Evaluation of pathological and volumetric changes in the maxillary sinus using CBCT in patients with periodontitis

Abstract

Background

The aim of this study is to evaluate maxillary sinus volume, the presence of sinus pathologies, and the location of the posterior superior alveolar artery (PSAA) in patients with periodontitis and periodontally healthy individuals using cone-beam computed tomography (CBCT).

Methods

Periodontal examinations were performed on patients who applied to our department for CBCT for any reason and who agreed to participate in the study, and 188 adult patients were included in the study. CBCT scans were evaluated for maxillary sinus volume, sinus pathology, and (PSAA) localization. Maxillary sinus pathologies were classified as mucosal thickening, polypoidal mucosal thickening, mucus retention pseudocyst, partial opacification, and total opacification. The location of the PSAA was examined in three types: intraosseous, submembranous, and in the external cortex of the lateral wall of the sinus. Maxillary sinus volume was calculated using the IRYS software program. Measurements were performed on axial CBCT sections, and inter- and intraobserver reliability was assessed. Associations between periodontitis and CBCT parameters were analyzed using chi-square and Mann–Whitney U tests.

Results

A total of 376 maxillary sinuses from 188 individuals were evaluated. Maxillary sinus pathology was significantly more prevalent in patients with periodontitis compared with periodontally healthy individuals (39.2% vs. 25.3%, p = 0.004). In addition, maxillary sinus volume was significantly lower in the periodontitis group than in healthy controls (10.50 ± 6.52 vs. 12.33 ± 4.98, p = 0.009). The presence of pathology in the maxillary sinus was found to be statistically significantly higher in males (40.3%) than in females (27.7%) (p = 0.015). No significant association was observed between periodontitis and PSAA localization.

Conclusion

Periodontitis is a disease that can lead to pathological and morphological changes in the maxillary sinus. PSAA localization does not differ significantly between groups, whereas maxillary sinus volume is influenced by periodontal health and sinus pathology. Therefore, three-dimensional evaluation of the region using CBCT is important prior to implant surgery and other maxillofacial surgical procedures involving the maxillary sinus.

Introduction

Periodontitis is a chronic inflammatory disease with a multifactorial etiology, characterized by the destruction of the tooth-supporting tissues [1]. Disease progression leads to the extension of inflammation into deeper tissues, disruption of bone homeostasis, and ultimately tooth loss [2]. Although periodontopathogens may exert adverse effects on systemic health [3], alterations observed in adjacent anatomical structures of the posterior maxilla are more plausibly explained by local odontogenic and anatomical mechanisms [4]. In particular, the close anatomical relationship between the posterior maxillary teeth, the alveolar bone, the maxillary sinus (MS) floor, and the course of the posterior superior alveolar artery (PSAA) suggests that periodontal destruction may directly influence MS morphology and function [5, 6].

Previous studies have reported an association between chronic periodontitis and pathological changes in the MS mucosa [7–12]. Knowledge of the maxillary sinus volume is important in the preoperative setting for assessing the risk of Schneiderian membrane perforation, estimating the required graft volume, and determining the most appropriate surgical technique [13]. However, most previous studies have focused primarily on sinus mucosal alterations, and the extent to which periodontal disease is associated with volumetric changes of the MS remains insufficiently elucidated.

The PSAA is one of the terminal branches of the maxillary artery and courses along the lateral wall of the MS [13]. It supplies blood to both the sinus mucosa and the posterior teeth [13, 14]. Previous cone-beam computed tomography (CBCT) studies have investigated the anatomical course and positional variations of the PSAA in relation to the lateral sinus wall due to its clinical relevance in implant placement and sinus lift procedures [13–15]. However, data regarding whether inflammatory conditions related to periodontitis are associated with variations in PSAA localization remain limited and inconsistent.

Traditional two-dimensional radiographic methods (panoramic radiography, Water’s radiography) have limitations in evaluating the MS and surrounding anatomical structures, such as superposition, distortion, and limited depth perception [16]. CBCT is a highly accurate imaging modality for evaluating MS volume and identifying anatomical variations of the PSAA [14]. Accordingly, the assessment of MS volume and PSAA location in patients with periodontitis using CBCT represents the most appropriate approach for comparison with healthy individuals.

The aim of this study was to evaluate MS volume, PSAA localization, and sinus pathologies in patients with periodontitis using CBCT and to compare the findings with those of healthy individuals. In this way, the effects of periodontal disease on MS morphology will be elucidated, and clinically relevant anatomical alterations that should be considered during surgical planning will be contributed to the literature.

Materials and methods

Study design

This prospective and observational study was conducted with the approval of the Ethics Committee of Harran University Faculty of Dentistry (Decision No: HRU/25.19.29). All procedures were performed in accordance with ethical standards and the principles of the Declaration of Helsinki. In this prospective study, patients who applied to Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Harran University, for CBCT imaging were grouped into periodontal and healthy groups after undergoing periodontal examination before the CBCT scan. Periodontal examinations of the patients were performed by an expert with 10 years of experience in the field of periodontology. The diagnosis was established according to the 2018 World Workshop classification. Accordingly, periodontitis was defined as irreversible periodontal tissue destruction characterized by clinical attachment loss caused by plaque-associated inflammation, which is not observed in periodontally healthy or gingivitis patients [17]. Patients presenting with interdental clinical attachment loss in at least two non-adjacent teeth or ≥ 3 mm buccal/oral clinical attachment loss in a single tooth were classified as having periodontitis. Patients with bleeding on probing below 10%, without clinical signs of inflammation, pathological pocket formation, progressive clinical attachment loss, or radiographic alveolar bone loss were included in the healthy control group.

Study population and sample size

The required sample size was calculated using GPower software version 3.1. The effect size was set at d = 0.50, the significance level at α = 0.05, and the statistical power at 95% (1–β = 0.95). According to the GPower analysis, a total of 176 participants, with 88 individuals in each group, were required to achieve the target study power under the specified parameters. Within the scope of the study, CBCT images of 313 patients who were non-smokers and had no systemic or genetic diseases affecting the jaw bones were obtained. Following imaging, 64 patients were excluded due to the presence of defects, lesions, or pathologies in the region of interest, as well as patient- or device-related artifacts that interfered with the evaluation of anatomical structures in the relevant region. Subsequently, an additional 55 images in which the PSAA location could not be clearly identified were also excluded. These exclusion criteria were applied to ensure adequate image quality and reliable identification of anatomical structures. By excluding images with artifacts or unclear PSAA visualization, potential measurement errors and misclassification bias were minimized.

Image acquisition

In line with the inclusion criteria, 194 CBCT images were evaluated using a Castellini X-Radius Trio Plus CBCT device (Imola, Italy) with exposure parameters of 16 mAs and 90 kVp were included in the study. CBCT images with a voxel size of 0.3 mm and a field of view (FOV) of 13 × 16 and 13 × 10 cm were reconstructed with a slice thickness of 1 mm using IRYS Viewer version 15.1 software. Although the native voxel size of the CBCT images was 0.3 mm, 1-mm-thick reconstructed slices were used to improve image standardization, reduce image noise, and facilitate more reliable segmentation of the sinus boundaries.

Image observation and measurements

MS volume, MS pathology, and the location of the PSAA were evaluated on the reconstructed images by two maxillofacial radiologists. The assessments were repeated by both observers at a two-week interval, and six images that could not be reconciled were excluded from the study. Ultimately, 188 images constituted the final study sample. The region of interest was manually delineated on axially planned maxillary sections using the IRYS software, and relative density values were visualized in detail (Fig. 1). All CBCT images were evaluated under standardized display conditions using the same software settings. Image density, contrast, and sharpness parameters were kept constant throughout the evaluation to ensure consistency and reproducibility of the radiographic assessment [18]. Prior to volumetric measurements, CBCT images were oriented with the head aligned parallel to the Frankfurt horizontal plane. Volumetric analysis was performed on 1-mm-thick reconstructed slices for providing standardization and repeatability and the anatomical boundaries of the MS were defined as the sinus roof, floor, and anterior and posterior walls [18]. In cases with mucosal thickening, sinus segmentation was performed using the semi-automatic volumetric tool of the software. Due to differences in gray scale values, mucosal thickening was automatically differentiated from the aerated sinus cavity during segmentation. The right and left MS were measured separately, and sinus volume was recorded in cubic centimeters (cm³). In the volumetric analysis, relative densities were marked between the minimum sinus value and the mean value (Fig. 2). The area was confined to prevent inclusion of air, soft tissue, surrounding bone marrow spaces, and the nasal cavity. For intra-observer reliability, 20% of the MS volume measurements were remeasured, and intraclass correlation coefficients were calculated and ICC values demonstrated excellent agreement (ICC > 0.90).

Fig. 1.

Delineation of the region of interest and relative density values

Fig. 2.

Determination of sinus boundaries in the semi-automatic volumetric region

CBCT images were evaluated in axial, coronal, and sagittal planes to determine the relationship between the presence of MS pathology and periodontitis. MS pathologies included mucosal thickening, polypoidal mucosal thickening, mucous retention pseudocyst, partial opacification, and total opacification (Fig. 3). Mucosal thickening was defined as a sinus mucosal thickness of ≥ 2 mm and was considered pathological [19]. A mucous retention pseudocyst was defined as a dome-shaped, well-circumscribed elevation of the sinus mucosa visible on coronal and/or sagittal Sect [20]. Polypoidal mucosal thickening was defined as localized, polyp-like mucosal protrusions into the sinus cavity [21]. Partial opacification was defined as incomplete loss of sinus aeration, whereas total opacification was defined as complete opacification of the sinus cavity [22]. The location of the PSAA was classified into three groups: intraosseous, submembranous, and within the external cortex of the lateral wall of the maxillary sinus (Fig. 4).

Fig. 3.

Corrected sagittal CBCT images demonstrated that: (a) Healthy sinus, (b) mucosal thickening, (c) polypoidal mucosal thickening, (d) mucous retention pseudocyst, (e) partial opacification, and (f) total opacification

Fig. 4.

Coronal CBCT images showing the types of the posterior superior alveolar artery: (a) submembranous (arrow); (b) within the external cortex of the lateral wall of the maxillary sinus (arrow); and (c) intraosseous (arrow)

Statistical analysis

Cohen’s kappa analysis was used to evaluate interobserver and intraobserver agreement for the categorical variables (MS pathology and PSAA localization). All statistical analyses were performed using SPSS for Windows software, version 23.0 (IBM Corp., Armonk, NY, USA). The normality of data distribution was assessed using the Kolmogorov–Smirnov test. As MS volume did not show a normal distribution, the Mann–Whitney U test was used to compare MS volume between independent groups (periodontitis vs. periodontally healthy individuals; males vs. females; presence vs. absence of sinus pathology). Pearson’s chi-square test was applied to analyze categorical variables, including the presence of MS pathologies, PSAA localization, and periodontal status according to gender. Analyses were performed at both the patient level (n = 188) and the sinus level (n = 376). Periodontal status and demographic variables were evaluated on a patient basis, whereas maxillary sinus pathologies, PSAA localization, and sinus volume measurements were analyzed on a sinus basis because each patient contributed two maxillary sinuses that could present different radiographic findings. In all analyses, a p-value of < 0.05 was considered statistically significant.

Results

Ultimately, of the 313 patients who agreed to participate in the study, 188 were included. Of these, 121 were female and 67 were male, with an age range of 18–79 years. Of these 188 participants, 93 (49.5%) were diagnosed with periodontitis and 95 (50.5%) were periodontally healthy. Sinus pathologies were evaluated on a sinus-based level (n = 376), and both right and left maxillary sinuses were analyzed independently. Excellent intraobserver and interobserver agreement was observed (ICC > 0.90; Cohen’s κ = 0.88). CBCT evaluation revealed that approximately one-third of the MSs exhibited pathological findings, with mucosal thickening being the most common pathology. Other less frequent findings included mucous retention pseudocysts, partial opacification, polypoidal mucosal thickening, and rare cases of total opacification (Table 1).Regarding PSAA localization, the intraosseous type was the most frequently observed, followed by the submembranous type, whereas localization on the external cortex was relatively uncommon (Table 1).

Table 1.

Descriptive analysis of participants according to gender, periodontal health status, presence of maxillary sinus pathology, and location of the PSAA

Variable type	Subgroup	n(%)
Gender	Female	121 (64.4)
	Male	67 (35.6)
	Total	188 (100)
Periodontal Status	Periodontitis	93 (49.5)
	Healthy	95 (50.5)
	Total	188 (100)
Presence of Pathology	Mucosal Thickening	61 (16.2)
	Mucous retention pseudocyst	24 (6.4)
	Partial Opacification	18 (4.8)
	Polypoidal Mucosal Thickening	17 (4.5)
	Total Opacification	1 (0.3)
	Absent	255 (67.8)
	Total	376 (100)
Location of PSAA	Intraosseous	265 (70.5)
	Submembranous	86 (22.9)
	On external cortex	25 (6.6)
	Total	376 (100)

Percentages are calculated based on patient-level data (n = 188) or sinus-level data (n = 376), depending on the variable analysed

Table 2 presents the distribution of periodontal health status, presence of MS pathology, and PSAA localization according to gender. When the distribution of periodontitis by gender was evaluated, the prevalence of periodontitis was found to be 47.8% in males and 50.4% in females. The proportions of periodontally healthy individuals were also similar between genders, with rates of 52.2% in males and 49.6% in females. The difference between genders was minimal, indicating that gender did not have a significant effect on the prevalence of periodontitis (p = 0.667).

Table 2.

Distribution of periodontal health status, presence of maxillary sinus pathology, and PSAA location according to gender

	Subgroup	Female	Male	P value
Periodontal Status	Periodontitis	61 (%50.4)	32 (%47.8)	0.667
	Healthy	60 (%49.6)	35 (%52.2)
Presence of Pathology	Present	67 (%27.7)	54 (%40.3)	0.015*
	Absent	175 (%72.3)	80 (%59.7)
Location of PSAA	Intraosseous	183 (%75.6)	82 (%61.2)	0.013*
	Submembranous	45 (%18.6)	41 (%30.6)
	On external cortex	14 (%5.8)	11 (%8.2)

Percentages are calculated based on patient-level data (n = 188) or sinus-level data (n = 376), depending on the variable analysed

Pearson’s chi-square test*=p < 0.05

The presence of MS pathology was found to be statistically significantly higher in males (40.3%) than in females (27.7%) (p = 0.015). When the distribution of PSAA types was examined, a statistically significant difference was observed between genders (p = 0.013). In females, the intraosseous localization was observed at a higher rate (75.6%) compared to other localizations. The submembranous type was more frequently observed in males (30.6%) than in females (18.6%). The lateral type was the least frequently observed localization in both genders but was more common in males. These findings suggest that PSAA types may vary according to gender.

Table 3 demonstrates the relationship between periodontal status and both the presence of MS pathology and PSAA localization. When the association between periodontitis and MS pathology was analyzed, the prevalence of sinus pathology was found to be 39.2% in the periodontitis group, whereas this rate was 25.3% in healthy individuals. The proportion of cases without pathology was 60.8% in the periodontitis group and 74.7% in the healthy group. These findings indicate that the presence of periodontitis significantly increases the likelihood of MS pathology (p = 0.004).

Table 3.

Association between the presence of sinus pathology, PSAA localization, and periodontitis

	Subgroup	Periodontitis n (%)	Healthy n (%)	Total (n)	P value
Presence of Pathology	Present	73 (%39.2)	48 (%25.3)	121	0.004*
	Absent	113 (%60.8)	142 (%74.7)	255
Location of PSAA	Intraosseous	134 (%72.0)	131 (%68.9)	265	0.798
	Submembranous	40 (%21.5)	46 (%24.2)	86
	On external cortex	12 (%6.5)	13 (%6.8)	25

Pearson’s chi-square test*=p < 0.05

When the relationship between the presence of periodontitis and PSAA localization was evaluated, no statistically significant difference was found (p = 0.798). In both groups, the PSAA was most frequently observed with an intraosseous localization.

The comparison of MS volumes according to gender, periodontal status, and presence of pathology is presented in Table 4. The mean volume of MSs with pathology (9.94 ± 4.93) was calculated to be statistically significantly lower than that of sinuses without pathology (12.13 ± 6.13) (p = 0.001).

Table 4.

Comparison of MS volume according to gender, periodontal status, and presence of MS pathology

Comparison	Group	N	%	Median (Min-max)	Mean ± SD(cm³)	Mean Rank	U	Z	p
Gender	Male	134	35.6	12.2 (0–70)	12.79 ± 7.63	209.81	13359.000	-2.829	0.005*
	Female	242	64.4	10.3 (0–21)	10.67 ± 4.44	176.70
Periodontal Status	Periodontitis	186	49.5	9.9 (0–70)	10.50 ± 6.52	165.58	13087.000	-2.616	0.009*
	Healthy	190	50.5	12.0 (0–27)	12.33 ± 4.98	210.94
Presence of Pathology	Present	121	32.2	9.9 (0–24)	9.94 ± 4.93	162.55	12287.500	-3.189	0.001*
	Absent	255	67.8	11 (1–70)	12.13 ± 6.13	200.81

Percentages are calculated based on patient-level data (n = 188) or sinus-level data (n = 376), depending on the variable analysed

N Number of observations, % Percentage, Median (Min–Max) Median value with range, Mean ± SD Mean value with standard deviation, Mean Rank Average rank for Mann–Whitney U test, U Mann–Whitney U statistic, Z Standardized test statistic, P p-value

*=p < 0.05

A statistically significant difference was also observed between the MS volumes of individuals with periodontitis (10.50 ± 6.52) and periodontally healthy individuals (12.33 ± 4.98) (p = 0.009). When evaluated according to gender, MS volume was found to be significantly greater in males (12.79 ± 7.63) compared to females (10.67 ± 4.44) (p = 0.005).

Discussion

This study demonstrated that MS pathology is significantly more common in patients with periodontitis, and sinus volume is significantly lower compared to periodontally healthy individuals. These findings support the concept that periodontal inflammation and posterior maxillary bone loss may contribute to inflammatory and morphological changes in the MS, possibly through local odontogenic and anatomical mechanisms [9].

Although no significant association was found between periodontitis and PSAA localization, gender-dependent differences in PSAA distribution were observed. This suggests that periodontal status may not affect the anatomical course of PSAA, but individual anatomical variations—especially those related to pathology—should be carefully considered during surgical planning in the posterior maxilla.

The combined assessment of MS pathologies, sinus volume, and PSAA localization provides a more comprehensive understanding of the potential clinical implications of periodontitis for MS health and surgical risk assessment. CBCT-based three-dimensional assessment has enabled reliable evaluation of these parameters and facilitated clinically relevant anatomical interpretations.

In this study, the most common MS findings were mucosal thickening and mucous retention pseudocysts, while no pathology was detected in a substantial proportion of cases. These results are consistent with previous CBCT- and CT-based studies. Rege et al. and Ritter et al. similarly reported mucosal thickening as the most frequent sinus pathology, with mucous retention pseudocysts and polypoidal changes observed less frequently [23, 24].

The higher prevalence of MS pathology in males observed in the present study is consistent with previous CBCT-based reports, which have also shown a greater frequency of sinus pathologies and mucosal changes in males compared with females [25, 26]. These findings suggest that gender may be a relevant factor in the evaluation of MS pathologies.

Periodontitis not only affects the periodontal ligament and alveolar bone but may also lead to secondary changes in anatomically related adjacent structures. In the posterior maxilla, the close proximity of tooth roots to the MS floor facilitates a clinically significant interaction between periodontitis and sinus tissues. Numerous recent studies have reported a significant correlation between alveolar bone loss and mucosal thickening [7, 9, 10].

In addition to periodontal disease, several other factors may influence maxillary sinus volume and mucosal conditions. Conditions such as allergic rhinitis, chronic sinus inflammation, smoking exposure, and odontogenic infections may contribute to mucosal thickening and changes in sinus aeration. Furthermore, tooth loss in the posterior maxilla and the associated alveolar bone resorption may alter the anatomical relationship between the sinus floor and the alveolar crest, potentially affecting sinus morphology and volume [7, 9, 11, 12].

In a retrospective CBCT study, Zhang et al. investigated the relationship between the periodontal status of maxillary molars and mucosal thickening and found that alveolar bone loss and reduced residual bone height significantly influenced mucosal thickening [7]. Especially in cases with moderate to severe alveolar bone loss, the rate of more pronounced mucosal thickening has been reported to be higher compared to mild bone loss [7]. This finding suggests that periodontitis may exert a stimulatory effect on the sinus mucosa. Similarly, in a cross-sectional study evaluating 415 CBCT images, AlRowis et al. reported that the prevalence of sinus mucosal thickening increased significantly with increasing severity of alveolar bone loss [9].

In a more recent study, Ekşi et al. (2025) identified significant positive correlations between periodontal bone loss in the maxillary posterior region and sinus membrane thickness, demonstrating that membrane thickness was notably higher in areas with advanced bone loss [10]. Lathiya et al. suggested that periodontitis may act as a potential etiological factor for odontogenic MS pathology and that changes in sinus mucosal thickening may be associated with this process [11]. Additionally, Ren et al. demonstrated that the likelihood of sinus mucosal thickening increased as the severity of alveolar bone loss progressed [12]. Consistent with the existing literature, the present study also revealed a significantly higher prevalence of sinus pathology in patients with periodontitis.

In the present study, PSAA localization was not significantly associated with periodontal status, indicating that periodontal destruction in the posterior maxilla does not appear to influence the anatomical course of the artery. This finding is consistent with previous CBCT-based evidence suggesting that positional variations of the PSAA are more closely related to individual anatomical characteristics and structural features of the lateral wall of the MS rather than periodontal bone loss [27].

Previous CBCT-based studies have reported gender-related differences in PSAA localization [14, 28]. In line with these reports, the present study observed similar overall distribution patterns of PSAA types in both genders, with the intraosseous type being the most common, followed by the submembranous type and localization on the external cortex of the lateral wall. However, the intraosseous type was more prevalent in females, whereas the submembranous type was more frequently observed in males. Although localization on the external cortex of the lateral wall was generally uncommon, its higher prevalence in males is consistent with previous findings [14]. The observed consistency between the two studies might be explained by the use of the same imaging modality and the inclusion of study populations with similar ethnic backgrounds. Collectively, these findings indicate that PSAA localization may exhibit gender-related anatomical variations that should be considered during anatomical evaluation and surgical planning.

A clinically important finding of this study is the gender-dependent distribution of the PSAA, with the submembranous type being significantly more prevalent in males. From a surgical perspective, the submembranous localization is particularly precarious as the artery is positioned directly between the lateral bone wall and the Schneiderian membrane. During a lateral window sinus lift, this anatomical arrangement increases the risk of accidental arterial laceration during osteotomy or membrane reflection. Such complications can lead to significant intraoperative hemorrhage, which not only obscures the surgical field but also increases the risk of membrane perforation [13, 15]. Given that nearly one-third of male patients in this study presented with this high-risk variant, these results emphasize that preoperative CBCT assessment is not merely a diagnostic formality, but an essential safety protocol.

Liechti et al., in their cross-sectional study, reported no significant gender-related difference in periodontal status between male and female participants [29]. Similarly, no significant difference in the prevalence of periodontitis according to gender was observed in the present study. This finding suggests that gender alone may not be a determining factor in the development of periodontal disease. Although evidence indicates that hormonal fluctuations in females may influence gingival and periodontal health [30, 31], several studies have shown that poorer periodontal status in males is more closely associated with oral hygiene habits and smoking behavior [32, 33]. These findings collectively suggest that periodontal disease is shaped by an interaction of hormonal and behavioral factors rather than gender alone.

Based on previous studies and the findings of the present investigation, the potential of periodontitis to induce alterations in MS tissues may be explained by the combined effects of anatomical barrier disruption, dissemination of inflammatory mediators, and microbial invasion.

[7, 34, 35]. In particular, the reduction in the distance between the sinus floor and periodontal tissues due to alveolar bone loss may facilitate the transmission of inflammation and bacterial by-products to the sinus [22, 36]. Consequently, pathological findings such as mucosal thickening, mucous retention pseudocyst, and sinus opacifications may be more frequently associated with this increased inflammatory burden.

In the present study, MS volume was significantly lower in patients with periodontitis compared with periodontally healthy individuals, suggesting that periodontal inflammation and posterior maxillary bone loss may contribute to volumetric alterations of the sinus, likely through local odontogenic mechanisms [37]. In addition, the presence of sinus pathology was associated with a significant reduction in MS volume, supporting the notion that inflammatory changes of the sinus mucosa can decrease the effective aerated sinus cavity [38]. These findings are in line with previous observations that inflammatory sinus conditions are accompanied by reduced sinus volume and structural changes of the sinus walls [37, 38]. The observed reduction in maxillary sinus volume in patients with periodontitis may be explained either by a direct effect of periodontal inflammation or indirectly through increased mucosal thickening, which reduces the aerated sinus cavity [38].

In the present study sex-related differences in MS volume were observed, with larger volumes in males. Previous CT-based studies reporting larger sinus volumes in males support the generalizability of this observation [39, 40]. Collectively, these results indicate that periodontitis is associated with an increased prevalence of sinus pathology and a consequent decrease in MS volume, which may have clinical implications for surgical planning in the posterior maxilla [7, 38].

This study has several limitations. Although the study was conducted prospectively, its observational design does not allow causal inferences to be drawn. CBCT imaging, although accurate, is limited by voxel size, approximate relative density values, and potential variability from manual sinus and PSAA measurements. Furthermore, clinical periodontal measurements were not correlated with radiographic parameters, and periodontal status was evaluated only based on the presence or absence of periodontitis without analyzing disease severity or staging. In addition, some potential confounding factors, such as a history of allergic rhinitis, previous sinus disease, environmental tobacco exposure, and the presence of missing posterior teeth, were not specifically controlled in the present study. One important limitation of this study is that both maxillary sinuses from the same individual were included in the analysis. Since the right and left sinuses of the same patient are not statistically independent, this may have introduced a clustering effect and could potentially influence the statistical results. Future studies using multilevel or clustered statistical approaches are recommended to address this limitation. These factors may influence maxillary sinus conditions and should therefore be considered in future studies.

Based on these limitations, future studies should include larger, multicenter, or longitudinal designs to confirm and expand these findings. Investigating correlations between the severity of periodontitis and radiographic parameters, as well as controlling for confounding factors such as prior sinus surgery or systemic conditions, is recommended. Clinically, preoperative CBCT assessment remains important for planning dental implants or sinus surgery in patients with periodontitis to minimize complications.

Conclusion

Within the limitations of this study, periodontitis was significantly associated with both increased MS pathology and alterations in MS volume compared with periodontally healthy individuals. Furthermore, the location of the PSAA does not differ significantly in individuals with periodontitis compared to healthy individuals. These findings emphasize the value of thorough CBCT evaluation of the MS region in patients with periodontitis, particularly during preoperative planning for implant placement or MS–related surgical procedures. Moreover, the higher prevalence of the submembranous PSAA type in males highlights the importance of careful preoperative CBCT assessment to identify potential vascular risks and optimize surgical planning in the posterior maxilla.

Abbreviations

CBCT

Cone-beam computed tomography

MS

Maxillary sinus

PSAA

Posterior superior alveolar artery

Authors’ contributions

Protocol/project development: MHY, SK. Data collection and management: MHY, MOE. Data analysis: SK, MOE. Manuscript writing/editing: MHY, SK, MOE.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Committee of Harran University Faculty of Dentistry (Decision No: HRÜ/25.19.29). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all participants prior to inclusion in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.