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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 371-375

Characteristics and prevalence of underwood's septae on digital panoramic radiographs


1 Department of Oral Medicine and Radiology, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, MNR Dental College and Hospital, Sangareddy, Telangana, India

Date of Submission27-Apr-2020
Date of Decision09-Aug-2020
Date of Acceptance20-Aug-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Anudeep Raina
Department of Oral Medicine and Radiology, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_73_20

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   Abstract 


Background: The term Underwood's septae is eponymously used for maxillary sinus septae. Septae may be defined as cortical bony partitions found in the form of inverted gothic arches that protrude from the sinus walls, dividing the sinus into two or more cavities. Aim: This study was aimed to determine the prevalence of maxillary sinus septae on digital panoramic radiographs. Settings and Design: This retrospective radiographic study was carried out in the Department of Oral Medicine and Radiology at Teerthanker Mahaveer Dental College and Research Centre, Moradabad. Materials and Methodology: This retrospective study comprised of panoramic radiographs of 100 subjects of either gender, aged between 16 and 80 years. Bony projections having a minimum height of 2.5mm were considered as septae according to the criteria suggested by Velasquez Plata D et al. The location of maxillary sinus septae was defined by Underwood classification as anterior, middle, and posterior. Statistical analysis: The data were analyzed using the SPSS statistical software 21.0 Version. Results and conclusion: Maxillary sinus septae were seen in 18 out of 100 radiographs, out of which unilateral maxillary sinus septae were noted in 08 cases (right-sided in 3, left-sided in 5) while bilateral septae were seen in 10 cases. The prevalence of maxillary sinus septae was found to be 18% on digital panoramic radiographs. Oral radiologists should thus report maxillary sinus septae and the possibility of surgical complications that may arise during maxillary sinus surgeries.

Keywords: Dentate population, digital panoramic radiograph, edentulous, maxillary sinus septa, Underwood's septa


How to cite this article:
Raina A, Sunil M K, Pradhan L, Yeluri G, Ravindra S V, Handa R. Characteristics and prevalence of underwood's septae on digital panoramic radiographs. J Indian Acad Oral Med Radiol 2020;32:371-5

How to cite this URL:
Raina A, Sunil M K, Pradhan L, Yeluri G, Ravindra S V, Handa R. Characteristics and prevalence of underwood's septae on digital panoramic radiographs. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2021 Jan 22];32:371-5. Available from: https://www.jiaomr.in/text.asp?2020/32/4/371/305277




   Introduction Top


The anatomist Arthur Underwood first reported Maxillary sinus septae in the year 1910.[1],[2] Consequently, the term Underwood's septae is eponymously used for maxillary sinus septae.[2] Septae may be defined as cortical bony partitions found in the form of inverted gothic arches that protrude from the sinus walls dividing the sinus into two or more cavities.[3],[4] Different hypotheses such as varying eruption phases of teeth, different resorption rates of the adjacent sinus floor area tooth loss, pneumatization, and finger like outpouching of ethmoid infundibulum during embryonic development have been attributed to the formation of maxillary sinus septae.[5]

Septae may be complete extending from one sinus wall to an opposing wall or may be seen as an incomplete 'fin' like sharp bony protrusion from a sinus wall without compartmentalizing the antral cavity.[2] Septae may exhibit a varied contour although they are mostly thin and wide.[2] Maxillary sinus septae are usually found against the medial wall.[2] They are characteristically made of cortical bone but may also contain cancellous bone.[2]

These septae may be radiographically demonstrated as white radiopaque structures or curved lines extending from the floor of the maxillary sinus.[2],[5] Their prevalence varies from 9% to 56% according to various studies conducted on panoramic radiographs, computed tomography, and cone-beam computed tomography.[2] According to the criteria suggested by Ulm and co-workers, thin bony radiopaque lamellae in the maxillary antrum with a height of at least 2.5 mm should be considered as maxillary sinus septa.[5] Based on their location in the maxillary antrum, septae may be classified as anterior: present between the mesial and the distal aspect of the second premolar, middle: being present between the distal aspect of second premolar to the distal aspect of the second molar and posterior present in the distal portion of the second molar region.[5]

Septae that are missed may lead to unanticipated problems during surgeries like sinus augmentation procedures.[1],[5] Few complications that these anatomical structures may pose include perforation of Schneiderian membrane, amputation of alveolar sinus-vascular plexus, maxillary sinusitis, and limitation in creating a window in the lateral antral wall.[4],[5] Hence, the knowledge of the anatomy of maxillary sinus septae and their presence may forewarn surgeons to modify maxillary sinus surgeries to prevent untoward complications.

Need for this study

The available literature showed that panoramic radiographs can delineate these anatomical variations being especially useful in developing countries where advanced imaging is not easily available.[1],[5] Also, only a few studies have been performed to assess the prevalence of maxillary sinus septae on panoramic radiographs in the Indian population. Hence this retrospective study was performed to determine the prevalence of maxillary sinus septae on 100 panoramic radiographs and to describe their characteristics in both dentulous and partially edentulous subjects in the Moradabad population.


   Material and Methods Top


This radiographic study was carried out in the Department of Oral Medicine and Radiology at Teerthanker Mahaveer Dental College and Research Centre, Moradabad. This retrospective study comprised of 100 radiographs selected from the archives over a recent period of six months belonging to subjects of either gender, aged between 16 and 80 years who had visited the Radiology Department of Oral Medicine and Radiology, at Teerthanker Mahaveer Dental College and Research Centre, Moradabad, UP and for whom an orthopantomogram was already taken. No fresh radiographs were taken for any of the patients for this study. These panoramic radiographs had been taken on Planmeca Proline digital panoramic system at 68Kbp, 5mA expose time 18 seconds and were visualized on Lenovo computer with optimal brightness setting using Romexis software under ideal viewing conditions. The inclusion criteria of the study were panoramic radiographs of optimum quality depicting the maxillary sinus region and belonging to patients in the age group of 16–80 yrs. The exclusion criteria of the study comprised radiographs that showed evidence of trauma/surgeries in the maxillary sinus region, signs of maxillary sinus pathologies, and systemic disorders affecting growth of the maxillofacial region. Based on the inclusion and exclusion criteria 100 radiographs were included in this study. This sample size was estimated according to the significance levels and statistical test that was to be employed during result analysis. These radiographs were randomly selected and interpreted by two observers for the presence or absence of maxillary sinus septae and the data was recorded only after a consensus between the two observers was reached. According to the criteria suggested by Velasquez Plata D et al. in 2002, bony projections having a minimum height of 2.5mm were considered as septae.[6] The location of maxillary sinus septae was defined by Underwood classification as utilized by Bhattacharya et al. in the year 2015 on panoramic radiographs as anterior (mesial to the distal aspect of the 2nd premolar), middle (distal to the second premolar to the distal of the second molar), and posterior (mesial to the distal aspect of the third molar.[5],[7] An ethical clearance was obtained prior to conduct of this study. The institutional ethical clearance certificate numbered (TMDCRC/IEC/19-20/OMR2 was granted on 06.11.2019). The declaration of Helsinki (2013) was adapted and a patient consent was obtained in accordance with this declaration of precedence of well-being of the study subjects over the benefits of those in the interest of science. The duration of the conduct of the study was 3 months.

Statistical analysis

The data for the present study was entered in the Microsoft Excel 2007 and analyzed using the SPSS statistical software 21.0 Version. The descriptive statistics included frequency.The intragroup comparison for the different time intervals was done using the Chi-square test.The level of significance for the present study was fixed at 5%.


   Results Top


This study included 100 panoramic radiographs of which 50 belonged to males and 50 to females. Of these 18 showed the presence of maxillary sinus septae, 8 in males, and 10 in females.Unilateral maxillary sinus septae were noted in 08 cases while bilateral septae were seen in 10 cases [Figure 1] and [Figure 2] Right-sided maxillary sinus septae were noted on 03 panoramic radiographs, while left-sided septae were seen on 05 radiographs.
Figure 1: Digital panoramic radiograph showing unilateral maxillary sinus septa

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Figure 2: Digital panoramic radiograph showing bilateral maxillary sinus septae

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On the right side, a maximum number of septae were noted in the posterior region of the dentate group[Figure 3]. 2 were present in theanterior region, 3 in the middle while 8 in the posterior region of the dentate subjects [Graph 1], [Table 1].
Figure 3: Right-sided maxillary sinus septa in the posterior region of dentate group

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Table 1: Presence or absence of septae on right side (N = 13)

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On the right side, in the partially dentate group no septae were observed in any of the three regions.

On the left side, the maximum number of septae was noted in the dentate group in the anterior region [Figure 4]. 7 septae in the anterior, 3 in the middle, and 4 in the posterior region of dentate subjects were seen [Graph 2], [Table 2].
Figure 4: Left-sided maxillary sinus septa in the anterior region of dentate group

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Table 2: Presence or absence of septae on left side (N = 15)

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On the left side in the partially dentate group, only 01radiograph showed septa in the middle region.

In males, 08 radiographs showed septae while 10 radiographs in females showed septae. In males, unilateral (left) septae were seen in 05 cases while bilateral septae were seen in 06 cases. In females, unilateral (03 on the left and 03 on the right) septae were seen in 06 cases while bilateral septae were seen in 06 cases.

In males, 4 radiographs showed septae in the anterior region, 4 in the middle region, and 5 in the posterior region.

In females, 14 radiographs showed septae while 5 radiographs showed septae in the anterior region, 2 in the middle region, and 7 in the posterior region [Table 3] and [Table 4].
Table 3: Gender wise distribution on right side

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Table 4: Gender wise distribution on left side

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   Discussion Top


As cited by Malec M et al. the prevalence of maxillary sinus septae on radiographs range from 9-70% with a mean of 36%.[1] In our study, we found the prevalence of 18% which falls within the range cited by Malec Met al.[1]

According to a study conducted by Bhattacharya et al. in 2015 on 400 panoramic radiographs to check for the prevalence of maxillary sinus septae in the Indian population was found to be 34%.[5] These differences in the prevalence of septae may be attributed to differences in sample size observer inference variability and subset of the Indian population studied.

Although panoramic radiography is a relatively cost effective and easy available imaging modality with less radiation exposure, it should be used cautiously owing to a few shortcomings such as inherent distortion of the image and superimposition of other anatomical landmarks.[5] However, it can provide useful information in circumstances where advanced imaging is not readily available. Numerous studies have indicated that CT is the preferred method for visualization of maxillary sinus septa. CT may thus be required whenever in doubt or for affirmation of the findings on panoramic radiographs.

Unilateral maxillary sinus septae were seen in 8 cases (44%) while bilateral septae were seen in 10 cases (56%). Hence in our study, the prevalence of bilateral maxillary sinus septae was higher compare to unilateral septae which is in accordance with a study conducted by Orhan K et al. in 2013 who found unilateral septae in 40.1% of cases evaluated by CBCT and bilateral septae in 59.8% cases.[8]

In our study, we noted that the maximum number of septae were present in the posterior region of the dentate group while in the partially dentate group, the septae were more predominant in the middle region.This is in accordance with a study conducted by NeychevV et al. in 2017 in CBCT images of 200 patients. According to their study, patients with teeth showed a predominance of maxillary sinus septae in the posterior region while in edentulous patients the prevalence was higher in the middle region.[4]

In our study, we found more septae on the left side (i.e. on 5 radiographs) which is in accordance with the study conducted by Velasquez Plata D et al. in 2002 on 186 CT scans.[6]

In our study among 18 radiographs depicting maxillary sinus septae, we found 8 in males and 10 in females. A study conducted by Abdul-Hameed A et al. in 2016 on CT images of 130 subjects showed that the prevalence of the septae was more in male subjects.[9] This difference in gender prevalence can be attributed to differences in sample size and population group studied.

Considering the above findings, it is of significant importance for the treating oral physician to be aware of normal anatomic variants such as maxillary sinus septae. Owing to the surgical complications that may arise due to its presence especially in maxillary sinus surgeries, their recognition and identification are of utmost value.[10] Through this study, an economic and relatively easy radiographic technique to identify the maxillary sinus septae in the Indian/Uttar Pradesh population is presented. Further research with large sample size is recommended to elucidate the characteristics of maxillary sinus septae and their variations.

Limitations and Future Prospects of the study

Owing to the inherent distortion and lack of three dimensional imaging through panoramic radiographs, similar studies employing larger sample sizes with advanced imaging modalities like cone beam computed tomography is suggested.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Malec M, Smektala T, Trybek G, Sporniak-Tutak K. Maxillary sinus septa: Prevalence, morphology, diagnostics and implantological implications. Systematic review. Folia Morphol2014;73:259-66.  Back to cited text no. 1
    
2.
Greenstein G. Impact of septa during bone augmentation in the maxillary sinus. Implant Dentistry, Latest CE Courses, Oral Surgery, Periodontics, May 2017.  Back to cited text no. 2
    
3.
Taleghani F, Teharanchi M, Shahab S, Zohri Z. Prevalence, location and size of maxillary sinus septa: Computed tomography scan analysis. J Contemp Dent Pract 2017;18:11-5.  Back to cited text no. 3
    
4.
Neychev D, Kanazirska P, Simitchiev K, Yordanov G. Cone beamcomputer tomography Images: An important tool in the analysis of anatomical variations of maxillary sinus related to Underwood septa. Biotechnol Biotechnol Equip2017;31:1210-5.  Back to cited text no. 4
    
5.
Bhattacharya P, Patil K, Guledgud M. Maxillary sinus septa A panoramic radiographic study. Int J Stomat Occ Med 2015.  Back to cited text no. 5
    
6.
Velasquez-Plata D, Hovey RL, Peach CC, Alder ME. Maxillary sinus septa: A 3- dimensional computerized tomographic scan analysis. Int J Oral Maxillofac Implants 2002;17:854-60.  Back to cited text no. 6
    
7.
Lee-Jin W, Lee-JS, Kim-Seop H. Analysis of location and prevalence of maxillary sinus septa. J Periodontal Implant Sci 2010;40:56-60.  Back to cited text no. 7
    
8.
Orhan K, Seker Kusakci B, Aksoy S, Bayindir H. Cone beam computer tomography evaluation of maxillary sinus septa prevalence, location and morphology in children and an adult population. Med PrincPract 2013;22:47-53.  Back to cited text no. 8
    
9.
Abdul-Hameed A, Daudu ZA, Mohammad MS, Abubakar B, Shiitu BS, Danjuma UJ, et al. Normal anatomical variations of maxillary sinus septa using computerized tomography from Sokoto Northwestern Nigeria. West Afr J Radiol [serial online] 2016;23:12-5. Available from: https://www.wajradiology.org/text.asp?2016/23/1/12/155741.  Back to cited text no. 9
    
10.
Tadinada A, Jalali E, Al-Salman W, Jambhekar S, Katechia B, Almas K. Prevalence of bony septa, antral pathology, and dimensions of the maxillary sinus from a sinus augmentation perspective: A retrospective cone-beam computed tomography study. Imaging Sci Dent 2016;46:109-15.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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