CBCT-Based 3D Assessment of Maxillary Sinus and Pharyngeal Airway in Unilateral Cleft Lip and Palate

Abstract

Background

Cleft lip and palate (CLP) is one of the most common congenital craniofacial anomalies, often associated with structural variations in the maxillary sinus and pharyngeal airway. These alterations may predispose individuals to complications such as sinusitis and obstructive sleep apnea. While previous studies have investigated these structures, most relied on two-dimensional imaging, which has inherent limitations for evaluating three-dimensional structures. Moreover, the maxillary sinus and airway have rarely been evaluated together in a unified three-dimensional framework, despite their close developmental relationship. Cone Beam Computed Tomography (CBCT) offers improved three-dimensional assessment. This study aimed to evaluate maxillary sinus and pharyngeal airway volumes in individuals with unilateral CLP (UCLP) using CBCT and compare findings with a matched control group.

Methods

This retrospective study analyzed CBCT images of 30 individuals with UCLP and 30 age- and sex-matched healthy controls (ages 12–20). Images were processed using ITK-SNAP software. Maxillary sinuses were segmented bilaterally, and pharyngeal airway volumes were defined using standardized anatomical landmarks. Volume measurements were obtained using a semi-automatic method, and statistical analyses were performed via SPSS.

Results

The UCLP group showed a significantly lower left maxillary sinus volume compared to controls (p = 0.011), while right sinus volumes were not significantly different. Pharyngeal airway volumes were lower in the UCLP group but not statistically significant (p > 0.05). No significant differences were observed based on cleft side, sex, or age within either group.

Conclusion

This study revealed a unilateral reduction in left maxillary sinus volume in UCLP patients, while other volumetric differences were not statistically significant. Despite limited statistical variation, the known anatomical deviations in UCLP may increase susceptibility to respiratory and sinus pathologies. However, this volumetric evaluation was limited by the absence of functional or dynamic assessment of airway performance. CBCT provides a reliable modality for detailed volume analysis. Future studies should incorporate larger, multicenter samples and dynamic assessments to further clarify functional implications and guide clinical decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-08174-0.

Introduction

Cleft lip and palate (CLP) anomalies can be classified according to the involvement of the primary and secondary palates, with distribution patterns varying by sex, type, and anatomical location [1]. CLP is a complex condition that can affect multiple systems, including feeding, speech, hearing, dentition, facial morphology, psychological well-being, and respiratory tract health [2, 3].

One frequently observed complication in individuals with CLP is maxillary sinusitis. However, the underlying causes remain unclear, leading to increased interest in studies evaluating the morphology and volume of the maxillary sinus [4–7]. Due to the distinct embryological development of the maxilla, anatomical variations such as abnormal positioning of the sinus ostium may result in impaired drainage and predisposition to sinusitis [6]. Nonetheless, some studies have reported no significant differences in maxillary sinus volume between individuals with CLP and healthy controls [8–10]. Most of these studies utilized two-dimensional imaging techniques, including conventional radiographs and computed tomography [6, 8, 9].

Some studies have reported differences in adenoid tissue size in patients with unilateral cleft lip and palate, whereas others have described variations in pharyngeal airway volume. However, the relationship between adenoid tissue, pharyngeal airway volume, and cleft lip and palate remains inconsistent in the literature, indicating the need for more reliable and comprehensive data [11–16]. Previous studies have largely relied on lateral cephalometric images and other two-dimensional methods, which have inherent limitations in evaluating complex three-dimensional anatomical structures [11, 17–19].

In recent years, Cone Beam Computed Tomography (CBCT) has become a widely accepted imaging modality for the three-dimensional assessment of the maxillary sinus and the pharyngeal airway, owing to its lower radiation dose and faster image acquisition compared with conventional computed tomography, while allowing visualization of structures in all three planes [20]. Although several studies have analyzed either the maxillary sinus or the pharyngeal airway morphology in patients with cleft lip and palate, few have examined both structures simultaneously. Given their close developmental relationship, a combined three-dimensional assessment may provide deeper insight into the compensatory remodeling patterns that occur due to unilateral deformity. Furthermore, previous research often mixed bilateral and unilateral cases or applied variable imaging protocols, limiting comparability. The present study addresses these gaps through a standardized CBCT-based evaluation of both structures in surgically repaired unilateral CLP patients.

The null hypothesis of this study was that there would be no significant differences in maxillary sinus or pharyngeal airway volumes between individuals with unilateral cleft lip and palate and non-cleft controls.

The aim of this study is to perform three-dimensional measurements of the maxillary sinus and pharyngeal airway volumes in individuals with CLP using CBCT images, compare the results with existing literature, and evaluate the impact of CLP on these anatomical structures, with the ultimate goal of informing potential treatment protocols targeting these regions.

Methods

This retrospective study was based on CBCT images obtained between 2012 and 2018 from the archives of the Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Gazi University. CBCT scans were obtained from consecutive cases that met the inclusion criteria during the study period. Randomization was not applicable due to the retrospective design; however, the control group was matched with the UCLP group in terms of age, sex, and orthodontic treatment history to minimize confounding effects. Ethical approval was obtained from the Gazi University Ethics Committee under protocol number 2021 − 831.

All CBCT images were acquired using a Planmeca Promax 3D device (Helsinki, Finland) with patients in an upright position. Images that included the entire maxillary sinus and pharyngeal airway regions were selected. Acquisition parameters included: 10 mA, 90 kVp, 0.4 mm voxel size, and 160 × 160 mm field of view (FOV). All CBCT scans were obtained with patients seated, ensuring that the Frankfurt Horizontal Plane (FHP) was parallel to the floor. During image acquisition, patients were instructed to keep their teeth in light centric occlusion, maintain the tongue in a natural resting position, and hold their breath during the short exposure period to minimize motion artifacts.

The study sample consisted of 30 individuals with UCLP, and a control group of 30 healthy individuals matched for age, sex, orthodontic history, and absence of syndromic conditions. Inclusion criteria were:

• Age between 12 and 20 years,

• No history of orthodontic treatment, participants with previous orthodontic treatment were excluded to prevent confounding effects of treatment-induced skeletal or dental changes on maxillary sinus and pharyngeal airway volumes.

• Absence of any syndromic or systemic disease,

• Sufficient image quality for volumetric analysis.

Image analysis and segmentation

All tomographic data were exported in DICOM format and imported into ITK-SNAP software (version 3.8.0) for volumetric analysis. Prior to segmentation, all CBCT datasets were reoriented in ITK-SNAP according to the FHP to standardize head position and ensure that the axial, coronal, and sagittal planes were perpendicular to the world coordinate axes. Volumetric measurements of the maxillary sinus and pharyngeal airway were performed using the semi-automatic “Active Contour” segmentation mode of the software (Fig. 1). Following segmentation, all regions were reviewed slice-by-slice in the axial, sagittal, and coronal planes, and manual corrections were applied when necessary to eliminate over- or under-segmentation.

Fig. 1.

Axial, coronal, and sagittal CBCT slices demonstrating image reorientation according to the Frankfurt Horizontal Plane prior to segmentation

The segmentation process was carried out as follows:

• Air-filled spaces were identified using grey-scale value thresholds. Since all scans were acquired with the same device and exposure parameters, a fixed grey-value threshold range (− 1024 to − 504) was applied. This range was determined through preliminary testing on multiple images.

• The region of interest was manually outlined according to anatomical boundaries (Fig. 2), For the maxillary sinus, the medial, lateral, superior, and inferior walls were defined as the anatomical boundaries, while for the pharyngeal airway, the superior, inferior, and anterior boundaries were defined using the Frankfurt Horizontal Plane (FHP), a plane parallel to the FHP passing through the anteroinferior point of the third cervical vertebra (C3), and a plane perpendicular to the FHP intersecting the anterior nasal spine (ANS), respectively. During segmentation, the nasal cavity and turbinates were carefully excluded by setting the medial wall (lateral nasal wall) as the boundary. In ITK-SNAP, a combination of the brush and region-growing tools was used to isolate only the air-filled space within the sinus cavity, with the osteomeatal complex serving as the medial limit.

Fig. 2.

Determination of the maxillary sinus region on CBCT slices for volumetric analysis. a Axial view, b Sagittal view, and c Coronal view. In all three planes, the red dashed boxes represent the 'Region of Interest' (ROI) defined for volume measurement. The intersection of blue reference lines indicates the orientation used for consistent volumetric calculations of the sinus cavity

• Seed points were placed within the outlined region,

• The software automatically delineated the outer contours using the edge attraction algorithm,

Following semi-automatic segmentation, all regions were validated by visual inspection in the axial, sagittal, and coronal planes to ensure anatomical accuracy. When necessary, over- or under-segmented areas were manually corrected using the software’s editing tools. Additionally, intra-observer reliability was assessed by repeating measurements on randomly selected scans after a three-week interval, and the intraclass correlation coefficient (ICC) was calculated.

Measurement regions

Maxillary sinus volume: In UCLP patients, both cleft and non-cleft sides were measured separately; in the control group, right and left sides were measured independently.

Pharyngeal airway volume: To ensure reproducibility and minimize subjectivity, anatomical standardization was performed using fixed skeletal reference planes. The superior boundary was defined by the FHP. The inferior boundary was established as a plane parallel to the FHP passing through the anteroinferior point of the C3. The anterior boundary was defined by a plane perpendicular to the FHP intersecting the ANS. Volumetric analysis was conducted strictly within these standardized limits (Figs. 3 and 4). These reference planes were selected because they are based on stable skeletal landmarks that remain clearly identifiable on CBCT images and provide reproducible anatomical limits independent of soft-tissue variations. Although cleft-related anatomical distortion may affect local morphology, these osseous structures allow consistent standardization across subjects.

Fig. 3.

Three-dimensional reconstruction of the segmented pharyngeal airway region used for volumetric analysis. Semi-automatic segmentation and 3D reconstruction of the upper airway on CBCT data. a Axial view, b Sagittal view, c Coronal view; the green highlighted areas represent the segmented airway volume. d Free-standing view of the generated 3D airway model

Fig. 4.

Reference planes used for airway segmentation: Frankfurt Horizontal Datum/Plane (FHD), inferior pharyngeal boundary, and posterior nasal plane

Statistical analysis

A priori power analysis was performed to determine the required sample size based on the mean and standard deviation values for oropharyngeal airway volume reported by Çelikoğlu et al. (2014) [12]. The sample size calculation was performed using G*Power 3.1 software (Heinrich-Heine-University, Düsseldorf, Germany). Based on the mean and standard deviation values reported by Çelikoğlu et al. (2014), a two-tailed independent t-test with α = 0.05, power (1–β) = 0.80, and an effect size (d) = 0.82 indicated a minimum of 26 participants per group. The inclusion of 30 subjects per group in the present study thus ensured adequate statistical power. Statistical analyses were conducted using IBM SPSS Statistics software (IBM Corp., Armonk, NY, USA).

The normality of data distribution was assessed using the Kolmogorov–Smirnov test. Descriptive statistics (mean, standard deviation, minimum, and maximum values) were calculated for all variables. Depending on the distribution characteristics, parametric or non-parametric tests were applied as appropriate. Between-group comparisons were performed using independent-samples t-test or Mann–Whitney U test, and within-group comparisons were performed using paired-samples t-test or Wilcoxon signed-rank test. A significance level of p < 0.05 was considered statistically significant.

To assess intra-observer reliability, 16 randomly selected CBCT images from a total of 60 were remeasured by the same observer three weeks after the initial measurements. Methodological error due to repeated measurements was evaluated using the intraclass correlation coefficient (ICC) along with the corresponding confidence interval. Additionally, repeated measures analysis of variance (Repeated Measures ANOVA) was applied to evaluate the consistency of repeated measurements.

Results

A total of 30 individuals with UCLP and 30 healthy control subjects matched for age, sex, and orthodontic treatment status were included in the study. The mean age of the UCLP group was 16.4 ± 3.0 years (range: 13.1–19.8), while the control group had a mean age of 17.1 ± 2.5 years (range: 14.6–20.0). Among the individuals with UCLP, 7 had a left-sided cleft and 23 had a right-sided cleft (Table 1).

Table 1.

Distribution of participants by age and sex

Group	n	Male n (%)	Female n (%)	Mean Age ± SD	Age Range
UCLP Group	30	19 (63.3%)	11 (36.7%)	16.4 ± 3.0 years	13.1 – 19.8
Control Group	30	16 (53.3%)	14 (46.7%)	17.1 ± 2.5 years	14.6 – 20.0

UCLP Unilateral Cleft Lip and Palate, SD Standard Deviation

Maxillary sinus volumes

In the UCLP group, the mean maxillary sinus volumes were evaluated according to the side of the cleft. The mean sinus volume on the cleft side was 12024.2 ± 4553.5 mm³, while the volume on the non-cleft side was 12643.3 ± 4345.1 mm³. Intra-group comparison revealed no statistically significant difference between the cleft and non-cleft sides (p = 0.133). When analyzed by sex, the mean cleft-side sinus volume was 9690.5 ± 4885.2 mm³ in females and 9776.1 ± 4950.0 mm³ in males. The non-cleft side volumes were 9935.8 ± 3644.7 mm³ in females and 10125.6 ± 4239.2 mm³ in males. No statistically significant differences were observed between the cleft and non-cleft sides for either females (p = 0.920) or males (p = 0.840). Furthermore, inter-group comparison demonstrated that the sinus volume corresponding to the cleft side (predominantly the left side in our sample) was significantly smaller in the UCLP group (12024.2 ± 4553.5 mm³) compared with controls (15599.8 ± 4063.3 mm³; p = 0.011), whereas no significant difference was observed for the contralateral/non-cleft side (p = 0.193) (Table 2).

Table 2.

Maxillary sinus volumes in cleft and non-cleft sides of UCLP patients, including sex-based comparisons

Comparison	Side	n	Mean ± SD (mm³)	p-value
UCLP Group	Cleft side	30	12024.2 ± 4553.5	0.133
	Non-cleft side	30	12643.3 ± 4345.1
Female	Cleft side	11	9690.5 ± 4885.2	0.920
	Non-cleft side	11	9935.8 ± 3644.7
Male	Cleft side	19	9776.1 ± 4950.0	0.840
	Non-cleft side	19	10125.6 ± 4239.2

UCLP Unilateral Cleft Lip and Palate, SD Standard Deviation. p-values were calculated using independent samples t-test. A p-value < 0.05 was considered statistically significant

Pharyngeal airway volumes

According to cleft side, right-sided UCLP patients (n = 23) showed a mean airway volume of 16263.4 ± 4964.0 mm³, whereas left-sided patients (n = 7) showed 19988.3 ± 12585.2 mm³, with no statistically significant difference (p = 0.145). In the UCLP group, airway volume was 16785.5 ± 5793.1 mm³ in females and 16142.0 ± 8991.5 mm³ in males (p = 0.65). In controls, it was 20113.4 ± 9541.3 mm³ in females and 21567.3 ± 6988.7 mm³ in males (p = 0.53). Airway volume in the UCLP group (mean age 16.4 ± 3.0 years) was 18037.7 ± 8314.2 mm³ (range: 14396.3–46382.1), and in the control group (mean age 17.1 ± 2.5 years) it was 21544.5 ± 8132.2 mm³ (range: 16498.8–58455.9); the difference was not significant (p = 0.285) (Table 3).

Table 3.

Pharyngeal airway volumes in UCLP subgroups and control group

Cleft Side	n	Mean ± SD (mm³)	p-value
Right-sided UCLP	23	16263.4 ± 4964.0	0.145
Left-sided UCLP	7	19988.3 ± 12585.2
Total UCLP	30	18037.7 ± 8314.2	0.285
Control	30	21544.5 ± 8132.2

UCLP Unilateral Cleft Lip and Palate, SD Standard Deviation. p-values were calculated using the Mann–Whitney U test. A p-value < 0.05 was considered statistically significant

Reliability analysis

To assess measurement reliability, repeated measurements were performed. The intraclass correlation coefficient (ICC) was calculated as 0.991 for maxillary sinus volume measurements and 0.946 for pharyngeal airway volume measurements, indicating a high level of measurement reliability. Since all measurements were performed by a single experienced observer, interobserver analysis was not applicable. However, intraobserver reliability was confirmed by repeated measurements after a three-week interval, showing excellent consistency.

Discussion

Cleft lip and palate are common congenital craniofacial anomalies resulting from failure of fusion of facial processes during early fetal development [2, 3]. The high incidence of maxillary sinusitis in individuals with cleft lip and palate has led to increased interest in studies investigating maxillary sinus size, volume, and morphology. In this context, previous studies have reported structural alterations in the maxillary sinus associated with cleft lip and palate [4–7]. Furthermore, associated symptoms such as snoring, hypopnea, and breathing difficulties have led to growing interest in assessing pharyngeal airway volumes. Studies in the literature have reported that individuals with CLP tend to exhibit smaller airway volumes compared to healthy individuals [11–14].

De Rezende Barbosa et al. [20] reported that individuals with unilateral cleft lip and palate had significantly smaller maxillary sinus volumes compared to the control group. In contrast, Rodrigues et al. [21] found no statistically significant difference in maxillary sinus volume between unilateral cleft lip and palate patients and controls, although a tendency toward smaller sinus volumes on the cleft side compared with the contralateral side was observed. The same study also reported statistically significant differences in maxillary sinus volume according to age and sex.

Another possible explanation for these discrepancies is that, in some studies, maxillary sinus and pharyngeal airway development may not have been fully completed at the time of imaging [22, 23]. In the present study, the mean age of the 30 individuals with UCLP was 16.4 ± 3.0 years, while the mean age of the 30 healthy controls was 17.1 ± 2.5 years.

Previous research has demonstrated that both maxillary sinus and pharyngeal airway dimensions are influenced by growth. Bhushan et al. [24] reported that sinus height continues to increase until approximately 18 years of age, while width and length reach adult size by age 12. Lorkiewicz et al. [25] identified the most rapid volume increase between birth and four years of age. Belgin et al. [26] found a decrease in sinus volume with increasing age, and noted that males aged 18–24 years exhibited significantly larger sinus volumes than females in the same age group.

With regard to pharyngeal airways, Linder et al. [27] observed that pharyngeal growth continues until approximately 16 years of age. Tourne [28] reported that skeletal dimensions of the nasopharyngeal airway change until early childhood. In contrast, soft tissue changes have been shown to cause a reduction in the sagittal dimension of the nasopharynx until the age of 20, after which no further changes were observed [29].

In studies evaluating maxillary sinus dimensions in individuals with cleft lip and palate, two-dimensional radiographs and cone-beam computed tomography have commonly been used [2, 3, 12, 13, 15, 16]. While panoramic and lateral cephalometric radiographs are commonly used for maxillary sinus analysis, pharyngeal airways are generally assessed using lateral cephalograms [13, 30–33]. However, two-dimensional modalities provide only linear or area-based estimations and cannot yield true volumetric measurements, as accurate volume assessment inherently requires three-dimensional data [34–36].

When three-dimensional imaging techniques used for volumetric measurements are compared, imaging of the airway with CBCT allows three-dimensional visualization and volumetric assessment of the airway. This difference may be explained by the fact that conventional CT images are acquired with patients in the supine position, in which airway volume may vary, whereas CBCT images are typically obtained with patients in an upright position [37]. In our study, maxillary sinus and pharyngeal airway volumes were measured using CBCT, with scans obtained while participants were in an upright posture.

Segmenting the pharyngeal airway was more difficult to delineate on CBCT images compared with the maxillary sinus, as airway regions present more complex and less clearly defined anatomical boundaries, making threshold selection particularly critical for accurate segmentation [38]. In our study, grayscale values were fixed between − 1024 and − 504 grey-scale values. This range was optimized through preliminary testing on multiple images. Segmentations were performed using ITK-SNAP, a software commonly employed in both medical and dental applications [38–40].

Accurate identification of anatomical boundaries is essential for obtaining reliable results in maxillary sinus and pharyngeal airway imaging. In the literature, inconsistencies and variability in the definition of anatomical boundaries of the same structures have hindered comparison between studies and complicated the interpretation of findings [39]. In the present study, after adjusting image density values, the “Edge Attraction” mode in ITK-SNAP was used as a semi-automatic aid to facilitate boundary detection for both the maxillary sinus and the pharyngeal airway. Following initial segmentation, all regions were carefully reviewed slice-by-slice in the axial, sagittal, and coronal planes, and manual corrections were applied when necessary to avoid over- or under-segmentation.

For the standardization of pharyngeal airway measurements, reference planes described in a previous study were adapted [22]. The upper boundary was defined as the Frankfurt Horizontal Plane (FHP), the lower boundary as a plane parallel to the FHP passing through the anteroinferior margin of the third cervical vertebra, and the anterior boundary as a plane perpendicular to the FHP intersecting the anterior nasal spine. These planes represent skeletal landmarks that are easily reproducible on cone-beam computed tomography images. Standardization of the pharyngeal airway using these reference planes facilitates accurate evaluation and comparison across studies.

Consistent with previous reports, our study found no statistically significant differences between the right and left maxillary sinus volumes [41–43]. Similarly, comparisons between cleft and non-cleft sides in individuals with UCLP also revealed no significant differences, aligning with earlier findings [2, 44]. De Rezende Barbosa et al. [20] reported significantly smaller maxillary sinus volumes in UCLP patients compared with controls (p < 0.0001), whereas Rodrigues et al. [21] found no significant difference between groups (UCLP: 9728.5 ± 4795.2 mm³; controls: 10 146.8 ± 4581.2 mm³; p = 0.677). The inconsistent findings reported in the literature regarding maxillary sinus volume in individuals with unilateral cleft lip and palate may be related to differences in age distribution and sex composition of study populations. Previous studies have demonstrated that maxillary sinus volume varies significantly with both age and sex, which may partially explain the discrepancies observed across studies.

Pharyngeal airway volumes were compared between the UCLP and control groups. CBCT was selected as the imaging modality because it allows accurate volumetric assessment of air-filled spaces surrounded by soft tissues [37]. A review of the literature indicates that studies evaluating pharyngeal airway volumes in individuals with UCLP are limited in number and are restricted in terms of sample size as well as age and sex distribution [13–15]. In the present study, no statistically significant difference in pharyngeal airway volume was observed between the UCLP and control groups. The high standard deviation values of total airway volumes in both groups may explain the lack of statistical significance [12, 16, 33]. In addition, subgroup analyses based on age and sex revealed no statistically significant differences in pharyngeal airway volumes within either group. Consistent with these findings, previous studies have also reported no significant differences between sexes [3, 12, 15]. The finding of a smaller sinus volume on the left side should be interpreted cautiously, as this corresponds to the cleft side in the majority of cases. Hence, the observed asymmetry likely represents cleft-related developmental deficiency rather than inherent left–right differences.

Limitations

This study has several limitations. Although statistical power was adequate, the relatively small sample size limits the generalizability of the findings. The retrospective design prevented standardization of variables such as head posture, tongue position, and breathing phase, potentially affecting pharyngeal airway measurements. CBCT imaging provides static, anatomical snapshots and lacks functional or dynamic assessment capabilities. Additionally, the inclusion of participants aged 12–20 introduces variability related to growth and development. However, this age range was intentionally selected to encompass the late growth period during which maxillary sinus and pharyngeal airway development approach maturity, and age- and sex-matching between groups helped minimize developmental variability.

Furthermore, landmark identification and segmentation may involve a degree of subjectivity, particularly in regions where anatomical boundaries are not clearly defined. Although measurements were performed by an experienced observer and high intra-observer reliability was confirmed, observer-dependent variability cannot be completely eliminated. ITK-SNAP was used to facilitate boundary detection; however, all segmentations required manual slice-by-slice verification and correction, and therefore some operator dependency remains. Finally, the number of right-sided UCLP cases was relatively small, which may have increased variability in subgroup analyses and affected the detection of potential side-related differences.

Conclusion

Within the limitations of this exploratory study, a statistically significant reduction in maxillary sinus volume was observed only on the cleft side in individuals with UCLP whereas the contralateral sinus and pharyngeal airway volumes did not differ significantly from healthy controls. Volumetric measurements were not significantly influenced by sex or age. These findings indicate that the observed anatomical differences are primarily side-specific rather than generalized. Future multicenter studies with larger and more balanced samples, incorporating functional and clinical parameters, are needed to further clarify the clinical relevance of these volumetric variations.

Authors’ contributions

S E.Ş. and K.G. conceptualized and designed the study. E.Ş. collected and curated the data. E.Ş. and K.G. performed data analysis and interpretation. S.K. contributed to manuscript writing, critical revision, and overall organization. All authors reviewed and approved the final version of the manuscript.

Funding

The authors declare that there is no funding.

Data availability

The datasets used and, or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This retrospective cross-sectional study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Gazi University Ethics Committee under protocol number 2021 − 831. Informed consent was obtained from all participants or their legal guardians.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.