European Archives of Oto-Rhino-Laryngology

https://doi.org/10.1007/s00405-019-05651-x

HEAD AND NECK

Is the maxillary sinus volume affected by concha bullosa, nasal septal

deviation, and impacted teeth? A CBCT study
Melek Tassoker1 · Guldane Magat1 · Bekir Lale2 · Melike Gulec1 · Sevgi Ozcan1 · Kaan Orhan3,4

Received: 16 July 2019 / Accepted: 12 September 2019

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose Various mechanisms play an important role in the growth of maxillary sinus cavities. The purpose of this study
was to investigate the correlations of maxillary sinus volume (MSV) with nasal septal deviation (NSD), concha bullosa (CB)
and impacted teeth using cone-beam computed tomography (CBCT) images.
Methods From 55 patients, a total of 110 maxillary sinus images were obtained and examined. Data including age, gender,
impacted third molar, canine teeth, NSD, and CB were examined. MSV was measured using the MIMICS software (Mate-
rialise HQ Technologielaan, Leuven, Belgium). All statistical analyses were performed using the SPSS (Statistical Package
for Social Sciences, version 21) software and p values < 0.05 were considered to indicate statistical significance.
Results Mean volume of the right maxillary sinus was 13.566 c­ m3, while the left was 13.882 c­ m3. The rate of patients with
right and left impacted third molar teeth was 49.1% and 47.3%, respectively. The rate of right and left impacted canines was
1.8% and 5.5%, respectively. NSD was found in 56.4% of CBCT examinations and right and left CB were observed in 30.9%
and 32.7% of the patients’ examinations, respectively. Males had a significantly higher mean sinus volume than females for
both sides (p < 0.05). There were no significant correlations between MSV and age (p > 0.05). No significant differences
were found between MSV and impacted teeth, NSD and CB (p > 0.05).
Conclusion NSD, CB, impacted teeth, and age were not found to be related to MSV. Gender had an effect on MSV and males
had higher mean sinus volume than females.

Keywords Maxillary sinus volume · Nasal septal deviation · Concha bullosa · Cone-beam CT

Introduction month of intrauterine life [4]. Pneumatization of the sinus

continues to 15–18 years of age [5]. The average volume
The largest and the first to develop of the four paranasal of maxillary sinus is 14–18 c­ m3 in adults and this volume
sinuses is the maxillary sinus [1, 2], which plays an impor- decreases with aging in both genders after the maximum
tant role in the formation of facial contours [3]. The begin- growth period [6].
ning of the development of maxillary sinus is in the 3rd The floor of the maxillary sinus is formed by the alveo-
lar process of the maxilla, and when the maxillary sinuses
are larger than average size, the molar and premolar teeth
* Melek Tassoker roots are in close relationship to maxillary sinus [1]. After
[email protected]
the extraction of these teeth, sinus pneumatization may
1
Department of Oral and Maxillofacial Radiology, Faculty be seen [1]. There are only a few studies in the literature
of Dentistry, Necmettin Erbakan University, Konya, Turkey investigating the relationship between impacted teeth and
2
Department of Orthodontics, Faculty of Dentistry, Necmettin MSV [1, 2] and it is believed that impacted teeth may have
Erbakan University, Konya, Turkey a negative effect on MSV [2].Pathological conditions can
3
Department of Oral and Maxillofacial Radiology, Faculty also change the sinus volume [2] such as neoplastic and
of Dentistry, Ankara University, Ankara, Turkey systemic diseases [6]. Chronic rhinosinusitis was found
4
OMFS IMPATH Research Group, Department of Imaging to be negatively correlated with MSV because the bony
and Pathology, Faculty of Medicine, University of Leuven walls of the sinus were thicker in those patients [6]. It has
and Oral and Maxillofacial Surgery, University Hospitals been also stated that rapid maxillary expansion as part
Leuven, Leuven, Belgium

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 European Archives of Oto-Rhino-Laryngology

of orthodontic treatment increases the volumetric size of Data acquisition

maxillary sinuses [1, 7].
Panoramic radiographs, computed tomography (CT), CBCTs of all patients were performed on 3D Accuitomo
cone-beam computed tomography (CBCT), lateral ceph- CBCT machine (J Morita Manufacturing Corp, Kyoto,
alometry, and magnetic resonance imaging (MRI) were Japan) according to manufacturer’s recommendations with
used to measure MSV on cadaveric or dry skulls and following parameters; 90 kV, 5 mA, 17.5-s exposure time
patients in the literature. Since it was first introduced in and 140 × 100 mm FOV (field of view) size. The images
1998 [8], CBCT has become popular in diagnosis and included in the study were converted to DICOM (Digital
treatment planning in dentistry [9]. When compared with Imaging and Communications in Medicine) format to cal-
a CT scan [10, 11], which is considered the gold standard culate the MSV. All data were created as single DICOM
of displaying paranasal sinuses, CBCT is preferred for the files from 0.25 mm thickness axial slices.
patient because of the lower radiation dose [12], the higher
resolution and the lower scanning time [13]. It has three-
dimensional cross-sectional imaging, eliminating distor- The methodology of measurements
tion and superposition situations [14].
Concha bullosa (CB) is the pneumatization of the mid- All measurements were performed by a single observer
dle turbinate and it is considered the most common ana- (B.L.) using the same methods. To evaluate intra-observer
tomic variation in the osteomeatal unit [15]. It is believed reliability, the same observer performed the measurements
that osteomeatal obstructions predispose to sinus disease for the second time after a 4-week interval.
[16]. A deviated nasal septum or CB may be potential The MSV was measured using MIMICS 21.0 software
contributors to sinus disease by narrowing the osteomeatal (Materialise HQ Technologielaan, Leuven, Belgium).
unit, but their impact on the MSV remains to be clarified The right and left MSVs were calculated for each patient
[15]. We suggest that CB, nasal septal deviation (NSD) separately. The thresholding was limited to a minimum of
or impacted teeth may restrict the MSV. The objective of −1024 HU and a maximum of 526 HU [18]. The maxillary
this study was to investigate the correlations of MSV with sinus was clipped according to around the bone structure
NSD, CB and impacted teeth using CBCT images. and the narrowest area of the ostium between the infun-
dibulum and the processus uncinatus using the software’s
“edit masks” tool [19]. Then, the connection with the out-
side air was interrupted by slice using segmentation tools.
Methods Finally, the “region growing” tool was used to divide the
segmentation created by thresholding several objects and
Subjects removing the floating pixels. MSVs were automatically
calculated using the “calculate 3D” tool of the software
For this retrospective investigation, CBCT images (Fig. 1).
obtained for different aim-related dental diagnoses and The presence of NSD was determined on coronal CBCT
treatment planning of patients who attended the Oral and images by the method of Bhandary and Kamath [20]. A
Maxillofacial Radiology Clinic, Faculty of Dentistry Nec- linear line was drawn from the maxillary anterior spine to
mettin Erbakan University between September 2014 and crista galli. The angle between the most deflected part of
April 2019 were evaluated. Patients older than 18 years the nasal septum and this linear line was measured and was
of age were included in the study. Patients with previous called the deflection angle. If this deviation was greater
nasal, nasopharyngeal, paranasal sinus or adenoidectomy than 9°, the NSD was considered to be present. Angles less
surgery, jaw–facial trauma, congenital nasal anomalies, than 9° were scored as none [21] (Fig. 2).
sinonasal diseases like allergic rhinitis and chronic rhino The presence of CB was evaluated on a coronal image
sinusitis and missing teeth (except the maxillary third according to Bolger et al. [16]. They classified CB as
molars) were excluded. From 55 patients (41 females and lamellar, bullous and comprehensive. In this study, if there
14 males) with a mean age of 22.20 ± 7.64 years, a total of were any of these three types, CB was accepted as “yes”
110 maxillary sinus images were obtained and examined. (Fig. 3). The right and left middle turbinate were evaluated
The original sample size of 55 subjects was determined by separately. There was no ostiomeatal obstruction in the
a power software based on the assumption of an 11.8 ± 4.7 patients with CB. In patients with unilateral CB, MSVs on
­c m 3 based upon a previous study [17] for MSV, with a the CB side and contralateral sides were compared.
90% power and a two-sided alpha of 0.05. The estimated The impacted maxillary canine and molar teeth were
sample size was 54 subjects. evaluated in axial, coronal and sagittal images. Teeth that

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European Archives of Oto-Rhino-Laryngology

Fig. 1  Three-dimensional
reconstruction of the maxillary
sinuses

Fig. 2  Definition of the nasal septal deviation on a coronal CBCT Fig. 3  Concha bullosa on the left side on a coronal CBCT slice
slice

were not exposed to the oral cavity and had more than were expressed as "mean ± standard deviation" for all meas-
75% of root growth were considered to be impacted [22]. ured parameters. The categorical data were expressed as
MSVs were compared on the impacted tooth side and con- number (n) and percentage (%). The Cronbach’s alpha coef-
tralateral side. ficients and Kappa values were determined for intra-observer
agreements. The appropriateness of the parameters to nor-
Statistical analysis mal distribution was examined by the Kolmogorov–Smirnov
test. Since all data were not normally distributed, the
Statistical Package for the Social Sciences (SPSS) 21.0 soft- Mann–Whitney U test was used to determine whether the
ware package (Version 21, SPSS Inc., Chicago, IL, USA) measurements differed according to gender, impacted teeth,
was used for statistical analysis. The descriptive statistics NSD, and CB. The difference between right and left MSVs

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was evaluated by the Wilcoxon signed-rank test. The rela- Table 2  The prevalence of NSD, CB, and impacted molar and canine
tionship between age and measurements was assessed by teeth (number and percentage)
Spearman’s correlation test. The Chi-square test was used Male Female p value
to determine whether there is any difference between the
Right NSD 3 (21.4) 14 (34.1) 0.510
genders in terms of impacted teeth, NSD, and CB. In addi-
Left NSD 5 (35.7) 9 (34.1) 0.313
tion, a multivariate analysis was done to verify the results.
Right CB 2 (36.6) 15 (14.3) 0.119
p < 0.05 was considered statistically significant.
Left CB 2 (39.0) 16 (19.3) 0.089
Right impacted molar 6 (51.2) 21 (42.9) 0.589
Left impacted molar 8 (43.9) 18 (57.1) 0.392
Results
Right impacted canine 1 (7.1) 0 (–) 0.095
Left impacted canine 2 (14.3) 1 (2.4) 0.121
The Cronbach’s alpha coefficients and Kappa values for
intra-observer were ranged from 0.87–0.93 with highly NSD nasal septal deviation, CB concha bullosa
reproducible.
In this study, the average age of the sample was
22.20 ± 7.64 with age range of 18–51 years. The average 1.8% and 5.5%, respectively (Table 2). There were no sig-
age was 22.46 ± 7.60 for females, and 21.43 ± 7.99 for males. nificant differences between age and impacted teeth, between
There was no significant difference between genders in terms gender and impacted teeth (p > 0.05) (Table 2). No signifi-
of age (p > 0.05). cant differences were found between MSV and impacted
The mean volume of maxillar y sinuses was molar and canine teeth (p > 0.05) (Table 3).
13.724 ± 5023.121 ­cm3. The mean volume of the right maxil- According to the multivariate analysis, there was no sta-
lary sinus was 13.566 c­ m3, while the left was 13.882 c­ m3. No tistically significant difference in right and left MSV based
statistically significant difference was found between both on NSD, right and left CB, impacted molar and canine teeth
sides in terms of MSV (p > 0.05) (Table 1). The mean right (p > 0.05; Wilk’s Λ = 0.573, 0.883, 0.953, 0.636, 0.421,
and left MSVs for males and females were 16.106 ± 5.524, 0.958, 0.978, respectively). Gender has a significant effect
12.699 ± 4.184, 17.332 ± 7.183, and 12.704 ± 3.983 ­cm3, on the right and left MSV (p < 0.05; Wilk’s Λ = 0.038).
respectively (p < 0.05) (Table 1). There were no significant
correlations between MSV and age (p > 0.05).
The presence of the right NSD was 30.9%, while the pres- Discussion
ence of the left NSD was 25.5% (Table 2). The presence of
NSD did not differ statistically by gender and age (p > 0.05) Having the largest volume among the paranasal sinuses and
(Table 2). The MSVs of the patients with NSD were not sig- displaying anatomical proximity to dental structures, the
nificantly higher than the maxillary volumes without NSD maxillary sinus is of great interest to dentists [19]. In this
(p > 0.05) (Table 3). study, we suggested that maxillary sinuses may be affected
The right and left CB were observed in 30.9% and by the condition of adjacent structures such as CB, NSD and
32.7% of the patients’ examinations, respectively (Table 2). impacted teeth.
Mann–Whitney U test revealed that CB was not statistically To maintain normal physiology, the paranasal sinuses
different according to gender and age (p > 0.05) (Table 2). It require a proper amount of ventilation. Any obstructive
was observed that there was no statistically significant dif- pathology affecting the osteomeatal complex can change
ference between MSVs of the patients with CB and without sinus physiology [6]. Some studies reported that CB may
CB (p > 0.05) (Table 2). predispose to maxillary sinusitis by obstructing osteomeatal
The right and left impacted third molar teeth were discov- complex and blocking maxillary sinus drainage and may
ered in 49.1% and 47.3% of CT examinations of the patients, damage the development of the maxillary sinus [23, 24],
respectively, while the right and left impacted canines were but others did not [6, 25]. It is reported that the MSV was

Table 1  The descriptive Maxil- Mean MSV Female Male p value for gender p value for side
statistics of maxillary sinus lary sinus
volume according to sex and volume
side (unit: ­cm3)
Right 13.724 ± 5023.121 12.699 ± 4.184 16.106 ± 5.524 0.021* 0.19
Left 12.704 ± 3.983 17.332 ± 7.183 0.019*
*
p < 0.05

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Table 3  The mean value of maxillary sinus volume according to the canine impaction was corrected. As a limitation, differ-
NSD, CB, and impacted molar and canine teeth (unit cm3) ent levels of impaction and angulation were not evaluated
Number Right Volume Left Volume p value in this study. Oz et al. [1] concluded that deeply impacted
canines decrease the MSV.
Right NSD
The mean volume of maxillar y sinuses was
Absent 38 14.261 ± 5.026 14.487 ± 5.890 0.136
13.724 ± 5023.121 ­cm3 in this study. CBCT may underes-
Present 17 12.015 ± 3.744 12.531 ± 3.539
timate MSV, because it cannot differentiate between secre-
Left NSD
tions and soft tissues. This could affect all the MSV meas-
Absent 41 13.720 ± 4.991 13.978 ± 5.337 0.925
ures and should be taken into consideration as a limitation of
Present 14 13.448 ± 4.634 13.808 ± 5.396
this study. The development of paranasal sinuses is affected
Right CB
by individual differences (genetic factors), infections and
Absent 38 13.805 ± 5.218 14.302 ± 6.061 0.758
environmental conditions. In a study conducted on the CT
Present 17 13.033 ± 3.569 12.945 ± 3.041
images of individuals of Japanese background, the mean of
Left CB
the MSV was found to be higher than in other races (the
Absent 37 14.025 ± 5.092 14.411 ± 5.871 0.616
mean of the right MSV: 23.6 c­ m3, the mean of the left MSV:
Present 18 12.624 ± 3.919 12.797 ± 3.888
20.9 ­cm3) [27]. In a study conducted on European and Zulu
Right impacted molar
cadavers, it was observed that the mean MSVs of the two
Absent 28 14.258 ± 5.527 14.539 ± 6.446 0.625
races were significantly different from each other statistically
Present 27 12.849 ± 3.753 13.202 ± 3.835
(for the European race: the mean of the right MSV: 16.39
Left impacted molar
­cm3, the mean of the left MSV: 16.42 ­cm3; for the Zulu race:
Absent 29 14.426 ± 5.382 14.630 ± 6.265 0.986
the mean of the right MSV: 11.13 ­cm3, the mean of the left
Present 26 12.608 ± 3.804 13.049 ± 3.978
MSV: 10.99 c­ m3) [28]. This result was associated with the
Right impacted canine
difference in the height–weight ratio of this ethnicity and
Absent 54 13.633 ± 4.768 13.973 ± 5.328 0.452
the differences in the methods used in volume measurement
Present 1 9.018 ± 0.0 9.964 ± 0.0
[27].
Left impacted canine
Different methods have been used for evaluating pneu-
Absent 52 13.266 ± 4.340 13.452 ± 4.415 0.285
matization in paranasal sinuses in the literature and differ-
Present 3 18.780 ± 9.249 21.337 ± 13.387
ent results may be based on this [19]. It is emphasized that
NSD nasal septal deviation, CB concha bullosa the segmentation method, which is more diagnostic than the
linear measurement based on geometric method, is the most
accurate and reliable in terms of measuring sinus volume.
affected only by severe septum deviations and the MSV was The maxillary sinus has no uniform boundary and these lin-
smaller on the deviated side than on the contralateral side ear measurements may be different from the reality [19].
[26]. In this study, NSDs were not classified based on the Additionally, injectable materials can be used for measuring
severity like mild, moderate, and severe. Different method- sinus volume, but this cannot be performed in in vivo condi-
ologies defining NSD can vary the results. In this study, we tions and the procedure is difficult [19]. Anatomical meas-
failed to show a significant association between CB, NSD, urements that are made on cadavers will result in misleading
and MSV. This can be attributed to a relatively small sample and inaccurate outcomes due to the considerable soft tissue
size and different methodologies used. Patients with CB may loss [19]. Advancements in technology have made the use of
or not have obstruction of the ostiomeatal complex, and this 3D software possible for performing segmentation on radio-
can clearly affect sinus patency and possibly MSV. There graphs acquired with methods that allow 3D calculations
was no ostiomeatal obstruction in the patients with CB in such as CT, MRI, and CBCT. In this study, 3D segmentation
this study sample. Further studies with larger samples which was performed with MIMICS software on the CBCT images
cover the general population and including the condition of to measure the volume of maxillary sinuses bilaterally. It
ostiomeatal obstruction are required. was reported that MIMICS measurements highly correlated
This study concluded that impacted tooth was not related with the actual organ volumes [29].
to MSV but Table 3 showed that MSVs were generally This study showed that there was no significant dif-
smaller on the impaction side. Oz et al. [1] revealed that the ference between right- and left-sided MSVs. Although
shape and size of the maxillary sinus may be affected by a most studies found no statistically significant differences
neighboring impacted tooth. The authors observed that MSV between the left and right MSVs of the same individual
measurements from impaction site were significantly lower [19, 30], the right and left MSVs of the same individual
compared to the contralateral side and the MSV measure- can be different from each other. The potential different
ments after the orthodontic treatment were symmetric where dentition status of the individuals on the right and left

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 European Archives of Oto-Rhino-Laryngology

side should also be considered. The patients with miss- Ethical approval This study was approved by the Ethics Board Com-
ing teeth (except third molars) were excluded. Kalabalık mittee of Necmettin Erbakan University University, Faculty of Den-
tistry (decision no 2019/05).
and Tarim Ertas [2] examined the CBCT images of 252
patients, all of whom were missing maxillary premolar Informed consent Not required.
and molar teeth, between the ages of 12–85; an increase
in MSV with missing teeth was observed, especially in
patients over 61.
There are many studies in the literature investigating the
relationship between age and MSV. The current study indi-
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