conditions, the maxillary sinus mucous membrane is about 1-mm thick and radiographically undetectable.^[2] However, under pathological conditions, the thickness of the maxillary sinus mucous membrane is about 3 mm or greater.^[3] The maxillary sinus septa are underwood's septa composed of cortical bone that divide the floor of maxillary sinus into multiple chambers called recesses.^[4],[5]

Cone-beam computed tomography (CBCT) is a three-dimensional (3D) imaging modality that is useful in the evaluation of the maxillofacial structures for diagnostic and treatment planning purposes.^{[6],[7],[8],[9]} It shows the anatomical features of the maxilla and mandible without superimposition nor distortion.^{[10],[11],[12]} In the maxilla, CBCT provides an accurate evaluation of bone quality, quantity, and the relationship between maxillary sinus and the root apices of posterior teeth.^[13] CBCT is considered as a preoperative diagnostic tool for implant placement, particularly in cases that require sinus lift surgery.^{[14],[15],[16],[17]} In addition, CBCT is a helpful tool for the proper assessment of the maxillary sinuses in all three dimensions.^[18] Raghav et al.^[19] recorded the prevalence of incidental maxillary sinus pathologic findings by CBCT in a cohort study in which age ranged from 10 to 69 years. Their results revealed a high prevalence of incidental maxillary sinus abnormalities in a sample of asymptomatic dental patients.^[19] In addition, Tadinada et al.^[20] investigated the diagnostic efficiency of CBCT compared to panoramic imaging. They found that the percentage of maxillary sinus pathosis was 72% in the examined population. In addition, CBCT imaging was significantly more reliable in detecting maxillary sinus pathosis compared to panoramic imaging.^[20]

There are no available studies that assess the prevalence of anatomical variations and pathosis of the maxillary sinuses in Jeddah, Saudi Arabia. Thus, the aim of this study was to assess the prevalence of maxillary sinuses status in regard to anatomical variations and pathosis using CBCT as a diagnostic tool, in asymptomatic patients who are willing to receive dental implants at King Abdulaziz University Dental Hospital (KAUDH) in Jeddah, Saudi Arabia.

Materials and Methods

A retrospective chart review of the implant clinic at KAUDH of 263 patients was randomly selected to asses both maxillary sinuses at the right and left sides in the same patient. A total number of 526 CBCT images of both maxillary sinuses were included for evaluation in this study. Exclusion criteria included unsatisfactory quality of images, incomplete coverage of the maxillary sinuses, and symptomatic patients. CBCT images were evaluated for the following findings: number of teeth in intimate relation with the maxillary sinus and the presence of septa (as anatomical variations) and the presence, extent, and configuration of mucosal thickening (MT) as a sign of pathosis. All the patients were imaged using the iCAT scanner (Imaging Sciences International, Hatfield, PA, USA) using the exposure settings recommended by the manufacturer and a voxel size that ranged from 0.25 to 0.4 mm. Two calibrated dental radiology consultants evaluated the CBCT of the maxillary sinus images using the Vision software (Imaging Sciences International, Hatfield, PA, USA). The interobserver and intraobserver agreement values were calculated using Cohen's kappa test. Statistical analysis was done using IBM SPSS software version 21.0 (Chicago, IL, USA). Simple descriptive statistics were used to define characteristics of our study variables using percentages, mean, and range. The differences between the groups were assessed using the Chi-square test, and the level of significance was set at P < 0.05.

A written consent was obtained from all patients approving the use of their data for the research project. This project was approved by the Research Ethical Committee Review Board from King Abdulaziz University, Faculty of Dentistry. This project was approved by the committee and was in full accordance with the World Medical Association Declaration of Helsinki.

Results

Out of the 263 patients who were included in this study, 140 were female and 96 were male. The mean age was 35.68 years and the range was 13–75 years old.

The Cohen's kappa scores for both interobserver and intraobserver agreement values varied from 0.84 to 0.96.

Anatomical variations

The dental proximity to the sinus wall

The highest prevalence of dental proximity to the sinus wall was between the first left premolars and the anterior sinus wall [57.14%; [Table 1]], followed by the second right premolars [56.14%; [Table 1]]. Only a few cases out of the 526 images demonstrated a proximity of the first molars and none of the second molars to the anterior sinus wall [Table 1].

Table 1: The anatomical variation prevalence of dental proximity to the sinus wall

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The presence of septa in the maxillary sinuses

Our results revealed that the presence of septa in the right and left maxillary sinuses was high, 54.37% and 57.41%, respectively [Table 2]. Representative CBCT images of a healthy (clear) maxillary sinus and the presence of septa in the maxillary sinus are shown in [Figure 1] and [Figure 2], respectively.

Table 2: The prevalence of septa in the maxillary sinuses as anatomical variation

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Figure 1: A sagittal view shows a healthy (clear) maxillary sinus that is well aerated and completely radiolucent (arrow)

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Figure 2: A sagittal view displaying thin bony septum extending from the floor of the maxillary sinus

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Maxillary sinus pathosis

Mucosal thickening characterization

We characterize the MT (mucositis) according to the location and configuration using the sagittal view. Irregular MT configuration of the maxillary sinus is shown in [Figure 3] compared to the healthy maxillary sinus shown in [Figure 1]. In [Figure 4] and [Figure 5], we represented examples of MT in the maxillary sinus, localized versus generalized. [Figure 6] is an example of localized odontogenic MT that resulted from deep caries in the maxillary second molar.

Figure 3: A sagittal view shows the presence of an irregular mucosal thickening configuration along the anterior antral wall and floor (brace)

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Figure 4: A sagittal view depicting minimal localized mucosal thickening at the junction between the antral floor and anterior wall (arrow)

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Figure 5: A sagittal view displaying a case of extensive mucosal thickening affecting more than one wall with small round radiolucent “bubbles” representing air trapped within the mucositis (arrows)

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Figure 6: A sagittal view displaying a case of odontogenic mucositis (solid arrows). Note the deep caries in the second maxillary molar approaching the pulp horns (dashed arrow)

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Mucosal thickening causes and variations in our studied population

Our study also investigated the causes of the MT of the maxillary sinuses, odontogenic versus nonodontogenic in origin. Interestingly, odontogenic mucositis was the least common finding. The majority of MT cases (87.07%) were not related to teeth pathosis as shown in [Table 3]. The dental conditions related to the odontogenic mucositis are mostly deep fillings (3.42%), followed by root canal treatment (3.23%) and periapical pathosis (3.23%) [Table 3].

Table 3: Conditions associated with mucosal thickening (mucositis)

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MT in the maxillary sinuses due to pathosis was noted with varying degrees [Table 4]. The total prevalence of maxillary sinuses pathosis was 52.7% [Table 4].

Table 4: The prevalence of pathologic mucosal thickening in the maxillary sinuses

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The prevalence of generalized MT in the left maxillary sinus was similar to that in the right sinus, 38.78% and 36.12%, respectively [Figure 7] and [Table 4]; P> 0.05]. In addition, the prevalence of localized MT in the left maxillary sinus was also similar to that of the right sinus, 13.31% and 17.11%, respectively [Figure 7] and [Table 4]; P> 0.05]. There was no statistical significance in the presence of MT between left and right maxillary sinuses (P > 0.05). The first molars were the most commonly related teeth to areas of MT, followed by the second molars with a prevalence of 41.79% and 26.86, respectively [Table 5].

Figure 7: The percentages of mucosal thickening extent on each side of the maxillary sinuses. (a: left sinus, b: right sinus)

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Table 5: The prevalence of teeth in close relationship to the mucosal thickening according to tooth type

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Discussion

The prevalence of maxillary sinus pathosis in our studied population from Saudi Arabia was high (52.7%). This is in agreement with other studies where they others found the prevalence of maxillary sinus pathosis to be (72%)^[20] and (94%).^[17] This higher prevalences can be explained, at least in part, due to the fact that these studies included all paranasal sinuses not just the maxillary sinuses compared to our study.

MT, which is also called mucositis, would make dental implant placement in the maxilla contraindicated. Improper assessment of the corresponding maxillary sinus can lead to implant failure if such assessment was not overlooked. Therefore, the assessment of the maxillary sinuses before any surgical procedure using CBCT is crucial together with the proper clinical examination. Proper clinical examination must include extraoral and intraoral examinations with detailed medical and dental history taking to identify the origin of the present disease, rollout any previous or current allergic episodes, headache, pain associated with jaw or facial points, previous endodontic or periodontal surgery, and habits such as smoking for definitive diagnosis and proper dental management.^[20],[21]

In our study, the prevalence of maxillary sinus septa was relatively high on both sides. In 2012, Pommer et al.^[5] showed a significantly lower prevalence of maxillary sinus septation in the Asian population.^[5] The variety of the results could be due to the different septa definition criteria of their study compared to ours, and they also used 2D panoramic radiographs that most probably underestimated the presence of septa compared to our study that included CBCT as diagnostic method. According to the position statement released by the American Academy of Oral and Maxillofacial Radiology, cross-sectional imaging such as CBCT is recommended before implant placement.^[22] This reduces the risk of complications such as sinus membrane perforation, postoperative sinusitis, and graft infection. A modification of the surgical techniques is required to avoid these complications in the presence of septa.

In the current study, the prevalence of maxillary sinus disease from an odontogenic origin was 12.93%. Our results are in agreement with Mehra and Jeong study^[21] where they reported an odontogenic origin of maxillary sinusitis in 10%–12% of their studied cases. In addition, in our population, dental proximity to the sinus wall was the first left premolars followed by the second right premolars. Our results are in contrast to others where the second and first molars showed a closer proximity to the maxillary sinus compared to premolars.^[23]

One limitation of our study was the factor of allergies, as the cause was not always well documented. Further controlled studies are needed to determine the extent of radiographic signs of maxillary sinus pathosis (most commonly MT) that can be safely grafted for implant treatment without hindering the success rate of these implants. Proper management and referral to an ENT specialist in case of maxillary sinus pathosis that is nonodontogenic in origin is important before any surgical intervention.

Conclusions

The prevalence of maxillary sinus mucositis in our population was high. Thus, preoperative radiographic assessment using CBCT is highly recommended before dental implant placement to allow the proper assessment and diagnosis of maxillary sinus disease, if present. The assessment of maxillary sinus disease before surgical intervention will provide a higher standard of care and decrease the risk of complications and failures of dental implants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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