GENDER DETERMINATION USING COMPUTED

TOMOGRAPHIC MEASUREMENT OF MAXILLARY AND

FRONTAL SINUS: A COMPARATIVE STUDY

Dissertation Submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

In Partial Fulfillment for the Degree of

MASTER OF DENTAL SURGERY

BRANCH IX

ORAL MEDICINE AND RADIOLOGY

2015-2018

ACKNOWLEDGEMENT

“No one who achieves success does so without acknowledging the help of others“.

-Alfred North Whitehead

I dedicate this dissertation with great gratitude and all the respect to the Almighty

God without whose kind support and generous blessings this work of mine would not

have been completed.

My deep sense of gratitude to Capt.Dr.S.GOKULANATHAN, B.Sc, M.D.S., Dean,

Vivekanandha Dental College for Women, for permitting me to pursue this study.

With submissive ambition, I aspire to register my gratitude to my respected HOD,

Department of Oral Medicine and Radiology and the Principal of Vivekananda Dental

College for Women, Prof. Dr.N.BALAN M.D.S., for his inspiring guidance, invaluable

counsel and encouragement throughout the course of the study. This work would not have

seen the light of the day without his affectionate and compassionate counselling, which

reposed by confidence in myself to undertake the challenges in the study.

I am deeply grateful to my guide, Professor Dr.M.SUDHAA MANI, MDS for her

constant guidance, advice and support.

My deep gratitude to Reader, Dr. S.YASMEEN AHAMED, MDS, for his timely

advice. I extend my gratitude to Senior lecturers, Dr. BABU SUSAI RAJ, MDS,

Dr. P.AMBIGA, MDS, Dr. G.S.SIVA RAMAN, MDS, for their help, support and

encouragement.

I would also like to thank Mr.K.Janardhana Reddy, Radiology technician,

Vivekanandha Medical care hospital, for his continuous support to carry out my CT

measurements for the study and Mr. Nandakumar, Statistician for his valuable help in

performing the statistical analysis.

I take great pleasure to extend my gratitude to my dear friend Edwina J for her

friendly help and co-operation throughout my postgraduate life.

My deepest appreciation to my dear mother, Mrs.S.Ananthabai,

father,Mr.P.Duraipandian, sister, Er.Supriya and brother, Dr.Athiban, for their evergreen

love and moral support. I offer my heartfelt thanks to my husband Dr.Pratap for his

infinite encouragement, unlimited help and patience.

Finally, I would like to express my special thanks and appreciation to all the persons

who helped me in one way or another whose names are not mentioned here, but certainly

not forgotten.

Truly,

Dr. D.A.Divya Kanimozhi

ABBREVIATIONS

ANOVA

AP

CT

DNA

LRA

i.e

IGF-1

ML

mA

mm

Kvp

MANOVA

PDGF

SPSS

Analysis of variance

Anteroposterior length

Computed tomography

Deoxyribo nucleic acid

Logistic regression analysis

That is

Insulin-like growth factor-1

Mediolateral width

Milli Ampere

Millimetre

Kilo voltage peak

Multivariate analysis

Plasma derived growth factor

Statistical package of social science

TABLE OF CONTENTS

S.NO CONTENTS PAGE NO

01 INTRODUCTION 1

02 AIMS AND OBJECTIVES 5

03 REVIEW OF LITERATURE 6

04 MATERIALS AND METHODS 18

05 RESULTS 25

06 DISCUSSION 45

07 SUMMARY 54

08 CONCLUSION 56

09 BIBLIOGRAPHY 57

10 ANNEXURES 63

LIST OF TABLES

Table

Number

Tables Page

number

Table 1 Comparison of mediolateral width in males and females for

maxillary sinus

25

Table 2 Comparison of anteroposterior length in males and females for

maxillary sinus

25

Table 3 Total distance across right and left maxillary sinus in males and

females

26

Table 4 Comparison of different parameters of frontal sinus 26

Table 5 Summary of Canonical Discriminant Functions for Maxillary sinus 27

Table 6 Discriminate analysis for maxillary sinus measurements to

discriminate between males and females

28

Table 7 Predicted group membership for maxillary sinus 29

Table 8 Summary of Canonical Discriminant Functions for frontal sinus 30

Table 9 Discriminate analysis for frontal sinus measurements to

discriminate between males and females

30

Table 10 Predicted group membership for frontal sinus 32

Table 11 Comparison of measurements of maxillary and frontal sinus

according to age groups

32

LIST OF FIGURES

Figure

Number

Figures Page

number

Figure 1 Paranasal sinuses 6

Figure 2 Developmental pattern of maxillary sinus 8

Figure 3 Developmental pattern of frontal sinus 8

Figure 4 Fan beam CT 10

Figure 5a The Mediolateral diameter of the maxillary sinus on right side

measured from the CT axial section

19

Figure 5b The Mediolateral diameter of the maxillary sinus on left side

measured from the CT axial section.

20

Figure 6a The Anteroposterior length of the maxillary sinus on right side

measured from the CT axial section.

20

Figure 6b The Anteroposterior length of the maxillary sinus on left side

measured from the CT axial section.

21

Figure 7 Total distance across both sinuses measured from the axial CT

section

21

Figure 8 The thickness of the anterior wall of the frontal sinus measured at

the level of the orbital roof on axial section

22

Figure 9 The depth of the frontal sinus measured on axial section 23

Figure 10 Maximum Anteroposterior length of frontal sinus measured on

scout image

23

Figure 11 Presence of septa within maxillary sinus 43

Figure 12 Absence of frontal sinus 43

Figure 13 Presence of 2 septae and 3 lobulations 44

Figure 14 Presence of Scalloping 44

LIST OF GRAPHS

Graph

Number

Graphs Page

number

Graph 1 Comparison of mediolateral width (mm) in males and females for

maxillary sinus

39

Graph 2 Comparison of anteroposterior length (mm)in males and females

for maxillary sinus

39

Graph 3 Total distance (mm) across right and left maxillary sinus in males

and females for maxillary sinus

40

Graph 4 Comparison of maximum depth on axial section for frontal sinus 40

Graph 5 Comparison of thickness of anterior wall on axial section for

frontal sinus

41

Graph 6 Comparison of anteroposterior length of frontal sinus on scout

image

41

Graph 7 Distribution of Total subjects in age subgroups

42

INTRODUCTION

Page 1

INTRODUCTION

George Buschan – A pioneer in dental anthropology has done various studies about

anthropometric characteristics which is of fundamental importance.1 Many parts of the

skeleton can be used for identification of a person, however the most reliable parts of the

skeleton are those which are anatomically variable or which do not exhibit change due to

trauma, illness or surgical intervention.2 Matching specific features detected on the dead

bodies with data recorded during the life of an individual is an important aspect in forensics,

and can be performed by fingerprint analysis, deoxyribonucleic acid matching,

anthropological methods, radiological methods and other techniques which can facilitate age

and sex identification.3 Determination of gender and estimation of stature from the skeleton is

vital to medicolegal inquiries. Skull is composed of hard tissue and is the best preserved part

of skeleton after death, hence, in many cases it is the only available part for forensic

examination.2

Forensic anthropology may be defined as the application of biological or physical

anthropology in the service of justice.4 Forensic personal identification is a fundamental topic

of forensic sciences and technologies to identify live subjects, recently deceased bodies and

human remains often at a crime scene by using several appropriate techniques5.

Craniometric features are included among these characteristics which are closely

related to forensic dentistry.2 Sexual dimorphism refers to the systemic difference in the form

(either in shape or size) between individuals of different sexes in the same species.

Researchers have revealed that the shape and size of the maxillary sinus differ between males

and females and in various populations.6 It has been stated that during adulthood, their

shapes and sizes change especially due to loss of teeth. After the maximum growth period,

the volume of the maxillary sinus decrease in both genders. This is explained by the fact that

INTRODUCTION

Page 2

the loss of minerals in the bone matrix contracts the maxillary sinus and result in a decrease

in the maxillary sinus volume in both genders.7 The frontal sinus is another Craniometric

feature with significance in forensic identification due to its irregular shape and because of

the individual characteristics which makes the frontal bone unique for every individual, just

as with finger prints even for monozygotic twins.8 Frontal sinus has great variability and its

structure does not change after the age of 18 years except for very rare occurrences as

fractures, tumors or severe infections.8 The studies on correlation of the morphology of the

frontal sinus with gender showed that the frontal sinus is smaller in women, an aspect that

points out its unique characteristic and importance in human identification, as well as in the

determination of age.9

Radiography was used as forensic tool for human identification, especially in cases

where the body is decomposed, fragmented, or burned (Kiruba et al., 2014).10Historically, the

application of x-ray in forensic sciences was introduced in 1896, just one year following the

x-ray discovery by Prof. Wilhelm Conrad Roentgen on November 8,1985. It was Schuller

from Vienna who proposed the possibility of utilizing radiological images of the frontal sinus

for identification purposes in 1921. The first complete radiological identification by using

pneumatic cells of the skull was described by Culbert & Law in 1927 (Culbert & Law, 1927;

Gruber & Kameyama, 2001; Carvalho et al., 2009).1

By the end of the 19th Century Radiography is applied in many medicolegal and

forensic anthropological investigations such as i)Age estimation (Greulich and Pyle, 1959;

Murphy and Gantner, 1982) ii)Sex estimation (Krogman and Iscan, 1986) iii)Ancestry

estimation (Stewart, 1979) iv)Stature estimation (Murphy and Gantner, 1982) v) Locating

and recovering bullets and other foreign bodies and determining the direction, angle and

location of wounds (Eckert and Garland, 1984)vi) Detecting air-embolisms (Camps, 1969)

vii) Detecting fractures and other trauma (Camps, 1969; Eckert and Garland, 1984)

INTRODUCTION

Page 3

viii)Examining hyoid or cartilage fractures in hanging or strangulation victims (Camps, 1969;

Fatteh and Mann, 1969) ix) Illustrating dental morphologies and anomalies (Eckert and

Garland, 1984; Krogman and Iscan, 1986) x) Separating skeletal remains from wood charcoal

and other charred material (Krogman and Iscan, 1986; Morgan and Harris, 1953) xi)

Diagnosing premortem skeletal health (Krogman and Iscan, 1986), xii)Detecting metallic

poisons such as arsenic, lead and mercury in suspected poisoning cases (Fatteh and Mann,

1969; Schmidt and Kallieris, 1982)1

In the last years of 20th century and first decade of 21st century, the use of radiological

techniques has improved and became widespread after introduction of computed tomography

(CT) by Godfrey Hounsfield in 1972. Today, forensic scientists are regularly using

radiographic images as part of the autopsy procedures and forensic identification1. The value

of radiography has become well established in the criminal and medicolegal work of police

officers and medical examiners (Cornwell, 1956). Anthropologically, CT has been applied in

the study of fossil skull and bite mark analysis.

Computed tomography (CT) scans are excellent imaging modality used to evaluate

the paranasal sinuses, craniofacial bones, as well as the extent of pneumatisation of the

sinuses and provides detailed information that is not available from standard radiographs.

Hence, CT measurements of maxillary and frontal sinuses are useful to estimate gender.3

Establishing positive identification of an unknown individual is important in our

society for both legal and humanitarian reasons. Legally, issues of inheritance and

succession to property, collection of insurance policies and pensions, administration of wills,

lawsuits involving negligent parties, prosecution of homicide, detection of fraudulent deaths,

accident reconstruction, issuance of a death certificate and other matters concerning property

INTRODUCTION

Page 4

and business interactions all depend on the ability to establish a positive identification

(Phrabhakaran et al., 1999; Sopher, 1972; Wentworth and Wilder, 1932).

There was very less literature to evaluate and compare maxillary and frontal sinus

dimensions for gender dimorphism using Computed Tomography (CT). So this study intends

to evaluate the reliability and accuracy of maxillary and frontal sinus for gender

determination using CT and its application as an aid in forensic investigation for gender

determination.

AIMS AND OBJECTIVES

Page 5

AIMS AND OBJECTIVES

AIMS:

To compare maxillary and frontal sinus dimensions and to assess its reliability and accuracy

for gender determination using CT scan

OBJECTIVES:

To measure the maxillary and frontal sinus dimensions.

To determine if any gender differences in maxillary and frontal sinus dimensions

To correlate the dimensions and assess the reliability of parameters in gender

determination.

To evaluate which sinus is more accurate in gender determination.

REVIEW OF LITERATURE

Page 6

REVIEW OF LITERATURE

Paranasal sinus anatomy is variable from individual to individual and so is the

incidence of the anatomical variations. Human skeletal remains can be used for

identification of height, age, race, and sex that are considered the four fundamental

elements of forensic science and physical anthropology. It has been reported that

maxillary and frontal sinuses stay intact in severely disfigured victims, whereas the

skull and other bones may be not. Hence it is of significance in forensic identification

because of individual characteristics which make the maxillary and frontal bone

unique for every individual.

PARANASAL SINUSES

The paranasal sinuses are located within the bones of the skull and face as air

filled spaces. They are centred on the nasal cavity and have various functions,

including moisturizing the air, equilibrating air pressure changes, assisting with

resonance, expanding the olfactory mucosa area, decreasing the weight of the cranium

and serving as a crumple zone to protect vital structures in the event of facial

trauma. Four sets of paired sinuses are recognized: maxillary, frontal, sphenoid, and

ethmoid11 (Fig 1).The embryological development of the paranasal sinus is a very

complex process, and its description varies among different authors. The paranasal

sinus shows unpredictable growth pattern and it is extremely variable even on right

and left side within an individual and from one individual to another12

Fig.1 Paranasal sinuses

REVIEW OF LITERATURE

Page 7

The maxillary sinus is the first to develop as early as the tenth week of

gestation invaginations of the mucosa and extension from the primitive ethmoid

infundibulum13.The maxillary sinus begins to form from an out pouching of the lateral

wall of the ethmoid area of the nasal capsule within the infundibulum and

immediately posterior to the developing uncinate process. This outgrowth enlarges

slowly throughout fetal life due to the constriction by the perichondrium of the nasal

capsule, limiting extension into the maxillary process (maxilla). Hence it appear as a

slit between maxilla, inferior turbinate and ethmoidal cells.

Only as the nasal capsule is resorbed during its ossification does the maxillary

sinus have an opportunity to enter the developing maxillary process. It is located

within the bone of the maxilla on each side of the nasal cavity and communicates with

the nasal cavity through an opening (called an ostium) that is located high on the

medial wall and opens into the semilunar hiatus of the middle nasal meatus on the

lateral nasal cavity.

As the tooth develops it restricts the expansion of sinus into the maxilla.

Further growth of the maxillary sinus into the maxilla follows the development of the

maxilla and the descent of the teeth. The average dimensions of the maxillary sinus

are 33 mm in height, 23-25 mm in width, and 34 mm in the anteroposterior axis; the

average volume is 15 ml (Karmody CS et al., 1977)13

Growth is progressive in all dimensions more so anteroposteriorly, similar to

the cranial elongation. It undergoes two periods of rapid growth, between birth and

age of three years, also between ages seven and eighteen years14 (Fig.2)

REVIEW OF LITERATURE

Page 8

Fig. 2 Developmental pattern of maxillary sinus

According to classical knowledge based on x-rays, frontal sinus is not apparent at

birth and development begins during the second year of life (Yoshino et al., 1987;

Quatre homme et al., 1996; Kirk et al., 2002). The frontal sinus begins development

in the region of frontal recess of the frontal nasal meatus in a foetus aging 4th months

of gestation. In the latter weeks of the fetal life, the frontal recess of the middle nasal

meatus transforms upwards into an oval thin-walled space corresponding to the

developing frontal sinus. It adheres to the ethmoidal labyrinth, integrating with it. The

frontal sinus rarely is visible on radiographs earlier than the second year of life. The

sinus invades the frontal bone by about 5 years of age and slowly grows to reach an

adult size in late adolescence. Frontal sinus are either absent or insignificant at birth,

but gradually increase in size and reach maximum dimension at around eighteen years

of age. Further pneumatisation due to atrophic changes may occur in old age15 (Fig.3)

Fig.3 Developmental pattern of frontal sinus

REVIEW OF LITERATURE

Page 9

COMPUTED TOMOGRAPHY

In 1972 Godfrey Hounsfield, an engineer, announced the invention of a

revolutionary imaging technique that used image reconstruction mathematics

developed by Alan Cormack in the 1950s and 1960s to produce cross-sectional

images of the head. Currently this form of imaging is called computed tomography,

abbreviated as CT. Hounsfield and Cormack shared the Nobel Prize in Physiology or

Medicine in 1979 for their pioneering work16.

CT offers high resolution images and overcomes many of the limitations of

two dimensional images. However, drawbacks of this methodology include expense

and increase radiation exposure. CT scanners place the patient at the centre of a

mounted on a rotating frame which holds a radiation source and detector. As the

cylindrical scanner assembly rotates around the patient the detector recognizes a

series of x-rays that have passed through the patient (Sukovic et al, 2003).

A fan shaped x-ray beam from the radiation source acquires a series of axial

plane slices that are subsequently stacked to create a three-dimensional reconstruction

(fig 4). There are only a few reports on identification of unknown bodies using CT

scans of maxillary and frontal sinus (Reichs, 1993; Riepert et al., 2001; Tatlisumak et

al., 2007; Pfaeffli et al., 2007; Blau et al., 2008; Uthman et al., 2010)15.

Identification of human remains by comparison of antemortem and

postmortem radiographs is a well-established procedure among forensic scientists. It

is even used as substitute for fingerprints and in particular maxillary and frontal

sinuses have always been unique in every person (Yoshino et al., 1987; Harris et al.,

1987; Kullman et al., 1990)17.

REVIEW OF LITERATURE

Page 10

Fig. 4 Fan beam CT

STUDIES ON COMPUTED TOMOGRAPHIC MEASUREMENT OF

MAXILLARY AND FRONTAL SINUS

A retrospective study was conducted by Ertugrultatlisumak et al. (2008)18

on paranasal sinuses using CT scans to determine the morphological characteristics of

the frontal sinus. The width, height and anteroposterior length of each sinus and total

width were obtained from CT scans. The study included 300 cases (123 male and 177

female). The mean age was 40.74 (range 20–83). The complete absence of frontal

sinus was not observed among the cases. All measurements are larger on the left side

and were significantly larger in males than females. There was a significant difference

in the anteroposterior lengths of right and left sides in both males and females.

An anatomical study was conducted by Jose Marcos Ponde et al. (2008)19 on

macerated skulls for evaluation of frontal sinus after section on axial plane 1 inch

above the supercilliary arcs. The measures of anteroposterior, sagital and transversal

diameters were taken. The frontal sinus was absent in 24.3% cases. The mean antero-

posterior diameter was 7.849 mm, the mean transversal diameter was 40.59 mm and

REVIEW OF LITERATURE

Page 11

the median sagittal diameter was 33.40 mm. The statistical analyses demonstrated a

significant difference concerning gender.

A study conducted by A.T. Uthman et al (2010)20 on 90 patients for

identification of unknown bodies using spiral CT images of frontal sinus and skull

measurements. The measurements selected for the study were frontal sinus width,

height anteroposterior length and the distance between the highest points of the two

sinuses and the distance between the highest points of each sinus to its maximum

lateral limit were included. The skull measurements includes maximum skull length,

prostio-bregmatic height and maximum skull width. All data were subjected to a

descriptive and discriminative analysis using the SPSS. The discriminative analysis

showed that the ability of the frontal sinus to identify gender was 76.9%, adding the

skull measurements to the frontal sinus measurements gave a higher overall

classification accuracy. The study stated that CT serves as a valuable tool for skull

measurements.

In a study conducted by Uthman et al. (2010)2 for gender identification using

CT measurements of maxillary sinuses the height of maxillary sinus has provided the

overall accuracy of 71.6% and hence it is stated as the best discriminant parameter.

Using multivariate analysis, 74.4% of male sinuses and 73.3% of female sinuses were

correctly classified.

A study by Goyal et al. (2012)21 assessed the frontal sinus for sex

determination using univariate and multivariate statistics. The univariate Mann-

Whitney U-tests used to test for sexual dimorphism of the frontal sinus failed to reach

statistical significance (p-value ≤ 0.05 considered significant). In addition to this,

multivariate logistic regression equations allowed the correct identification of sex in

only 60% of cases, suggested that possible reasons for the low sexual dimorphism

REVIEW OF LITERATURE

Page 12

may be the frontal sinus high inter-individual variability, which indicates that the

frontal sinus may have limited applications as the sole predictor of sex. The study

concluded that caution must be used when evaluating the frontal sinus for

identification purposes, sex determination, or anything else being studied.

PernillaSahlstrand-Johnson et al. (2011)22 conducted a study to estimate

different dimensions of the maxillary and frontal sinuses measured on computed

tomography (CT) of the head. The degree of agreement between the automated

measurement of the volume of maxillary sinuses and the volume calculated according

to the equation width × anteroposterior × craniocaudal diameter × 0.5, was almost

perfect (ICC 0.90-0.93 and random error of 1.9-2.4 cm3). The study concluded that

there was a significant difference of the maxillary sinus volume between males and

females, mainly due to the fact that male exhibit higher and wider maxillary sinuses

than females.

Ahmed A. Masir et al. (2013)6 conducted a study on three dimensional

computed tomography images of 144 patients (288 maxillary sinuses) with no clinical

evident craniofacial and maxillary sinus abnormalities. The linear dimensions and

volume of maxillary sinus were measured for different age categories and gender. The

study results stated that the male’s maxillary sinus width and height were significantly

larger than females in 7-12 (p<0.01) and 21-30 (p=0.02) years age categories.

Moreover, maxillary sinus depth were found to be larger in males than females in 21-

30 years age category (p<0.01). Males also exhibited larger maxillary sinus volume

than females in 21-30 (p<0.01) years age categories. The study concluded that the

maxillary sinus sizes and volume showed sexual dimorphism at most age categories.

REVIEW OF LITERATURE

Page 13

A study was done by MassaratJeha et al. (2014)23 to investigate whether

the bizygomatic distance, AP diameter & width of the maxillary sinus

&intermaxillary distance could be used for determination of gender using CT scan. A

statistically significant difference with p<0.0001 was observed in the bizygomatic

distance with mean±SD of 9.55±0.41cm for male & 9.262±0.52 for female. The

strongest correlated variable with bizygomatic distance was the intermaxillary

distance (r = 0.3037) in male & AP diameter of sinus (r = 0.5980) in female. The

study concluded that Computerized Tomography measurements of bizygomatic

distance & maxillary sinus dimensions may be useful to support gender determination

in forensic medicine when other methods are inconclusive.

A study conducted by Camargo et al (2007)24 to determine gender using

radiographic evaluation of frontal sinus. The right and left areas and the maximum

height and width of the frontal sinus were determined in 100 radiographs taken by the

Caldwell technique of 50 women and 50 men between 20 and 30 years old. The mean

values of the frontal sinus were greater in males and the left area was larger than the

right area, based on Student's t-test at the 5% level of significance.

In a study conducted by Belaldavar, et al (2014)25 in 300 digital

postero‑anterior view radiographs, 147 males and 142 females show presence of

frontal sinus with seven individuals showing unilateral/bilateral absence of frontal

sinuses. Absence of frontal sinus was observed in 4% of cases, out of which 1.3% of

males and 3.3% of females showed bilateral absence. 0.6% of males and 2.66% of

females showed unilateral absence. The mean values of the frontal sinus height, width

and area are greater in males. Thus, frontal sinus provides average accuracy in sex

determination among Indian population.

REVIEW OF LITERATURE

Page 14

An anatomical study was done by Vidya C S et al (2014)26 in 50 macerated

skulls(Males=28, Females=22) of age group 40-60 yrs are cleaned and subjected to

3D axial multislider CT scan. Axial and coronal images of slice thickness of 4mm

were obtained. Frontal sinus (symmetry and lobulations) were observed and

classified. Frontal sinus asymmetry was observed in 15 (30%) individuals and about

2% frontal sinus was absent. The features of frontal sinus morphology make it most

convenient part of the skeleton for forensic identification.

Neha et al (2015)9conducted a study to determining the gender of individuals

by mathematical method using measurement of the frontal sinus. The study group

included 140 subjects in the age group of 20-50 years which consists of 70 males and

70 females. Digital Posterioanterior radiograph was taken using standard technique

for the evaluation of frontal sinus. The mean values of the frontal sinus Height, width

and area are greater in males. Right frontal sinus is larger than left frontal sinus in

both the sex. The mathematical model based on logistic regression analysis gives an

concordance index for gender determination of 64.29%. Hence the areas of frontal

sinus and logistic regression technique proves to be useful in determination of gender.

A study conducted by Ranjith Kumar Kanthem et al (2015)3for

determination of the sex of an individual from different dimensions of the maxillary

sinus using computed tomography (CT) scan. The height, length, width, and volume

of the maxillary sinus on both sides were measured. The study concluded that the

volume of the right maxillary sinus can be used as accurate diagnostic parameter for

sex determination

A research was conducted by GianguidoCossell et al (2015)29 to analyse the

reliability of frontal sinus by cone beam‑computed tomography (CBCT) for individual

REVIEW OF LITERATURE

Page 15

identification. CBCT from 150 patients (91 female, 59 male), aged between 15 and 78

years, was analysed. Correlation analysis showed that sinus surfaces were strongly

correlated with their volume (r = 0.976). Frontal sinuses were separate in 21 subjects

(14 %), fused in 67 (44.6 %) and found on only one side (unilateral) in 9 (6 %). A

Prominent Middle of Fused Sinus (PMS) was found in 5 subjects (35.3 %). The intra-

(0.963–0.999) and inter-observer variability (0.973–0.999) showed a great agreement

and a substantial homogeneity of evaluation. The study concluded that comparison of

frontal sinus images by CBCT can be used as an additional method in the

identification process, providing the expert with greater reliability.

A preliminary research study conducted by S.S. Tambawala et al (2015)30

to evaluate the sexual dimorphism of maxillary sinus dimensions using the CBCT

imaging modality. The overall values of the maxillary sinus parameters were

significantly greater in the males as compared to the females with the right height

(90.0%) and the left height (83.3%) being the best predictors. This study states that

the maxillary sinus height provides best gender discrimination.

A study was conducted by Soman BA et al (2016)31 for morphometric

evaluation of the frontal sinus in relation to age and gender. The study group

consisted of 200 subjects (100 males and 100 females) in the age groups 14‑20 years,

21‑30 years, 31‑45 years, 45 years and above. Posteroanterior (PA) cephalogram

radiographs were taken using standardized technique. The processed films were

traced and frontal sinus pattern was established as per Yoshino’s classification

system. The mean values for length, width, and area of the frontal sinus were found to

be higher in males as compared to females and area of frontal sinuses increase with

age except in males who were 45 years and above. The left width, left area, and

bilateral asymmetry in relation to gender was found to be statistically significant. The

REVIEW OF LITERATURE

Page 16

study concluded that morphologic evaluation of frontal sinus is a useful technique to

determine gender and seems promising in personal identification

A retrospective study was conducted by BalajiBabuBangi et al

(2015)32 comprising 100 subjects (50malesand 50 females) above the age group of 20

years. The CT images were used to measure the mediolateral, superoinferior and

anteroposterior and the volume of the maxillary sinuses. Discriminative analysis was

done using the values derived and the 𝑡 test for independent samples was used to

compare these values in males and females. The study concludes that given a cranium

of unknown origin gender determination can be done using maxillary sinus

dimensions through computed tomography.

A retrospective study was conducted by ErtugrulTatlisumak et al (2017)15

from paranasal CT scans of 180 males and 180 females. The width and height of

frontal sinus were measured on a coronal plane, and the anteroposterior length was

measured on an axial plane. Previous studies shown that frontal sinus dimensions

were usually higher in females and lower in males after 40-49 years of age than their

younger counterparts, but the measurements were lower in females and higher in

males in 70≥ years of age group than 60-69 years of age. Left frontal sinus was

dominant in young age groups but right frontal sinus was dominant in groups 40-49

years of age or older. The study concluded that the results of such studies may affect

forensic identification from frontal sinus measurements.

In a study by Matthew K.Lee et al (2010)33 to describe the frontal sinus

anatomy to explore gender variation for cranioplasty and sinus surgery using CT

imaging, forehead and frontal sinus dimensions have been measured. The study

REVIEW OF LITERATURE

Page 17

concluded that males had larger overall frontal sinus dimensions, and this was most

pronounced in the medial area of the supraorbital ridge known as the glabella.

Beom-ChoJun et al (2005)34 stated that the maxillary sinus continues to grow

until the 3rd decade in males and the 2nd decade in females. The mean maxillary

sinus volume in early adults was 24,043 mm3 (males) and 15,859.5 mm3 (females).

There was a significance difference in the sinus volume (P < 0.05) according to

gender, and there was a significant difference in the maxillary sinus volume according

to age before it reached maximum.

A study was performed by Neha Patil et al (2012)36 to evaluate the uniqueness

and reliability of the frontal sinuses by comparing various patterns of frontal sinus as

observed on Waters’ radiographs for individual identification. The study proposes that

the size, shape, unilateral or bilateral presence, absence, and septa were observed to

be unique in each case. There was no two sinuses that are the same i.e, the sinus is

unique to each individual.

MATERIALS AND METHODS

Page 18

MATERIALS AND METHODS

ETHICAL CLEARANCE AND PERMISSIONS:

A detailed protocol explaining the purpose and procedures of the study was

approved by the Institution Review Board, Vivekanandha Dental College for women

(Annexure 1). The study was initiated after obtaining ethical clearance.

METHOD:

The study included cranial computerized tomography images (CT) of 50

patients (25 males and 25 females) aged between 18-65 years. These patients

underwent CT examination of head and neck for other medical problems that are not

related to the maxillary sinus and frontal sinus. All patients were examined on Spiral

Computed Tomography scanner at Vivekanandha Medical care hospital by using

computed tomography system (GE HiSpeed CT/e) digital software version CT/e

series 10.00. The CT Scans were made with a matrix of 512 x 512, 22mm FOV, 120

kvp, 130 mA, and exposure time of 1.0 seconds. All CT scans were made by trained

radiology technicians in the technique and operation of the CT machine.

INCLUSION CRITERIA:

Patients admitted for CT evaluation of head and neck region

CT images without any artefacts.

EXCLUSION CRITERIA:

CT images with facial trauma, evidence of previous sinus surgery,

pathological lesions involving maxillary and frontal sinus

MATERIALS AND METHODS

Page 19

PROCEDURE:

The visible pneumatisation was accepted as presence of the sinus. The greatest

diameter of sinus were taken after going through different slices in axial sections from

measuring 3 to 4 measurements. The measurement will be based on certain

anatomical landmarks. The measurements were performed as follows:

1. The Maximum Mediolateral diameter (Width (mm)). The width was

measured as the longest perpendicular distance from the medial wall of the

sinus to the outermost point of the lateral wall of the lateral process of the

maxillary sinus parallel to hard palate on right and left side (Fig.5a and 5b)

2. Maximum Anteroposterior diameter (Length (mm)). The length dimension

was measured on as the longest distance anteroposteriorly along the nasal

floor on right and left side (Fig.6a and 6b)

3. Total distance: the total distance from the outermost point of one maxillary

sinus to the outermost point of the opposite sinus.(Fig.7)

(Fig. 5a)The mediolateral diameter of the maxillary sinus on right side measured from

the CT axial section.

MATERIALS AND METHODS

Page 20

(Fig. 5b)The mediolateral diameter of the maxillary sinus on left side measured from

the CT axial section.

(Fig.6a)The Anteroposterior length of the maxillary sinus on right side measured

from the CT axial section.

MATERIALS AND METHODS

Page 21

(Fig.6b)The Anteroposterior length of the maxillary sinus on left side measured from

the CT axial section.

(Fig.7)Total distance across both sinuses measured from the axial CT section.

MATERIALS AND METHODS

Page 22

The frontal sinuses are absent at birth which later develops and attain its

maximum size between seventeen and eighteen years of age hence in our study mean

age of subject were 18 year of age . The measurements of the frontal sinus was done

in axial and scout images. The measurements are measured as follows:

1) Anterior wall thickness as measured at the level of orbital roof from axial sections.

(Fig.8)

2) Maximum depth as measured from axial sections. (Fig.9)

3) The anteroposterior length of both sinuses was measured from scout image as a

mean on lateral view (scout image) as the peripheral border of the frontal sinus was

traced and the highest (h) and lowest (l) points of its extension were marked.

Perpendicular to the interconnecting line h and l the maximal anteroposterior length of

the frontal sinus was measured (Fig.10)

(Fig.8)The thickness of the anterior wall of the frontal sinus measured at the level of

the orbital roof on axial section

MATERIALS AND METHODS

Page 23

(Fig.9)The depth of the frontal sinus measured on axial section

(Fig.10)Maximum anteroposterior length of frontal sinus measured on scout image

MATERIALS AND METHODS

Page 24

CT scans of those subjects included in the study were further divided into 3

age groups as 18-32, 33-49, and 50-65 years and each measurement parameter was

compared among the subgroups. The measurement obtained was subjected to

discriminate analysis. To determine reliability and reproducibility of the maxillary

and frontal sinus measurements both intra and inter- examiner calibrations was done.

STATISTICAL ANALYSIS:

The maxillary and frontal sinus datas were transferred on Microsoft Excel

2013 software (Microsoft office Professional Plus, Microsoft Corporation, Redmond,

USA). The data were analysed using SPSS version 16. The Canonical discriminant

functional analysis was performed to assess whether the maxillary and frontal sinus

measurements could be used for gender determination. MANOVA test was carried

out to find the difference between two groups.

Multiple logistic regression was performed to generate an equation and

optimum cutting score (Zc) was derived that could be reliably used to classify the

observations according to gender. The paired t-test was done for comparison of the

means of the dimensions measured for the two groups and p value < 0.05 was taken as

statistically significant. ANOVA test is used to correlate the measurements of

maxillary and frontal sinus with age subgroups. A two-way mixed intra-class

correlation coefficient was carried out to test the degree of reliability

RESULTS

Page 25

RESULTS

The total sample composed of 50 subjects with 25 males and 25 females. Aplasia of

the frontal sinus (18%) was observed in 9 cases (1male and 8 females). Among the

total subjects highest value was seen in 18-32 Age group.

TABLE 1. COMPARISON OF MEDIOLATERAL WIDTH (mm) IN MALES

AND FEMALES FOR MAXILLARY SINUS

Parameters Sex N Mean SD t p

Mediolateral width Right Male 25 27.88 3.43 1.09 0.279

Female 25 26.52 5.18

Mediolateral width Left Male 25 27.64 3.70 0.30 0.767

Female 25 28.00 4.79

Table 1 reveals mediolateral width of MS in males and females. The mediolateral

width of right and left side for males was 27.88 ± 3.43 and 27.64 ± 3.70, when

compared with the females (26.52±5.18 and 28.00±4.79) showed no significance.

TABLE 2. COMPARISON OF ANTEROPOSTERIOR LENGTH (mm) IN

MALES AND FEMALES FOR MAXILLARY SINUS

Sex N Mean SD t P

Anteroposterior length(Right) Male 25 38.56 2.31 2.40 0.020*

Female 25 36.56 3.47

Anteroposterior length(Left) Male 25 38.40 2.18 1.89 0.065

Female 25 36.84 3.51

RESULTS

Page 26

Table 2 reveals anteroposterior length of MS in males and females. The

anteroposterior length of right side for males and females was 38.56 ± 2.31 and 36.56

± 3.47 showed statistically significant P value of 0.020. The anteroposterior length of

left side MS showed no statistical significance

TABLE 3. TOTAL DISTANCE (mm) ACROSS RIGHT AND LEFT

MAXILLARY SINUS IN MALES AND FEMALES FOR MAXILLARY SINUS

Sex N Mean SD t p

Total distance Male 25 86.44 5.74 3.30 0.002**

Female 25 81.08 5.74

Table 3 reveals total distance across MS in males and females. The total distance

across the maxillary sinus in males and females was 86.44 ± 5.74 and 81.08 ± 5.74

which showed highly significant P value of 0.002.

TABLE 4. COMPARISON OF DIFFERENT PARAMETERS (mm) OF

FRONTAL SINUS

Parameters(mm) Sex N Mean SD t p

Maximum depth Male 24 10.83 2.73 2.38 0.022*

Female 17 9.12 1.36

Thickness of anterior wall Male 24 5.33 1.52 0.62 0.539

Female 17 5.65 1.69

Anteroposterior length Male 24 12.54 3.43 2.00 0.052*

Female 17 10.65 2.21

RESULTS

Page 27

Table 4 reveals comparison of different parameters of frontal sinus in males and

females from axial section and scout image. The maximum depth of frontal sinus in

males and females was 10.83 ± 2.73 and 9.12 ± 1.36 respectively which showed

statistical significant p value (<0.05) (Graph 4). The thickness of anterior wall for

males and females was 5.33± 1.52 and 5.65± 1.69 respectively. There was no

statistical significance with respect to the thickness of anterior wall of frontal sinus

(Graph 5). The maximal anteroposterior length of frontal sinus measured from scout

image for males and females were 12.54± 3.43 and 10.65±2.21 respectively which

showed statistically significant p value < 0.05. (Graph 6)

TABLE 5. SUMMARY OF CANONICAL DISCRIMINANT FUNCTIONS FOR

MAXILLARY SINUS

Eigenvalues

Function Eigenvalue % of

Variance

Cumulative

%

Canonical

Correlation

1.00 0.468 100.00 100.00 0.565

a. First 1 canonical discriminant functions were used in the analysis.

Wilks' Lambda

Test of

Function(s)

Wilks'

Lambda

Chi-

square

Df Sig.

1.00 0.681 17.482 5 0.004

RESULTS

Page 28

TABLE 6. DISCRIMINATE ANALYSIS FOR MAXILLARY SINUS

MEASUREMENTS TO DISCRIMINATE BETWEEN MALES AND

FEMALES

Canonical Discriminant Function Coefficients

Parameters Function

Mediolateral ( width) Right 0.224

Mediolateral ( width) Left -0.304

Anteroposterior(length) Right -0.035

Anteroposterior(length) Left 0.076

Total distance 0.164

(Constant) -12.917

The measurements of maxillary sinus were subjected to Canonical

discriminant functional analysis. (Table 5&6) Wilks' Lambda (MANOVA test) was

carried out to find the difference between two groups. Multiple logistic regression was

performed to generate an equation and optimum cutting score (Zc) was derived that

could be reliably used to classify the observations according to gender.

The variables used to discriminate between males and females resulted in an

overall accuracy of 64.0% for maxillary sinus (Table 7). Stepwise logistic regression

analysis (LRA) was performed to generate an equation and optimum cutting score

(Zc) was derived that could be reliably used to classify the observations according to

gender.

RESULTS

Page 29

Regression equation for gender determination using maxillary sinus

D = -12.917+( 0.224xMediolateral ( width) Right)-( 0.304xMediolateral ( width)

Left)-( 0.035xAnteroposterior (length) Right+(0.076xAnteroposterior (length) Left)+

(0.164x Total distance)

Cutting Score (Zc):

Using the sample sizes and Wilk’s lambda for these two groups Cutting Score is

calculated and the respective values of cutting score is -0.05399. Against this Cutting

Score each respondent’s discriminant score is examined. If his score is less than Zc

value, then he is classified in female group, otherwise in male group.

TABLE 7. PREDICTED GROUP MEMBERSHIP FOR MAXILLARY SINUS

Classification Results

Gender Predicted Group Membership Total

Original Male Female

Count Male 17 8 25

Female 10 15 25

% Male 68 32 100

Female 40 60 100

64.0% of original grouped cases correctly classified.

Table 7 reveals, when logistic regression equation was applied for maxillary sinus

dimension 68% males and 60% females were correctly categorised. The overall

accuracy of maxillary sinus for gender determination was 64.0%

RESULTS

Page 30

TABLE 8. SUMMARY OF CANONICAL DISCRIMINANT FUNCTIONS FOR

FRONTAL SINUS

Eigenvalues

Function Eigenvalue % of

Variance

Cumulative

%

Canonical

Correlation

1.00 .232(a) 100.00 100.00 .434

a. First 1 canonical discriminant functions were used in the analysis.

Wilks' Lambda

Test of

Function(s)

Wilks'

Lambda

Chi-square Df Sig.

1.00 .812 7.832 3 .050

TABLE 9. DISCRIMINATE ANALYSIS FOR FRONTAL SINUS

MEASUREMENTS TO DISCRIMINATE BETWEEN MALES AND

FEMALES

Canonical Discriminant Function Coefficients

Parameters Function

Maximum depth .341

Thickness of anterior wall -.185

Scout image .165

(Constant) -4.370

RESULTS

Page 31

Similarly, the measurements of frontal sinus were subjected to Canonical

discriminant functional analysis. (Table 8&9) Wilks' Lambda (MANOVA test) was

carried out to find the difference between two groups. Multiple logistic regression was

performed to generate an equation and optimum cutting score (Zc) was derived that

could be reliably used to classify the observations according to gender.

The variables used to discriminate between males and females resulted in an

overall accuracy of 65.9% for frontal sinus (Table 10). Stepwise logistic regression

analysis (LRA) was performed to generate an equation and optimum cutting score

(Zc) was derived that could be reliably used to classify the observations according to

gender.

Regression equation for gender determination using Frontal sinus

D = -4.37+0.341xMaximum depth- 0.185x Thickness of anterior wall+ 0.165x

anteroposterior length

Using the sample sizes and Wilk’s lambda for these two groups Cutting Score

is calculated and the respective values the cutting score is -0.2651. Against this

Cutting Score each respondent’s discriminant score is examined. If his score is less

than Zc value, then he is classified in female group, otherwise in male group.

RESULTS

Page 32

TABLE 10. PREDICTED GROUP MEMBERSHIP FOR FRONTAL SINUS

Classification Results

Gender Predicted Group Membership Total

Original Male Female

Count Male 19 5 24

Female 9 8 7

% Male 79.2 20.8 100

Female 52.9 47.1 100

65.9% of original grouped cases correctly classified.

Table 10 reveals, when logistic regression equation was applied for frontal sinus

dimension 79.2% males and 47.1% females were correctly categorised. The overall

accuracy of Frontal sinus for gender determination was 65.9%

TABLE 11. COMPARISON OF MEASUREMENTS OF MAXILLARY AND

FRONTAL SINUS ACCORDING TO AGE GROUPS

Parameters N Mean SD ANOVA p

Mediolateral

width (Right) of

MS

18 - 32 9 30.67 4.97 6.14 0.004**

33 - 49 21 27.67 4.88

50 - 65 20 25.15 2.03

Total 50 27.20 4.40

Mediolateral

width(Left) of MS

18 - 32 9 29.11 4.59 5.98 0.011*

33 - 49 21 28.90 4.78

50 - 65 20 26.10 2.85

Total 50 27.82 4.24

RESULTS

Page 33

Anteroposterior

length (Right) of

MS

18 - 32 9 37.75 4.44 5.09 0.049*

33 - 49 21 37.52 3.41

50 - 65 20 37.22 1.97

Total 50 37.56 3.08

Anteroposterior

Length (Left) of

MS

18 - 32 9 38.15 4.92 5.32 0.077

33 - 49 21 37.71 2.76

50 - 65 20 36.22 1.93

Total 50 37.62 3.00

Total distance

across MS

18 - 32 9 86.22 4.87 0.97 0.386

33 - 49 21 83.71 7.80

50 - 65 20 82.70 4.90

Total 50 83.76 6.29

Maximum depth

of FS

18 - 32 8 10.75 3.11 0.39 0.678

33 - 49 18 9.83 2.50

50 - 65 15 10.13 1.92

Total 41 10.12 2.40

Thickness of

anterior wall of

FS

18 - 32 8 6.00 1.51 0.96 0.392

33 - 49 18 5.56 2.01

50 - 65 15 5.07 0.88

Total 41 5.46 1.58

Anteroposterior

length of FS

18 - 32 8 13.00 5.76 1.14 0.331

33 - 49 18 11.06 2.34

50 - 65 15 11.93 1.62

Total 41 11.76 3.10

RESULTS

Page 34

Table 11 shows comparisons of measurements of maxillary and frontal sinus

in age subgroups. When compared with the age subgroups, the highest value for

maxillary sinus and frontal sinus is observed in 18-32 age group. The lowest value is

observed in 50-65 age group. Significant correlation is seen with respect to

mediolateral width on right and left side and anteroposterior length on right side for

maxillary sinus using ANOVA test. Similarly, when frontal sinus dimensions were

correlated with age subgroups there is no statistical significance.

Intraobserver and Interobserver Error Rate

In order to test the degree of reliability for the methods used in this study,

intraobserver and interobserver error testing was carried out after initial measurements

were taken. A two-way mixed intra-class correlation coefficient was carried out to

compare the results of the original and secondary measurements for each of the

measurements made. A score of 1 indicated a perfect correlation, whereas 0

indicated no correlation at all. The single measures intra-class correlation score was

0.998, which indicates excellent repeatability using the In Vivo 5.4.1 software.

Reliability for Mediolateral width (Right) of maxillary sinus

Method 1 (space saver) was used for this analysis

RELIABILITY ANALYSIS SCALE (ALPHA)

Intraclass Correlation Coefficients

Two-Way Mixed Effects Model (Consistency Definition)

ICC 95% Confidence Interval

RESULTS

Page 35

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9910 .9842 .9949 221.7491 .0000

Average of

Raters

.9955 .9921 .9974 221.7491 .0000

Degrees of freedom for F-tests are 49 and 49. Test Value = 0.

Reliability Coefficients

N of Cases = 50.0

Alpha = .9955

Reliability for Mediolateral width (Left) of maxillary sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9882 .9793 .9933 168.2760 .0000

Average of

Raters

.9941 .9895 .9966 168.2760 .0000

Degrees of freedom for F-tests are 49 and 49. Test Value = 0.

Reliability Coefficients

N of Cases = 50.0

Alpha = .9941

RESULTS

Page 36

Reliability for Anteroposterior length (Right) of maxillary sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9877 .9785 .9930 162.1980 .0000

Average of

Raters

.9938 .9891 .9965 162.1980 .0000

Degrees of freedom for F-tests are 49 and 49. Test Value = 0.

Reliability Coefficients

N of Cases = 50.0

Alpha = .9938

Reliability for Anteroposterior length (Left) of maxillary sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9808 .9664 .9890 103.0021 .0000

Average of

Raters

.9903 .9829 .9945 103.0021 .0000

Degrees of freedom for F-tests are 49 and 49. Test Value = 0.

Reliability Coefficients

N of Cases = 50.0

Alpha = .9903

RESULTS

Page 37

Reliability for Total distance across maxillary sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9988 .9978 .9993 1611.6556 .0000

Average of

Raters

.9994 .9989 .9996 1611.6556 .0000

Degrees of freedom for F-tests are 49 and 49. Test Value = 0.

Reliability Coefficients

N of Cases = 50.0

Alpha = .9994

Reliability-Maximum depth of frontal sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9979 .9961 .9989 953.3000 .0000

Average of

Raters

.9990 .9980 .9994 953.3000 .0000

Degrees of freedom for F-tests are 40 and 40. Test Value = 0.

Reliability Coefficients

N of Cases = 41.0

Alpha = .9990

RESULTS

Page 38

Reliability for Thickness of anterior wall at the level of orbital roof for frontal

sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater .9905 .9822 .9949 209.4103 .0000

Average of Raters .9952 .9910 .9975 209.4103 .0000

Degrees of freedom for F-tests are 40 and 40. Test Value = 0.

Reliability Coefficients

N of Cases = 41.0

Alpha = .9952

Reliability for anteroposterior length of frontal sinus

Measure Value Lower

Bound

Upper

Bound

F-Value Sig.

Single Rater . 9961 .9927 . 9979 511.5574 .0000

Average of

Raters

.9980 .9963 .9990 511.5574 .0000

Degrees of freedom for F-tests are 40 and 40. Test Value = 0.

Reliability Coefficients

N of Cases = 41.0

Alpha = .9980

RESULTS

Page 39

Graph 1: COMPARISON OF MEDIOLATERAL WIDTH (mm) IN MALES

AND FEMALES FOR MAXILLARY SINUS

Graph 2: COMPARISON OF ANTEROPOSTERIOR LENGTH (mm)

IN MALES AND FEMALES FOR MAXILLARY SINUS

25.5

26

26.5

27

27.5

28

Right Left

27.88

27.64

26.52

28

Mea

n

Mediolateral width of maxillary sinus

Male Female

35.5

36

36.5

37

37.5

38

38.5

39

Right Left

38.5638.4

36.5636.84

Mea

n

Anteroposterior length of maxillary sinus

Male Female

RESULTS

Page 40

Graph 3: TOTAL DISTANCE (mm) ACROSS RIGHT AND LEFT

MAXILLARY SINUS IN MALES AND FEMALES

Graph 4: COMPARISON OF MAXIMUM DEPTH OF FRONTAL SINUS IN

MALES AND FEMALES

78

79

80

81

82

83

84

85

86

87

Male Female

86.44

81.08

Mean

Total distance across maxillary sinus

8

8.5

9

9.5

10

10.5

11

Male Female

10.83

9.12

Mean

Maximum depth of frontal sinus

RESULTS

Page 41

Graph 5: COMPARISON OF THICKNESS OF ANTERIOR WALL OF

FRONTAL SINUS IN MALES AND FEMALES

Graph 6: COMPARISON OF ANTEROPOSTERIOR LENGTH OF FRONTAL

SINUS IN MALES AND FEMALES

5.15

5.2

5.25

5.3

5.35

5.4

5.45

5.5

5.55

5.6

5.65

Male Female

5.33

5.65

Mean

Thickness of anterior wall of frontal sinus

9.5

10

10.5

11

11.5

12

12.5

13

Male Female

12.54

10.65

Mean

Anteroposterior length of frontal sinus

RESULTS

Page 42

Graph 7 DISTRIBUTION OF TOTAL SUBJECTS IN AGE SUBGROUPS

9 . 18 %

21 . 42 %

20 . 40 %

18 - 32

33 - 49

50 - 65

Distribution of total subjects in age subgroups

RESULTS

Page 43

ANATOMICAL VARIATIONS OBSERVED

Fig.11 Presence of septa within maxillary sinus

Fig.12 Absence of frontal sinus

RESULTS

Page 44

Fig.13 Presence of 3 septae and 3 lobulations within frontal sinus

Fig.14 Presence of scalooping within frontal sinus

DISCUSSION

Page 45

DISCUSSION

“Forensic anthropology is examination of human skeletal remain for law

enforcement”. The forensic anthropologists may discover the evidences from the

skeleton of many years37. The gender determination can be done with 100% accuracy

if the skeleton exists completely. However victim identification in mass disasters like

aircraft crashes, terrorist attacks, landslides, earthquakes, explosions and warfare, the

gender determination rate is 98% when there is existence of pelvis and cranium, 95%

with only pelvis and long bones and 80–90% with only long bones. The skull is the

most reliable part of skeleton next to the pelvis for gender determination but it is not

reliable until after puberty20.

The uniqueness and interindividual variation in size, shape, symmetry,

permanence of anatomical landmarks provides scientific information in forensic

anthropology. The nasal cavity is surrounded by four paired air-filled spaces, the

paranasal sinuses (maxillary, frontal, sphenoid and ethmoid)38.The maxillary and

frontal sinus are unique with interindividual variation hence they are useful tools for

gender dimorphism39 .Andreas Vesalius is considered by many scholars as the father

of the Anatomy. He described the frontal sinus in his famous book “Di Humani

Corporis Fabrica”, as a cave full of air. Falopius, one of Vesalio`s pupil, has detailed

the sinus referring to their absence in newborns19.

There are currently many techniques used in forensic science to identify an

unknown person, the most reliable being DNA analysis. However, this method is time

consuming as well as expensive, and may not be possible if the remains are extremely

degraded, or exposed to extreme environmental conditions. In such cases, other

methods can be used like radiographic evaluation of maxillary and frontal sinus,

especially in cases where only skull remains are available.

DISCUSSION

Page 46

In the present research, we have included CT images of 50 subjects (25 males

and 25 females) and different parameters of maxillary sinus (MS) and frontal sinus

(FS) were estimated for gender dimorphism. The parameters for MS includes

maximum mediolateral width (ML) of right and left side, anteroposterior length (AP)

of right and left side and total distance across MS were measured from axial images.

With respect to FS, the anterior wall thickness at the level of orbital roof and

maximum depth were measured from axial images and the anteroposterior length of

frontal sinuses was measured from scout image.

In the present study, the MS mediolateral width of right and left side for males

was 27.88 ± 3.43 and 26.52 ± 5.18, when compared with the females (26.52±5.18 and

28.00±4.79) did not showed statistical significance. But among the age subgroups

mediolateral width of right side MS showed highly significant p value

0.004.Peviousstudies by Asmaa T. Uthman et al2 have stated the mean value for the

mediolateral width of MS for male group was (24.7± 4 mm) for the right side and

(25.6± 4.4 mm) for the left side with statistical significance. Female group had

statistically significant lower values for both right and left sides (22.7± 3.2 and 23± 4

mm), respectively (p < 0.05). Similar studies by Ahmed A. Masiret al6and Pernilla

Sahlstrand-Johnson et al22 stated that males exhibit higher and wider maxillary

sinuses. But the results of the present study mediolateral width is inconsistent with

previous reports. The right maxillary sinus showed larger dimension (27.88 ± 3.43) in

males when compared with females (26.52±5.18) while left side did not showed

significance.

In this study the anteroposterior length of right side for male and female was

38.56 ± 2.31 and 36.56 ± 3.47 which showed statistically significant P value of 0.02.

The AP of left side in male and female was 38.40 ± 2.18 and 36.84 ± 3.15 which

DISCUSSION

Page 47

showed no statistical significance (p value 0.065). Massarat Jehaet al23reported in a

study that the AP length of MS in male was 36.43±4.26mm when compared with

female it was larger (34.93±4.14mm) with significant p value. In another retrospective

study by Balaji Babu Bangi et al32 the anteroposterior length for right side in males

and females was 3.576 ± 0.413 and 3.376 ± 0.413and left side it was 3.559 ± 0.385

and 3.384 ± 0.388 respectively. The p value (> 0.05) did not showed significance. The

results of the present study is similar to the previous study by Balaji Babu Bangi et al

where the results were insignificant. The right and left AP diameter (38.56 ± 2.31,

38.40 ± 2.18) is larger in males than females (36.56 ± 3.47, 36.84 ± 3.15).

In the present study the total distance across the maxillary sinus in males and

females was 86.44 ± 5.74 and 81.08 ± 5.74 which showed highly significant P value

of 0.002. Previous study by Asmaa T. Uthmanet al2the total distance across the MS

was calculated as 82.4 ± 7.7 mm for male group and 77.9 ± 6.2 mm for female group.

The results of the present study was consistent with study by Asmaa T. Uthman et al.

Also, we observed intra-sinus septa of maxillary sinus (Fig.11) this can be

correlated with pneumatisation of the sinus as stated by Malecet al35. This confirms

with the Vinter’s theory that the “septa remains in the margin of two post

pneumatisation regression zones allowing for transfer of masticatory pressure”.

In this study, 18% of FS were missing (Fig.12) with 2% in males and 16% in females.

Additionally, in this study we observed presence of septa, lobulations and scalloping

(Fig.13, 14). The race, geography and climate are few factors that have been

implicated in the abnormal development of the frontal sinus2.

In a study performed by Neha Patilet al36 to evaluate the uniqueness and

reliability of the FS the size, shape, presence, absence, and septa were observed to be

unique in each case. Danesh-sani SA et al40, investigated the prevalence of agenesis of

DISCUSSION

Page 48

the FS using CT and reported agenesis in 8.32% of cases. Similarly, a study by

Krogman et al., absence of frontal sinus in 5% adults, while Gulisano et al. (1978)

observed its absence in 4.8% of the cases31. But in a study by Ertugrul tatlisumak et

al18 the complete absence of frontal sinus was not observed among the

cases.Koertvelyessy28 conducted a study on Eskimo crania reported that the degree of

environmental coldness in which the population lives correlates positively with degree

of pneumatisation.

In the present study the maximum depth of frontal sinus in males and females

was 10.83 ± 2.73 and 9.12 ± 1.36 respectively which showed statistical significant p

value (<0.05). The studies by Pernilla et al22 stated the maximum depth of frontal

sinus for male and female is 10 ± 3 and 9.6 ± 3 respectively with the significant p

value 0.034. The mean depth of the frontal sinus by Matthew K.Lee et al. stated that it

was 8.0 to 9.3 mm and did not vary significantly at any distance frommidline33 The

results were consistent with previous report by Matthew et al. and Pernilla et al.

In the present study the thickness of anterior wall for males and females was

5.33± 1.52 and 5.65± 1.69 respectively. There was no statistical significant p value

(0.539). The thickness of anterior wall of FS as determined by Pernilla et al22 was 2.1

± 1 and 2.1 ± 0.8 for male and female with no significant p value 0.824. In Matthew K

Lee et al33 the mean anterior table thickness ranged from 2.6 to 4.1 mm .Also in their

study it was stated, males were found to have greater dimensions in most frontal sinus

measurements. This was supported by the fact that male forehead was marked by

more acute nasofrontal angle (119.9° versus 133.5°) and a steeper posterior forehead

inclination (−7.2° versus −3.5°).There are only limited studies where anterior wall

thickness of frontal sinus was estimated therefore future research can be done to

validate this parameter.

DISCUSSION

Page 49

In the present study, anteroposterior length was 12.54± 3.43 and 10.65±2.21

for males and females respectively with significant p value 0.052. In previous studies

by Tatlisumaket al18 the anteroposterior length of FS for males and females was

calculated as 13.15 ± 5.23 and 10.80 ±4.10. Pondeet al19calculated AP length as

8.0265± 2.7 and 7.9718±3.10 for males and females. A.T. Uthmanet al20 conducted a

study on frontal sinus to identify unknown individuals, the anteroposterior length was

measured from scout image which was 18.24±8.92 in males and 12.22±6.96 in

females. The results of the present study was similar to Tatlisumak et al and

A.T.Uthman et al.

CT scan provides crucial role in depicting the structures and its extension to

adjacent structures41. In a recent report by Rennie et al42. The pyramidal form of the

maxillary sinus was present in 52.4 %. Five different anterior shapes were reported:

Type 1 (triangular), Type 2 (upside down triangle), Type 3 (square), Type 4

(irregular) and Type 5 (rectangular) were identified in the anterior view. Jun et al43

reported that the maxillary sinus shows two active pneumatisation periods after birth.

The first period from birth to 3 years and the second period from 7-12 years. He

illustrated that the sinus “changes into the shape of an upside down pyramid” due to

the developmental changes in the structure of the craniofacial skeleton that surrounds

the maxillary sinus. Malecet et al44 noted their location in the anterior, middle and

posterior regions depends on the tooth development.

It has been stated in the literature that to an extent mastication and effects of

treatment influences sinus development45. Kilic et al. (2010) reported that Orthodontic

extractions might affect the developing sinus, the removal of the more commonly

extracted premolars would affect the sinus than molar extractions. In many

individuals, tooth roots extend into the sinus, and in several instances orthodontic

DISCUSSION

Page 50

mini-screw implants were near or even penetrating the sinus. (Odita et al., 1986) Such

difference could be related to the change in the sinus size with age and the

environmental factors46.

Schliephake47 reported that for craniofacial growth and maintenance of body

skeleton, Insulin-like growth (IGF-1) factor plays an important role. Also it has been

stated the combination of IGF-I with PDGF (Plasma derived growth factor) is

effective in promoting bone regeneration in dentoalveolar defects around implants or

after periodontal bone loss. Geary et al48 stated that males have a greater birth weight,

length, and head circumference and reduced skinfold thickness compared with

females, and differences in head size can be observed as early as 20 week gestation.

It has been stated in a study by Ahmed A. Masriet al6 there is reverse

developmental changes in size of maxillary sinus i.e. maxillary sinus sizes being

larger in girls than boys in the age group 0 to 6 years. This is supported by reports of

Vatten et al49 who stated that the levels of IGF in umbilical cord plasma and after

birth were higher in girls than in boys stated that IGF (Insulin growth factor) and

these discoveries provide possible explanations for the reverse developmental

changes.

According to Enlow, males need to have correspondingly bigger lungs to

support their relatively more massive muscles and body organs. Males need a larger

airway, which begins with the nose and nasopharynx. In other words, physiological

changes in nasal cavity size and shape occur as a direct result of respiration-related

needs, such as warming and humidifying inhaled air6. As the maxillary sinus occupies

the remaining space within the nasomaxillary complex, it also increases in size in

males.

DISCUSSION

Page 51

In studies by Spaethet al50 stated 17.1% of frontal sinus showed definitive size

with statistically significant differences in later ages of both genders. In accordance

with the study conducted by Mc‑Laughlin et al51 and Ertugrul et al18 the frontal sinus

continued to expand until the age of 40 years because of hormonal and mechanical

stresses of mastication.

In the present study the anteroposterior length and the depth of FS showed

statistical significance but when compared with age subgroups the ANOVA test

results did not showed significant association with age. Previous studies have

demonstrated that frontal sinus dimensions changes due to pneumatisation. However,

in certain diseases like sinusitis and in the elderly, FS may enlarge due to bone loss52.

This variability has also been described in the literature and is considered to be a

useful tool in forensic identification as a “forensic fingerprint” (Harris et al. 1987,

Nambiar et al., 1999)31. There are, however, limitations in the use of the frontal sinus

in personal identification because they are affected by caraniofacial configurations,

hormonal levels and pathological conditions and the influence of genetic and

environmental factors on size of frontal sinus.

The measurements of maxillary and frontal sinus were compared with age

subgroups, the highest value for maxillary and frontal sinus was observed in 18-32

age group and the lowest value is observed in 50-65 age group. The present study

results states that the size of maxillary and frontal sinus decreases as age progresses.

Among the variables analysed the maxillary sinus dimensions such as mediolateral

(width) of right and left side, anteroposterior (length) of right side were the best

predictors of age allocation with statistical significance. To assess the reliability,

intraobserver and interobserver error rate was calculated. After the initial data

collection, intraexaminer and interexaminer calibration was done to assess whether

DISCUSSION

Page 52

the image-based measurements developed for this study could be reliably reproduced,

the data were evaluated using an intra-class correlation coefficient. The test revealed

a significant correlation (0.998) between initial and repeat measurements. Thus it can

be concluded that the methods utilized for this study could be reproduced reliably.

Using regression equation 68% males and 60% females were correctly

categorised using maxillary sinus dimensions. Similarly, using frontal sinus

dimensions 79.2% males and 47.1% females were correctly categorised. The overall

accuracy of maxillary and frontal sinus was 64.0% and 65.9% respectively. Attia et

al. (2007) stated that the overall accuracy of MS dimension was 69.9% for gender

dimorphism53. In a study conducted by Uthman ET al2 for sexual dimorphism using

MS, the accuracy rate was 71.6%. A.T. Uthman et al20 emphasized the ability of the

frontal sinus to identify gender was 76.9%. In a study by Belaldavar et al25 the

accuracy rate was 64.6% for FS. However, gender determination with the help of

skeletal remains becomes a confusing puzzle for forensic experts especially when the

skeletal remains are fractured or incomplete. In such cases, the use of dental remains

such as teeth is an excellent piece of evidence that can be used to determine gender54

When the dimensions of MS are correlated, the right AP length and total

distance of MS showed statistical significance. The ML width and AP length of

maxillary sinus are larger on right side in males than females. Similarly, when FS

dimensions were correlated, the anterior wall thickness and anteroposterior length of

FS showed statistical significance. Hence, from the current research and previous

reports, all morphological parameters can be marked as a good attempt for personal

identification along with the morphological evaluation.

Furthermore, from review of the literature it was evident that very few studies

on the Indian population have been conducted in relation to morphological evaluation

DISCUSSION

Page 53

of the frontal sinus and the forensic applications of all morphological parameters.

Hence more studies on frontal sinus with larger sample size and considerations of

various ethnic groups will enable interpretation at the community level.

SUMMARY

Page 54

SUMMARY

The present study was aimed to compare maxillary and frontal sinus dimensions and to assess

its reliability and accuracy for gender dimorphism using CT scan images. A total of 50 CT

images of subjects between 18-65 years were selected who underwent CT examination of

head and neck for other medical reasons. The maximum dimensions of maxillary and frontal

sinus parameters was considered and subjected to multiple logistic regression analysis and an

equation was derived that can be used to estimate gender.

The summary of the results are as follows:

The mediolateral width of MS on right and left side for males was 27.88 ± 3.43 and

26.52 ± 5.18, when compared with the females showed no statistical significance.

The anteroposterior length of MS on right side for males and females was 38.56 ±

2.31 and 36.56 ± 3.47 showed statistically significant P value of 0.020. The

anteroposterior length of left side showed no statistical significance

The total distance across the MS in males and females was 86.44 ± 5.74 and 81.08 ±

5.74 which showed highly significant P value of 0.002.

The maximum depth of FS in males and females was 10.83 ± 2.73 and 9.12 ± 1.36

respectively which showed statistical significant p value (<0.05)

The thickness of anterior wall of FS for males and females was 5.33± 1.52 and 5.65±

1.69 respectively. There was no statistical significance with respect to the thickness of

anterior wall of frontal sinus

The maximum anteroposterior length of FS measured from scout image for males and

females were 12.54± 3.43 and 10.65±2.21 respectively which showed statistically

significant p value < 0.05

SUMMARY

Page 55

When the dimensions of MS are correlated, the right AP length and total distance of

MS showed statistical significance. The ML width and AP length of maxillary sinus

are larger on right side in males than females.

When FS dimensions were correlated, the anterior wall thickness and anteroposterior

length of FS showed statistical significance

Aplasia of the frontal sinus (18%) was observed in 9 cases (1 male and 8 females)

The overall accuracy of maxillary and frontal sinus was 64.0% and 65.9%

respectively.

When compared with the age subgroups, the highest value for maxillary sinus and

frontal sinus is observed in 18-32 age group. The lowest value is observed in 50-65

age group. The present study results states that the size of maxillary and frontal sinus

decreases as age progresses.

CONCLUSION

Page 56

CONCLUSION

Computed tomography (CT) provides an excellent method for imaging maxillofacial

region. It has been stated in literature that skull remains intact despite other bones are

disfigured. Personal identification is the primary area of concern in forensic. From the present

study results we conclude that the dimensions of maxillary and frontal sinus can be used for

gender dimorphism. This study also proposes the reliability and accuracy of both sinus hence

the study proves vital in identifying gender of a person in forensic anthropology.

BIBLIOGRAPHY

Page 57

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ANNEXURES

Page 63

VIVEKANANDHA DENTAL COLLEGE FOR WOMEN

DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY

PROFORMA

GENDER DETERMINATION USING COMPUTED TOMOGRAPHIC

MEASUREMENT OF MAXILLARY AND FRONTAL SINUS: A

COMPARATIVE STUDY

Patient name: Op-no: Age & gender:

MAXILLARY SINUS MEASUREMENTS

AXIAL IMAGE

1. Maximum Mediolateral Width (mm)

Image Right Left

2. Maximum Anteroposterior Length (mm)

Image Right Left

3. Total distance across both sinus (mm)

Image Total distance

ANNEXURES

Page 64

FRONTAL SINUS MEASUREMENTS

AXIAL IMAGE

1. Maximum depth

Image Measurement

2. Thickness of Anterior wall at the level of Orbital roof

Image Measurement

SCOUT IMAGE

1. Anteroposterior length(mm)

ANNEXURES

Page 65

MASTER CHART

INITIAL CT MEASUREMENTS

ANNEXURES

Page 66

INTEREXAMINER CALIBRATION

ANNEXURES

Page 67

INTRAEXAMINER CALIBRATION