Zainab.docx J Bagh College Dentistry Vol. 28(1), March 2016 Cone beam computed Oral Diagnosis 99 Cone Beam Computed Tomography in an Evaluation and Diagnosis of Anatomical Variations and Pathological Lesions in Maxillary Sinus Prior to Maxillary Sinus Lift Surgery Zainab H. Al-Ghurabi, B.D.S, M.Sc. (1) Abstract: Thorough assessment of the maxillary sinus is very important. Recently 3-dimensional image with Cone Beam Computed Tomography (CBCT) is very dependable in Maxillary Sinus diagnosis. The aim of this study is to: shade light on the role of (CBCT) diagnosis of the maxillary sinus anatomical variation and pathological finding among smokers and nonsmokers prior to maxillary sinus lift techniques. Materials and Method: In this study 60 males with age ranged between 20-50 years old, referred for (CBCT) assessment of maxillary sinus in the Specialist Health Center of Al-Sadder city. The scanning were performed using Kodak 9500 (CBCT), the KV was 90, mA10 and scanning time 10 s. Voxel size 0.3mm with( DICOM ) software on a multiplaner reconstruction window in which the axial, coronal and sagittal plane could be visualized in 0.3 mm interval, 40 were smokers and 20 nonsmokers, both sides were evaluated to assess the presence of septa, maxillary sinus membrane (Schneiderian membrane)thickening, complete opacification and adenoid polyp. Result:The maxillary for nonsmoker patients (20) patients were clean and have no any pathological or anatomical changes, among smoker patients, it was found that 7 (17.5%) of them had a clean maxillary sinus, 25 (62.5%) patient from smokers, the mucosal thickening was clear and measured more than 4 mm, 20 (80%) of them bilateral maxillary sinus were involved and 5 (20%) of them have a unilateral thickening, 6 (15%) of the smoker patient have bilateral involved adenoid with max sinus, and 2(5%) of them have full opacification., no septa was found in this study. Conclusion:Cone Beam Computed Tomography(CBCT)was themost useful technique to diagnose maxillary sinusbefore maxillary sinus augmentation, an evaluation ofCone Beam Computed Tomography(CBCT)scans before implant surgery or sinus augmentation procedures has extreme clinical importance in evaluation of anatomic structures, such as thickening of the Schneiderian membrane and presence of pathological lesion such as adenoid polyp. Key words: Cone beam computed tomography, maxillary sinus, anatomical variations. (J Bagh Coll Dentistry 2016; 28(1):99-102). INTRODUCTION Sound knowledge of maxillary sinus and its anatomical variationsis very importantfor surgeons,especially before surgical procedures, such as insertion of dental implants with or without maxillary sinus lifting (1-3). Anatomic variations within the sinus, such as septa and mucosal thickening of the sinus floor increase the possibility of the sinus membrane perforation during pre- implant surgery in maxillary sinus(4). Very few knowledge about the thickening and the dimension of the maxillary sinusmembrane, there is no specific method for evaluationand classification of mucosal findings in it. Many findings determined that, the thickening of maxillary sinus mucosa less than 2 mm was consider asa normal variant(5,6). Radiographically, the normal maxillary sinus, because it is air filled so it is radiolucent structure, while its walls appear as radiopaque(7). In the case of a diseased sinus, a radiologist may observe clouding (opacifying) or mucosal thickening(8). (1) Lectuere, Department of Oral Diagnosis, College of Dentistry, University of Baghdad. Thorough assessment of the maxillary sinus is very important. Panoramic imaging technique is used widely in dentistry but it is still 2- dimensional image that loss some important anatomical details recently, (CBCT) isconsidered as an acceptable alternative. Since the end of 90s(CBCT) has become a popular imaging technique in dentistry, even for visualization of the paranasal sinuses(9,10). (CBCT) can accurately capture, display and provide undistorted 3-dimensional view of maxillofacial anatomy and pathology. It is important to be acquainted with different anatomic and pathologic findings in maxillary sinus, (CBCT) scanning has become the standard in dentistry for evaluating the maxillary sinuses because of the ability to accurately scanning the sinus in multiple views with thin sectioning (11). (CBCT) images allow localizing the anatomic structures and providing information about bone dimensions and morphology (12,13). The relationship between smoking and thickening of sinus mucosa was directrelationship (17). The effect of smoking and non-allergic inhalants cause chronic inflammation of the nasal and sinus mucosa which may lead to adenoid polyp formation (18). J Bagh College Dentistry Vol. 28(1), March 2016 Cone beam computed Oral Diagnosis 100 The present study was designed to: 1-Shed light on the importance of (CBCT) in pre implant evaluationfor patients who have alveolar bone loss in the maxillary sinus area. 2- To compare the maxillary sinus appearance and pathological images between smokers and nonsmokers. MATERIALS AND METHODS In the present study 60 males with age ranged between 20-50 years old,(mean 35 years)referred to(CBCT) scanning for maxillary sinus in Specialist Health Center in AL-Sadder City.The scanning were performed using Kodak 9500 (CBCT), French origin, the Kv was 90, mA10 and time of scan 10 s. Voxel size 0.3mm with(DICOM) software on a multiplaner reconstruction window in which the axial, coronal and sagittal plane could be visualized from period between September 2014 to march 2015. CBCTscan was done for all patients to assess the presence of any anatomical variation or pathological finding pre implant associated with maxillarysinusaugmentation. Scanning of maxillary sinus was performed by using three orthogonal slices. The (CBCT) scans were analyzed by independent two readings by the specialist radiologist.The criteria of evaluation based on scanning of:(1) presence of septa, (2)mucosal thickening more than 2mm,(mucosa was measured from different point corresponding to the underlying bone in the area of 1st,2nd premolars and 1st,2nd molars, the highest point was recorded),(3)full opacification of maxillary sinus and/or any other (4) pathological finding. Classification of mucosal thickening (14). (1) Flat: shallow thickening without well- defined(irregular)outlines. (2)Semi-spherical: thickening with well defined(round)outline (3) Mucocele-like: complete opacificationofthe sinus. All patients were asked about: Age, tobacco use, classified as with duration of more than 2 years, history of sinusitis and time of last extraction. All patients were informed about the aim and method of the study and they fill a special consent form after their agreement in participation. Chi square statistical analysis was used to compare the result finding between smokers and nonsmokers. (A) (B) Figure 1: (A&B) Coronal View Showing Bilateral Thickening of Maxillary Sinus Membrane. Figure 2: Coronal view Showing Unilateral Thickening of Maxillary Sinus Membrane (A) (B) Figure 3: (A) Axial & (B) Coronal Showing Full Opacification of the Lt. Maxillary Sinus J Bagh College Dentistry Vol. 28(1), March J Bagh College Dentistry Vol. 28(1), March Oral Diagnosis Figure 4 Represent Bilateral Maxillary Sinus Adenoid RESULT The included in the sample, 40 of them smokersand 20 As shown in the table nonsmoker patient pathological or anatomical changes Table 1 Presence of septa Thickening Adenoid Full opacification Figure 4: J Bagh College Dentistry Vol. 28(1), March Oral Diagnosis Figure 4: (A) Axial and (B) Coronal View Represent Bilateral Maxillary Sinus Adenoid RESULTS The (CBCT) scanning luded in the sample, 40 of them and 20 nonsmoker As shown in the table nonsmoker patients were ological or anatomical changes Table 1: Clear the P Criteria Presence of septa Clear Thickening More than 4 mm. Bilateral Unilateral Adenoid Bilateral Full opacification Total Figure 4: The Percentages 0 10 20 30 40 50 60 70 80 90 100 Clean J Bagh College Dentistry Vol. 28(1), March (B) : (A) Axial and (B) Coronal View Represent Bilateral Maxillary Sinus Adenoid Polyp scanning of 60 patient luded in the sample, 40 of them nonsmokers. As shown in the table 1, maxillary sinus were totally clear ological or anatomical changes the Percentage of th the Side among T Presence of septa More than 4 mm. Bilateral Unilateral Bilateral Full opacification *Percentages were calculated from 25 cases ercentages of the Thickening, Adenoid and Full O Clean More than 4 J Bagh College Dentistry Vol. 28(1), March : (A) Axial and (B) Coronal View Represent Bilateral Maxillary Sinus Adenoid of 60 patients were luded in the sample, 40 of them were maxillary sinus clear and have no ological or anatomical changes (mucosal ercentage of the Thickening, Adenoid and Full O the Side among T Smokers No. (%) 0 7 (17.5%) 25 (62.5%) 20 (80%) * 5 (20%) * 6 (15%) 2 (5%) 40 (100%) *Percentages were calculated from 25 cases of the Thickening, Adenoid and Full O Thickening More than 4 mm. J Bagh College Dentistry Vol. 28(1), March 101 : (A) Axial and (B) Coronal View Represent Bilateral Maxillary Sinus Adenoid were were maxillary sinus for and have no (mucosal thickening and full opacification) smoker 40 s sinus with maxillary sinus which fig bilateral maxillary sinus fig1, maxillary sinus opacification which was seen only among smoker patient patients sinus as shown significant since the anatomi pathological smoker e Thickening, Adenoid and Full O the Side among Two Study G Non-smokers No. (%) 0 20 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 20 (100%) *Percentages were calculated from 25 cases of the Thickening, Adenoid and Full O Adenoid J Bagh College Dentistry Vol. 28(1), March 2016 thickening and full opacification) smoker patients 40 smoker patient sinus, and 25 (62.5%) from 40 with maxillary sinus whichmeasured fig1,from those 25 patients20 bilateral maxillary sinus fig1, and 5 (20%) of the maxillary sinus Two patients opacification which was seen only among smoker patients fig 3, patients have sinus(bilateral involved as shown in figure 4. The difference between significant since the anatomi pathological finding smokersgroup. e Thickening, Adenoid and Full O Study Groups smokers X2 0 20 (100%) 36.667 20 (100%) *Percentages were calculated from 25 cases of the Thickening, Adenoid and Full O Full opacification thickening and full opacification) s it was found that, 7 (17.5%) moker patient were showed a clear maxillary 25 (62.5%) from 40 with maxillary sinusmucosal thickening measured more than 4 mm as shown from those 25 patients20 bilateral maxillary sinus were inv and 5 (20%) of the unilateral thickening as clear in figure patients(5%) of smoker patients opacification which was seen only among smoker , 6 patients (15%) among smoker have a pathology bilateral involved) which is in figure 4. The difference between two significant since the anatomi findings were found only e Thickening, Adenoid and Full Opacification roups. Groups' difference Likelihood ratio 0 45.479 *Percentages were calculated from 25 cases of the Thickening, Adenoid and Full Opacification Full opacification Cone beam computed thickening and full opacification), while among it was found that, 7 (17.5%) were showed a clear maxillary 25 (62.5%) from 40 patient associated mucosal thickening more than 4 mm as shown from those 25 patients20 (80%) of them were involved as clear in unilateral thickening as clear in figure 2. (5%) of smoker patients opacification which was seen only among smoker 6 patients (15%) among smoker pathology of maxillary ) which is adenoid two groups was highly significant since the anatomical changes s were found only pacification in Respect to Groups' difference Likelihood ratio d.f. 0 45.479 3 pacification for Both G Smokers Non-smokers Cone beam computed , while among it was found that, 7 (17.5%) from were showed a clear maxillary associated mucosal thickening more than 4 mm as shown (80%) of them as clear in unilateral thickening of have full opacification which was seen only among smoker 6 patients (15%) among smoker of maxillary adenoid polyp, groups was highly cal changes and s were found only among in Respect to p-value 0 0.000 (HS) for Both Groups. smokers Cone beam computed J Bagh College Dentistry Vol. 28(1), March 2016 Cone beam computed Oral Diagnosis 102 DISCUSSION In the present study after the evaluation of maxillary sinus it was found that the thickening of sinus membranehas the highest percentage among the other changes (62%), while the full opacification was found in only 2patients (5%) ,this com in conformity with Ilze et al.,(15) who found that, there was thickening in 19 patient from 33 patient, 14 bilateral and 5 unilateral , slight difference of the percentage between twostudies may be due to sample size differences and also conform with Regaetal.,(16) who stated that, the most prominent anatomical changes was thickening of maxillary sinus membrane followed by full opacification. It is clear thatthere is a direct relationship between smoking and thickening of sinus mucosa which is agreement with Janner et al.,(17). In this study, it was found that 6 patients involved with adenoid polyp and all of them were bilatera, since the smoker effect on the sinuses as its effect on lung epithelial, especially these adenoid were found only among smoker patientsand this disagree with Ilze et al.,(15)who found no pathological findings among his sample. While Gorgulu et al.,(18) result is very near to the presentresults, they approved that, smoking is found to be the only risk factor for development of maxillary sinus and nasal polyp, and they concluded that the smoking restriction and avoiding exposure to cigarette smoking by patient with nasal polyps may be important in prevention of the recurrence of nasal and sinus polyp. 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