ORIGINAL ARTICLE

Retrospective study of maxillary sinus dimensions

and pneumatization in adult patients with
an anterior open bite
Jesung Ryu,a Sung-Hwan Choi,b Jung-Yul Cha,c Kee-Joon Lee,d and Chung-Ju Hwangd
Seoul, Korea

Introduction: The aim of this study was to evaluate differences in the maxillary sinus floor levels between adults
with an anterior open bite and those without. Methods: This retrospective study included 30 subjects: 15 adults
with an anterior open bite (mean age, 21.5 6 4.3 years) and 15 control subjects with normal occlusion (mean
age, 21.7 6 3.1 years). Cone-beam computed tomography and lateral cephalograms were analyzed before
treatment. Results: The open-bite group exhibited a significantly greater maxillary posterior alveolar height
(P \0.05). The craniocaudal heights of the maxillary sinus in the region between the first and second molars
and between the second premolar and first molar were significantly greater in the open bite group (40.5 and
39.0 mm, respectively) than in the control group (36.7 and 34.7 mm, respectively; P \0.05 for both). The
basal bone heights in the regions between the first and second molars, the second premolar and first molar,
and the first and second premolars were significantly smaller in the open-bite group than in the control group
(P \0.001 for all). Conclusions: Vertical pneumatization of the maxillary sinus floor in the region between
the first and second molars and between the second premolar and first molar is greater in adults with an anterior
open bite than in those without, whereas basal bone height in the maxillary posterior region is lower in the open-
bite patients. (Am J Orthod Dentofacial Orthop 2016;150:796-801)

O
pen bite is associated with a vertical skeletal malocclusion.4,5 However, there are few reports on the
dysplasia in the jaws that arises below the cranial relationship between the development of the maxillary
base, and it often requires surgical treatment. The sinus and malocclusion. Oktay5 compared differences
etiology of open bite is associated with genetic and envi- in the maxillary sinus area among various skeletal
ronmental factors that influence craniofacial traits.1 The profiles using panoramic radiography. Panoramic
skeletal and dentoalveolar characteristics of open bite radiography has low resolution, and vertical and hori-
include a long face with a steep mandibular plane angle, zontal image magnifications and superimpositions of
vertical growth with extrusion of posterior teeth in the anatomic structures are problems. Therefore, cone-
maxillary arch, and an obtuse gonial angle.2,3 beam computed tomography (CBCT), which provides
The maxillary sinus floor comprises the maxillary multiplanar views with a uniform and low magnifica-
alveolar process and the hard palate. The growth and tion, should be used to overcome the limitations of
development of the maxillary sinus are associated with panoramic radiography.
maxillary structures and the maxillary posterior teeth, In adults, the maxillary sinus floor extends between
and are consequently influenced by any form of skeletal adjacent teeth, creating elevations in the antral surface.6,7
This is considered an anatomic limitation that can
From the Department of Orthodontics, College of Dentistry, Yonsei University, adversely affect orthodontic tooth movement including
Seoul, Korea. intrusion or bodily movement.8 Oh et al9 reported that
a
Postgraduate student. tooth movement using light continuous forces is neces-
b
Fellow, The Institute of Cranio-Facial Deformity.
c
Associate professor, The Institute of Cranio-Facial Deformity. sary to move through the cortical bone of the maxillary
d
Professor, The Institute of Cranio-Facial Deformity. sinus wall in adults. Nevertheless, unpredicted complica-
All authors have completed and submitted the ICMJE Form for Disclosure of tions such as root resorption, pulp ischemia, alveolar bone
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Chung-Ju Hwang, 50-1 Yonsei-ro, Seodaemun-gu, loss, and perforation of the sinus membrane were found
Seoul 03722, Korea; e-mail, [email protected]. to occur while moving the teeth through the maxillary si-
Submitted, September 2015; revised and accepted, March 2016. nus in an animal study and a human biopsy study.9-12
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved. To our knowledge, no authors have investigated dif-
http://dx.doi.org/10.1016/j.ajodo.2016.03.032 ferences in the sinus floor levels between adult patients
796
Ryu et al 797

with an anterior open bite and those with normal occlu-

Table I. Characteristics of subjects
sion using CBCT.
The aim of this study was to evaluate differences in Normal occlusion Anterior open bite
the maxillary sinus floor levels between adults with an (7 men, 8 women) (7 men, 8 women)
Mean (SD) Mean (SD) P value
anterior open bite and those with a normal occlusion us-
Age (y) 21.7 (3.1) 21.5 (4.3) 0.367*
ing CBCT. We tested the null hypothesis that there is no Range (y) 19-28 18-31
significant difference in the sinus floor level between ANB (
) 2.7 (1.7) 3.5 (4.1) 0.538y
subjects with and without an anterior open bite. SN-MP (
) 33.7 (3.9) 44.6 (3.8) \0.001y
SN-MP, Angle of sella-nasion line to the mandibular plane.
*P value calculated with the Mann-Whitney U test; yP value calcu-
MATERIAL AND METHODS lated with the Independent t test.
The study sample comprised 30 subjects with or
size) on the device (Alphard 3030h; Asahi Roentgen,
without an anterior open bite whose dental records
Kyoto, Japan). The acquired data were imported into In-
were retrospectively reviewed at the Departments of
vivo software (version 5.2; Anatomage, San Jose, Calif)
Oral and Maxillofacial Surgery and Orthodontics, Col-
in DICOM multifile format.
lege of Dentistry, Yonsei University, Seoul, Korea.
We selected the following reference planes on the
The inclusion criteria for the open-bite group were
CBCT images: axial plane, which passed through the
same ethnicity (Korean), age 18 years or older, anterior
anterior nasal spine in a direction parallel to the Frankfort
open bite greater than 1 mm, and mandibular plane
horizontal plane; sagittal plane, which passed through
angle (sella–nasion line to the mandibular plane) greater
the anterior nasal spine and the posterior nasal spine in
than 38
. The exclusion criteria were loss of at least 1
a direction perpendicular to the axial plane; and coronal
permanent tooth, severe craniofacial deformities such
plane, which passed through the anterior nasal spine in
as cleft lip or palate, and a history of orthodontic treat-
a direction perpendicular to the axial and sagittal planes.
ment or orthognathic surgery.
Then, measurements of the maxillary sinus dimen-
All participants were required to exhibit good overall
sions were obtained, as described below, using previ-
health conditions. Patients with serious medical condi-
ously reported methods on CBCT images.13
tions requiring hospitalization in the past 3 months
were excluded to prevent any confounding effects of 1. Linear measurements of the maxillary sinus height
these conditions or medications on the results. (craniocaudal height). The axial cut was oriented
Of the 30 subjects, 15 (7 men, 8 women; mean age, parallel to the maxillary posterior occlusal plane at
21.5 6 4.3 years) fulfilled the abovementioned criteria the alveolar crest level, and the sagittal cut was ori-
and were enrolled in the open-bite group. All patients ented midway between the buccal and palatal
were scheduled for surgical correction of their anterior cortices. For the coronal cut, the axial image was
open bite. CBCT images were already obtained to estab- rotated until the orientation axis was perpendicular
lish a surgical treatment plan. to the buccal cortex (Fig 1).
The remaining 15 patients (7 men, 8 women; mean The same adjustments were repeated for the regions
age, 21.7 6 3.1 years) had a normal occlusion and between the maxillary first and second molars, sec-
were a part of growth studies at The Institute of Cranio- ond premolar and first molar, and first and second
facial Deformity, College of Dentistry, Yonsei University, premolars; the coronal cut was precisely oriented
Seoul, Korea (Table I). This study conformed to the te- in the interdental regions. The maxillary sinus
nets of the Declaration of Helsinki for medical protocols height was measured from the lowest point of the
and ethics and was approved by the institutional review cortical boundary of the orbital floor to the lowest
board of Yonsei Dental Hospital. border of the cortical boundary of the sinus floor.
The lateral cephalograms were obtained (Cranex In each of the 3 interdental areas, the basal bone
31 ceph; Soredex, Helsinki, Finland) before treatment height was measured from the lowest point of the
and were digitized using V-ceph (version 5.5; Osstem, cortical boundary of the sinus floor to the lower
Seoul, Korea) by an observer (J.R.) who was blinded to border of the alveolar crest. Eventually, 6 measure-
the clinical status of the patients. In this study, we iden- ments were acquired as follows: craniocaudal height
tified 4 anteroposterior and 11 vertical cephalometric between the first and second molars, craniocaudal
measurements. height between the second premolar and first
CBCT images were obtained with the subjects in a molar, craniocaudal height between the first and
standard upright position (scanning time, 17 seconds; second premolars, basal bone height between
field of view, 20 3 17.9 cm; 80 kV(p); 5 mA; 0.39 voxel the first and second molars, basal height between

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798 Ryu et al

Fig 1. CBCT measurements of craniocaudal dimensions. CC height, Craniocaudal height; BB height,

basal bone height.

the second premolar and first molar, and basal bone Statistical analysis
height between the first and second premolars. There were no significant differences in the CBCT
2. Linear measurements of the maxillary sinus depth (an- measurements between the right and left sides; there-
teroposterior dimension) and width (mediolateral fore, subsequent analyses were performed using the
dimension). These measurements were obtained along average values of the data for both sides. All statistical
the roots of the zygoma on each side. The orientation analyses were performed using SPSS software (version
axis for the coronal cut was adjusted so that it pre- 21.0; IBM Korea, Seoul, Korea). The Shapiro-Wilk test
cisely passed along the inferior cortical boundary of was used to verify the normality of data distribution. In-
the zygoma root on both sides (Fig 2). Measurements dependent t tests and the Mann-Whitney U test were
were repeated until the maximum anteroposterior and applied to detect significant differences in lateral ceph-
mediolateral dimensions were obtained. alometric and CBCT measurements between the 2
3. Cross-sectional area measurements. The cross- groups. A P value of \0.05 was considered statistically
sectional area of the maxillary sinus in the region significant.
between the maxillary second premolar and first
molar was measured on a sagittal slice, because RESULTS
the software had a problem in reproducibility with
There were no significant differences in anteroposte-
regard to calculation of the total volume of the sinus
rior cephalometric measurements between the groups
from 3-dimensional reconstructive images (Fig 3).
(P .0.05 for all; Table II). On the other hand, the
Reproducibility was evaluated by comparing mea- open-bite group exhibited significantly greater clock-
surements obtained during the initial and repeated ex- wise rotation of the mandibular planes (SN-MP and
aminations of randomly collected cephalometric and FMA; P \0.001 for both) and greater maxillary posterior
CBCT data from 20 patients over a 2-week interval by alveolar height (U6-PP; P 5 0.013; Table II).
the same examiner (J.R.). The method error was calcu- In the sagittal plane, the craniocaudal height of the
lated using Dahlberg's formula.14 Errors ranged from maxillary sinus between the first and second premo-
0.46 to 0.53 mm for linear measurements and from lars could not be measured in 2 patients from the
0.81
to 0.89
for angular measurements; these values open-bite group and 1 patient from the control group
were not significant. because the anterior boundary of the maxillary sinus

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Ryu et al 799

Fig 2. CBCT measurements of the anteroposterior (AP) depth and mediolateral (ML) width. Dotted
line, measured axial section line.

Table II. Overall comparisons of lateral cephalometric

measurements between the normal occlusion and
open-bite groups
Normal occlusion Anterior open bite P
Measurement Mean (SD) Mean (SD) value
Anteroposterior
ANB (
) 2.7 (1.7) 3.5 (4.1) 0.536
Wits (mm) 3.0 (2.2) 3.7 (6.9) 0.684
Go-Me (mm) 83.3 (6.0) 80.2 (5.0) 0.139
Overjet (mm) 2.5 (0.7) 2.8 (3.9) 0.798
Vertical
SN-MP (
) 33.7 (3.9) 44.6 (3.8) \0.001
FMA (
) 24.4 (3.9) 35.4 (3.7) \0.001
SN-PP (
) 11.2 (3.1) 10.2 (3.0) 0.393
FH-PP (
) 1.9 (2.3) 1.0 (2.7) 0.304
PP-MP (
) 22.5 (3.8) 34.4 (4.1) \0.001
SN-OP (
) 19.1 (5.3) 23.4 (3.5) 0.057
AFH (mm) 136.4 (6.4) 140.4 (9.4) 0.330*
PFH (mm) 91.3 (7.0) 82.6 (7.9) 0.004
Facial height 66.8 (2.9) 58.8 (2.5) \0.001
ratio (%)
Overbite (mm) 2.3 (1.0) 2.0 (1.5) \0.001*
Fig 3. CBCT measurements of the cross-sectional area. U6-PP (mm) 25.9 (2.4) 28.3 (2.5) 0.013

P values were calculated with the independent t test unless other-

wise noted.
was located posterior to the second premolar in these
SN-MP, Angle of sella-nasion line to the mandibular plane; FMA,
patients. angle of the Frankfort line to the mandibular plane; SN-PP, angle
The heights of the maxillary sinus in the regions be- of sella-nasion line to the palatal plane; FH-PP, angle of the
tween the first and second molars, second premolar and Frankfort line to the palatal plane; PP-MP, angle of the palatal
first molar, and first and second premolars in the open- plane to the mandibular plane; SN-OP, angle of sella-nasion line
to the occlusal plane; AFH, anterior facial height; PFH, posterior
bite group were 40.5, 39.0, and 32.1 mm, respectively;
facial height; Facial height ratio, the ratio of posterior facial
heights in the control group were 36.7, 34.7, and height to anterior facial height; U6-PP, maxillary posterior alveolar
29.2 mm, respectively. The craniocaudal heights of the height.
maxillary sinus in the region between the first and *P value calculated with the Mann-Whitney U test.
second molars and between the second premolar and
first molar were significantly greater in the open-bite first and second premolars were significantly smaller in
group than in the control group (P 5 0.040 and the open-bite group than in the control group
P 5 0.023, respectively; Table III). (P \0.001 for all; Table III). The basal bone height was
The basal bone heights in the regions between the first the shortest in the region between the maxillary first and
and second molars, second premolar and first molar, and second molars, increasing gradually in the mesial direction.

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800 Ryu et al

In this study, there was no significant difference in the

Table III. Overall comparison of CBCT measurements
anterior facial height, which could have affected mea-
between the normal occlusion and open-bite groups
surements of vertical sinus height and basal bone height
Normal Anterior between the groups. However, the maxillary posterior
occlusion open bite P alveolar height (U6-PP) was significantly greater in the
Measurement Mean (SD) Mean (SD)value
open-bite group than in the control group (Table II).
Craniocaudal height
M1-M2 height (mm) 36.7 (5.0) 40.5 (4.7) 0.040 We speculate that the increased maxillary posterior alve-
PM2-M1 height (mm) 34.7 (4.3) 39.0 (5.3) 0.023 olar height in patients with an open bite may be associ-
PM1-PM2 height (mm) 29.2 (4.5) 32.1 (5.1) 0.122 ated with an inferiorly located sinus floor, consistent
Basal bone height with the opinions in previous studies.21,22 Arriola-
M1-M2 bone 11.5 (2.5) 7.0 (1.9) \0.001
Guillen and Flores-Mir22 reported that the molar height
height (mm)
PM2-M1 bone 12.0 (2.6) 8.3 (2.5) \0.001 was 4 mm greater in their open-bite group than in their
height (mm) control group, and Kucera et al21 reported that extrusion
PM1-PM2 bone 16.4 (2.8) 12.2 (2.4) \0.001 of the maxillary posterior teeth is a common finding in
height (mm) adults with a skeletal open bite. From a clinical perspec-
Anteroposterior 37.9 (4.9) 38.4 (3.0) 0.713*
tive, orthodontic treatment for patients with an anterior
depth (mm)
Mediolateral width (mm) 29.3 (3.3) 29.0 (3.5) 0.822 open bite should be primarily aimed at limiting or correct-
Cross-sectional 1187.6 (212.8) 1390.0 (251.4) 0.026* ing excessive dentoalveolar height in the posterior re-
area (mm2) gions. For the correction of a severe skeletal open bite,
The craniocaudal height between PM1 and PM2 of 2 patients in the
orthognathic surgery is generally necessary. However, or-
open-bite group and that of 1 patient in the control group could not thodontic camouflage treatment involving clinically
be measured because the anterior boundary of the maxillary sinus achievable molar intrusion using temporary anchorage
was located posterior to the second premolar in these patients. devices is an alternative that can improve this condition
P values were calculated with the independent t test unless otherwise and provide relatively acceptable esthetics without the
noted.
M1, First molar; M2, second molar; PM1, first premolar; PM2, sec-
risks and burdens of orthognathic surgery. To achieve
ond premolar. meaningful molar intrusion, a study on the anatomic lim-
*P value calculated with the Mann-Whitney U test. itations of orthodontic tooth movement, including a
maxillary sinus floor comprising cortical bone, is required.
There were no significant differences in anteroposte- Daimaruya et al10 performed histologic evaluations and
rior and mediolateral CBCT measurements between the confirmed that the alveolar bone around the root apices
groups (P 5 0.713, P 5 0.822, respectively; Table III). was remodeled when the maxillary premolars were
The cross-sectional area of the maxillary sinus on the im- intruded using a skeletal anchorage system in the bony
ages was significantly greater in the open-bite group nasal floor. The nasal floor membrane and a thin layer of
than in the control group (1390.0 and 1187.6 mm2, newly formed bone, which was intranasally elevated,
respectively; P 5 0.026; Table III). covered the intruded molar root. Nevertheless, external
apical root resorption without the formation of reparative
DISCUSSION cementum was observed. Therefore, because excessive
The maxillary sinus is the largest of the paranasal si- force can cause root resorption, the patients in the open-
nuses and exhibits a pyramidal shape, with the lowest point bite group in our study required careful treatment.23
lying in the region of the maxillary first and second molars. According to our results, we rejected the null hypoth-
With increasing age, the sinus floor tends to resorb, esis. There was a significant difference in pneumatiza-
creating dehiscences around the tooth roots.15-17 tion of the maxillary sinus floor between groups (Table
Pneumatization is a physiologic process that occurs in III), with more vertical pneumatization in the region be-
all paranasal sinuses during the growth period, resulting tween the first and second molars and between the sec-
in increases in the sinus volumes.18 The extent of pneu- ond premolar and first molar in the open-bite group
matization varies among subjects and between the right compared with that in the control group. Moreover,
and left sides. Although the precise mechanisms underly- the basal bone height was smaller in the open-bite group
ing pneumatization remain poorly understood, factors than in the control group, considering the inverse rela-
associated with variability in pneumatization include tionship between maxillary sinus pneumatization and
ethnicity, bone density, palatal height and width, and remaining basal bone.18
body size.7,19 The process of pneumatization is more Endo et al24 found no significant relationship between
significant after posterior tooth extraction and is maxillary sinus size and the sagittal relationship between
associated with atrophy of the adjacent alveolar bone.7,20 the maxilla and mandible. However, sinus pneumatization

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Ryu et al 801

is more of a vertical phenomenon than a sagittal phenom- 5. Oktay H. The study of the maxillary sinus areas in different ortho-
enon. Therefore, it can be inferred that sinus pneumatiza- dontic malocclusions. Am J Orthod Dentofacial Orthop 1992;102:
143-5.
tion is related to vertical malocclusion, not sagittal
6. Park JH, Tai K, Kanao A, Takagi M. Space closure in the maxillary
malocclusion. In the previous study, patients with larger posterior area through the maxillary sinus. Am J Orthod Dentofa-
cranial bases and nasomaxillary complexes tended to cial Orthop 2014;145:95-102.
exhibit larger maxillary sinuses.24 These results suggest 7. Sharan A, Madjar D. Maxillary sinus pneumatization following ex-
that dentofacial morphologic features can influence the tractions: a radiographic study. Int J Oral Maxillofac Implants
2008;23:48-56.
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8. Sharan A, Madjar D. Correlation between maxillary sinus floor
To the best of our knowledge, this is the first study to topography and related root position of posterior teeth using
determine differences in the maxillary sinus floor levels panoramic and cross-sectional computed tomography imaging.
between adults with an anterior open bite and those Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:
without. However, the nonrandomized, retrospective 375-81.
9. Oh H, Herchold K, Hannon S, Heetland K, Ashraf G, Nguyen V, et al.
design and small sample size may have limited the results,
Orthodontic tooth movement through the maxillary sinus in an
with the retrospective design increasing the susceptibility adult with multiple missing teeth. Am J Orthod Dentofacial Orthop
to bias in data selection and analysis. Mainly, the small 2014;146:493-505.
sample size restricted the ability to extrapolate these find- 10. Daimaruya T, Takahashi I, Nagasaka H, Umemori M, Sugawara J,
ings to the general population, regardless of whether the Mitani H. Effects of maxillary molar intrusion on the nasal floor
and tooth root using the skeletal anchorage system in dogs. Angle
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Orthod 2003;73:158-66.
ally, our patients had a limited skeletal Class I or weak 11. Wehrbein H, Bauer W, Wessing G, Diedrich P. The effect of the
Class II sagittal malocclusion. Evaluation of the different maxillary sinus floor on orthodontic tooth movement. Fortschr
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