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FORENSIC ODONTOLOGY: ORIGINAL RESEARCH ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 384-389

3D evaluation of maxillary sinus in gender determination: A cone beam computed tomography study


Department of Oral Medicine and Radiology, Pushpagiri College of Dental Sciences, Thiruvalla, Kerala, India

Date of Submission04-Jun-2020
Date of Decision20-Oct-2020
Date of Acceptance22-Oct-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Anju Mathew
Senior Lecturer, Department of Oral Medicine and Radiology, Pushpagiri College of Dental Sciences, Perumthuruthy, Thiruvalla - 689 107, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_104_20

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   Abstract 


Background: Gender determination is a subdivision of forensic medicine and very crucial especially when information relating to the deceased is unattainable. Maxillary sinus remains intact even when the skull and other bones may be badly disfigured. Aim and Objectives: This study aimed at assessing the reliability of morphometric measurements performed on the maxillary sinus for gender determination by Cone Beam Computed Tomography. Materials and Methodology: The present study was conducted in the Department of Oral Medicine and Radiology to assess maxillary sinus dimensions of 100 patients with 200 sinuses [left and right maxillary sinuses] by Cone Beam Computed Tomography. Two independent observers measured the maxillary sinus parameters such as width, length, height, intermaxillary distance, bizygomatic distance in axial and coronal view. Discriminative analysis was performed using the derived values and independent t-test was used to compare the values between males and females. Results: The overall values of the maxillary sinus dimensions were significantly greater (p < 0.05) in males as compared to females except intermaxillary distance (p > 0.05). There was no significant difference while comparing the right and left side within the same gender (p > 0.05). Maxillary sinus height was a better discriminant parameter for sexual dimorphism with 80% accuracy. Conclusion: Maxillary sinus can be used as an aid in forensic anthropology for gender determination. CBCT measurement of Maxillary Sinus can be used as supplementary tool for gender determination.

Keywords: Bizygomatic distance, cone beam computed tomography, gender determination, intermaxillary distance, maxillary sinus


How to cite this article:
Mathew A, Jacob LE. 3D evaluation of maxillary sinus in gender determination: A cone beam computed tomography study. J Indian Acad Oral Med Radiol 2020;32:384-9

How to cite this URL:
Mathew A, Jacob LE. 3D evaluation of maxillary sinus in gender determination: A cone beam computed tomography study. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2021 Jan 20];32:384-9. Available from: https://www.jiaomr.in/text.asp?2020/32/4/384/305262




   Introduction Top


Gender determination remains a prime step towards establishment of positive individuality of the deceased individual.[1] Skeletal remains help in identifying gender as the bones are last to perish after death.[2],[3] There is 100% accuracy from skeletons which include skull, pelvis, foramen magnum, mandibular ramus and paranasal sinuses.[4],[5],[6],[7] Unfortunately, these bones are recovered in fragmented state making gender determination difficult. The only denser bones that are often recovered intact are maxillary sinuses [MS].[4] MS anatomy differs in its dimension and from person to person and in the same individual, subjective by age. This variation is vital in gender determination.[8] Cone Beam Computed Tomography (CBCT) is the preferred imaging modality which allows precise information of MS anatomy making it an ideal tool in forensic science.[2],[8]

On the basis of this background, this study was done to evaluate the dimensional variation of the maxillary sinuses for gender determination by CBCT.


   Materials and Methodology Top


A retrospective study was carried out in the Department of Oral Medicine and Radiology following the fundamental principles of the Declaration of Helsinki (2013). The ethical clearance for the study was obtained from the Institutional Ethical Committee [Vinayaka Missions Sankarachariyar Dental College/IEC/Approval No: 088 dated 23/11/2017]. The present study is an institution based study carried out within a time frame of 6 months (July-December 2019). The sample size estimation was done by using Raosoft software and the sample comprised of 100 patients (50 males and 50 females). All the selected patients were informed about the study and voluntary informed written consent was obtained from them. CBCT scans were performed on patients using KODAK 9500 CONE BEAM 3D SYSTEM which uses flat panel amorphous silicon sensor; patient in standing position; Field of View: 18 cm × 20 cm; voxel size of 0.3 mm; exposure parameters such as 80 kvp, 10 mA with exposure time of 14.2 seconds. Maxillary sinus dimensions of 100 patients with 200 {left and right bilateral maxillary sinuses}, based on the following inclusion and exclusion criteria were included in the study. CBCT images were selected from patients indicated for orthognathic surgery/for paranasal sinus evaluation. Subjects that fall within the age group of 20 – 60 years with full permanent dentition, high quality reconstructed images were considered under the inclusion criteria. Maxillary sinus pathology like cyst or tumors, any previous history of surgery, orthognathic surgery/fractures involving maxillary bone and documented craniofacial anomaly were excluded from the study.

Two independent observers measured the maxillary sinus parameters. Parameters height, width, depth, intermaxillary distance, and bizygomatic distance were measured on axial and coronal slice of CBCT image. All measures were taken between the widest points of all the sinuses in CS 3D Imaging Software 3.2.9 by activating the measurement mode present in the tools option.

Width (axial view)

Longest distance perpendicular from medial wall of the sinus to the most lateral wall of lateral process of the maxillary sinus [Figure 1].
Figure 1: Width in axial slice

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Depth (axial view)

Longest distance from the most anterior point to the most posterior point of the medial wall [Figure 2].
Figure 2: Depth in axial slice

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Height (coronal view)

Longest distance from the lowest point of the sinus floor to the highest point of the sinus roof [Figure 3].
Figure 3: Height in coronal slice

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Bizygomatic distance (axial view)

Measuring the maximum distance between the most prominent points of the right and left zygomatic arches from axial cut [Figure 4].
Figure 4: Bizygomatic distance in axial slice

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Intermaxillary distance (axial view)

Measuring the maximum distance between medial walls of right and left maxillary air sinuses from axial cut [Figure 5].
Figure 5: Intermaxillary distance in axial slice

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All data were transferred to Microsoft Excel 2010 software and subjected to statistical analysis using SPSS software 20.0. Independent t-test was used to compare between the right and left side of maxillary sinus measurements and to compare between males and females. Intra-class Correlation Coefficient (ICC) was used to determine inter-observer agreement.

Stepwise discriminant analysis was conducted to predict gender (Male or Female) from the different maxillary dimensions. Stepwise statistics revealed the significant predictors which were used to determine the discriminate function.


   Results Top


In the present study, Intra-class Correlation Coefficient was found to be ranging from 0.83 to 0.96 which indicated excellent reliability for intra and inter observer performances. The mean sinus dimensions for males - Width (Right -25.52 mm and Left -26.6 mm), Depth (Right – 31.4 mm and Left – 32.6 mm), Height (Right – 37.0 mm and Left – 36.40 mm), Intermaxillary distance (33.4 mm) and Bizygomatic distance (94.88 mm). The mean sinus dimensions for females - Width (Right -21.67 mm and Left -22.7 mm), Depth (Right – 27.80 mm and Left – 28.7 mm), Height (Right – 32.12 mm and Left – 32.6 mm), Intermaxillary distance (31.6 mm) and Bizygomatic distance (89.23 mm). The overall values of the maxillary sinus dimensions (Sinus width, depth, height and bizygomatic distance) were significantly greater in males as compared to females and found to be statistically significant (p < 0.05) except intermaxillary distance (p > 0.05) [Table 1]. There was no significant difference while comparing the right and left side (p > 0.05). Results of discriminant functional analysis of right (height, width, depth) and left (height, width, depth) are clearly described in [Table 2], [Table 3], [Table 4].The cross validated classification of sinus parameters revealed that using the right height 70% of original grouped cases could be correctly classified as females and 80% of original grouped cases could be correctly classified as males [Table 2]. The right width could correctly classify 72% and 70% of original grouped cases as females and males respectively [Table 3]. In case of right sinus depth, we could could correctly classify 72% and 70% of original grouped cases as females and males respectively [Table 4]. Using the left sinus height, 78% of original grouped cases could be correctly classified as females and 82% of original grouped cases could be correctly classified as males [Table 2]. The left width could correctly classify 72% and 82% of original grouped cases as females and males respectively [Table 3]. In case of left sinus depth, we could correctly classify 70% and 78% of original grouped cases as females and males respectively [Table 4].
Table 1: Comparison between male and female maxillary sinus dimensions

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Table 2: Classification results of discriminant functional analysis of right heightab and left heightCd

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Table 3: Classification results of discriminant functional analysis of right widthab and left widthcd

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Table 4: Classification results of discriminant functional analysis of right depthab and left depthcd

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   Discussion Top


Gender determination from human skeletal remains is an important step in forensic profile, especially when the evidence relating to the deceased is unavailable. Since skeletal bones are often fragmented, the emphasis has been diverted to the use of structures that can be recovered without much destruction such as the maxillary sinus, which demands in for the role of forensic odontology.[7] After birth, the maxillary sinus continues to pneumatise into the developing alveolar ridge as the permanent teeth erupt. Pneumatisation ends at the age of 20 with the completion of the eruption of the third molars. It has been stated that genetic diseases, post infections and environmental factors can disturb the sizes of maxillary sinus.[9] Considering this factor the patients with disease conditions were excluded from the study.

The present study was designed to determine the reliability and accuracy of measuring Maxillary Sinus dimensions as a method for gender identification using CBCT on 100 patients. The results showed that the maxillary sinus exhibits anatomic variability between genders. A significant sex difference was found in relation to maxillary sinus dimensions with respect to following parameters such as width, length, height, and bizygomatic distance. The values of males were relatively greater than values of females. Within the males, left side width and depth were greater compared to the right side while in females, left side width, depth, height were greater compared to the right side. For these two explanations can be given. First, males need to have correspondingly bigger lungs to support relatively massive body muscles and organs [According to Enlow].[10] Second, males need larger nasal cavity complex as a direct result of respiration related needs such as warming and humidifying air.[10] The maxillary sinus height depicted 70% of original grouped cases could be correctly classified as females and 80% of original grouped cases could be correctly classified as males. The mean bizygomatic distance was significantly higher in males (94.88 mm) than females (89.23 mm). In our study, the maxillary sinus height and bizygomatic distance showed relatively better discrimination to study sexual dimorphism.

Our study was in accordance to study carried out by Doaa A El Baz et al. in 2019, where they assessed maxillary sinus dimensions in a sample population of Egypt by CBCT. They found that all maxillary sinus parameters showed higher mean value in males when compared to females.[3] Our study was comparable with study carried out by Dr. Cristalle Soman in 2019 in Saudi population by the use of Cone Beam Computed Tomography (CBCT) for evaluating gender through maxillary sinus.[8]

According to study conducted by Uthman et al.[11] in 2011 and Tambawala SS et al.,[5] maxillary sinus height was the best discriminate parameter that could be used to study sexual dimorphism with overall accuracy of 71.6%. Attia et al.in 2012, evaluated maxillary sinus dimensions, and concluded that the right height was a valuable tool in studying the sexual dimorphism with overall accuracy 69.9%.[12]

Ranjith Kumar Kanthem in 2015 carried out a study for identification of sex using maxillary sinus by computed tomography and reported that all parameters height, length, width, and volume of the maxillary sinus on both sides showed statistically significant results with a higher percentage of sexual dimorphism in the case of volume.[13] The results obtained in our study were in agreement with study carried out Azhar A et al., in 2015 which resulted with left MS width as the best discriminative parameter for assessing gender.[14]

In contrary, a study conducted by Saccucci M et al. on gender determination using maxillary sinus dimensions by CBCT resulted in no statistical difference in patient's maxillary sinus volumes between genders. They concluded that it is not possible to use the MS to discern sexual difference in corpse identification.[15] Akhilanand Chaurasia and Gaurav Katheriya in 2016 carried out a study in Lucknow that resulted in no significant (P > 0.05) difference in the study parameters (AP diameter, width and intermaxillary distance) among the age groups. It was found that only Bizygomatic distance was significantly (P = 0.01) different between males and females.[16]

Sanda Usha Rani et al. in 2017 carried out a similar study in Telengana population to identify sex and age by assessing maxillary sinus dimensions using MRI and found the volume and dimensions of the maxillary sinus were more in males when compared to the females with a statistically significant difference. The highest percentage of sexual dimorphism was seen in the volume of left maxillary sinus.[17]

Ruhi Sidhu et al. in 2014 performed a study to check the accuracy and reliability of maxillary sinus in gender determination using morphometric parameters in Western Uttar Pradesh and found that the mean area and perimeter of maxillary sinus in males was 1.7261 cm2 and 5.2885 cm whereas, the mean area and perimeter in females was 1.3424 cm2 and 4.3901 cm. Discriminant functional analysis showed that, 76% of the original grouped cases were correctly classified and the overall sensitivity and specificity was found to be 80% and 72%. They concluded that morphometric analysis (area and perimeter) of maxillary sinus can assist in gender determination.[18] C Tirumala Ravali in 2017 did a retrospective analysis for assessing the reliability of morphometric measurements performed on the maxillary sinus for sex determination using CBCT scans and results showed that the female group had statistically significant lower values for both the right and left maxillary sinuses with regard to the width, length, and height dimensions.[19]

Paknahad et al. in 2016 conducted a study that aimed to evaluate whether maxillary sinus measurements on CBCT scans can be applied for gender determination on a sample size of 100 which included 50 men and 50 women. They found that the correct predictive accuracy rate of sex determination was 78% in females and 74% in males with overall accuracy of 76%. Based on discriminant analysis, the most pronounced variable in differentiation of sex groups was maxillary sinus height.[20] Mukul Prabhat et al. in 2016 investigated whether maxillary sinus parameters can be used to determine the gender of an individual for forensic identification and the result proved that their study method was able to predict the gender with an accuracy of 80.0% in males and 86.7% in females, with an overall accuracy rate of 83.3%.[21] Ramhari S. Sathawane et al. in 2020 carried out a comparable study by assessing maxillary sinus dimensions to figure out gender by CBCT scans. They observed that the accuracy rate of gender determination was 73% in males and 69% in females, with overall accuracy of 71%. The most pronounced parameter in differentiation of gender was the maxillary sinus height.[22]

Fernandes CL established the role of the MS in ethnic classification. They had found that European crania had significantly larger antral volumes than the Zulu crania. Males were found to have larger volumes than females. On the other hand, Zulu male sinuses were narrower than Zulu female sinuses and race was found to highly significant, with European sinuses being wider than Zulu sinuses.[23]

Thus, the variations in some of the results of maxillary air sinus dimensions in above studies are probably due to concoction of various factors like diverse ethnic and racial groups with differences in body stature, skeletal size, height and physique; genetic and environmental factors; anatomical variations of sinus; alterations in osteoclastic and osteoblastic activity and pneumatization process of sinus.[24] The variations in the results obtained for different populations also suggest that this study can be done for different populations all over the world to generate equations for sex determination.

Limitations and future prospects of the Study

This is only a preliminary study carried out in South Kerala population and the study population was not divided into sub-groups based on their age, further studies on large samples are required to make it a conclusive gender predicting tool and for attaining standardization.


   Conclusion Top


Gender determination plays a key role in forensic medicine. To conclude, this study shows that the maxillary sinus height and bizygomatic distance are the most reliable discriminant parameter that could be used for the purpose of gender discrimination. The study also proposes the reliability, usability and accuracy of CBCT for evaluating maxillary sinus dimensions in the field of forensic science. This study thereby suggests the importance of sexual dimorphism of maxillary sinus dimensions i.e., width, depth, height, intermaxillary distance and bizygomatic distance when other methods and procedures used in the field of forensic science seem to be inconclusive. This research work could thus prove vital in recognizing the gender of a person in forensic anthropology. The results of the present work showed all the parameters of maxillary sinus had highly significant difference between males and females. Males had higher value when compared to females. Maxillary sinus height and bizygomatic distance were better discriminant parameters for sexual dimorphism. CBCT provides an excellent and reliable tool for analysing maxillary sinus dimensions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for taking radiographs and utilise the information obtained from their radiographic images to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.

Key Message

Sexual dimorphism is one of the integral aspects in personal identification of an unknown corpse thus narrowing down the diagnosis towards a correct possibility. Maxillary sinus remains intact although the skull and other bones may be badly disfigured in victims who are destroyed. Radiographic images could provide adequate measurements for maxillary sinuses that cannot be approached by other means. Hence, morphometric analysis of maxillary sinuses can assist in gender determination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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



 

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