Dental

Communication

Biosci. Biotech. Res. Comm. 10(3): 580-586 (2017)

Correlation of the maxillary sinus volume with gender

and some of craniofacial indices using cone beam

computed tomography

Shahab Etemadi

, Golnaz Seylavi*

and Afshin Yadegari

Assistant Professor, Department of Oral and Maxillofacial Radiology, Isfahan (Khorasgan) Branch, Islamic

Azad University, Isfahan, Iran

Post Graduate Student, Department of Oral and Maxillofacial Radiology, Isfahan (Khorasgan) branch,

Islamic Azad University, Isfahan, Iran

Assistant Professor, Department of Oral and Maxillofacial Surgery, Isfahan (Khorasgan) Branch, Islamic

Azad University, Isfahan, Iran

ABSTRACT

Maxillary sinus volume is variable and thus, is a topic of interest for surgeons performing endoscopic surgeries. Also,

it may be helpful for sexual identi cation. This study sought to measure the maxillary sinus volume using cone beam

computed tomography (CBCT) and assess its correlation with gender and some craniofacial indices. In this descriptive,

analytical, cross-sectional study, CBCT scans of 70 patients (35 males and 35 females) older than 18 years of age were

evaluated. To measure the maxillary sinus volume, axial CBCT sections with 2mm slice thickness and Digimizer software

were used. Sinus volume was calculated using the formula: volume=sum of the thickness of each slice multiplied by

the surface area of each slice. The mean width and height of the palate in the coronal plane, anterior-posterior length

of the palate in the sagittal plane and distance between the two zygomatic buttresses were measured on the axial CBCT

sections in both males and females. The Pearson’s correlation coef cient, independent t-test and paired t-test were used

for statistical analyses. The mean maxillary sinus volume was 15.9±6.05 cm3 and 13±2.85 cm3 in males and females,

respectively. The mean volume of the maxillary sinus was larger in males, and a signi cant correlation was noted

between the mean volume of the maxillary sinus and width and height of the palate as well as the distance between the

two zygomatic buttresses (P<0.05). Despite the larger volume of the maxillary sinus in males, this parameter cannot be

used for sexual identi cation because the area under the receiver operating curve (ROC) was 62.7%.

KEY WORDS: CONE-BEAM COMPUTED TOMOGRAPHY; SEXUAL IDENTIFICATION; MAXILLARY SINUS

580

ARTICLE INFORMATION:

*Corresponding Author:

Received 19

July, 2017

Accepted after revision 28

Sep, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF: 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

DOI: 10.21786/bbrc/10.3/36

Etemadi, Seylavi and Yadegari

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS CORRELATION OF THE MAXILLARY SINUS VOLUME WITH GENDER 581

INTRODUCTION

Maxillary sinus is an irregular cavity within the maxil-

lary bone, which develops under the orbit. Development

of the maxillary sinus starts in the third week of preg-

nancy and continues to the pubertal period (Wang etal.

1994). Accurate measurement of the maxillary sinus

volume may be helpful prior to sinus  oor augmenta-

tion for implant placement (Gray etal.2000). Maxillary

sinus volume is variable and thus, is a topic of interest

for surgeons particularly the oral and maxillofacial sur-

geons (Fernandes, 2004). Recently, demand for sexual

identi cation in forensic medicine has increased due to

an increase in rate of crime (Saccucci etal.2015). The

correlation of volumetric analyses of the maxillary sinus

and sexual identi cation has been a controversial topic

(Ariji etal. 1994; Jasim etal. 2013; Vidya etal. 2013;

Ekizoglu etal.2014; Möhlhenrich etal. 2015).

Conventional radiographs are not accurate for deter-

mination of the volume of the maxillary sinus due to the

superimposition of images of other paranasal sinuses and

craniofacial skeleton on the superior part of the maxil-

lary sinuses (Wolf etal.1993). Considering the complex

structure of the sinus, magnetic resonance imaging and

computed tomography (CT; gold standard) are used for

three-dimensional visualization of the sinus anatomy.

However, their use is limited due to high patient radi-

ation dose (CT), limited access and high cost (Schwab

etal.1998; Lenza etal.2010). Thus, this study aimed to

measure the volume of the maxillary sinus using cone

beam computed tomography (CBCT) and assess its asso-

ciation with gender and some craniofacial indices.

MATERIAL AND METHODS

This study was conducted on CBCT scans of the right

and left maxillary sinuses of 70 patients including 35

females and 35 males over 18 years of age, who pre-

sented to the Oral and Maxillofacial Radiology Depart-

ment of Islamic Azad University, Isfahan branch. Images

with optimal quality were chosen. All images had been

taken with the same CBCT unit (Galileos-Sirona, Ben-

sheim, Germany) with high resolution and 0.1 mm voxel

size and exposure settings of 85 kV and 21-35 mAs

(based on the patient’s weight) and were analyzed using

SIDEXIS software. Patients with a history of surgery or

facial asymmetry, completely or partially edentulous

patients, those with in ammatory diseases of the sinus

such as sinusitis, periodontal patients, those with tumors

such as angioma, squamous cell carcinoma and lym-

phoma, history of facial bone fracture, cysts, infection

and sinus polyps were excluded.

Distance between the zygomatic buttresses: Distance

between the zygomatic buttresses was calculated on

axial sections of the upper midface according to a study

by Ariji etal. [9] and Waitzman etal.(1992). To calculate

this distance, on axial sections visualizing the inferior

border of the zygomaticomaxillary suture, a horizontal

line was drawn connecting the outermost points of the

zygomatic buttresses in the two sides and its length was

measured in millimeters (Figure 1a).

Width and height of the palate: To calculate the pala-

tal width on coronal sections according to Byasaletal.

(2011), a horizontal line was drawn from the palatal

margin of the crestal bone of the  rst molar tooth in

one side to the palatal margin of the crestal bone of the

other side and its length was measured. To measure the

height of the palate in this region on coronal sections,

as shown in Figure 1b, a line was drawn from the palate

perpendicular to the line connecting the alveolar crest

borders of the two sides and its length was measured.

Length of the hard palate: To measure the length of

the hard palate on sagittal sections, the distance between

the anterior nasal spine and posterior nasal spine at the

midline (where the anterior nasal spine was visible) was

measured (Figure 3C).

Maxillary sinus volume: To measure the maxillary

sinus volume, axial CBCT sections with 2mm slice thick-

ness and 2mm intervals were used. The CBCT sections

were subjected to Digimizer version 4.1.1 software and

the surface area of the sinus was automatically meas-

ured and stored in Excel format. The surface area of all

sections of the sinus (about 20 to 25 sections) in both

sides was calculated for each patient. Then, to calculate

the volume of the sinus in cubic centimeters, the follow-

ing formula was used: Sum of the surface area of the

sinus in each section thickness of each section (Figure

2). Data were collected and analyzed using SPSS ver-

sion 24.Independentt-test and paired t-test were used to

compare differences in the right and left sides and in the

mean size of variables.

RESULTS AND DISCUSSION

Two groups (n=35) of males and females in the age range

of 18 to 74 years were evaluated. The mean age was 37.2

years in females and 34.3 years in males. Independent

t-test showed that the mean age of males and females

was not signi cantly different (P=0.30). The mean vol-

ume of the maxillary sinus was 14.452.71 cm

. Inde-

pendent t-test showed that the mean volume of the sinus

in the right (P=0.02), left (P=0.006) and both (P=0.01)

sides was signi cantly greater in males than females. In

other words, a signi cant association existed between

gender and maxillary sinus volume in the right and left

sides (P<0.05, Table 1).

The area under the ROC curve was 0.627 or 62.7%

(smaller than 0.70) (Graph 1).

Etemadi, Seylavi and Yadegari

582 CORRELATION OF THE MAXILLARY SINUS VOLUME WITH GENDER BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

FIGURE 1. (a) Distance between the two zygomatic buttresses.

(b) Measurement of the width and height of the palate at the

maxillary  rst molar site. (C) Measurement of the anterior-pos-

terior length of the hard palate

Table 1. Comparison of the mean volume of the maxillary sinus between

males and females in the right and left sides (in cm3)

Side

Females Males Independent t-test

Mean

Standard

deviation

Mean

Standard

deviation

t P value

Righ t 13/1 2/9 15/8 6/3 2/31 0/02

Left 12/9 2/8 16/01 5/8 2/86 0/006

Total 13 2/85 15/9 6/05 2/58 0/01

Table 2. Comparison of the mean volume of the maxillary sinus in the

right and left sides based on gender (in cm3)

Gender

Right Left Independent t-test

Mean

Standard

deviation

Mean

Standard

deviation

t P value

Females 13/1 2/9 12/9 2/8 0/51 0/61

Males 15/8 6/3 16/01 5/8 0/41 0/68

Total 14/4 55/1 14/5 4/8 0/09 0/92

Paired t-test showed that the mean volume of the

maxillary sinus in the right and left sides in females

(P=0.61), males (P=0.68) and in total (P=0.92) was not

signi cantly different (Table 2).

Independent t-test showed that the mean anterior-pos-

terior length of the palate in sagittal plane was not sig-

ni cantly different between males and females (P=0.23)

but the mean distance between the two zygomatic but-

tresses in the axial plane (P<0.001), palatal width in the

 rst molar region in the coronal plane (P=0.007) and

height of the palate in the  rst molar region in the coro-

nal plane (P=0.002) were signi cantly greater in males

than in females. Thus, no signi cant association existed

between gender and anterior-posterior length of the pal-

ate in sagittal plane; but gender had a signi cant associa-

tion with the other three variables (Table 3).

The Pearson’s correlation coef cient showed that no

signi cant association existed between age and vol-

Etemadi, Seylavi and Yadegari

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS CORRELATION OF THE MAXILLARY SINUS VOLUME WITH GENDER 583

Table 3. Comparison of the mean craniofacial parameters in males and females (in mm)

Parameter

Females Males Independent t-test

Mean

Standard

deviation

Mean

Standard

deviation

t P value

Distance between zygomatic

buttresses in axial plane

85/2 4/2 88/9 4/1 3/70 <0/001

Anterior posterior length of the

palate in sagittal plane

51/2 3/2 52/6 6/1 1/20 0/23

Width of the palate in  rst

molar site in coronal plane

33/2 2/6 34/9 2/8 2/79 0/007

Height of the palate in the  rst

molar site in coronal plane

11/8 1/7 13/8 3/3 3/25 0/002

Table 4. Pearson’s correlation coef cient for the correlation between the mean

size of the maxillary sinus and age and craniofacial parameters

Variable

Maxillary sinus volume

r P value

Age -0/182 0/18

Distance between zygomatic buttresses in axial plane 0/424 <0/001

Anterior posterior length of the palate in sagittal plane 0/119 0/33

Width of the palate in  rst molar site in coronal plane 0/241 0/044

Height of the palate in the  rst molar site in coronal

plane

0/547 <0/001

FIGURE 2. Method of measurement of maxillary sinus surface area using Digimizer software

ume of the maxillary sinus (P=0.18). The anterior-pos-

terior length of the palate in the sagittal plane had no

signi cant association with the maxillary sinus volume

(P=0.33). But an association existed between the palatal

width in the  rst molar site in the coronal plane and the

volume of the maxillary sinus (P=0.044). The Pearson’s

correlation coef cient showed that a signi cant associa-

tion existed between the distance between the two zygo-

matic buttresses in the axial plane and also the height of

the palate in the  rst molar region in the coronal plane

with the volume of the maxillary sinus (P<0.001, Table 4).

Maxillary sinus is the closest paranasal sinus to the

oral cavity and since implant treatments along with

open or closed sinus lift surgery (due to pneumatization

of the maxillary sinus) have greatly increased, knowl-

edge about the anatomy of the maxillary sinus is impor-

Etemadi, Seylavi and Yadegari

584 CORRELATION OF THE MAXILLARY SINUS VOLUME WITH GENDER BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

tant (Gray etal. 2000). Sexual identi cation is an impor-

tant parameter in forensic medicine. Use of maxillary

sinus dimensions measured on CT scans may help in this

regard in cases where other methods fall short; however,

this method has its own drawbacks as well (Lerno, 1983).

Since a decade ago, CBCT is recommended as a modality

for maxillofacial imaging (Farman etal. 2006; Moreira

etal. 2009). This modality enables image reconstruction

without superimposition and has lower patient radiation

dose compared to CT (Moreira etal. 2009). It is believed

that the quality of CBCT images is equal to that of con-

ventional CT in visualization of maxillofacial structures

(Silva etal. 2008; Loubele etal. 2009; Carra ello etal.

2010).

In our study, the mean volume of the right maxillary

sinus was 14.45.1 cm

and the mean volume of the left

maxillary sinus was 14.54.8 cm

. Also, maxillary sinus

volume in males was signi cantly greater than that in

females (P<0.05). In 2013, Jasim etal. measured the vol-

ume and dimensions of the maxillary sinus and evalu-

ated its association with age and gender using CT. They

reported that the volume and dimensions of the maxil-

lary sinus in males were greater than that in females

and volume of the sinus decreased by an increase in age

(Jasim etal. 2013). To calculate the volume of the maxil-

lary sinus, they used a method similar to ours; however,

in our study in contrast to theirs, no signi cant associa-

tion was found between age and volume of the maxil-

lary sinus (P=0.30). This difference may be due to the

age group of patients since Jasim etal. (2013) evaluated

patients in older age group (40-69 years).

In 2016, Prabhat etal. evaluated the size and volume

of the maxillary sinus and its association with sexual

identi cation using CT. They reported that volume of

the maxillary sinus in males was signi cantly greater

than that in females. They stated that use of maxillary

sinus volume increases the accuracy of sexual identi-

 cation by 83.3% (Prabhat et al. 2016). In our study,

volume of the maxillary sinus in males was greater than

that in females. However, since the area under the ROC

curve was 62.7% (<70%), maxillary sinus volume cannot

be used as a reliable indicator for sexual identi cation.

These differences in measurements may be due to ana-

tomical differences of the sinus in different geographical

areas and among different races. Another reason may be

the difference in method of calculation of sinus volume

and sample size, since our sample size was twice as big

as that of Prabhat etal.(2016).

Senturk etal. in 2015 evaluated the effect of weather

and altitude on volume of the paranasal sinuses and

found no signi cant association between the volume

of the maxillary sinus and age or between the size of

the sinus in the two sides (Sahlstrand-Johnson, 2011). In

our study, no signi cant difference was noted between

the volume of the maxillary sinus and age or between

the volume of the maxillary sinuses in the two sides

(P>0.05). Ariji etal. in 1993 evaluated the correlation

of the maxillary sinus volume and aging and found that

the mean volume of the right and left maxillary sinuses

was 14.646.32 cm

. They found no signi cant differ-

ence in the volume of the maxillary sinus between males

and females. Sinus volume had an ascending trend to

GRAPH 1. ROC curve for sexual identi cation using maxillary

sinus volume in the right and left sides

Etemadi, Seylavi and Yadegari

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS CORRELATION OF THE MAXILLARY SINUS VOLUME WITH GENDER 585

20 years of age and then decreased. They also reported

that a signi cant association exists between the volume

of the maxillary sinuses and the distance between the

two zygomatic buttresses and the zygomatic occipital

distance (Ariji etal. 1994). The maxillary sinus volume

reported by Arihi et al. (1994) was comparable to the

value obtained in our study (14.452.71 cm

However, in our study, the volume of the maxil-

lary sinus in males was signi cantly higher than that

in females and no signi cant association was noted

between the sinus volume and age. In our study, aside

from the relationship of the maxillary sinus volume with

age and sex, its correlation with some other craniofacial

parameters such as width and height of the palate in the

 rst molar area in the coronal plane, anterior-posterior

length of the palate in the sagittal plane and the distance

between the two zygomatic buttresses in the axial plane

was also eval uated and it was found that a correlation

existed between the volume of the maxillary sinus and

the distance between the two zygomatic buttresses; this

 nding was comparable to that of Ariji etal. Moreover,

it was found that the greater the width and height of the

palate, the greater the size of the maxillary sinus would

be (P<0.05). But no signi cant correlation was found

between the sinus volume and the anterior-posterior

length of the hard palate (P>0.05).

CONCLUSION

The current results showed that Despite the presence of

a signi cant association between gender and volume of

the maxillary sinus (P<0.05), since the area under the

ROC curve was 0.627 or 62.7% (smaller than 0.70), vol-

ume of the maxillary sinus cannot serve as a de nite

and reliable indicator for sexual. Also, a correlation was

noted between the maxillary sinus volume and width

and height of the palate at the  rst molar site and the

distance between the two zygomatic buttresses.

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