GENDER DETERMINATION USING COMPUTED...
Transcript of GENDER DETERMINATION USING COMPUTED...
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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