Cephalometric Analysis for Gender Determination Using ... · ResearchArticle Cephalometric Analysis for Gender Determination Using Maxillary Sinus Index: A Novel Dimension in Personal

Research ArticleCephalometric Analysis for Gender DeterminationUsing Maxillary Sinus Index A Novel Dimension inPersonal Identification

Tanya Khaitan1 Arpita Kabiraj2 Uday Ginjupally3 and Ritika Jain4

1Department of Dentistry Murshidabad Medical College and Hospital Berhampore West Bengal 742101 India2Department of Oral Pathology amp Microbiology Index Institute of Dental Sciences Indore Madhya Pradesh 452016 India3Department of Oral Medicine amp Radiology Kamineni Institute of Dental Sciences Narketpally Andhra Pradesh 508254 India4Centre for Development Studies Trivandrum 695011 India

Correspondence should be addressed to Tanya Khaitan tanyakhaitangmailcom

Received 6 December 2016 Revised 14 February 2017 Accepted 26 February 2017 Published 8 March 2017

Academic Editor Tommaso Lombardi

Copyright copy 2017 Tanya Khaitan et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Purpose Radiography is important in forensic odontology for the identification of humansThemaxillary sinus is the largest of theparanasal sinuses and first to develop Sinus radiography has been used for identification of skeletal remains and determination ofgender Hence the aim and objectives of the present study were to establish a newmethod for gender determination usingmaxillarysinus index from lateral cephalometric radiographs and to establish the reliability of maxillary sinus for gender determinationMethods A total of 50 adult digital lateral cephalometric radiographs (25 males and 25 females) were included in the studyThe maxillary sinus analysis was performed on these radiographs using the height and width measurement tools of Sidexis XGsoftware Maxillary sinus index was calculated discriminant function analysis performed and discriminant equation derived fordetermination of gender Results The mean maxillary sinus height and width were found to be higher in males whereas themaxillary sinus index was greater in females The discriminant function analysis derived in the study was able to differentiate thesex groups with sensitivity of 68 and specificity of 76 Conclusions From the results of the present study it may be concludedthat morphometric analysis of maxillary sinus can be used as a reliable tool in gender determination

1 Introduction

Personal identification is a subtle perception and often one ofthe most significant priorities in the investigation of criminalcases mass disasters and in forensic concerns Genderdetermination is one of the important parameters in forensicidentification The study of anthropometric characteristicsis of fundamental importance to solve problems related tosuch cases Among the human bones next to the pelvis theskull is the most easily sexed portion of the skeleton but thedetermination of the gender from the skull is not well reliableuntil after puberty In cases of mass disasters even the skulland other bones are badly blemished however it has beenreported that maxillary sinuses remain intact [1 2]

Maxillary sinuses are two air filled spaces located in themaxillary bone The apex of the sinuses extends into the

zygomatic process occupying the zygomatic bone and thefloor is formed by the alveolar process the first secondand third molars and the roots of canines may elevate thesinuses or may perforate their floor [3] Sinus radiographyhas been used for identification of skeletal remains anddetermination of gender There are various imaging modal-ities varying from conventional techniques such as waterrsquosview and lateral cephalogram to advanced technologiesincluding computed tomography and cone beam computedtomography [1] Lateral cephalogram plays a predominantrole providing architectural and morphological details of theskull thereby revealing supplementary characteristics andmultiple points for comparison Various researchers havealleged this conventional radiograph as cost effective easilyavailable and reliable in providing accuracy of 80ndash100[1 3 4]

HindawiInternational Journal of DentistryVolume 2017 Article ID 7026796 4 pageshttpsdoiorg10115520177026796

2 International Journal of Dentistry

Table 1 Comparison between maxillary sinus height width and MSI in males and females

Gender 119873 Mean Std deviation Std error 95 CI 119901 value

Height Males 25 304 187 037 05648 to 3122 00066Females 25 285 252 050

Width Males 25 380 317 063minus08230 to 2377 03254

Females 25 373 333 067

Maxillary sinus index (MSI) Males 25 126 011 002minus01486 to minus001389 00202

Females 25 134 012 002

Considering this background the aim and objectivesof the present study were to develop a new method forgender determination using maxillary sinus index fromlateral cephalometric radiographs establish the reliabilityof maxillary sinus for gender determination and explorewhether the height width and maxillary sinus index can beused for determination of gender

2 Material and Methods

The study was initiated after the protocol had been approvedby the Institutional Ethical Committee A total of 50 healthysubjects belonging to both genders (25 males and 25 females)of age group 25ndash55 years attending the outpatient departmentof Oral Medicine and Radiology were selected for the studyby simple random sampling Subjects with history of facialtrauma fracture of maxillary sinus congenital developmen-tal abnormalities and any maxillary sinus pathology wereexcluded from the study The importance and need for thestudy were explained to each individual

All the study samples were instructed to remove anydental appliances and metal objects from the head and neckregion The subjects were told about the procedure andsubjected to digital lateral cephalogram (Sirona OrthophosXG Model 6229343 D3352 SN 05685) with proper radiationprotection measures under exposure factors as applicable totheir age The radiographs were then stored with patientsdetails incorporated All radiographs were interpreted andthe maxillary sinuses height and width were measured usingSidexis next generation software (version 25 Sirona Ger-many) (Figure 1) Themeasurements obtained were recordedand entered in the proforma specially designed for the studyTherefore the maxillary sinus index (MSI) was calculated asfollows MSI = maxillary sinus widthheight

The results obtained were subjected to statistical anal-ysis using SPSS version 1601 (statistical package for socialsciences) software The mean values and standard deviationof the maxillary sinus height width and MSI in malesand females were obtained and tabulated using paired 119905-test The mean differences were also calculated for the sameand 95 confidence intervals (CI) evaluated Discriminantfunction analysis was performed for determination of genderDiscriminant equation was also derived with gender as aclassifying variable and MSI as an independent variable Thediscriminant scores (119863) thus obtained were recorded andgender differentiation was done accordingly Sensitivity andspecificity were determined to assess the accuracy of the

Width

Height

2540mm

3904mm

Figure 1 Maxillary sinus height and width measurements radio-graphically using Sidexis next generation software

results and reliability of the procedure Significance level wasbased on 119901 value lt 005

3 Results

The mean maxillary sinus height was found to be 304mmin males and 285mm in females and it was statisticallysignificant with (05648 to 3122) 95 CI and 119901 value of00066The mean maxillary sinus width was 38mm in malesand 373mm in females which was statistically nonsignificantwith (minus08230 to 2377) 95 CI and 119901 value of 03254 Themean MSI was higher in females (134) when comparedwith males (126) with (minus01486 to minus001389) 95 CI and asignificant 119901 value of 00202 (Table 1) In the present studythe lowest value was presented by MSI indicating MSI to becomparatively a better indicator for sex determination amongall the variables

Discriminant analysis was done using gender as a grou-ping variable and MSI as an independent variable and

International Journal of Dentistry 3

Table 2 Calculation of the discriminant equation and discriminant score (119863)

Males Females

Function at group centroids minus0375 0375 Classified as male if119863 lt 0Classified as female if119863 gt 0

Table 3 Discriminant analysis showing specificity of 76 andsensitivity of 68

Predicted group TotalOriginal(count)

Males 19 6 25Females 8 17 25

Males 76 24 100Females 32 68 100

discriminant equation was obtained as follows119863 = 11509 minus8871 timesMSIThis equation provided to calculate ldquo119863rdquo will aidin prediction of gender by substituting the values of specificmeasurements (MSI) in the equation A greater calculated119863(119863 gt 0) indicates female gender while 119863 value less than thereference value (119863 lt 0) indicates male gender The moreextreme the calculated 119863 value from the cut-off value thehigher the probability that the predicted gender is correct(Table 2) The obtained determinant equation was applied tothe study sample and revealed that 19 out of 25 were correctlyidentified as males and 17 out of 25 as females with sensitivityof 68 and specificity of 76 (Table 3)

4 Discussion

Identification of skeletal and human remains is one of themost difficult areas of expertise in forensic sciences Deter-mination of gender is exceptionally vital as it can positivelyrule out a certain percentage of possibilities instantaneouslyRadiology can assist in giving precise dimensions for whichcertain formulae can be applied to determine gender Whenthe skeleton exists completely sex can be determined with100 accuracy The precision rate is 98 in cases of pelvisand cranium 95 in pelvis and long bones and 80ndash90only with long bones [3 5] Gender can be determined byvariousmethodologies such as sexual dimorphismwith toothmorphology pulpal DNA analysis study of lip prints palatalrugae and finger prints and evenwith radiological techniquesby morphometric analysis of paranasal sinuses [1]

Maxillary sinus is the largest and first to develop amongall the paranasal sinuses At 10 weeks in utero the maxillarysinus starts to develop After birth it continues to pneumatizeinto the developing alveolar ridge as the permanent teetherupt By 12-13 years the sinus floor is in level with the nasalfloor and by 20 years with the completion of the eruption ofthe third molars the pneumatization of the sinus ends and itreaches 5mm inferior to the nasal floor Henceforth subjectsincluded in the present study were above the age of 20 [3 5]

The maxillary sinus dimensions tend to stabilize afterthe second decade of life Radiographic images provideadequate measurements for maxillary sinuses that cannot beapproached by other means [6 7] Thus the maxillary sinusheight width and maxillary sinus index were considered inour study

During adulthood the shape and size of the maxillarysinus change especially due to loss of teeth After themaximum growth period the volume of the maxillary sinusdecrease in both genders This is attributed to the fact thatthe loss of minerals in the bone matrix of the entire bodystructure surrounding the maxillary sinus in all directionscontracts the maxillary sinus and results in decrease in themaxillary sinus volume [8]

Similar study conducted by Fernandes in (2004) aboutgender determination from measurement of the maxillarysinuses showed that the maxillary sinus was larger in malesthan in females with an accuracy rate of 790 [9] Teke et al(2007) established the accuracy of gender determination of694 in females and 692 inmales [10] Uthman et al (2011)concluded that 744 of male sinuses and 733 of femalesinuses were sexed correctly and the overall percentage forsexing maxillary sinuses correctly was 739 [6] Vidya etal (2013) studied the height length width and volume ofmaxillary sinuses of 30 dry skulls of south Indian originand stated that the measurements and volume of maxillarysinus of males were slightly more [11] Chandra et al (2014)established the accuracy and reliability of maxillary sinusin gender determination using morphometric parameters(area and perimeter) using lateral cephalogram The correctpredictive accuracy was found to be 708 in males and625 in females [3] Kanthem et al (2015) found that thedimensions and volume of maxillary sinuses of right andleft side using computed tomography were markedly largerin males compared with females [1] All the results of theaforementioned studies were nearly analogous to the presentstudy

Gender determination is one of the integral aspects inpersonal identification of an unidentified cadaver thus nar-rowing down the diagnosis towards an accurate possibilityMost of the bones conventionally used (pelvis skull longbones etc) are often recovered either in a fragmentedcurtailed or commingled state especially in catastrophesand mass disasters making identification a complicated taskVarious authors have reported that zygomatic bones andmaxillary sinus remain intact although the skull and otherbones may be badly disfigured in victims who are incinerated[1 3]

Lateral cephalometry being a two-dimensional con-ventional radiographic technique is readily available andinexpensive and permits a good assessment of the softtissue elements that defines the paranasal sinuses and their


surrounding structures Therefore the morphometric analy-sis of maxillary sinus has been proved to be a valuable toolin the assessment of sexual dimorphism This is relativelya new and reliable method for gender determination usingmaxillary sinus index However further studies are desirableon large sample size

Conflicts of Interest

The authors declare that they have no conflicts of interest

References

[1] R Kanthem V Guttikonda S Yeluri and G Kumari ldquoSexdetermination usingmaxillary sinusrdquo Journal of Forensic DentalSciences vol 7 no 2 pp 163ndash167 2015

[2] A M Attia A M El-Badrawy and H M Shebel ldquoGenderidentification from maxillary sinus using multi-detector com-puted tomographyrdquoMansoura Journal of Forensic Medicine andClinical Toxicology vol 1 pp 17ndash28 2012

[3] S Chandra P Devi N Taneja K Sah and N Kaur ldquoForensicimportance of maxillary sinus in gender determination amorphometric analysis from Western Uttar Pradesh IndiardquoEuropean Journal of General Dentistry vol 3 no 1 pp 53ndash562014

[4] R U Mathur A M Mahajan R C Dandekar and R B PatilldquoDetermination of sex using discriminant function analysis inyoung adults of Nashik a lateral cephalometric studyrdquo Journalof Advanced Medical and Dental Sciences Research vol 2 no 1pp 21ndash25 2014

[5] L Kiruba C Gupta S Kumar and A D1015840Souza ldquoA studyof morphometric evaluation of the maxillary sinuses in nor-mal subjects using computer tomography imagesrdquo Archives ofMedicine and Health Sciences vol 2 no 1 pp 12ndash25 2014

[6] A T Uthman N H Al-Rawi A S Al-Naaimi and J F Al-Timimi ldquoEvaluation of maxillary sinus dimensions in genderdetermination using helical CT scanningrdquo Journal of ForensicSciences vol 56 no 2 pp 403ndash408 2011

[7] P Sahlstrand-Johnson M Jannert A Strombeck and K Abul-Kasim ldquoComputed tomography measurements of differentdimensions of maxillary and frontal sinusesrdquo BMC MedicalImaging vol 11 article no 8 2011

[8] H H Jasim and J A Al-Taei ldquoComputed tomographicmeasurement of maxillary sinus volume and dimension incorrelation to the age and gender (comparative study amongindividuals with dentate and edentulous maxilla)rdquo Journal ofBaghdad College of Dentistry vol 252 no 1 pp 87ndash93 2013

[9] C L Fernandes ldquoForensic ethnic identification of crania therole of the maxillary sinusmdasha new approachrdquo American Journalof Forensic Medicine and Pathology vol 25 no 4 pp 302ndash3132004

[10] H Y Teke S Duran N Canturk and G Canturk ldquoDetermina-tion of gender by measuring the size of the maxillary sinusesin computerized tomography scansrdquo Surgical and RadiologicAnatomy vol 29 no 1 pp 9ndash13 2007

[11] C S Vidya N M Shamasundar B Manjunatha and KRaichurkar ldquoEvaluation of size and volume of maxillary sinustodetermine gender by 3D computerized tomography scanmethod using dry skulls of South Indian originrdquo InternationalJournal of Current Research and Review vol 5 no 3 pp 97ndash1002013

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Table 1 Comparison between maxillary sinus height width and MSI in males and females

Gender 119873 Mean Std deviation Std error 95 CI 119901 value

Height Males 25 304 187 037 05648 to 3122 00066Females 25 285 252 050

Width Males 25 380 317 063minus08230 to 2377 03254

Females 25 373 333 067

Maxillary sinus index (MSI) Males 25 126 011 002minus01486 to minus001389 00202

Females 25 134 012 002

Considering this background the aim and objectivesof the present study were to develop a new method forgender determination using maxillary sinus index fromlateral cephalometric radiographs establish the reliabilityof maxillary sinus for gender determination and explorewhether the height width and maxillary sinus index can beused for determination of gender

2 Material and Methods

The study was initiated after the protocol had been approvedby the Institutional Ethical Committee A total of 50 healthysubjects belonging to both genders (25 males and 25 females)of age group 25ndash55 years attending the outpatient departmentof Oral Medicine and Radiology were selected for the studyby simple random sampling Subjects with history of facialtrauma fracture of maxillary sinus congenital developmen-tal abnormalities and any maxillary sinus pathology wereexcluded from the study The importance and need for thestudy were explained to each individual

All the study samples were instructed to remove anydental appliances and metal objects from the head and neckregion The subjects were told about the procedure andsubjected to digital lateral cephalogram (Sirona OrthophosXG Model 6229343 D3352 SN 05685) with proper radiationprotection measures under exposure factors as applicable totheir age The radiographs were then stored with patientsdetails incorporated All radiographs were interpreted andthe maxillary sinuses height and width were measured usingSidexis next generation software (version 25 Sirona Ger-many) (Figure 1) Themeasurements obtained were recordedand entered in the proforma specially designed for the studyTherefore the maxillary sinus index (MSI) was calculated asfollows MSI = maxillary sinus widthheight

The results obtained were subjected to statistical anal-ysis using SPSS version 1601 (statistical package for socialsciences) software The mean values and standard deviationof the maxillary sinus height width and MSI in malesand females were obtained and tabulated using paired 119905-test The mean differences were also calculated for the sameand 95 confidence intervals (CI) evaluated Discriminantfunction analysis was performed for determination of genderDiscriminant equation was also derived with gender as aclassifying variable and MSI as an independent variable Thediscriminant scores (119863) thus obtained were recorded andgender differentiation was done accordingly Sensitivity andspecificity were determined to assess the accuracy of the

Width

Height

2540mm

3904mm

Figure 1 Maxillary sinus height and width measurements radio-graphically using Sidexis next generation software

results and reliability of the procedure Significance level wasbased on 119901 value lt 005

3 Results

The mean maxillary sinus height was found to be 304mmin males and 285mm in females and it was statisticallysignificant with (05648 to 3122) 95 CI and 119901 value of00066The mean maxillary sinus width was 38mm in malesand 373mm in females which was statistically nonsignificantwith (minus08230 to 2377) 95 CI and 119901 value of 03254 Themean MSI was higher in females (134) when comparedwith males (126) with (minus01486 to minus001389) 95 CI and asignificant 119901 value of 00202 (Table 1) In the present studythe lowest value was presented by MSI indicating MSI to becomparatively a better indicator for sex determination amongall the variables

Discriminant analysis was done using gender as a grou-ping variable and MSI as an independent variable and



Males Females





Males 76 24 100Females 32 68 100


4 Discussion












References



















Biomaterials












Journal of





















Males Females





Males 76 24 100Females 32 68 100


4 Discussion












References



















Biomaterials












Journal of























References



















Biomaterials












Journal of


























Biomaterials












Journal of



















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Cephalometric Analysis for Gender Determination Using ... · ResearchArticle Cephalometric Analysis for Gender Determination Using Maxillary Sinus Index: A Novel Dimension in Personal