Comparison of the distances between the maxillary sinus floor and root tips of the upper first and second molar teeth by using oral panoramic images

Transcription

1 بسم اهلل الرمحن الرحيم The National Ribat University Faculty of Graduated Studies and Scientific Research Comparison of the distances between the maxillary sinus floor and root tips of the upper first and second molar teeth by using oral panoramic images A thesis submitted for partial fulfillment required of M.SC in Human and Clinical anatomy BY: Hiba Abdalaziz Hamadain Obeid Supervisor: Dr. Yasser Seddeg Abdul-ghani

2 قال تعاىل: }ي ب أ ي ه ب انن بش إ ك نز ى ف ي ر ي ت ي ان ج ع ث ف إ ب خ ه ق ن بك ى ي ر ر اة ث ى ي ط ف خ ث ى ي ع ه ق خ ث ى ي ي ض غ خ ي خ ه ق خ و غ ي ر ي خ ه ق خ ن ن ج ي ن ك ى و ق ر ف ي ان أ ر ح بو ي ب ش بء إ ن أ ج م ي س ث ى خ ر ج ك ى ط ف ه ب ث ى ن ز ج ه غ ىا أ ش ذ ك ى و ي نك ى ي ي ز ى ف و ي نك ى ي ي ر د إ ن أ ر ر ل ان ع ر ن ك ي ه ب ي ع ه ى ي ث ع ذ ع ه ى ش ي ئ ب و ر ر ي ان أ ر ض ه بي ذ ح ف إ ر ا أ س ن ن ب ع ه ي ه ب ان بء اه ز س د و ر ث ذ و أ ج ز ذ ي ك م ز و ج ث ه يج } صذق هللا ا ؼظ ١ ص سة ا حش ا ٠٢ ت سل )5( I

3 Dedication I would like to dedicate this work to: My parents... My husband.. My brothers and sisters.. My supervisors.. My colleagues.. II

4 Acknowledgment First and foremost, I would like to express my thanks and gratitude to my supervisor Dr. Yasser Seddeg Abdul- ghani for his guidance throughout the study. Also I would like to express my thanks and gratitude to Professor Tahir Osman, and Dr. Kamal Elbadawi Babiker for support during study period. I would also like to thank all of my friends and colleagues in department of Anatomy. Finally with great appreciation I would like to thank my family members for their patience and sincere support. III

5 Abstract Background: Maxillary molar teeth and their roots are remarkable structures due to their close vicinity to the maxillary sinus. Maxillary sinus also known as antrum of Highmore is the largest of paranasal sinuses; a 15 cc volume pyramid-shaped air filled osseous cavity situated within the body of maxilla. Maxillary sinus is framed by the inferior orbital wall in the top, and (pre)molar teeth roots in the bottom. In % of the population the maxillary sinus is free of microbial organisms or foreign bodies. This sterility may be compromised by direct invasion of infections or endodontic interventions within the molar and premolar teeth. Authors have tried to classify the distances between the root tips of the maxillary first and second molar and maxillary sinus floor into 4 types. The purpose of this study is to Compare the frequency of maxillary first and second molar root tips and the maxillary sinus floor using oral panoramic images. Methods: This study is cross sectional, descriptive carried out among 100 participants (48 male and 52 female) 400 teeth. Panoramic images of the different age groups during the time from July till September 2017 at Khartoum state, Sudan. Results: The four types of the distances between the root tips of the maxillary first and second molar and maxillary sinus floor were observed and type I (outside) was seen in 105 (26.25)%, type II (contact) in 155 (38.75)%, type III (shadow) in 62 (15.5)% and type IV (inside) in 78 (19.5)%. There were no statistically significant differences in the evaluated the types percentage of the distances between males and females. IV

6 Conclusion: Knowledge of the types percentage may greatly help clinicians and surgeons background knowledge of anatomical positions of molar root tips against maxillary sinus floor, for pre-endodontic and pre-implantation strategy making and its important during treatment of the maxillary sinusitis. V

7 مستخلص الدراسة الخلفية: األضشاس ا طاح ت ا ؼ ٠ ت صز س ا ا حشو ١ ب اصخز ائ ر ه خ اصذ ا ف طم ضا سة خض ٠ ف ػظ ا فه ا ؼ. ا خضا ٠ ف ا ضا سة أل ف حض ا 55 زا ا خض ٠ ف ٠ ض بخض ٠ ف ١ م س ٠ ؼخبش اوبش 3 حض ٠ ف ا ؤ ف ػظ ش ا شى ئ با اء ص د ض صض ػظ ا فه ا ؼ ٠ حذ ا ا ضذاس ا حضاص ا ضف األػ صز س األص ا ا الؼت لب األضشاس ا طاح ت األصف % ا ضىا ضذ أ حض ٠ ف ا فه ا ؼ خا ا ىائ اث ا ضشر ١ ت أ األصضا ا غش ٠ بت. زا ا خؼم ١ لذ ٠ خؼشض خط سة ا غز ا باشش ؼذ أ ػ طش ٠ ك ػالس ا ؼصب ألضشاس ا طاح ت أ ألص ا ا خ حمغ لب ا. ا ؤ ف ١ حا ا إ ٠ ضاد حص ١ ف بؼذ اب ١ ل ت صز س األضشاس ا طاح ت ا ؼ ٠ ت األ ا زا ١ ت غ لاع ا خض ٠ ف ا ؼ ألسبؼ أ اع.ا ذف زا ا خص ١ ف ماس ت األبؼاد اب ١ ل ت صز س األضشاس ا ؼ ٠ ت األ ا زا ١ ت لاع حض ٠ ف ػظ ا فه ا ؼ باصخخذا ص س ا ف ا با سا ١ ت. الطريقة: ز ا ذساصت صف ١ ت أصش ٠ ج ػ اإل اد( 55 ا زو س 588 شاسن 80( باصخخذا ا ص س ا با سا ١ ت خخ ف األػ اس ف ا فخشة ١ ٠ حخ صبخ بش ا ض دا ال ٠ ت ا خشط. النتيجة: ف 5852 األ اع األسبؼت ا ضخؼ ت م ١ اس األبؼاد اب ١ ل ت صز س األضشاس ا ؼ ٠ ت األ ا زا ١ ت لاع ا خض ٠ ف ا فى ا ؼ حظج صذ أ ا ع األ ي )إ ا خاسس) )26.25%( ا ع ا زا )ا ال ش( ب ضب )38.75%( ا زا ذ )ا ظالي ا شابغ )إ ا ذاخ ) ب ضب )19.5%( ا زو س اإل اد. االستنتاج: ٠ الحظ ص د فش ل ثا الحظ ب ضبت ) ب ضب )15.5%( ف األبؼاد راث أ ١ اب ١ ؼشفت األبؼاد ا ى أ حضاػذ وز ١ شا األطباء ف ا ؼالس ا ضش ٠ ش شض ٠ ؼط ا ضشاح ١ خ ف ١ ت ؼشف ١ ت ػ ا ضغ ا خشش ٠ ح اب ١ ل ت صز س األضشاس ا ؼ ٠ ت األ ا زا ١ ت ماب لاع ا خض ٠ ف ا ؼ ا فى ضغ خطت إصخشاح ١ ض ١ ت لب ػالس ػصب األص ا أ لب ا م ١ ا بزساػت األص ا. VI

8 List of Tables Table Title Page Table 4.1 Study group distribution 20 Table 4.2 Age group distribution 21 Table 4.3 Distance of upper right maxillary first molar 22 Table 4.4 Distance of upper left maxillary first molar 23 Table 4.5 Distance of upper right maxillary second 24 molar Table 4.6 Distance of upper left maxillary second 25 molar Table 4.7 Assessment of vertical distance between maxillary molar root tips and the sinus floor in all teeth under study 26 VII

9 List of Figures Figure Title Page Fig 1.1 types 1, 2, and 3 of root tip to sinus floor 4 relationship Fig 1.2 Type 4 of root-maxillary sinus floor 5 relationship Fig 2.1 Shape and Position of the maxillary sinus 8 Fig 2.2 the ostium 9 Fig 2.3 Anatomy of the first and second maxillary 11 molar teeth Fig 2.4 Morphology of the first and second 12 maxillary molar teeth Fig 4.1 Study group distribution 20 Fig 4.2 Age group distribution 21 Fig 4.3 Distance of upper right maxillary first 22 molar Fig 4.4 Distance of upper left maxillary first molar 23 Fig 4.5 Distance of upper right maxillary second 24 molar Fig 4.6 Distance of upper left maxillary second 25 molar Fig 4.7 Assessment of vertical distance between maxillary molar root tips and the sinus floor in all teeth under study 26 VIII

10 Contents No Title Page Al-aya I Dedication II Acknowledgment III Abstract(English) IV-V Abstract(Arabic) VI List of tables VII List of figures VIII Contents IX-XI CHAPTER ONE Introduction and objectives 1. Introduction and objectives Introduction Objectives General objectives Specific objectives 6 CHAPTER TWO Literature review 2. Literature review Anatomy of the maxillary sinus and 7 maxillary first and second molar teeth Anatomy of the maxillary sinus Anatomy of the maxillary first and second 9-10 molar teeth 2.2. Morphology of the first and second maxillary molar teeth 12 IX

11 2.3 Development of the maxillary sinus and 13 maxillary first and second molar teeth Development of the maxillary sinus Development of the maxillary first and 15 second molar teeth 2.4 Eruption of the maxillary first and second 15 molar teeth 2.5 Previous studies CHAPTER THREE Material and methods 3. Material and Methods Study design Study area Study duration Sample criteria Sample size Method of study Data collection Data analysis Ethical approval 18 CHAPTER FOUR Results 4. Results CHAPTER FIVE Discussion 5. Discussion X

12 CHAPTER SIX Conclusions &Recommendations 6. Conclusions &Recommendations Conclusions Recommendations 29 CHAPTER SEVEN References 7. References Data Collecting Sheet XI

13 CHAPTER ONE Introduction & objectives XII

14 1. Introduction and objectives 1.1. Introduction: Maxillary molar and pre-molar teeth and their roots are remarkable structures due to their close vicinity to the maxillary sinus. Maxillary sinus also known as antrum of Highmore is the largest of paranasal sinuses; a 15 cc volume pyramid-shaped air filled osseous cavity situated within the body of maxilla. Maxillary sinus is framed by the inferior orbital wall in the top, and (pre) molar teeth roots in the bottom (1). In % of the population the maxillary sinus is free of microbial organisms or foreign bodies (2,3). This sterility may be compromised by direct invasion of infections or endodontic interventions within the molar and premolar teeth. Contamination of maxillary air sinus renders highly morbid infections as well as oroantral fistulae or root displacement caused by the molar and premolar teeth extraction and implantation (4). It is demonstrated by Wehrbein and Diedrich in 1992 that longer molar root projection into the maxillary sinus measured in panoramic radiographs results in greater amount of pneumatization and sinus expansion after extraction which effectively reduced the bone thickness in which implantation will be performed (5). Protrusion of the dental root apices into the sinus results in direct spreading of infections during endodontic therapy or during extraction causing maxillary sinusitis (6). Periapical surgical procedures of the upper molar teeth may be complicated by maxillary sinus wall aperture as described by Ericson et al (7). in 18% patients undergoing periodontal surgeries of maxillary molar teeth. The authors demonstrated that penetration of foreign bodies into the sinus cavity through the iatrogenic aperture can result in inflammation of the sinus mucosa initiating maxillary sinusitis process (7,8). Perforation 1

15 of the sinus membrane is another potential complication of periapical surgeries in maxillary molar teeth. In the study by Persson, the rate of this complication was estimated as 44% of cases, but the overall surgical success rate was 78% which showed no significant negative effect of perforation of the sinus membrane on the prognosis of the surgery (9). The relationship between maxillary molar root-tips and the sinus floor which constitutes the bone thickness supporting the roots is known to be an important determinant of the prognosis of orthodontic procedures involving the maxillary molars. A common dilemma in adult orthodontic treatment is deciding how best to treat missing posterior teeth. One treatment option is to orthodontically close the space. But closure can be difficult, especially if the open space is in the maxillary posterior area, because tooth movement through the maxillary sinus is limited (10). Better knowledge of the distance between molar teeth root apices and maxillary sinus greatly influences conduction of surgical procedures on the upper molar and premolar teeth. Several studies have been carried out to measure this distance in normal populations by using computed tomography (CT) and cone-beam computerized tomography imaging. The highest distance was observed between maxillary floor and the first premolar root tip while the second molar distobuccal root tip was the nearest dental point to the maxillary sinus floor. There was no significant variation among male and female genders regarding this distances. Additionally, there was no variation of distances detected among right and left sides (11). The aim of the present study was to compare the relationships and distances between maxillary root tips of first and second maxillary molar and the maxillary sinus floor by using oral panoramic images among 2

16 Sudanese population in Khartoum state in time between July to September The literature described 4 types for qualitative evaluation of the maxillary root tips and inferior wall of the sinus. Panoramic images were evaluated for vertical relationship of root tips of the maxillary first and second molar teeth and the maxillary sinus floor. The distance between the apex of each root of mentioned teeth and the sinus floor was measured by built-in measuring tool of radiography viewing software provided by Regius 110 work station (Tokyo Japan). Type 1 was defined as cases in which the root was located in distant position from cortical borders of the Sinus (outside) (fig 1.1); Type 2 represented the close contact of the maxillary root tip and maxillary sinus floor (contact) (fig 1.1); and type 3 indicated overlapping of the root s shadow into the maxillary sinus without actual penetration into the cavity (shadow) (fig 1.1); Root apices protruding into the sinus cavity were categorized as type 4 relationship (inside) (fig 1.2). The variations of the frequency and distances should be kept in mind during any dental procedure around the upper molar teeth. No previous local study in the distances between the root tips of maxillary first and second molar and maxillary sinus floor was done in Sudan. This study could have clinical role for better understanding and management of upper molar teeth and maxillary sinusitis management in Sudanese population.. 3

17 (Fig 1.1): Panoramic radiographs demonstrating types 1, 2, and 3 of root tip to sinus floor relationship. Root apex is in close contact with maxillary sinus floor cortical bone (type 1). Root apex is overlapped by maxillary sinus shadow (type 2). Root tips are located distantly to the sinus floor. 4

18 (Fig1.2): Type 4 of root-maxillary sinus floor relationship.in the right side the first molar root penetrates to the maxillary sinus. 5

19 1.2. Objectives General objective: To compare the relationships and distances between maxillary root tips of first and second maxillary molar and the maxillary sinus floor by using oral panoramic images among Sudanese population in Khartoum state Specific objectives: 1. Panoramic images were evaluated for vertical relationship of root tips of the maxillary first and second molar teeth and the maxillary sinus floor. 2. Determine and compare the type of distances between the maxillary first and second molar root tips and the maxillary sinus floor by using oral panoramic images between the right and left side. 3. To assess the distances types regarding the age. 6

20 CHAPTER TWO Literature Review 7

21 2. Literature Review 2.1. Anatomy of the maxillary sinus and first and second maxillary molar teeth: Anatomy of the maxillary sinus: The maxillary sinus is the space within the body of the maxilla (fig 2.1); known in earlier days as the maxillary antrum (of Highmore). The sinus is pyramidal in shape (fig 2.1); the base at the lateral wall of the nose and the apex in the zygomatic process of the maxilla. The roof of the sinus is the floor of the orbit. The floor of the sinus is the alveolar part (tooth-bearing area) of the maxilla; it lies at a lower level than the floor of the nose (fig 2.1);. Anterior and posterior walls are the corresponding walls of the maxilla, Certain ridges appear within the cavity; a constant one is at the junction of roof and anterior wall, produced by the downward passage of the infra orbital nerve within its canal. The maxillary sinus is present at birth, but is no more than a shallow slit, slightly overgrown into a short culde-sac anteriorly and posteriorly. It excavates the lateral wall of the nose, beneath the middle concha, and lies just beneath the medial side of the floor of the orbit. The body of the neonatal maxilla lateral to this is full of developing teeth.the sinus varies in size; a large one may extend into the zygomatic process of the maxilla and into the alveolar process so that the roots of the three molar teeth (and possibly of the premolars also) lie immediately beneath the floor or project into it (fig 2.1);. The roots are usually enclosed in a thin layer of compact bone; when this is absent the apex of the root is in contact with the mucous membrane. Extraction of such a tooth must leave a fistula by rupture of the mucous membrane. These fistulae mostly heal spontaneously. The ostium of the sinus (fig 2.2); is high up and well back 7

22 on its nasal wall. It is 2-4 mm in diameter. (A second smaller ostium often lies posteriorly). It opens at the posterior end of the semilunar hiatus in the middle meatus of the lateral wall of the nose (12). The floor of the maxillary sinus is related to the roots of the teeth in variable degrees: Between the roots of adjacent teeth & the roots of the same tooth. Elevated in spots to accommodate the apices of the roots Roots may protrude into the sinus cavity The permanent teeth which may related to the floor of the maxillary sinus: First molar. Second and third molars Second and first premolars. Rarely the canine Fig (2.1): Maxillary sinus position and shape 8

23 (Fig 2.2): Opens into the nasal cavity through the ostium, an opening found on the highest part of the medial wall of the sinus top of the sinus, located within the hiatus semilunaris in the middle meatus of the nasal cavity Anatomy of the first and second maxillary molar teeth: The bulk of a tooth consists of dentine, a hard a vascular calcified tissue penetrated by minute canals,the dentinal tubules. The part of the tooth that projects into the mouth is the crown which is covered by enamel, the hardest of all calcified animal tissues, and the part held in the jaw is the root which is covered by cementum, a calcified tissue rather like bone. The term 'clinical crown' refers to the part of the tooth seen in the mouth and does not exactly correspond to the enamel-covered 'anatomical crown' whose lower part is obscured in the gingival sulcus by the free gingival margin of the gum. 9

24 The junction between enamel and cementum is the cervical margin or neck, which forms a slightly narrowed 'waist' to the tooth. Because enamel and cementum meet, dentine is not exposed on the surface. Inside the dentine is the pulp cavity, which communicates with the exterior via the root canal and the apical foramen at the apex of the tooth. The cavity is filled by dental pulp, with nerves (below), blood vessels and lymphatic s, all of which gain access to the pulp through the apical foramen. The pulp is covered with a single layer of tall columnar cells,the odontoblasts, lying in of the dentine. Throughout life they retain the power to produce dentine within the pulp cavity if the surface of the dentine is breached. The odontoblasts give off fine cytoplasmic processes that occupy the dentinal tubules.the periodontal ligament holds the cementum to the bony walls of the tooth socket. It consists of collagen fibers passing obliquely from the alveolar bone towards the apex of the tooth; the fibers 'sling' the tooth in position against pressure on its occlusal surface. It is really the modified periosteum of the alveolar bone. The ligament is radiolucent; in a radiograph of the tooth it shows as a clear interval between tooth and bone shadows contact with the inner surface (fig 2.3) (12). 10

25 teeth (Fig 2.3): Anatomy of the first and second maxillary molar 11

26 2.2. Morphology of the first and second maxillary molar teeth: Posterior to the premolars are three molars whose size decreases distally. Each has a large rhomboid (upper jaw) or rectangular (lower jaw) occlusal surface with four or five cusps. The maxillary first molar has a cusp at each corner of its occlusal surface and the mesiopalatal cusp is connected to the distobuccal by an oblique ridge. A smaller cusplet or tubercle (cusplet of Carabelli) usually appears on the mesiopalatal cusp (most commonly in Caucasian races). The tooth has three widely separated roots, two buccal, of which the mesiobuccal is larger and broader and the distobuccal is rounder and smaller, and one large palatal: their proximity to the maxillary air sinus is thought to be the reason first molar roots are wide apart and second and third molar roots are converged. The smaller maxillary second molar has a reduced or occasionally absent distopalatal cusp. Its three roots show varying degrees of fusion (fig 2.4). (Fig 2.4): Morphology of the first and second maxillary molar teeth 12

27 2.3. Development of the maxillary sinus and the first and second maxillary molar teeth: Development of the maxillary sinus: Paranasal air sinuses develop as diverticula of the lateral nasal wall and extend into the maxilla, ethmoid,frontal, and sphenoid bones. They reach their maximum size during puberty and contribute to the definitive shape of the face (13). The maxillary sinuses are the only sizable sinuses present at birth. At birth they have the size of a small lima bean measuring about 8x4 mm, and are situated with their longer dimension directed anteriorly and posteriorly. They develop at the third month of intrauterine life, in the place existing between the oral cavity and the floor of the orbit. They develop as evagination of the mucous membrane of the lateral wall of the nasal cavity at the level of the middle nasal meatus forming a minute space that expands primarily in an inferior direction into the primordium of the maxilla. The maxillary sinus enlarges variably and greatly by pneumatization until it reaches the adult size by the eruption of the permanent teeth. Enlargement of the maxillary sinus is consequent of facial growth. Growth of the sinus slows down with decline of facial growth during puberty but continues throughout life Development of the first and second maxillary molar teeth: Teeth are derived by budding of the epithelium (ectoderm) lining the mouth. The buds of ectoderm produce only the enamel; they evoke a reaction in the surrounding mesoderm, which differentiates to produce the dentine and cementum. In the mouth cavity (stomodeum) of the 5-week 13

28 embryo [12 mm (^-inch) long] an in growth of ectoderm occurs over the site of the future gums. A curved sheet of ectoderm grows into the adjacent mesoderm, tilting medially. This is the primary dental lamina. From its outer surface a series of buds grow into the mesoderm one for each deciduous tooth. At a later stage a similar series of buds grow (more medially) from the depths of the primary dental lamina one bud for each permanent tooth. These epithelial buds are the tooth germs and when they are well formed the primary dental lamina becomes absorbed. Remnants of this epithelium may later grow into cysts or tumors. The tooth germs grow away from the mouth surface into a wineglass-shaped mass, attached by its stalk to the primary dental lamina. This mass is the enamel organ. Its surface epithelium becomes columnar; the cells lining the concavity are ameloblasts which produce enamel. The epithelium of the rest of the enamel organ takes on a different appearance; its cells develop long branching processes and fluid separates them. From this appearance the mass is known as the stellate reticulum. After the ameloblasts commence to secrete enamel the stellate reticulum undergoes atrophy. Beyond the stellate reticulum the enamel organ is prolonged as an epithelial sheath around the root. The mesoderm within the cavity of the wineglass shaped enamel organ is evoked to differentiate into the dental papilla. Its surface cells become the columnar odontoblasts which produce dentine. The ameloblasts (ectodermal) lining the concavity of the enamel organ and the odontoblasts (mesodermal) covering the convexity of the dental papilla lie in contact.though the ameloblasts were there first, so to speak, it is the odontoblasts that become active first, producing dentine and, later, the ameloblasts produce enamel. As the two substances accumulate, the secreting cells are pushed further away from the amelodentinal junction. Around the root the dentine is contained by the epithelial sheath prolonged down from the enamel organ. The mesoderm 14

29 of the dental papilla persists as the pulp of the tooth, surrounded by the dentine it has secreted. Cementum is produced in the mesoderm outside the dentine of the root. The process is comparable to membranous ossification. As the cementum is formed the epithelial sheath around the dentine is absorbed and the cementum becomes firmly bound to the dentine of the root. The crown of the tooth is fully formed before eruption, but the root is only one-third formed. At this stage the tooth lies within a fibrous tissue condensation within the bone of the jaw, the dental follicle, and in the permanent teeth it communicates by a tiny orifice with the surface of the bone. The fibrous tissue in this orifice is the gubernaculums Eruption of the first and second maxillary molar teeth: The tooth erupts by a combination of elongation of the root and absorption of the overlying bone. The elongating root is unsheathed in an up growth of alveolar bone (12). - The normal times of eruption are: 6 years: First permanent molars 2.5. Previous studies: In study done by department of Oral and Maxillofacial Surgery, Shiraz University of Medical Sciences 149 males aging from 15 to 45 years with mean age of 31 years and 151 females aging between years with mean age of years were recruited. Root tip distances to maxillary floor and relationship type of the root apices and maxillary sinus were recorded for a total number of 1200 right and left first and second molar teeth from all groups. Among all root tips, the type 2 vertical relationship defined as the root in contact with the sinus inferior wall, was the most frequent (38.1%) qualitative relationship encountered 15

30 Statistical analysis for variation among the first and second molar teeth regarding their qualitative relationship of root-tips and the maxillary sinus floor revealed a significant difference between the root-tips of the first and second molar teeth (P<0.001). The most frequent type of relationship among first molar teeth was the type 1 while the type 2 relationship was more dominant among the second molar teeth. None of the root tips of the first molar teeth presented with the type 4 relationship while the frequency of the type 4 relationship in the second molar teeth was 2.4%. Our study showed the roots of the first molar had more distance to the maxillary sinus floor than the second molars in all groups. This finding addressed the same results by Eberhardt et al (15). The same results were described by Pagin et al (16). Also, Huang et al reported that the first molar roots had more risk to displace the maxillary sinus rather than other posterior teeth (17). 16

31 CHAPTER THREE Materials &Methods 17

32 3. Materials and Methods 3.1. Study design: Cross sectional, observational study design Study area: In Khartoum state, Sudan Study duration: In time between July to September Sample criteria: The sample group of this study were selected randomly among Sudanese peoples of both sexes within ages range between years which having had a complete first and second molars in the maxilla. Subjects were removed from the study if they had previous maxillofacial trauma, orthognathic surgery, reconstructive surgery, and implant procedures in the posterior of the maxilla Sample size: About 100 individuals, 48 male and 52 female Method of the study: Radiographic examination with help of panoramic radiography were taken from oral cavity of each individual. 17

33 3.7. Data collection: Data will be collected from registered radiographic by self-administered questionnaire Data analysis: Data analyzed by SPSS (Statistical Package for Social Sciences) version 16 and data was expressed as frequencies. Correlations between the variables were performed using one way ANOVA test. The results were presented as tables and graphs and discussed in details, and the conclusion was recorded Ethical approval: Ethical approval was obtained from local ethical committee and all participants were informed about the study. 18

34 CHAPTER FOUR Results 19

35 4. Results As shown in table (4.1) and figure (4.1), the total number of participants underwent the study were 100 cases, 48 (48%) were males and 52 (52%) were females. Root tip distances to maxillary floor and relationship type of the root apices and maxillary sinus were recorded for a total number of right and left first and second molar teeth from all groups. Among all root tips, the type 2 vertical relationship defined as the root in contact with the sinus inferior wall, was the most frequent (38.75 %) qualitative relationship encountered (Table 4.7). The most frequent type of relationship among first molar teeth was the type1 71 (35.5%) while the type 2 relationship was more dominant among the second molar teeth 94 (47%). Type 1 in which the root was located in distant position from cortical borders of the Sinus (outside) found in 105 cases (26.25 %). Type 2 represented the close contact of the maxillary root tip and maxillary sinus floor (contact) was found in 155 cases (38.75%), and type 3 indicated overlapping of the root s shadow into the maxillary sinus without actual penetration into the cavity (shadow) was found in 62 cases (15.5%), root apices protruding into the sinus cavity were categorized as type 4 relationship(inside) was found in 78 cases (19.5%) as shown in table (4.7). As shown in figure (4.7), the most common distances between the root tips of maxillary first and second molar and the maxillary sinus floor observed in this study was type 2 (contact) in 38.75% than the others (type 1, type 4 and type 3 ) respectively. 19

36 Table (4.1): Study group distribution. Gender Frequency Percent male 48 48% Female 52 52% Total % Fig (4.1): Study group distribution. 20

37 Table (4.2): Age group distribution. Age distribution Frequency Percent % % % % Total % Fig (4.2): Age group distribution. 21

38 Table (4.3): distance of upper right maxillary first molar teeth. Distribution Frequency Percent Outside 37 37% Contact 29 29% Shadow 17 17% Inside 17 17% Total % Fig (4.3): distance of upper right maxillary first molar teeth

39 Table (4.4): distance of upper left maxillary first molar teeth. Distribution Frequency Percent Outside 34 34% Contact 32 32% Shadow 13 13% Inside 21 21% Total % Fig (4.4): distance of upper left maxillary first molar teeth. 23

40 Table (4.5): Distance of upper right maxillary second molar teeth. Distribution Frequency Percent Outside 18 18% Contact 46 46% Shadow 17 17% Inside 19 19% Total % Fig (4.5): Distance of upper right maxillary second molar teeth. 24

41 Table (4.6): Distance of upper left maxillary second molar teeth. Distribution Frequency Percent Outside 16 16% Contact 48 48% Shadow 15 15% Inside 21 21% Total % Fig (4.6): Distance of upper left maxillary second molar teeth. 25

42 Table (4.7): Assessment of vertical distance between maxillary molar root tips and the sinus floor. Teeth Type 1 Type 2 Type 3 Type 4 First molar (right and 71 (35.5%) 61 (30.5%) 30 (15%) 38 (19%) left) Second molar (right 34 (17%) 94 (47%) 32 (16%) 40 (20%) and left) Total 105 (26.25%) 155 (38.75%) 62 (15.5%) 78 (19.5%) Type 1 Type 2 Type 3 Type 4 Fig (4.7): Assessment of vertical distance between maxillary molar root tips and the sinus floor. 26

43 CHAPTER FIVE Discussion 27

44 5.Discussion Panoramic radiography, also known as orthopantography (OPG) or panoramic tomography, makes it possible to depict in a single image a complete representation of the jaws, teeth, temporomandibular joints (TMJ), and the alveolar lobes of the maxillary sinuses. The extraordinary capabilities and possibilities provided by the panoramic radiograph give dentists the opportunity to record and analyze all components of the masticatory system and their interrelationships. Within these parameters, the panoramic radiograph forms the basis of a logically conceived and relatively low-radiation strategy for diagnostic examinations. This will reduce the risk of an incomplete and possibly incorrect examination, which in the worst-case scenario could lead to malpractice. In this regard, the panoramic radiograph always leads to a broadening of horizons because it improves the dentists knowledge of radiographic anatomy and thus improves her/his skill in distinguishing between and among normal and pathologic conditions. This in conjunction with a better understanding of the interrelationships of systemic medical problems and dental/oral problems can open new avenues for treatment planning (14). Appropriate knowledge of the distance and relationship between the posterior maxillary teeth root-tips and the maxillary sinus is important when endodontic and pre-prosthetic surgical procedures are planned. Protrusion of the maxillary molar root apices results in post-extraction pneumatization which causes reduction in bone thickness required for implantation. This assessment is critical when endodontic procedures are performed for maxillary molar teeth. The aim of the present study was to compare the relationships and distances between maxillary root tips of first and second maxillary molar and the maxillary sinus floor by using oral panoramic images in Sudanese. 27

45 This study shows that the most frequent type of relationship among first molar teeth was the type1 71(35.5%) while the type 2 relationship was more dominant among the second molar teeth 94 (47%). There is lack of evidence to show the correlation of thickness of maxillary sinus floor and other skeletal factors. Determining the effects of skeletal variations on the distance between molar root tips and the maxillary sinus floor helps the surgeons have better estimation of the risks and cautions which come along the desired procedure In the present study we used oral panoramic radiographs to evaluate qualitative and quantitative relationship between first and second maxillary molar roottips and maxillary sinus floor, our study showed the roots of the first molar had more distance to the maxillary sinus floor than the second molars in all groups. This finding addressed the same results by Eberhardt et al (15). The same results were described by Pagin et al (16). Also, Huang et al reported that the first molar roots had more risk to displace the maxillary sinus rather than other posterior teeth (17). 28

46 CHAPTER SIX Conclusion &Recommendations 29

47 6. Conclusion & Recommendations 6.1. Conclusion: -The panoramic radiograph forms the basis of a logically conceived and relatively low-radiation strategy for diagnostic examinations. - The most frequent type of relationship among first molar teeth was the type1 71 (35.5%) while the type 2 relationship was more dominant among the second molar teeth 94 (47%) which is similar to the majority of other studies, the most common distances between the root tips of maxillary first and second molar and the maxillary sinus floor observed in this study was type 2 (contact) in 38.75% than the others (type 1, type 4 and type 3 ) respectively. -This relationship has not previously been investigated and the finding may greatly help clinicians and surgeons background knowledge of anatomical positions of molar root tips against maxillary sinus floor, for pre-endodontic and pre-implantation strategy making Recommendations: - More studies are needed new methods can be used for evaluation of the type of distances like CB CT scan- x ray. - Larger sample size is recommended for more accuracy. 29

48 CHAPTER SEVEN References 30

49 7. References 1. Drăgan E, Rusa O, Nemţoi A, Melian G, Mihai C, Haba D. Maxillary sinus anatomic and pathologic CT findings in edentulous patients scheduled for sinus augmentation. Rev Med Chir Soc Med Nat Iasi 2014;118: Didilescu A, Rusu M, Săndulescu M, Georgescu C, Ciuluvică R. Morphmetric analysis of the relationships between the maxillary first molar and maxillary sinus floor. Open Journal of Stomatology 2012;2: Waite DE. Maxillary sinus. Dent Clin North Am 1971;15: Nimigean V, Nimigean VR, Măru N, Sălăvăstru DI, Bădiţă D, Tuculină MJ. The maxillary sinus floor in the oral implantology. Rom J Morphology Embryology 2008;49: Wehrbein H, Diedrich P. The initial morphological state in the basally pneumatized maxillary sinus a radiological-histological study in man. Fortschr Kieferorthop 1992;53: Hauman CH, Chandler NP, Tong DC. Endodontic implications of the maxillary sinus: a review. Int Endod J 2002;35: Ericson S, Finne K, Persson G. Results of apicoectomy of maxillary canines, premolars and molars with special reference to oroantral communication as a prognostic factor. Int J Oral Surgery 1974;3: Jerome CE, Hill AV. Preventing root tip loss in the maxillary sinus during endodontic surgery. J Endo 1995;21:

50 9. Persson G. Periapical surgery of molars. Int J Oral Surgery 1982;11: Park JH, Tai K, Kanao A, Takagi M. Space closure in the maxillary posterior area through the maxillary sinus. Am J Ortho dento facial orthopedic 2014;145: Kilic C, Kamburoglu K, Yuksel SP, Ozen T. An Assessment of the Relationship between the Maxillary Sinus Floor and the Maxillary Posterior Teeth Root Tips Using Dental Cone-beam Computerized Tomography. Eur J Dent 2010;4: Chummy S. Sinnatamby. Last s Anatomy: Regional and Applied. 12th edition: Elsevier Ltd. 2011: p T.W.Sadler. Langmans medical embryology. 12th edition: Lippincott Williams. 2012: p Friedrich A. Pasler, Heiko Visser. Pocket atlas of dental radiology. 2007:p Eberhardt JA, Torabinejad M, Christiansen EL. A computed tomography study of the distances between the maxillary sinus floor and the apices of the maxillary posterior teeth. Oral Surgery Oral Med Oral Pathology 1992;73: Pagin O, Centurion BS, Rubira-Bullen IR, Alvares Capelozza AL. Maxillary sinus and posterior teeth: accessing close relationship by conebeam computed tomography scanning in a Brazilian population. J Endodontic 2013;39: Huang IY, Chen CM, Chuang FH. Caldwell-Luc procedure for retrieval of displaced root in the maxillary sinus. Oral Surgery, Oral Med, Oral Pathology, Oral Radiology, Endodontic 2011;112:e

51 بسم هللا الرمحن الرحمي The National Ribat University Faculty of Graduate Studies and scientific research Data Collecting Sheet Comparison of the distances between the maxillary sinus floor and root tips of the upper first and second molar teeth by using oral panoramic images Name: Age : Sex 1- distance of upper right maxillary first molar teeth.: (A) Outside (B) Contact (C) Shadow (D) Inside 2- distance of upper left maxillary first molar teeth.: (A) Outside (B) Contact (C) Shadow (D) Inside 3- distance of upper right maxillary second molar teeth.: (A) Outside (C) Shadow (B) Contact (D) Inside 4- distance of upper left maxillary second molar teeth.: (A) Outside (C) Shadow (B) Contact (D) Inside 32