See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/307742208

Assessment of the relationship between roots of maxillary first molar to the

floor of the maxillary sinus on cone beam computed tomography

Article · January 2015

DOI: 10.15713/ins.jmrps.20

CITATIONS READS

0 118

6 authors, including:

Shubhasini Attavar Raghavan Praveen N. Birur

KLE Institute of dental sciences, bangalore K.L.E.S' Institute of Dental Sciences, Bangalore
21 PUBLICATIONS 40 CITATIONS 46 PUBLICATIONS 117 CITATIONS

SEE PROFILE SEE PROFILE

Shubha Gurudath Keerthi Gurushanth

K.L.E Institute of Dental Sciences and Research Center Bengaluru India KLE Society's Institute of Dental Sciences, Bangalore
26 PUBLICATIONS 103 CITATIONS 17 PUBLICATIONS 26 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Understanding OSMF View project

oral cancer View project

All content following this page was uploaded by Shubha Gurudath on 20 June 2018.

The user has requested enhancement of the downloaded file.

 Journal of Medicine, Radiology, Pathology & Surgery (2015), 1, 2–5

ORIGINAL ARTICLE

Assessment of the relationship between roots of maxillary

first molar to the floor of the maxillary sinus on cone beam
computed tomography
A. R. Shubhasini1, B. N. Praveen2, R. Bhanushree3, G. Shubha3, G. Keerthi3, Sangeetha4
1
Reader, Department of Oral Medicine and Radiology, KLE Society’s Institute of Dental Sciences, Bengaluru, Karnataka, India, 2Professor and Head, Department
of Oral Medicine and Radiology, KLE Society’s Institute of Dental Sciences, Bengaluru, Karnataka, India, 3Senior Lecturer, Department of Oral Medicine and
Radiology, KLE Society’s Institute of Dental Sciences, Bengaluru, Karnataka, India, 4Post-graduate Student, Department of Oral Medicine and Radiology, KLE
Society’s Institute of Dental Sciences, Bengaluru, Karnataka, India

Keywords Abstract
Cone-beam computed tomography, maxillary Background: The thickness of maxillary sinus floor may reduce markedly because of
sinus, three-dimensional imaging
protrusion of root apices of posterior teeth into the sinus. The possibility of oro-antral
communication after extraction is highest for a maxillary first molar, as this tooth erupts
Correspondence:
B. N. Praveen, Department of Oral Medicine
first and is frequently extracted early.
and Radiology, KLE Society’s Institute of Aim: To assess the relationships between the roots of the maxillary first molar and the
Dental Sciences, Bengaluru - 560 022, maxillary sinus floor.
Karnataka, India. Materials and Methods: This is a retrospective study in which 29 cone-beam computed
Email: [email protected] tomography scans of maxillary first molar and floor of the maxillary sinus was obtained.
The relationship between maxillary first molar teeth and the maxillary sinus floor was
Received 21 May 2015; analyzed and among three roots which are most likely to be closest assessed. A t-test was
Accepted 30 Jun 2015 used to compare measurements between female and male patients. ANOVA with Tukey
test was used to compare between age groups.
doi: 10.15713/ins.jmrps.20
Results: Totally, 21 (72.41%) mesiobuccal roots, 18 (62.06%) distobuccal roots, and
14 (48.27%) palatal roots showed a Class 1 relationship. Of 8 cases 2 (37.5%) cases
which belonged to Class 0 had protrusion of root into the sinus.
Conclusion: Any suspected periapical pathologies of maxillary molars needs thorough
three-dimensional radiographic assessment to understand the approximation of the
maxillary sinus.
Clinical Significance: In our study, Class 0 relationship was the highest for palatal
root. Most of the root apices had Class 1 relationship with the floor of the sinus. Hence,
one should keep this in mind while conducting periapical or pre-prosthetic surgical
procedure in the maxillary posterior region to prevent complications.

Introduction the maxillary sinus floor before planning any periapical surgical
treatment for maxillary posterior teeth. If the root apices of the
The maxillary sinus is the first paranasal sinus to develop and
maxillary posterior teeth protrude into the maxillary sinus, the
ends its growth at approximately 20 years of age with the eruption
thickness of the floor of the maxillary sinus markedly reduces.
of the third molars.[1] The extension of the adult maxillary sinus
is variable. The floor of the maxillary sinus creates elevations in After extraction, some complications such as oro-antral fistulae
the antral surface, if it extends between roots of adjacent teeth, or root displacement, most commonly for the maxillary first
which are commonly referred as “hillocks.”[2] The age of an and second molars may occur. As the first maxillary molar is the
individual, presence or absence of teeth and pneumatization of first permanent tooth to erupt and is frequently prematurely
the maxillary sinus contributes to variation in the topography of extracted, the possibility of oro-antral communication after
the inferior wall of the maxillary sinus.3 It is essential to assess extraction is higher.[3] The roots of first and second molar and
the proximity of the roots of the maxillary posterior teeth to the floor of maxillary sinus have a close relationship to each

2 Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 1:4 ● Jul-Aug 2015
Proximity of molar roots to maxillary sinus Shubhasini, et al.

other.[4] The projecting roots are usually separated from it by classification given by Didilescu et al. 21 (72.41%) mesiobuccal
various bone thicknesses, but they are sometimes separated by roots, 18 (62.06%) distobuccal roots, and 14 (48.27%) palatal
the sinus mucosa alone. Various radiographic techniques like roots showed a Class I relationship [Table 1].
panoramic radiography, cone beam computed tomography The mean distance for mesiobuccal, distobuccal, and palatal
(CBCT) can be used to assess the proximity of the roots of first root to the maxillary sinus floor was highest for the age group
and second molars to the floor of the sinus.[1,5] This study was of 40-49 years, which was statistically significant (ANOVA test).
conducted to evaluate the relationship between the floor of the There was no statistical significant age-related difference among
maxillary sinus and the maxillary first molar roots and to assess other age groups.
which among three roots is most likely to be the closest to the
maxillary sinus floor.
Discussion
This study was conducted to assess the anatomical
Materials and Methods
relationship of roots of maxillary first molar to the floor of the
The study was approved by the Institutional Ethics Committee. maxillary sinus. The influence of the age of the distance between
This was a retrospective study in which CBCT scans obtained root apices and floor of the maxillary sinus is also evaluated.
with Planmeca Promax three-dimensional (3D) Max, CBCT There is a close relation of the maxillary sinus floor to the root
unit and Kodak CBCT 9300 unit were retrieved from radiology apices of maxillary first and second molars in most cases, whereas
archives. CS 3D imaging software which included CBCT scan in some cases the apices of these teeth protrude into the sinus.[4]
volume of 200 μm × 200 μm × 200 μm and Planmeca Romexis The floor of the maxillary sinus extending between the roots of
software with image size 291 × 291 × 291 and voxel size 200 μm molar teeth leads to a marked reduction in the thickness of the
were used for the analysis. 29 CBCT scans which included the sinus floor. The most of the roots that protrude radiographically
floor of the maxillary sinus and maxillary first molar without any into the sinus are actually enveloped by a thin cortical layer
periapical pathologies were included in our study. with perforations in 14-28% of the cases when viewed under
The vertical relationship between apices of 29 maxillary histological sections.[4] The age of an individual, pneumatization
first molar teeth to the maxillary sinus floor was assessed by of the maxillary sinus, and presence or absence of teeth
measuring the shortest distance between two. The distances contributes to variation in the topography of the inferior wall
between the roots of maxillary first molar (mesiobuccal, of the maxillary sinus.[4] Before conducting surgical procedures
distobuccal, and palatal) and the sinus floor were measured in such as pre-prosthetic and preimplant surgeries on the maxillary
the coronal section and grouped according to classification posterior region, a clinician must be aware of the relation
given by Didilescu et al. Class 0: distance (d) = 0 mm; between teeth roots and the sinus floor. This is because of the
Class 1: 0 mm < d < 2 mm; Class 2: 2 mm ≤ d < 4 mm; high-risk of pneumatization of maxillary sinus after extraction of
Class 3: 4 mm ≤ d < 6 mm; Class 4: 6 mm ≤ d.[3] maxillary posterior teeth causing a reduction in the amount of
available bone for implant/denture placement. Any endodontic
Statistical analysis surgery of maxillary posterior teeth can result in accidental
oroantral communication leading to the passage of bacteria from
The mean distance from mesiobuccal, distobuccal, and palatal periapical tissue causing acute or chronic sinusitis.[2] Different
root to the maxillary sinus floor between groups was compared radiographic techniques can be used to assess the relationship
by ANOVA with Tukey test. The measurements were compared between the roots of maxillary teeth and sinus such as two-
between males and females using the t-test. P < 0.05 was dimensional (2D) intraoral periapical radiographs and
considered as statistically significant. orthopantomograms and 3D CBCT. 2D radiographs have the
main disadvantage of superimposition of anatomic structures
Results and also the horizontal and vertical magnification of up to 33%
and a lack of cross-sectional information.[1] 2D radiographs
CBCT scans of 29 maxillary first molars were included in our produced superimposition artifacts frequently resulting in over
study, among which for five CBCT scans patients details on age
was not available. Hence, 24 scans were included for assessing
Table 1: Distribution of each root among each group of
age-related changes.
classification
Of 24 CBCT scans, 12 were of males and 12 were of females.
Grouph Mesial root Distal root Palatal root
The age of the subjects ranged from 14 to 52 years with mean age
Class 0 1 4 8
of 27.3 years. Most subjects, 10 in number (41.7%) belonged to
age group 20-29 years. The mean distance of maxillary sinus floor Class 1 21 18 14
to the mesiobuccal root was 1.6410 mm; to that of distobuccal Class 2 6 5 5
root was 1.5469 mm, and to that of the palatal root was Class 3 1 2 1
1.1855 mm. In most of the cases the relationship of tip of three
Class 4 0 0 1
roots to the sinus floor belonged to Class 1 group according to

Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 1:4 ● Jul-Aug 20153
Shubhasini, et al. Proximity of molar roots to maxillary sinus

projection of roots of maxillary posterior teeth into the sinus

floor.[5] Among the recent radiographic techniques, CBCT is
appropriate to evaluate the integrity of the floor of the sinus after
extraction of the tooth.[3] Any suspected periapical pathologies
of maxillary molars need thorough 3D radiographic assessment
to understand the approximation of the maxillary sinus. Sharan
and Madjar reported that only 39% showed root protrusion
into the sinus in the CT images which showed root projecting
into the sinus when examined in panoramic radiographs. The
panoramic radiographs consistently showed a 2.1 times longer
projection of the roots of posterior teeth into the maxillary sinus
when compared to that on CT.[1]
Hassan found that neither periapical radiographs nor
panoramic radiographs were reliable to determine the exact
relationship between the floor of the maxillary sinus and the roots Figure 1: Class 0 relationship of left palatal root tip with floor of the
of the maxillary posterior teeth. He also concluded that periapical maxillary sinus
radiography was more reliable to assess this relationship than
panoramic radiography.[5]
Kilic et al. reported that the root tip of the maxillary first
premolar had the longest distance from sinus floor and the second
molar bucco-distal root tip had the shortest distance for both left
and right side.[2] Ali et al. concluded from their study that roots
protruding into the sinus in CT showed shorter projection length
when compared to panoramic radiography. The 2D panoramic
image is sufficient to provide information to the clinician about the
true relationship between the teeth roots and the sinus. However,
when additional information is required when panoramic
radiographs show root protrusion into the sinus, CT should be
advised.[4] Jung and Cho reported that among maxillary molars
the frequency of root protrusion into the sinus was more common
for the buccal roots. They also found that the mesiobuccal root of
the maxillary second molar was in close proximity to the floor of Figure 2: Class 1 relationship of right palatal root tip with floor of
the maxillary sinus.[6] Didilescu et al. reported that in the maxillary the maxillary sinus
first molar, the palatal root was the closest to the sinus floor.
Earlier Freisfeld et al. suggested three types of vertical relationship,
whereas few others suggested five vertical classifications. Based
on the thickness of the bony plate, authors have suggested a new
classification in 2012, which helped to assess furcation relation
also. They classified the relationship of root apex of the maxillary
first molar to the maxillary sinus floor as: Class 0: Distance
(d) = 0 mm; Class 1: Between 0 and 2 mm; Class 2: Between 2
and 4 mm; Class 3: Between 4 and 6 mm; Class 4: More than
6 mm. In their study, the palatal root had the highest prevalence
of Class 0 (44.33%), followed by mesiobuccal root (40.21%) and
distobuccal root (38.14%).3 A search of literature in search engines
Google and PubMed using keywords “Relationship of maxillary
first molar to maxillary sinus in Indian population” and “proximity
of maxillary first molar to maxillary sinus in Indian population” did
not reveal any previous studies in Indian population. In this study,
in most of the cases, the relationship of tip of three roots to the
sinus floor belonged to Class 1 group; 21 (72.41%), 18 (62.06%), Figure 3: Class 2 relationship of right palatal root tip with floor of
and 14 (48.27%) cases for mesiobuccal, distobuccal, and palatal the maxillary sinus
root, respectively [Table 1 and Figures 1-5]. The prevalence for
Class 0 relation was highest for the palatal root seen in 8 (27.58%) sinus. There was statistically significant the highest mean distance
cases. Of 8 cases 2 (37.5%) cases had protrusion of root into the observed for mesiobuccal, distobuccal, and palatal root to the

4 Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 1:4 ● Jul-Aug 2015
 Proximity of molar roots to maxillary sinus Shubhasini, et al.

Conclusion
Multiple factors affect the distance between the root tips of
maxillary molar and the maxillary sinus floor and each patient
needs to be evaluated individually. As observed in our study,
in most cases it can be expected that the distance is a Class 1
relation, that is, between 0 and 2 mm.

References
1. Sharan A, Madjar D. Correlation between maxillary sinus
floor topography and related root position of posterior teeth
using panoramic and cross-sectional computed tomography
Figure 4: Class 3 relationship of right mesiobuccal root tip with imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
floor of the maxillary sinus 2006;102:375-81.
2. Kilic C, Kamburoglu K, Yuksel SP, Ozen T. An assessment of the
relationship between the maxillary sinus floor and the maxillary
posterior teeth root tips using dental cone-beam computerized
tomography. Eur J Dent 2010;4:462-7.
3. Didilescu A, Rusu M, Sandulescu M, Georgescu C,
Ciuluvica R. Morphometric analysis of the relationships
between the maxillary first molar and maxillary sinus floor.
J Stomat 2012;2:352-7.
4. Ali SM, Hawramy FA, Mahmood KA. The relation of maxillary
posterior teeth roots to the maxillary sinus floor using
panoramic and computed tomography imaging in a sample of
kurdish people. Tikrit J Dent Sci 2012;1:81-8.
5. Hassan BA. Reliability of periapical radiographs and
orthopantomograms in detection of tooth root protrusion in the
maxillary sinus: correlation results with cone beam computed
tomography. J Oral Maxillofac Res 2010;1:e6.
6. Jung YH, Cho BH. Assessment of the relationship between
the maxillary molars and adjacent structures using cone beam
Figure 5: Class 4 relationship of right palatal root tip with floor of computed tomography. Imaging Sci Dent 2012;42:219-24.
the maxillary sinus

maxillary sinus floor for the age group of 40-49 years. However,
as the sample size was very small for this age group (two cases) it How to cite this article: Shubhasini AR, Praveen BN,
cannot be concluded as an age-related change. Although we found Bhanushree R, Shubha G, Keerthi G, Sangeetha. Assessment
no other significant association of distance of maxillary molar root of the relationship between roots of maxillary first molar
tips to the floor of the maxillary sinus, further studies are required to the floor of the maxillary sinus on cone beam computed
to large sample to evaluate for age-related changes. tomography. J Med Radiol Pathol Surg 2015;1:2-5.

Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 1:4 ● Jul-Aug 20155

View publication stats