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. 2024 Dec 19;24:1516. doi: 10.1186/s12903-024-05341-z

Maxillary sinus volume changes in individuals with different craniofacial skeletal patterns: CBCT study

Kevser Dinç 1, Derya İçöz 1,✉
PMCID: PMC11661000  PMID: 39702251

Abstract

Background

The maxillary sinus, which is crucial for craniofacial growth, is the largest and earliest sinus to develop among the paranasal sinuses. Our study aimed to evaluate the maxillary sinus volume (MSV) in individuals with different sagittal skeletal patterns via cone beam computed tomography (CBCT).

Materials and methods

In this study, CBCT images of 106 retrospectively selected patients (62 females and 42 males) were included. The ANB and SNA angles were measured to determine the skeletal pattern and position of the maxilla in the sagittal direction. Patients were divided into three groups according to ANB angle: Class I (ANB 2°±2°), Class II (ANB˃4°), and Class III (ANB < 0°). The position of the maxilla in the sagittal direction was divided into three groups according to the SNA angle: normal (SNA 82°±2°), retrognathic (SNA < 80°) and prognathic (SNA˃84°). The MSV was measured by two observers and the data obtained were statistically analyzed.

Results

The mean age of the participants was 22.5 ± 4.32. The mean MSV was 28.598 ± 7.9 cm3 in females and 34.231 ± 8.93 cm3 in males. The difference between the sexes was statistically significant in terms of MSV (p < 0.001). When the MSV was compared according to different skeletal patterns and positions of the maxilla, no statistically significant difference was detected between the SNA groups (p = 0.650) and the ANB groups (p = 0.905).

Conclusions

Different skeletal patterns and positions of the maxilla in the sagittal direction do not significantly change the MSV, but compared with sex, the MSV is greater in males than in females. The outcomes of this study may be beneficial in the context of dental interventions such as orthodontics and maxillofacial surgery.

Clinical trial number

Not applicable.

Keywords: Cone beam CT, Malocclusion, Maxillary sinus, Maxillary sinus volume, Skeletal pattern

Introduction

The maxillary sinuses, which are located bilaterally within the body of the maxilla and have the alveolar bone and hard palate at their base, are pneumatic cavities filled with air inside the maxillofacial complex [1]. Owing to their close relationship with the teeth in the maxilla, their location, and the volume they occupy, maxillary sinuses are important anatomical structures that dental practitioners should always consider and evaluate [2, 3].

The maxillary sinus, which is the largest and initiates development first among the paranasal sinuses, commences its formation during the third trimester of fetal development and undergoes pneumatization until approximately 15–18 years of age [4, 5]. The size of the maxillary sinus can have a significant impact on situations such as endodontic procedures, apical resection, periodontal flap surgery, tooth extraction, and orthognathic surgery [6, 7]. The maxillary sinus volume (MSV), which can vary due to pathological conditions such as systemic and neoplastic diseases, is approximately 14–18 cubic centimeters (cm3) in adults. After the period of maximum growth, the volume decreases with age regardless of sex [8]. Furthermore, alterations in the MSV can ensue as a result of orthodontic interventions, post-use of a facemask, or rapid maxillary expansion [9].

The maxillary sinus region is of paramount importance in orthodontic treatment, particularly for the placement of mini screw anchorage devices within the interalveolar septum between the maxillary premolars and molars. This situation emphasizes the importance of the relationship between the size and morphological characteristics of the maxillary sinus and different skeletal patterns [10].

To date, numerous studies have evaluated the maxillary sinus via different techniques [10–15]. The initial studies, which were conducted on dry skulls or cadavers by injecting different materials and using lateral cephalometric and panoramic radiography, were replaced by computed tomography (CT), cone beam computed tomography (CBCT), and magnetic resonance imaging (MRI) methods with advancements in technology [13]. The use of these methods allows accurate examination of the paranasal sinuses in different planes and three dimensions.

Compared with traditional CT, CBCT is preferred in dentistry for treatment and diagnostic planning, offering well-defined images and a lower radiation dose with a shorter processing time. Additionally, CBCT provides three-dimensional sectional imaging that eliminates image errors such as distortion, magnification, and superimposition [16].

As a result of our literature review, few studies have evaluated the effects of the maxillary position relative to the skull base and various skeletal patterns in the sagittal direction on the MSV and there is no consensus between them [2, 8, 9, 14, 17–19]. Based on these observations, the objectives of our study were as follows:

  • To evaluate the MSV in individuals with different sagittal skeletal patterns using CBCT.

  • To examine the relationship between MSV and sex.

  • To analyze the influence of the sagittal position of the maxilla on MSV.

The null hypothesis (H₀) of this study posits that MSV does not significantly vary with different sagittal skeletal patterns, sex, or sagittal maxillary positions. The our study seeks to provide meaningful insights that can contribute to advancements in orthodontic and maxillofacial surgical practices.

Materials and methods

This retrospective study has ethics committee approval from the meeting number 2024/15 of the Selcuk University Faculty of Dentistry Non-Interventional Clinical Research Evaluation Commission dated 07.05.2024.

Sample size and selection of individuals

In this study, the images of patients who underwent CBCT imaging for various dentomaxillofacial reasons between January 2018 and March 2024 at Selcuk University Faculty of Dentistry, Department of Oral and Maxillofacial Radiology were retrospectively examined.

The sample size for this study was calculated via G*Power software (ver. 3.1.9.7; Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany). On the basis of the article by Magat et al., the total number of samples was determined to be at least 78 with a 5% margin of error (α = 0.05) and 95% power (1-β = 0.95) [18].

All images used in our study were obtained via a CBCT device (Instrumentarium Dental, Palo DEx Group Oy Nahkelantie 160 FI-04300 TUUSULA, Finland) in our clinic. Images were acquired with a 13 × 15 cm FOV, 0.5 mm slice thickness, 89 kVp, 4–12 mA, and a voxel size of 0.320–0.380 mm³, with a 360° rotation over 8.14 s. Routine CBCT images of the patients were taken while standing in a natural head posture, with the jaws in a centric relationship, the teeth in maximum intercuspation, and the lips at rest, ensuring the Frankfort Horizontal (FH) plane was aligned parallel to the ground plane and the midsagittal plane perpendicular to it. During imaging, patients were instructed to remain still, avoid swallowing and hold their breath.

A total of 106 patients were included in the study in accordance with the inclusion and exclusion criteria. Attention was given to ensure that all boundaries of the maxillary sinus were fully visible in three dimensions, and those images with a field of view (FOV) of 13 × 15 cm, in which the reference points taken for skeletal cephalometric measurements could be clearly identified, were included in the study.

Our inclusion criteria for the study were as follows: adult patients (18 years and older), with all permanent maxillary premolars and molars fully erupted and root apices fully formed, and patients without root resorption or bone destruction around the maxillary premolars and molars. The exclusion criteria included: patients with any craniofacial anomaly, facial trauma, systemic diseases affecting the head and neck region, any pathology in the maxillary sinus, a history of maxillary sinus surgery or grafting, those who underwent orthodontic and/or orthognathic surgical treatment, and those with excessive mucosal thickening in the maxillary sinus (exceeding 10 mm) [20]. The sex and age of the patients included in this study were obtained from anamnesis records. CBCT images that did not meet the aforementioned selection criteria were excluded from the study.

Cephalometric and volumetric measurements

All the measurements were performed by the same observer. To assess the repeatability of the measurements, all MSVs were repeated by a second observer.

Cephalometric measurements for all patients were performed on midsagittal sections obtained from CBCT images via OnDemand3D Viewer software (CyberMed Inc, Seoul, Korea). The sagittal skeletal groups were classified according to ANB angles (normal value 2°±2°) into Class I (0 < ANB < 4), Class II (ANB > 4), and Class III (ANB < 0) [21]. The anteroposterior position of the maxilla relative to the anterior cranial base was categorized into three groups on the basis of the SNA angle: normal (SNA 82°±2°), prognathic (SNA > 84°), and retrognathic (SNA < 80°) [21] (Fig. 1).

Fig. 1.

Fig. 1

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ANB and SNA angles for cephalometric analysis. ANB: The angle that determines the relative positions of the maxilla and mandible in the sagittal plane. SNA: The angle between the maxilla and the anterior cranial base

CBCTs of the patients included in the study were exported to 3D Slicer 5.2.2 (Surgical Planning Lab, Harvard Medical School, Harvard University, Boston, MA, USA), a free and open access software, in Digital Imaging and Communications in Medicine (DICOM) format. To ensure standardization across all the CBCT data, the voxel sizes were preprocessed via the “Resample Scalar Volume” module with “b-spline” interpolation, and the spacing was set to ( 0.32 × 0.32 × 0.32 ) mm³. Thus, the repeatability and reliability of the data were ensured during the comparison of volume measurements. Segmentation of the maxillary sinus was performed semi-automatically via threshold-based segmentation via the ‘Segment Editor’ module, and the right and left MSVs were evaluated individually for each patient. For all the CBCT images, a minimum (-1000) to maximum (-500) HU threshold was selected to best visualize the airway boundaries and achieve optimal separation from the surrounding bony tissue [22]. After a mask that included only the maxillary sinus air spaces was created, the “scissors” tool from the “segment editor” module was selected, and the “erase outside/rectangle” and “erase outside/free form” tools were used to disconnect the maxillary sinus from the external environment. The maxillary sinus was then converted into a three-dimensional (3D) object by clicking on the “Show 3D” tool, thus generating a 3D model. Finally, the MSV was calculated in cm³ via the “Segment Statistics” option in the “Quantification” module (Fig. 2).

Fig. 2.

Fig. 2

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Three-dimensional image of the maxillary sinus and volume calculation in cm3

Statistical analysis

The IBM SPSS V.22 (for Windows, SPSS Inc., Chicago, IL) program was used for statistical analysis. The G*power 3.1 program was used for power analysis. Interobserver agreement was calculated with the intraclass correlation coefficient (ICC). Intraclass correlation coefficients of 0.8 and 0.9 were considered good and perfect fits, respectively [23]. Shapiro-Wilk tests and variance homogeneity tests were performed to analyse the parametric test assumptions of the data. The Mann-Whitney U test was used to compare MSV according to sex, the paired samples t test was used to compare the right and left MSVs, and Kruskal-Wallis test was used to compare the SNA and ANB groups. A p value of 0.05 was considered statistically significant.

Results

The ICC values were 0.987 and 0.964 for the right and left MSVs, respectively, indicating high interobserver agreement. A total of 106 people, consisting of 62 females (60.38%) and 42 males (39.62%) with a mean age of 22.5 ± 4.32 years, participated in the study. The mean SNA angle was 81.873o ± 3.23o and the mean ANB angle was 2.287o ± 4.16o. Descriptive statistics, including the means ± standard deviations (SDs) and frequency analyses, are presented in Table 1.

Table 1.

Descriptive analysis of parameters according to genders

Female (n = 64)
Mean ± SD		 Male (n = 42)
Mean ± SD		 Total (n = 106)
Mean ± SD
Age 21.609 ± 3.35 23.857 ± 5.24 22.5 ± 4.32
SNA (o) 81.491 ± 3.2 82.455 ± 3.23 81.873 ± 3.23
ANB (o) 2.77 ± 4.05 1.55 ± 4.26 2.287 ± 4.16

Female

n(%)

Male

n(%)

Total

n(%)

SNA Groups Normal 38(35.8%) 25(23.6%) 63(59.4%)
Prognathic 12(11.3%) 10(9.4%) 22(20.8%)
Retrognathic 14(13.2%) 7(6.6%) 21(19.8%)
ANB groups Class I 24(22.6%) 14(13.2%) 38(35.8%)
Class II 25(23.6%) 12(11.3%) 37(34.9%)
Class III 15(14.2%) 16(15.1%) 31(29.2%)
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While the MSV for the right sinus was 15.448 ± 4.45 cm3 and that for the left sinus was 15.381 ± 4.41 cm3, there was no statistically significant difference between the right and left MSVs (p = 0.648). For females the right MSV was 14.396 ± 4.13 and the left MSV was 14.201 ± 3.93 (p = 0.332); for males, the right MSV was 17.051 ± 4.48 and the left MSV was 17.179 ± 4.56 (p = 0.548).

MSV was greater in males than in females for both the right and left sinuses (p < 0.05). Although the MSV tended to be greater in prognathic cases than in normal and retrognathic cases, the difference between the groups was not statistically significant (p > 0.05). Similarly, when the relationship between ANB groups and MSV was evaluated, the MSV tended to be narrower in Class III patients, but the difference between the groups was not statistically significant (p > 0.05) (Table 2).

Table 2.

Distribution and statistical comparisons of MSV according to genders (Mann Withney-U test) and according to groups (Kruskal Wallis test)

MSV (right)
Mean ± SD (cm3)		 MSV (left)
Mean ± SD
(cm3)		 MSV (total)
Mean ± SD
(cm3)
Gender Female 14.396 ± 4.13 14.201 ± 3.93 28.598 ± 7.9
Male 17.051 ± 4.48 17.179 ± 4.56 34.231 ± 8.93
p 0.001* < 0.001* < 0.001*
SNA groups Normal 15.331 ± 4.82 15.135 ± 4.63 30.466 ± 9.36
Prognathic 16.277 ± 4.13 16.11 ± 4.21 32.387 ± 8.23
Retrognathic 14.933 ± 3.57 15.354 ± 4.09 30.288 ± 7.41
p 0.609 0.600 0.650
ANB groups Class I 15.502 ± 4.31 15.255 ± 4.41 30.757 ± 8.6
Class II 15.852 ± 4.8 15.764 ± 4.52 31.616 ± 9.23
Class III 14.901 ± 4.26 15.078 ± 4.42 29.979 ± 8.5
p 0.865 0.950 0.905
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*Statistically significant (p < 0.05), MSV: Maxillary sinus volume

Discussion

The maxillary sinuses are the largest of the paranasal sinuses and the alveolar process of the maxilla both supports the dentition and forms the inferior border of the maxillary sinus. Therefore, the roots of the maxillary posterior teeth are closely related to the maxillary sinus [1]. Because of this anatomical proximity, the maxillary sinuses are the paramount anatomical location for dentists [18]. It is essential to assess the maxillary sinus before performing dentoalveolar procedures such as endodontic surgery, implant surgery, extraction of impacted teeth, orthodontic interventions, and orthognathic surgery in the maxillary posterior region [18, 24]. Since the maxillary sinus does not have a clear shape and has an anatomically complex structure, dimensional evaluation of the maxillary sinus should be performed volumetrically [25, 26]. Therefore, in our study, we investigated volumetric changes in a group of dental patients. The minimum sample size required for our study was calculated to be 78 participants. However, to account for potential data loss and to enhance the statistical power and reliability of the results, the sample size was increased by more than 20%, resulting in a total of 106 participants included in the study.

Many factors affecting maxillary sinus dimensions have been mentioned in the literature, including sex, age, tooth loss, malocclusions, different growth patterns of the jaws, orthodontic treatments and surgical interventions [5, 9, 13, 14, 25–27]. In this study, the effects of sex, the position of the maxilla relative to the skull base and different skeletal patterns in the sagittal direction on the MSV were investigated. In the current study, the CBCT’s FOV did not allow us to classify based on the vertical growth pattern. However, in studies investigating the effects of vertical classification on MSV in the literature, it has been observed that while MSV tends to be larger in dolichocephalic individuals, no statistically significant differences were found between the groups [19, 28].

In this study, MSV was greater in males than in females, in accordance with the findings of several previous studies [19, 25–30]. However, studies in the literature have shown that sex has no statistically significant effect on MSV [18, 31]. Unlike their own studies, Lessa et al. [31] reported that the maxillary sinus was larger in males than in females because of the greater facial size in men. Similarly, the presence of larger MSVs in males than in females has been interpreted as sexual dimorphism and has been associated with males having larger dimensions than females do, as in many craniofacial structures [28]. Considering this situation, it is conceivable that MSV may be affected by dimensional differences between individuals. Particularly, the increased MSV observed in male individuals may serve as a clinical guide for orthodontic mini-screw applications and dental procedures performed near the sinus floor. In our study, no statistically significant difference was detected between the right and left MSVs in either females or males. There are studies in the literature that support this finding [32, 33]. However, a study has reported that individuals with nasal septal deviation exhibited a statistically significant difference between the right and left MSVs [34]. Furthermore, factors such as dental arch asymmetry, the number of missing teeth, the duration of tooth loss, and adjacent anatomical structures may also contribute to these volumetric differences.

The SNA angle indicates the position of the maxilla according to the cranial base in the sagittal plane [18]. In our study, no statistically significant relationship was detected between SNA groups and MSV, which is compatible with the literature [10, 26, 35, 36]. The ANB angle shows the position of the maxilla and mandible relative to each other and determines the skeletal pattern/skeletal malocclusion. A study conducted by Shrestha et al. [19], revealed that the MSV of Class II patients was significantly wider than that of Class III patients in a classification made according to ANB. In our study, although the mean MSV in Class II patients was greater than that in Class III patients, the difference was not statistically significant. The difference between the study results is thought to be related to the angle values used for ANB classification being different from those used in the present study. In addition, the study population, ethnic factors and measurement differences may also affect the study results. In a study using the same ANB classification as ours, no relationship was found between the classes created according to the ANB angle and MSV [30].

Our study demonstrated that MSV does not differ across different sagittal skeletal patterns and that sagittal discrepancies have no measurable impact on sinus anatomy. Ronsivalle et al. reported that rapid maxillary expansion (RME) significantly increases nasal cavity and pharyngeal airway volumes in growing individuals, emphasizing the interaction between skeletal interventions and airway dimensions [37]. Similarly, Tanaka et al. highlighted that orthodontic treatment, including multibracket appliances, may facilitate increases in maxillary sinus height and volume post-treatment, suggesting that biomechanical stimulation during orthodontic interventions can influence sinus morphology [38]. Therefore, only patients who had not undergone orthodontic treatment were included in our study to ensure accurate evaluation.

Various imaging methods such as cephalometric radiography, panoramic radiography, CT, MRI, and CBCT, have been used in the evaluation of maxillary sinuses in the literature [10, 13, 18, 24–27, 32, 39]. Compared with CT, CBCT offers advantages such as a relatively low radiation dose, shorter image acquisition time, and higher resolution, as well as more accurate measurement opportunities in airway evaluation because CBCT allows images to be taken while the patient is sitting or standing [2, 26]. In our study, both MSV measurements and cephalometric analyses were performed on CBCT images.

In our study, semi-automatic segmentation of the maxillary sinus was performed using the threshold-based segmentation tools available in 3D Slicer. Lo Giudice et al. [40] demonstrated the reliability of 3D Slicer in volumetric analyses, reporting a high ICC when compared with manual segmentation, the gold standard. While semi-automatic methods offer precise adjustments for complex anatomical regions, they depend on operator expertise, which can introduce variability [40]. In contrast, fully automatic methods, such as convolutional neural networks (CNNs), provide high efficiency and reduced operator dependency but require substantial computational resources and large training datasets. Semi-automatic methods remain advantageous in scenarios involving variable anatomy or low-contrast imaging regions, offering an accessible and practical solution for both clinical and research applications [41].

The limitations of this study include that it was conducted on a relatively small study population according to inclusion/exclusion criteria and therefore may not be a complete representation of the general population. In addition, the FOV in our study was sufficient for sagittal cephalometric analysis but inadequate for vertical analysis, limiting the scope of the study and excluding the assessment of vertical skeletal patterns. Future studies incorporating more comprehensive cephalometric analyses are needed to evaluate the relationship between various craniofacial features and MSV. Meanwhile, the retrospective nature of our study reflects the natural variability within the patient population. Consequently, the unequal distribution of participants in terms of gender and SNA groups represents a limitation stemming from this inherent variability. To validate these findings, future prospective studies with controlled and balanced participant groups are recommended.

Conclusion

In this study, the MSV was measured in groups according to the SNA and ANB angles and sex. According to the study results, the MSV was greater in males than in females and did not significantly differ between different sagittal skeletal patterns. The results of this study may be beneficial for orthodontic, orthognathic and other maxillofacial surgical interventions.

Acknowledgements

Not applicable.

Author contributions

Methodology was developed by K.D. Software was provided by K.D. Validation was conducted by K.D. and D.I. Formal analysis was carried out by D.I. Investigation was performed by K.D. Resources were provided by K.D. and D.I. K.D. and D.I. wrote the original draft. K.D. prepared the figures. D.I. prepared the tables. K.D. and D.I. reviewed the manuscript.

Funding

The authors declared that this study has received no financial support.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality of personal information but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was carried out in accordance with the principles outlined in the Declaration of Helsinki and received ethical approval from the Selcuk University Non-Interventional Clinical Research Ethics Committee (2024/15). This is a retrospective archive study. However, informed consent is obtained from all patients examined in our clinic.

Consent for publication

not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality of personal information but are available from the corresponding author on reasonable request.

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