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ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 30-35

Three-dimensional linear and volumetric assessment of the maxillary sinus following posterior teeth extraction with implications for dental implant: A split mouth cross-sectional cone-beam computed tomographic study


1 Ceramco Dental Care, King Edward Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Oral and Maxillofacial Radiology, Mahatma Gandhi Vidyamandir Dental College, Nashik, Maharashtra, India
3 Department of Dental Surgery, King Edward Memorial Hospital, Mumbai, Maharashtra, India
4 Department of Oral and Maxillofacial Radiology, SMBT Dental College, Sangamner, Maharashtra, India
5 Department of Oral and Maxillofacial Prosthodontics, SMBT Dental College, Sangamner, Maharashtra, India

Date of Submission21-Jul-2020
Date of Decision02-Apr-2021
Date of Acceptance07-Apr-2021
Date of Web Publication10-Jun-2021

Correspondence Address:
Dr. Ninad Milind Padhye
Ceramco Dental Care, Lokhandwala Complex, Andheri West, Mumbai - 400 056, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_18_20

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   Abstract 

Purpose: Maxillary sinus pneumatization is usually noted after posterior teeth extraction. The pneumatization occurs at the expense of the alveolar bone and may compromise the residual ridge dimensions for further procedures. This article aimed to assess three dimensionally the linear and volumetric changes of the maxillary sinus following posterior teeth extraction using a split mouth study design.
Materials and Methods: Fifty cone-beam computed tomography (CBCT) scans with unilateral missing molar(s) or premolar(s) were assessed. Linear craniocaudal measurement from the orbital floor to the maxillary alveolar ridge was noted, and the sinus volume was measured using 3Diagnosys software (v3.1, 3Diemme, Cantu, Italy) and compared between the test and control side. Statistical analysis was performed using a paired Student's t-test.
Results: Linear dimensions of the maxillary sinus increased from 33.12 (±3.99) mm on the control side to 33.34 (±3.95) mm on the test side (P = 0.0005). An increase in the volume from 13.78 (±2.55) ml to 13.99 (±2.61) ml was observed in the control and test side, respectively (P = 0.0002).
Conclusion: A significant increase in sinus dimension and volume is seen after posterior teeth extraction. This may hinder further implant-supported rehabilitative procedures in this region.

Keywords: Cone-beam computed tomography, extraction, maxillary sinus, pneumatization


How to cite this article:
Padhye NM, Shirsekar VU, Bhange PD, Nikam SS, Marathe AS. Three-dimensional linear and volumetric assessment of the maxillary sinus following posterior teeth extraction with implications for dental implant: A split mouth cross-sectional cone-beam computed tomographic study. J Dent Implant 2021;11:30-5

How to cite this URL:
Padhye NM, Shirsekar VU, Bhange PD, Nikam SS, Marathe AS. Three-dimensional linear and volumetric assessment of the maxillary sinus following posterior teeth extraction with implications for dental implant: A split mouth cross-sectional cone-beam computed tomographic study. J Dent Implant [serial online] 2021 [cited 2021 Jun 15];11:30-5. Available from: https://www.jdionline.org/text.asp?2021/11/1/30/318067




   Introduction Top


The maxillary sinus, which is the largest air sinus, is the first paranasal sinus to develop.[1] It shows first signs of development at 10 weeks in utero, and after birth, the sinus continues to pneumatize into the maxillary alveolar ridge. This growth continues till the age of 20-year-old, that is, till the eruption of the third molars.[2] At this stage, the sinus lies 5 mm inferior to the nasal floor.[3],[4]

Pneumatization, which is a physiologic phenomenon, causes an increase in the sinus volume. Its occurrence in the maxillary sinus is particularly exaggerated after maxillary posterior teeth extraction.[5],[6],[7],[8] The reason for this is still unclear, but many factors such as heredity, craniofacial configuration, density of the bone, and growth hormones influence the sinus pneumatization.[9],[10],[11] This phenomenon, which occurs in accordance with Wolff's law, is a type of disuse atrophy, wherein the decrease of functional forces transferred to the bone after tooth loss causes a shift in the remodeling process toward bone resorption.[2] The amount of sinus pneumatization after a tooth loss is mainly influenced by the degree of protrusion of the tooth roots in the sinus,[5] the thickness of the cortical bone lining apical to the tooth, and the size of the extracted tooth.[12]

Sinus pneumatization posttooth extraction can have several implications on the treatment planning. Among the forefront is the surgical hazard for implant-supported rehabilitation of the posterior maxilla. Implant insertion with inadequate bone quantity carries a risk of oro-antral communication, and in many cases, an additional surgical procedure of sinus floor augmentation with the use of bone graft becomes a prerequisite for implant placement.[13],[14],[15],[16],[17]

Previously, periapical and panoramic radiographs were used to assess the degree of sinus pneumatization and availability of bone following tooth extraction. Two-dimensional evaluation studies of the sinus changes have shown conflicting results. Some have found an increase in the sinus dimensions after extraction,[5],[6],[18] while others have found no change.[19],[20] However, three-dimensional imaging overcomes the limitations of two-dimensional imaging such as lack of cross-sectional information, superimposition, distortion, and magnification.[21],[22],[23],[24]

Considering the anatomical variations of the maxillary sinus and the effects of its pneumatization, a three-dimensional linear and volumetric assessment is required. This would help establish the changes in the sinus and the alveolar bone posttooth extraction, which would help in preprosthetic surgical as well as implant planning. Thus, the aim of the present study was to assess the linear and volumetric dimensions of the maxillary sinus following posterior teeth extraction.


   Materials and Methods Top


The material for this retrospective split-mouth study comprised dental cone beam computed tomography (CBCT) images taken from the archives of a private maxillofacial radiology center in Mumbai, India. Ethical approval was obtained from the institutional review board and the guidelines of the Helsinki Declaration of 1975, as revised in 2000 were followed for this retrospective study. The selected radiographs were from subjects without a history of nasal and sinus diseases, previous history of sinus surgery, or diseases affecting the bone. To be included in this study, subjects had to have unilateral missing premolar(s) or molar(s) which were extracted a minimum of 6 months prior without the outline of the extraction socket visible.

The CBCT images were all obtained from the same machine Orthophos XG (Sirona Group, Bensheim, Germany) set at 85 kV and 4 mA, with a 14 s exposure time. Each CBCT scan was carefully studied to determine the inferior-most point of the sinus border. The linear dimensions of the maxillary sinus were taken from the lowest point of the cortical boundary of orbital floor to the lowest border of the cortical boundary of the sinus floor in the maxillary alveolar ridge (craniocaudal extension) [Figure 1]a and [Figure 1]b.[25] Volumetric assessment was done using 3Diagnosys software (v3.1, 3Diemme, Cantu, Italy) where the digital imaging and communications in medicine data were imported into the software. Volume was cropped to include maxillary sinus and “Airway Mode” was selected in “3D option.” Measure volume tool was then used to calculate the volume of the maxillary sinus [Figure 2]a and [Figure 2]b. The split mouth evaluation eliminated the discrepancies caused due to radiographic distortion.
Figure 1: (a) Linear craniocaudal (in mm) of dentulous site (control site) in panoramic and tangential section. (b) Linear craniocaudal (in mm) of edentulous site (test site) in panoramic and tangential section

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Figure 2: (a) Volume of the sinus (in mm) of dentulous site (control site) *Arrow indicates the measured volume. (b) Volume of the sinus (in mm) of edentulous site (test site). *Arrow indicates the measured volume

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Statistical evaluation

All the recorded data were entered in Microsoft Excel (MS office version 2010) and tabulated. Data analysis was done using Windows PC-based software “MedCalc Statistical Software” version 13.3.1 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2014). All testing was done at alpha 0.05 (95% confidence limits). Statistical significance between parameters was checked by paired Student's t-test. Differences above the 95% confidence intervals were regarded as statistically significant.


   Results Top


A total of fifty CBCT images were collected and analyzed for this study. Of these, 32 (64%) were males and 18 (36%) were females, with a mean age of 46 ± 5.2 years. The linear craniocaudal measurement was done in three separate sections along an anteroposterior axis, and a mean value of the three measurements was recorded for both the test and control sides. [Table 1] shows the linear and volumetric measurements of the test and control site. The mean craniocaudal dimension of the test site and control sites was 33.34 (±3.99) mm and 33.12 (±3.95) mm, respectively, whereas the mean volumes were 13.99 (±2.55) ml and 13.78 (±2.61) ml, respectively. On individual score comparison, a significantly increased linear dimension (P = 0.0005) was noted in the test site where posterior teeth were extracted as compared to the site where the teeth were present. The volumetric analysis showed a significantly greater maxillary sinus volume (P = 0.0002) in the test side as compared to the control side [Table 2]. However, in 7 CBCT radiographs, the linear measurement of the control side was found to be greater than the test side, and in six radiographs, the volume of the control side was more than the test side.
Table 1: Linear Cranio-caudal (mm) and volumetric (ml) measurements of test and control site

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Table 2: Student's t-test to compare the test and control group


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   Discussion Top


Since there are no previous reports on the degree of maxillary sinus pneumatization after tooth extraction in an Asian Indian population, this study could be the first to estimate the linear and volumetric changes of this paranasal air sinus. In the present study, CBCT was used to avoid superposition of anatomic structures, horizontal and vertical magnification, as is usually seen in panoramic radiographs. A plethora of evidence points toward the reliability and accuracy of the CBCT as a tool to assess the linear measurements of the bone.[26],[27],[28],[29] Although panoramic radiographs can be used for anteroposterior and superiorinferior measurements, the mediolateral dimensions cannot be assessed.[30] Moreover, <1% of relative error of volumetric data obtained from CBCT and in vivo digital caliper measurement was attained by Stratemann et al.[31] proving the precision of CBCT for maxillary sinus volumetric evaluation.

A split mouth study design in the same subject, to evaluate and measure the sinus floor position changes posttooth extraction, eliminated the possibility of distortion which may happen when the same measurements are compared between two separate radiographs. Furthermore, according to a study done by Packota et al.,[32] it was found that sinus sizes between subjects can differ up to 25%, which was again eliminated from our study.

Postextraction changes of the maxillary sinus have found to occur within 3–6 months when the socket is healing.[33] The pneumatization of the sinus occurs at the cost of the residual alveolar bone height and width. Once mature bone is formed, the pneumatization process relatively slows down or stops entirely.[19] Thus, radiographs with >6-month period after tooth extraction were included in the study to evaluate the full effects of sinus pneumatization.

A split mouth CBCT evaluation of 32 unilateral edentulous subjects was performed by Farina et al. in 2011.[34] In this, the maxillary posterior region bone height was found to be low with a more coronal position of the maxillary sinus floor. The linear dimensional results of our study were in agreement to this study, where an increased pneumatization of the maxillary sinus led to a decreased residual bone height. This study along with our study confirmed, on a three-dimensional basis, the vertical resorption of the ridge as a consequence of tooth loss in the maxillary posterior region.

Our study primarily consisted of radiographs of Asian Indian population. Amusa et al.[35] studied the volumetric measurements of the maxillary sinus in dried skulls of African (Nigerian) population and observed that they were smaller than that obtained from the European Caucasian population. A mean sinus volume of 11.59 ± 5.36 ml and 14.98 ± 10.77 ml was noted which is marginally lesser than the dimensions recorded in our study. This difference may be attributed to the anatomical variations and racial factors such as high degree of alveolar bone atrophy due to Vitamin D deficiency in Asian Indian population.[36]

It was noted in our study from 21 out of 50 radiographs, that a greater pneumatization occurs (linear: 0.7 ± 0.4 mm; volume: 0.2 ± 0.04 ml) in subjects with multiple missing posterior teeth as compared to single tooth extraction. This may be due to reduced bone resistance to the sinus pneumatization by the adjacent teeth, which may prevent sinus from expanding by transferring functional forces to the areas of missing teeth. A higher pneumatization was appreciated (linear: 0.2 ± 0.13 mm; volume: 0.08 ± 0.02 ml) when the second molar tooth is extracted, as was seen from 9 out of 50 radiographs. This may be attributed to the close proximity of the sinus floor to the root tip of the second molar which may cause a loss of the thin bone separating the alveolar socket from the sinus during its extraction.[37],[38] Furthermore, in the current study, it was noted that a relatively larger pneumatization occurred in subjects with teeth surrounded by a superiorly curving sinus floor where the sinus extended between the roots of the adjacent teeth. This may be due to the incidence of decreased cortical bone thickness in such cases.[39] The results attained by Sharan and Madjar in 2008[19] were in contrast to these results, who performed a similar study in a two-dimensional radiographic image.

This study is clinically significant in cases where prosthetic rehabilitation using dental implants is to be considered. The study confirmed that, with long-term edentulism, there is a tendency for progressive enlargement of the maxillary sinus and atrophy of the alveolar bone, making such patients less suitable for implant treatment. In such conditions, the remaining bone volume and dimensions may be preserved by preventing sinus pneumatization either by immediate implant placement or by bone grafting of the extraction socket during the time of extraction.[40],[41] This may prevent the collapse of the thin cortical bone lining of the sinus floor and maintain architecture of the bone. This study also established the advantages of three-dimensional CBCT technology which can be used with much accuracy for determining the bone conditions before surgical interventions. Further longitudinal studies with a pre- and post-extraction three-dimensional assessment might be required to identify the precise sinus changes that occur.


   Conclusion Top


Within the limitations of this study, it can be inferred that significant linear and volumetric changes occur in the maxillary sinus, resulting in its exaggerated pneumatization, 6 months after tooth extraction in subjects with missing posterior teeth. These changes may be amplified in case of second molar extractions or multiple posterior teeth extractions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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