Juliana Pelinsari Lana Anatomic variations and lesions of the

Pollyanna Moura Rodrigues

Carneiro
maxillary sinus detected in cone beam
Vinı́cius de Carvalho computed tomography for dental
Machado
Paulo Eduardo Alencar de
implants
Souza
Flávio Ricardo Manzi
Martinho Campolina Rebello
Horta

Authors’ affiliations:
Juliana Pelinsari Lana, Pollyanna Moura Rodrigues
Carneiro, Paulo Eduardo Alencar de Souza, Flávio
Ricardo Manzi, Martinho Campolina Rebello
Horta, Department of Dentistry, Pontifı́cia
Universidade Católica de Minas Gerais, Belo
Horizonte, Brazil
Juliana Pelinsari Lana, Vinı́cius de Carvalho
Machado, Slice Diagnóstico Volumétrico por
Imagem, Belo Horizonte, Brazil
Corresponding author:
Martinho Campolina Rebello Horta
Departamento de Odontologia
Pontifı́cia Universidade Católica de Minas Gerais
Av. Dom José Gaspar 500, Prédio 45, Sala 110
CEP: 30535-901
Belo Horizonte, MG
Brasil
Tel.: (+55) 31 33194341
Fax: (+55) 31 33194166
e-mail: martinhohorta@pucminas.br
Key words: cone beam computed tomography, dental implants, maxillary sinus
Abstract
Objective: To evaluate the presence of anatomic variations and lesions of the maxillary sinus in
cone beam computed tomography (CBCT) of the maxilla required for dental implant planning.
Material and methods: This transversal prevalence study evaluated a sample of 500 consecutive
CBCT exams. The inclusion criteria were CBCT exams of the maxilla required for dental implant
planning. The CBCT exams were independently evaluated by two oral and maxillofacial radiologists
who assessed the presence of anatomic variations and lesions of the maxillary sinus. As most of the
CBCT exams did not allow the evaluation of the area close to the maxillary sinus roof, anatomic
variations that take place at this site were not assessed.
Results: The anatomic variations detected were pneumatization (83.2%), antral septa (44.4%),
hypoplasia (4.8%), and exostosis (2.6%). The identified lesions were mucosal thickening (  3 mm in
54.8% and >3 mm in 62.6%), polypoid lesions (21.4%), discontinuity of the sinus floor (17.4%), air-
fluid level (4.4%), bone thickening of the maxillary sinus wall (3.8%), antroliths (3.2%),
discontinuity of the sinus lateral wall (2.6%), sinus opacification (1.8%), and foreign body (1.6%).
Conclusion: Anatomic variations and lesions of the maxillary sinus were common findings in CBCT
exams of the maxilla required for dental implant planning. As some of these conditions can modify
dental implant planning and must require specialized treatment, its recognition is noteworthy in
dental practice, and especially in implantology. The amount and significance of the anatomic
variations and lesions detected in this study reinforces the importance of computed tomography in
preoperative dental implant planning.

Date:
Accepted 27 July 2011
To cite this article:
Lana JP, Carneiro PMR, Machado VC, de Souza PEA, Manzi
FR, Horta MCR. Anatomic variations and lesions of the
maxillary sinus detected in cone beam computed tomography
for dental implants.
Clin. Oral Imp. Res. 00, 2011, 1–6
doi: 10.1111/j.1600-0501.2011.02321.x
Computed tomography (CT) images allow
the location of anatomic structures and pro-
vide information about bone dimensions and
morphology, data of great importance for den-
tal implant planning (Boeddinghaus & Whyte
2008; Angelopoulos & Aghaloo 2011).
Cone beam computed tomography (CBCT)
uses a cone- or pyramidal-shaped beam to
acquire multiple projections in only one rota-
tion. On the other hand, multislice computed
tomography (MSCT) employs fan-shaped
beams rotating around the patient to acquire
multiple image slices (Boeddinghaus & Why-
te 2008; Koong 2010). The CBCT scanners
can provide lower radiation dose levels than
standard MSCT protocols, even though low-
dose MSCT protocols can deliver similar or
lower radiation dose levels than CBCT units
(Suomalainen et al. 2009; Koong 2010).
Although CBCT should be considered an
important diagnostic image modality in den-
tal practice, it is important to realize its
main limitations, such as specific artifacts,
limited volume, and the lack of soft tissue
information (Watanabe et al. 2011). Further-
more, CBCT must be used as a complement
for other diagnostic image modalities, rather
than a replacement technique (Koong 2010).
The paranasal sinuses include the paired
maxillary, frontal, ethmoid, and sphenoid

© 2011 John Wiley & Sons A/S 1

Pelinsari Lana et al
Maxillary sinus alterations detected in cone beam tomography

sinuses (Maves 2006). The maxillary sinus Table 1. Anatomic variations of the maxillary sinus detected in the 500 cone beam computed
tomography (CBCT) exams evaluated
can exhibit anatomic variations, such as
pneumatization, hypoplasia, antral septa, Anatomic variation Characteristics Frequency
1
and exostosis. Moreover, maxillary sinus Pneumatization Total 416 (83.2%)
lesions as mucosal thickening, sinusitis, Alveolar (unilateral) 62
Alveolar (bilateral) 354
mucous retention cyst, and antrochoanal Tuber (unilateral) 31
polyp are not uncommon (Shankar & Evans Tuber (bilateral) 79
2006). Palatine (unilateral) 34
Palatine (bilateral) 84
As the maxillary sinuses are significant
Anterior (unilateral) 4
anatomic structures in dental practice and Anterior (bilateral) 22
CBCT is an important diagnostic image Antral septa Total 222 (44.4%)
modality in dentistry, the recognition of Unilateral 121
Bilateral 101
anatomic variations and lesions of the max- Hypoplasia Total 24 (4.8%)
illary sinuses in CBCT is noteworthy. Unilateral 19
Therefore, the aim of this study was to eval- Bilateral 5
Exostosis Total 13 (2.6%)
uate the presence of anatomic variations and
Unilateral 11
lesions of the maxillary sinus in CBCT of Bilateral 2
the maxilla required for dental implant plan- 1
Pneumatization sites were multiple in 191 of the 416 cases showing this variation (46%). In 225
ning. cases (54%), the pneumatization was located only in a single site (alveolar).

Material and methods Table 2. Lesions of the maxillary sinus detected in the 500 cone beam computed tomography
(CBCT) exams evaluated
Lesion Characteristics Frequency
Study design
This transversal prevalence study evaluated a Mucosal thickening (>3 mm) Total 313 (62.6%)
Unilateral 133
sample of 500 consecutive CBCT exams
Bilateral 180
made in a private dental radiology clinic in Mucosal thickening (  3 mm) Total 274 (54.8%)
Belo Horizonte, Brazil, between March and Unilateral 155
September of 2010. The study was approved Bilateral 119
Polypoid lesion Total 107 (21.4%)
by the local ethics committee. Unilateral 87
The following inclusion criteria were Bilateral 20
applied: (1) CBCT exams of the maxilla; (2) Discontinuity of the sinus floor Total 87 (17.4%)
Unilateral 69
CBCT exams required for implant planning;
Bilateral 18
and (3) CBCT exams from patients who Associated to periapical lesion 25
accepted to participate in the study. Associated to bone graft 24
The CBCT exams were excluded on the Associated to implant fenestration 20
Associated to tooth extraction 7
basis of: (1) exams not displaying all the
Associated to bone graft and implant 3
extension of the lower third of the maxillary Associated to endodontic filling material 1
sinus; and (2) presence of technical artifacts No apparent cause 7
that make difficult the maxillary sinus evalu- Air-fluid level Total 22 (4.4%)
Unilateral 19
ation. Bilateral 3
Bone thickening Total 19 (3.8%)
Image acquisition and analysis Unilateral 18
The exams were performed by the i-CAT Bilateral 1
Antrolith Total 16 (3.2%)
cone beam computed tomograph (Imaging Unilateral 14
Sciences International, Hatfield, PA, USA). Bilateral 2
The tomograph specifications were: Field of Discontinuity of the sinus lateral wall Total 13 (2.6%)
Unilateral 11
view: 6 cm covering the maxilla region;
Bilateral 2
Voxel: 0.2 mm; Scan time: 40 s. Sinus opacification Total 9 (1.8%)
Image analysis was performed on the Unilateral 9
i-CAT software, on a multiplanar reconstruc- Bilateral 0
Foreign body Total 8 (1.6%)
tion window in which the axial, coronal, and Unilateral 8
sagittal planes could be visualized in 0.2 mm Bilateral 0
intervals.
The following anatomic variations were
considered: (1) Pneumatization; (2) Antral tion of the area where these anatomic varia- mucosal thickening measurements were
septa; (3) Hypoplasia; and (4) Exostosis. Sec- tions take place (area close to the maxillary made by a digital ruler); (2) Polypoid lesions
ondary ostium, ethmomaxillary sinus, and sinus roof). (mucous retention cyst and/or antrochoanal
Haller cells were not considered, as most of The following lesions were considered: (1) polyp); (3) Discontinuity of the sinus wall; (4)
the CBCT exams did not allow the evalua- Mucosal thickening:  3 mm or >3 mm (the Air-fluid level; (5) Bone thickening; (6) Antro-

2 | Clin. Oral Imp. Res. 0, 2011 / 1–6 © 2011 John Wiley & Sons A/S

lith; (7) Sinus opacification; and (8) Foreign
body.
The CBCT exams were independently
evaluated by two authors who assessed the
presence of anatomic variations and lesions
of the maxillary sinus. Disagreement among
examiners was discussed and resolved by
consensus. If no consensus was reached, the
case was excluded from the study.
For each anatomic variation and lesion
evaluated, the degree of agreement between
the two examiners was estimated using the
Kappa statistics for categorical measures
(Landis & Koch 1977). The Kappa analysis
was performed before the disagreements
among examiners were discussed and
resolved. Substantial agreement was reached
for mucosal thickening (K = 0.73), disconti-
nuity of the sinus wall (K = 0.75), and foreign
body (K = 0.79). Almost perfect agreement
was reached for polypoid lesions (K = 0.89),
antral septa (K = 0.90), pneumatization
(K = 1.0), hypoplasia (K = 1.0), exostosis
(K = 1.0), air-fluid level (K = 1.0), bone thick-
ening (K = 1.0), antrolith (K = 1.0), and sinus
opacification (K = 1.0).
Statistical analysis
Data were analyzed by descriptive statistics.
The frequency of occurrence of each ana-
tomic variation and lesion of the maxillary
sinus was calculated. The age of the patients
was described using median and range. The
gender of the patients was described using
frequency.
Results
In a total of 500 CBCT exams, 262 (52.4%)
were from female and 238 (47.6%) from male
patients. The patient’s age range was 16–
86 years, with a median age of 52 years.
The identified maxillary sinus alterations
are referred in Tables 1 and 2 as well as illus-
trated in Figs. 1–3.
Maxillary sinus pneumatization (maxillary
sinus extension into a particular anatomic
structure) was the most common anatomic
variation detected (Fig. 1a), observed in 416
patients (83.2%). Alveolar pneumatization
was present in all of the 416 cases. Pneuma-
tization sites were multiple in 191 (46%) and
single in 225 (54%) cases, in which it was
always alveolar. Antral septa (Fig. 1b) were
found in 222 (44.4%) cases. Maxillary sinus
hypoplasia (Fig. 1c) was apparent in only 24
cases (4.8%). Exostosis (Fig. 1d) was identi-
fied in 13 (2.6%) patients.
© 2011 John Wiley & Sons A/S
Pelinsari Lana et al
Maxillary sinus alterations detected in cone beam tomography
(a)
(c)
Fig. 1. Maxillary sinus pneumatization (a), antral septa (b), maxillary sinus hypoplasia (c), and exostosis (d).
Maxillary sinus mucosal thickening was
the most detected lesion (Fig. 2a and b).
The mucosal thickening was considered as
 3 mm in 274 (54.8%) and as >3 mm in
313 (62.6%) cases. Polypoid lesions (Fig. 3a
and b) were identified in 107 (21.4%)
patients. Discontinuity of the sinus floor
was found in 87 (17.4%) cases. Of these 87
cases, 25 were associated to periapical
lesions (Fig. 2c), 24 to intra-sinus bone graft
(Fig. 2d), 20 to implant fenestration (Fig. 2e),
seven to tooth extraction (Fig. 2f), three to
both intra-sinus bone graft and implant, one
to endodontic filling material fenestration
(Fig. 2g), and seven to no apparent cause
(Fig. 2h). Air-fluid level (Fig. 3c), bone thick-
ening of the maxillary sinus wall (Fig. 3d),
and antroliths (Fig. 3e) were, respectively,
found in 22 (4.4%), 19 (3.8%), and 16(3.2%)
cases. Discontinuity of the sinus lateral
wall (Fig. 3f) was identified in 13 (2.6%)
patients. Sinus opacification (Fig. 3g) and
foreign body (Fig. 3h) were, respectively,
found in only 9 (1.8%) and 8 (1.6%)
patients.
Discussion
Maxillary sinus pneumatization, the most
common anatomic variation observed in this
study, is characterized by the maxillary
sinus extension to alveolar ridge, anterior
region, maxillary tuber, palate, zygomatic
bone, and/or orbitary region (Sicher 1975;
White & Pharoah 2004). Alveolar pneumati-
zation has been reported in approximately
(b)
(d)
50% of the population (Schuh et al. 1984)
and was present in all of the 416 patients
showing sinus pneumatization in this report.
Atrophy of the maxilla caused by edentu-
lism is characterized by vertical and horizon-
tal bone loss (Gosau et al. 2009). The
maxillary sinus pneumatization, particularly
the alveolar extension, can exacerbate the
problem of reminiscent bone caused by atro-
phy of the maxilla, leaving only few milli-
meters of bone to implant insertion (Blake
et al. 2008).
Maxillary sinus hypoplasia (MSH) is the
underdevelopment of the maxillary sinus.
The maxillary sinus can become hypoplastic
during its embryological development or late
due to trauma, iatrogeny, or structural causes
(Stammberger 1986). The narrow infundibular
passage associated with the absence of a nat-
ural ostium should cause mucosal thickening
of the hypoplastic sinus (Weed & Cole 1994).
Furthermore, MSH also causes the lateral
extension of the lateral nasal wall, making
difficult the surgical procedures (Kapoor et al.
2002).
Antral septa was defined as a pointed bone
structure and maxillary sinus exostosis as a
rounded bone structure, both originated from
any maxillary sinus wall (Naitoh et al. 2009).
It is important to emphasize that antral
septa, detected in almost half of the CBCT
exams evaluated, might increase the risk of
sinus membrane perforation during the max-
illary sinus floor elevation surgery (Tatum
1986; Betts & Miloro 1994; Krennmair et al.
1999; van den Bergh et al. 2000). The acci-
dental perforation of this membrane can lead
3 | Clin. Oral Imp. Res. 0, 2011 / 1–6
Pelinsari Lana et al
Maxillary sinus alterations detected in cone beam tomography
(a)
(c)
(e)
(g)
Fig. 2. Maxillary sinus mucosal thickening  3mm (a) and >3mm (b). Discontinuity of the sinus floor associated to:
periapical lesion (c), intra-sinus bone graft (d), implant fenestration (e), tooth extraction (f), endodontic filling mate-
rial fenestration (g), and no apparent cause (h).
to development of acute or chronic sinusitis,
as well as subsequent bone graft resorption
(Abrahams et al. 2000; Aimetti et al. 2001).
Furthermore, antral septa can difficult the
lifting of the bone plate and of the sinus
membrane during surgery (Tidwell et al.
1992).
The paranasal sinuses mucosa is lined by
respiratory epithelium and normally shows
1 mm of thickness (White & Pharoah 2004).
Nevertheless, the presence of inflammation
can develop an increase of 10- to 15-fold in
the sinus mucosa thickness (White & Pharo-
ah 2004). Mucosal thickening is a character-
istic feature in both acute and chronic
sinusitis (Momeni et al. 2007), and a mucosal
4 | Clin. Oral Imp. Res. 0, 2011 / 1–6
(b)
(d)
(f)
(h)
thickening >3 mm is usually considered
pathologic (White & Pharoah 2004).
The characteristic findings of inflammatory
sinus disease are air-fluid level, mucosal
thickening, and sinus opacification. The only
distinctive feature of acute sinusitis is the
air-fluid level as an isolated finding, whereas
the characteristic feature of chronic sinusitis
is the bone thickening of the maxillary sinus
wall (Zinreich et al. 2003). Sinus opacifica-
tion and air-fluid level are the most specific
signs of bacterial rhinosinusitis (Wald 1993).
Discontinuity of the sinus floor was a signif-
icant finding and it is important to underline
that mucosal thickening >3 mm was identi-
fied in 73.5% of the patients showing this
lesion. Odontogenic sinusitis usually occurs
after disruption of the sinus mucous mem-
brane by conditions as dental infection, tooth
extraction, orthognathic surgery, maxillary
sinus floor elevation surgery, intra-sinus bone
graft, and dental implants (Ueda & Kaneda
1992; Timmenga et al. 1997; Kretzschmar &
Kretzschmar 2003). Odontogenic sinusitis
should be managed by a combination of sinus
surgery, antibiotic therapy, and removal of the
infection source (Lee & Lee 2010).
The polypoid lesions of the maxillary sinus
are represented by the mucous retention cyst
and the antrochoanal polyp. As both polypoid
lesions show fluid density in the sinus on
CT, it cannot be differentiated only by CT
findings (Shankar & Evans 2006). The
mucous retention cyst, characterized by a
dome-shaped radiopacity extending from the
sinus wall, occurs after obstruction of
mucus-secreting glands of the maxillary
sinus, is usually asymptomatic and can be
viewed as an incidental finding in 2–5% of
the sinus radiographs (Shankar & Evans
2006). As most mucous retention cyst of the
maxillary sinus show spontaneously regres-
sion or no significant volume change, a wait
and see approach may be appropriate in the
absence of any complication (Wang et al.
2007). Antrochoanal polyp is a benign polyp-
oid lesion (Pruna et al. 2000) that originates
from the maxillary sinus mucosa and extends
through its ostium to the choana (Hong et al.
2001; Yaman et al. 2010). Its etiology
remains unclear and the lesion is more com-
mon in children and young adults (Gendeh
et al. 2004). Computed tomography shows a
uniform density mass in the sinus extending
to the ipsilateral nasal cavity. Antrochoanal
polyps should be treated by surgical removal
(Yaman et al. 2010).
Antroliths are circumscribed pathologic
calcifications formed as a result of mineral
salt deposition around an organic nucleus in
the paranasal sinuses (Nass Duce et al. 2003;
Güneri et al. 2005; Rodrigues et al. 2009).
Radiographically, this lesion is a radiopaque
mass showing variable sizes and shapes
(Güneri et al. 2005). Treatment by surgical
removal is indicated only for large antroliths
associated to clinical symptoms (Güneri
et al. 2005).
Foreign bodies may have access into the
maxillary sinus through an oroantral com-
munication which remains as an oroantral
fistula. Furthermore, this access can also
occur by the dental alveolus of a newly
extracted tooth, by means of the root canal
or due to a surgical procedure near the maxil-
lary sinus (Laskin & Dierks 1999). Although
© 2011 John Wiley & Sons A/S

(a)
(c)
(e)
(g)
Fig. 3. Polypoid lesions (a and b), air-fluid level (c), bone thickening of the maxillary sinus wall (d), antrolith (e),
discontinuity of the sinus lateral wall (f), sinus opacification (g), and foreign body (h).
spontaneous removal of foreign body from
the maxillary sinus has been previously
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