ORIGINAL ARTICLE

Differences in distances between

maxillary posterior root apices and the
sinus floor according to skeletal pattern
Nguyen-Lan Ahn and Hyo-Sang Park
Daegu, Korea

Introduction: The aim of this study was to evaluate the distances from the maxillary posterior root apices to the
inferior wall of the maxillary sinus using cone-beam computed tomography images and the relationships
between roots and maxillary sinus according to age, sex, and skeletal pattern. Methods: Three-dimensional im-
ages of each root were checked, and the distances were measured along the true vertical axis from the apex of
the root to the sinus floor in 118 patients (63 male, 55 female) aged 10 to 28 years. Compare-means statistic tests
were done to assess the differences between groups classified according to age, sex, and skeletal pattern.
Results: The frequency of root contact with the sinus floor increased from 70% at the second premolar to
more than 80% at the buccal roots of the first and second molars. Male and older age (20-28 years) groups
had significantly smaller distances or more protrusion of the root into the sinus than female and younger age
(10-20 years) groups. The distances were shorter, or there was more protrusion of the root into the sinus in
the hyperdivergent, down-canted palatal plane, and large gonial angle groups. Conclusions: Male, older
age, hyperdivergent skeletal pattern, and large gonial angle groups had significantly closer distances between
maxillary root tips and the sinus floor or more protrusion of the roots into the sinus. The intrusion of the maxillary
molars in those situations may be difficult and slow because of the pneumatized maxillary sinus. (Am J Orthod
Dentofacial Orthop 2017;152:811-9)

T
he paranasal sinuses develop as an aid to facial
growth and architecture, or persist as residual rem-
nants of an evolutionary structure. The biologic
roles of these sinuses are debated, but a number of
possible functions have been proposed, including light-
ening the weight of the head, humidifying and heating
inhaled air, increasing the resonance of speech,
providing a buffer against facial trauma, and aiding
the immune defense for the nasal cavity.1 The maxillary
sinus is the largest paranasal sinus that overlies the
maxillary alveolar process. It develops late in fetal life
and ends its growth around 18 years of age.2 Along
with the sinus pneumatization process, the sinus floor
moves inferiorly and becomes closer to the roots of
From the Department of Orthodontics, School of Dentistry, Kyungpook National
University, Daegu, Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Hyo-Sang Park, Department of Orthodontics, School
of Dentistry, Kyungpook National University, Dalgubuldaero 2175 (Samduk 2-
Ga), Jung-Gu, Daegu, Korea 41940; e-mail, parkhs@knu.ac.kr.
Submitted, December 2016; revised and accepted, May 2017.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2017.05.021
maxillary teeth. In more than 50% of the population,
the inferior sinus wall lies among the roots of the poste-
rior maxillary teeth creating a “hillock” (elevation of the
sinus floor) or protrusion of the roots into the sinus.3,4 In
this situation, the thickness of the bone layer of the sinus
floor is reduced significantly. However, most roots that
protrude into the sinus are actually enveloped by a
thin cortical layer on histologic sections, and the rates
of true perforation are only 14% to 28%.3
There are many studies concerning the vertical and
horizontal relationships from maxillary posterior root
apices to the inferior wall of the sinus and their effect
on endodontic treatment, implant placement, tooth
extraction, and sinusitis.3-10 However, the impact of
this relationship on orthodontic tooth movement has
not received as much attention. Nowadays, with
microimplant anchorage, molar intrusion has become
more effective and efficient, but it is still considered a
difficult procedure in orthodontics.11 The maxillary sinus
with its cortical bone layer is a natural barrier for the
intrusion of the maxillary molars. The intrusion or bodily
movement of posterior teeth across the maxillary sinus
has been known to cause moderate apical root resorp-
tion and a higher degree of tipping.12,13 There have
811
812
been only a few studies assessing the correlation
between size of the sinus and malocclusion type.
Oktay14 found that female subjects with Class II maloc-
clusions had larger sinuses, whereas Endo et al15 stated
that there was no relationship between ANB angle and
sinus size. However, no study has evaluated distances
from the maxillary root tips to the sinus floor according
to different skeletal patterns.
Cone-beam computed tomography (CBCT) provides
an accurate evaluation of maxillary bone quality and
quantity around the root apices of posterior teeth
without distortion and overlapping of teeth with sur-
rounding structures.16,17 Howe18 compared the amount
of the bone around the root apices between CBCT and
direct measurements with a physical caliper of 69 maxil-
lary first molars in 37 cadaver specimens. The Pearson
correlation had a coefficient of r 5 0.85, showing that
CBCT is reliable for measurements. Therefore, we used
CBCT for measurements as did many previous studies.6-9
The aim of this study was to evaluate the distances
from the root apices of the maxillary posterior teeth to
the inferior wall of the maxillary sinus on CBCT images
and the relationships among these distances and age,
sex, and skeletal pattern.
MATERIAL AND METHODS
The data of patients who visited the Department of
Orthodontics at Kyungpook National University Dental
Hospital in Daegu, Korea, from 2011 to 2014 were
checked, and patients with clear pretreatment CBCT im-
ages and cephalometric radiographs were included in
this study.
This study was approved by the institutional review
board of the university. The patients who had facial
trauma, had received previous orthodontic treatment,
had at least 1 congenital or acquired missing tooth in
the posterior maxillary region, or had second premolars
with 2 separated roots were excluded.
Finally, 118 patients (mean age, 17.78 6 4.52 years;
range, 10-28 years) were selected. The sample consisted
of 63 male (mean age, 17.78 6 5.00 years) and 55 fe-
male (mean age, 17.78 6 4.52 years) subjects.
All measurements were done by 1 examiner (N.-L.A.).
To classify the sample according to anteroposterior and
vertical relationships, ANB angle, Frankfort-mandibular
plane angle (FMA), Frankfort-palatal plane angle, and
gonial angle were measured. The measurements on the
cephalometric radiographs were carried out with V-
Ceph dental software (version 6.0; Osstem, Seoul, Ko-
rea).
The sample was divided into subgroups, right and left
sides, younger (age, 10-20 years) and older (age, 20-
December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Ahn and Park
28 years) age groups, Class I (ANB, 0
-4
), Class II
(ANB, $4
), and Class III (ANB, #0
) groups. The sample
also was divided into hypodivergent (FMA, #23
), nor-
modivergent (FMA, 23
-32
), and hyperdivergent
(FMA, $32
) according skeletal divergency. According
to the palatal plane (PP) cant to the Frankfort horizontal
(FH) plane, the sample was divided into up-canted (FH-
PP, #2.5
), normal (FH-PP, 2.5
-2.5
), and down-
canted (FH-PP, $2.5
) groups, where down-canted
means that the PP is canted down anteriorly. In addition,
the sample was divided into 3 groups according to gonial
angle: large ($129
), normal (117
-129
), and small
(#117
) gonial angle groups (Table I).
On the CBCT images, the distances from the root
tips of the maxillary posterior teeth to the inferior
wall of the sinus floor were measured. Hence, 7 roots
per side were measured. The 3-dimensional (3D) mea-
surements were done with InVivo software (version
5.2; Anatomage, San Jose, Calif). At first, the 3D
constructed images were oriented with the FH plane
aligned horizontally, where the FH plane was con-
structed by orbitale at the right side and porions on
both sides. The coordinated images of each root in 3
coronal, axial, and sagittal planes were checked, and
the sliced image passing the root apex was chosen
for measurements. Thereafter, the shortest distances
between the root tips of the teeth to the sinus floor
wall were measured on the sliced image, if the roots
had no contact with the sinus floor. If there were con-
tacts between the roots and the sinus floor, the
longest length from the root apices to the bottom of
the sinus floor adjacent to the roots was measured.
All distances from the root apices to the sinus floor
were measured along the true vertical axis. The dis-
tances were recorded with positive values if there
was no contact between the root and the sinus floor,
and with negative values if the side of the root had
contact with the sinus or the root protruded into the
maxillary sinus (Fig). Immature roots with open apices
were not included for measurements.
Statistical analysis
For the statistical analysis, SPSS software (version
22.0; IBM, Armonk, NY) was used. A normality test
was done to check normal distribution of the sample,
and all groups and subgroups showed normal distribu-
tions. To evaluate the differences in distances from the
maxillary root tips to the sinus floor according to sides
of evaluation, a paired t test was carried out. To evaluate
differences according to age and sex, an independent t
test was used. One-way analysis of variance (ANOVA)
and the Tukey post hoc test were performed to
Ahn and Park 813

Table I. Distribution of roots that were measured

Subgroup Number of roots tested statistically
Characteristic
Mean 6 SD Name Value 5 6 DB 6 MB 6P 7 DB 7 MB 7P
Total 152 236 236 236 152 152 152
Side Right 76 118 118 118 76 76 76
Left 76 118 118 118 76 76 76
Sex Male 72 126 126 126 72 72 72
Female 80 110 110 110 80 80 80
Age (y) Younger 10-20 62 146 146 146 62 62 62
17.8 6 4.5 y Older 20-28 90 90 90 90 90 90 90
Anteroposterio relationship
ANB Class I 0
-4
48 94 94 94 48 48 48
1.8
6 3.5
Class II $4
50 70 70 70 50 50 50
Class III #0
54 72 72 72 54 54 54
Vertical relationship
FMA Hypodivergent #23
48 56 56 56 48 48 48
27.1
6 6.0
Normodivergent 23
-32
72 134 134 134 72 72 72
Hyperdivergent $32
32 46 46 46 32 32 32
FH.PP Up-canted PP #2.5
42 64 64 64 42 42 42
0.1
6 3.4
Normal PP 2.5
-2.5
72 120 120 120 72 72 72
Down-canted PP $2.5
38 52 52 52 38 38 38
Gonial angle Small angle #117
44 56 56 56 56 44 44
122.6
6 7.0
Normal angle 117
-129
84 140 140 140 140 84 84
Large angle $129
24 40 40 40 40 24 24

5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; MB, mesiobuccal; P, palatal.

investigate the differences between the 3 subgroups
classified according to skeletal pattern.
To check intraobserver reliability, 20 samples were
chosen randomly 4 weeks later, and measurements
were carried out again. A paired t test showed no signif-
icant differences between the 2 repeated measurements
(P 5 0.444). Method error for linear measurement,
calculated by Dahlberg’s formula,19 was 0.247 mm.
RESULTS
The numbers of roots with contact or no contact with
the sinus floor are shown in Table II. More than two
thirds of the roots had contact with the sinus floor.
The roots of the second premolars and the palatal roots
of the second molars showed the lowest percentages of
contact, approximately 70%. The highest contact ratios
were observed at the mesiobuccal roots of the first and
second molars, 84.35% and 82.25%, respectively.
Descriptive data of the distances between root tips
and the sinus floor for the right side, left side, and
both sides are given in Table III. The mesiobuccal roots
of the second molars were protruded the most deeply
into the sinus on both sides (mean value, 2.59 mm).
In contrast, the roots of the second premolars and the
palatal roots of the second molars had the smallest pro-
trusions into the maxillary sinus, with mean distances of
0.82 and 0.81 mm, respectively. Statistical
significance was found only at the roots of the second
premolars.
Regarding sex differences, all root apices in male sub-
jects were significantly more protruded into the sinus
than those of female subjects (P \0.01) (Table IV). The
mean differences were greater than 1 mm for all roots.
According to age, the older group (.20 years) tended
to have more protrusion of the roots into the sinus than
did the younger group (\20 years). However, significant
differences were found only at the distobuccal and
palatal roots of the first molars and the palatal roots of
the second molars (Table V). The mean differences be-
tween the 2 age groups were 0.5 to 1.8 mm.
Regarding the anteroposterior relationship, 1-way
ANOVA showed no significant difference in distances
from the maxillary root apices to the inferior wall of
the sinus among the Class I, Class II, and Class III maloc-
clusion groups (Table VI).
Only the first molar had a significant difference in
distances from the root apices to the sinus floor among
the 3 vertical skeletal patterns (P \0.01) (Table VII). The
Tukey post hoc test determined that the first molar roots
of the hyperdivergent patients had the largest protru-
sions into the sinus (about 2.2-3.6 mm) among the 3
groups. When comparing the hyperdivergent group
with the hypodivergent group, the hyperdivergent group
seemed to have more protrusion of the roots into the

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814 Ahn and Park

Fig. Measurement of the shortest distance (mm) from root apex to sinus floor: A, when the root had no
contact with sinus floor, the distance was recorded as a positive value; B, when the root had lateral con-
tact with the sinus floor, the distances were recorded as a negative value; C, when the root penetrated
into the sinus, the distances were recorded as a negative value.

the mesiobuccal roots of the second molars (Table

Table II. Numbers of roots contacted and not con-
VIII). The post hoc test pointed out that the roots of
tacted with sinus floor
the up-canted PP group were less protruded into the si-
Roots with Contact Roots with Noncontact nus than the roots in the normal and down-canted PP
Root contact (n) percent no contact (n) percent groups. The differences were statistically significant for
5 107 70.4 45 29.6 the roots of the first premolars and first molars when
6 DB 190 80.55 46 19.45
6 MB 199 84.35 37 15.65
compared with the normal PP group. The mean differ-
6P 174 73.7 62 26.3 ences were approximately 1.4 to 2.7 mm. The roots of
7 DB 118 77.65 34 22.35 the down-canted PP group seemed to have the greatest
7 MB 125 82.25 27 17.75 protrusion of the roots into the sinus, although the dif-
7P 106 69.7 46 30.3 ferences between the down-canted PP and the normal
5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; PP groups were insignificant.
MB, mesiobuccal; P, palatal. Regarding the gonial angle, there were significant
differences among the 3 subgroups for all roots except
sinus, although a significant difference was found only for those of the second premolars (Table IX). The post
at the palatal roots of the first molars. hoc test showed that the roots in the large gonial angle
In regard to the PP cants, there were significant dif- group were significantly more protruded into the sinus
ferences among the 3 subgroups in all roots except for than the roots in the small or normal gonial angle

December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Ahn and Park 815

Table III. Distances (mm) between root apices and the sinus floor on CBCT by sides
Left side Right side Paired t test Total
left-right
Root Mean 6 SD Maximum Minimum Mean 6 SD Maximum Minimum Mean 6 SD Maximum Minimum P value
5 1.06 6 4.09 13.11 8.26 0.58 6 3.96 9.86 7.61 0.82 6 4.02 13.11 8.26 0.033*
6 DB 1.36 6 2.43 10.23 6.54 1.18 6 2.76 11.71 8.14 1.27 6 2.60 11.71 8.14 0.340
6 MB 1.92 6 2.83 11.89 9.40 1.76 6 2.96 11.65 7.92 1.84 6 2.89 11.89 9.40 0.317
6P 1.65 6 4.14 9.97 8.50 1.91 6 3.97 11.59 9.20 1.78 6 4.05 11.59 9.20 0.290
7 DB 1.65 6 3.09 6.23 7.74 2.00 6 3.04 7.04 8.06 1.82 6 3.06 7.04 8.06 0.149
7 MB 2.54 6 3.12 7.45 9.33 2.64 6 2.89 5.59 7.98 2.59 6 3.00 7.45 9.33 0.658
7P 0.96 6 4.00 9.68 8.30 0.66 6 4.40 13.09 7.96 0.81 6 4.19 13.09 8.30 0.371

5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; MB, mesiobuccal; P, palatal.
*P \0.05.

Table IV. Distances (mm) between root apices and the Table V. Distances (mm) between root apices and the
sinus floor on CBCT by sex sinus floor on CBCT in different age groups
Male Female Independent t test Independent
Root Mean 6 SD Mean 6 SD P value Younger (10-20 y) Older (20-30 y) t test
5 1.73 6 3.33 0.00 6 4.42 0.007* Root Mean 6 SD Mean 6 SD P value
6 DB 1.80 6 2.35 0.67 6 2.42 0.001* 5 0.17 6 4.76 1.27 6 3.38 0.122
6 MB 2.44 6 2.52 1.15 6 3.14 0.001y 6 DB 0.97 6 2.74 1.73 6 2.28 0.032*
6P 2.60 6 3.52 0.84 6 4.42 0.001y 6 MB 1.64 6 3.02 2.15 6 2.65 0.188
7 DB 2.77 6 2.56 0.97 6 3.23 0.000y 6P 1.22 6 4.27 2.68 6 3.52 0.005y
7 MB 3.28 6 2.35 1.96 6 3.37 0.005* 7 DB 1.27 6 3.27 2.20 6 2.87 0.064
7P 1.87 6 3.20 0.14 6 4.74 0.002* 7 MB 2.15 6 3.43 2.89 6 2.63 0.154
7P 0.26 6 4.66 1.55 6 3.68 0.012*
5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal;
MB, mesiobuccal; P, palatal. 5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal;
*P #0.01; yP #0.001. MB, mesiobuccal; P, palatal.
*P \0.05; yP #0.01.

groups. The mean differences were greater than 1 mm.
There was no significant difference between the small
and normal gonial angle groups.
DISCUSSION
The advantage of using CBCT in diagnosis and treat-
ment planning for orthodontic patients has been
approved widely. CBCT provides precise images of the
bone around root apices without distortion and overlap-
ping of surrounding structures as in 2-dimensional ra-
diographs.16,17 Hassan20 matched orthopantomogram
data sets of 101 patients (628 teeth) and periapical
radiograph data sets of 93 patients (359 teeth) with
CBCT images to investigate the accuracy of 2-dimen-
sional images in detecting tooth root protrusion into
the maxillary sinus. The results demonstrated that both
periapical and panoramic radiographs are not reliable
in assessing the relationship between the root tips and
the maxillary sinus floor. Patcas et al21 compared
CBCT with multi-detector computed tomography for
linear measurements in 8 intact cadaver heads and
concluded that CBCT appeared to be more reliable for
linear measurements and less susceptible to metal arti-
facts. Therefore, in this study, CBCT was used to evaluate
the relationships between maxillary posterior root apices
and the inferior wall of the sinus floor.
More than two thirds of the roots had contact with
the sinus floor (Table II). The contact ratios at the mesio-
buccal roots of the first and second molars were high,
over 80%, and lower ratios were found at other roots,
but those were still high, approximately 70%. Ok
et al22 reported that in patients from 10 to 30 years of
age, about 65% to 70% of the maxillary molar roots
touched the sinus floor. The study of Jung and Cho8
of 83 patients (mean age, 28.8 years) also showed similar
findings. The highest contact (75.9%) was observed at
the mesiobuccal roots of the second molars, and the
lowest contact (57.2%) was evident at the palatal roots
of the second molars. However, Kilic et al9 and Pagin
et al10 reported that only 20% to 45% of the roots had
contacts, respectively. The smaller contact ratio in these
studies may be related to differences in the patients’
ages. Ariji et al23 found that the sinus volume increased
gradually from birth to 20 years of age and thereafter
decreased. The mean ages of their sample and the

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816 Ahn and Park

Table VI. Distances (mm) between root apices and the sinus floor on CBCT in different sagittal skeletal patterns
5 6 DB 6 MB 6P 7 DB 7 MB 7P
Class I 0.77 6 4.37 1.17 6 2.45 1.59 6 2.97 1.22 6 4.44 1.69 6 3.31 2.51 6 2.17 0.49 6 4.59
Class II 0.58 6 4.40 0.92 6 2.81 1.48 6 3.06 2.38 6 3.79 1.57 6 2.47 2.24 6 2.91 0.89 6 4.12
Class III 1.08 6 3.32 1.73 6 2.54 2.51 6 2.52 1.92 6 3.71 2.16 6 3.31 2.98 6 2.88 1.04 6 3.93
ANOVA 0.821 0.160 0.059 0.184 0.585 0.454 0.794
P value
5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; MB, mesiobuccal; P, palatal.

Table VII. Distances (mm) between root apices and the sinus floor on CBCT in different vertical skeletal patterns
5 6 DB 6 MB 6P 7 DB 7 MB 7P
Hypodivergent 1.40 6 3.55 1.82 6 2.72a 2.25 6 2.93a 1.74 6 4.13a 1.70 6 3.53 2.57 6 3.32 1.39 6 4.17
Normodivergent 0.12 6 4.65 0.72 6 2.63b 1.35 6 3.00b 1.16 6 4.21a 1.65 6 2.66 2.27 6 2.93 0.13 6 4.16
Hyperdivergent 1.53 6 2.80 2.20 6 2.60a 2.76 6 2.18a 3.62 6 2.83b 2.39 6 3.19 3.33 6 2.54 1.49 6 4.19
ANOVA 0.123 0.001y 0.007* 0.002* 0.499 0.248 0.160
P value
Different characters represent statistical difference.
5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; MB, mesiobuccal; P, palatal.
*P #0.01; yP #0.001.

Table VIII. Distances (mm) between root apices and the sinus floor on CBCT in different palatal plane inclinations
5 6 DB 6 MB 6P 7 DB 7 MB 7P
Up-canted PP 0.81 6 4.70a 0.30 6 2.79a 0.62 6 3.26a 0.12 6 4.32a 1.26 6 3.56a 1.86 6 3.49 0.67 6 4.53a
Normal PP 1.29 6 3.33b 1.73 6 2.08b 2.47 6 2.24b 2.43 6 3.67b 1.60 6 2.51ab 2.59 6 2.53 1.05 6 3.69ab
Down-canted PP 1.74 6 3.99b 1.40 6 3.11ab 1.87 6 2.89b 2.61 6 3.87b 2.86 6 3.25b 3.40 6 3.08 2.00 6 4.33b
ANOVA 0.006y 0.001z 0.000z 0.000z 0.045* 0.072 0.013*
P value
Different characters represent statistical difference.
5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; MB, mesiobuccal; P, palatal.
*P \0.05; yP #0.01; zP #0.001.

Table IX. Distances (mm) between root apices and the sinus floor on CBCT in different gonial angle groups
5 6 DB 6 MB 6P 7 DB 7 MB 7P
Small 0.89 6 4.46 0.68 6 3.25a 1.56 6 3.75a 1.14 6 4.68a 1.32 6 3.55a 1.82 6 3.57a 0.44 6 4.81a
Normal 0.29 6 3.90 1.21 6 2.29a 1.66 6 2.47a 1.56 6 3.76a 1.49 6 2.66a 2.48 6 2.58a 0.44 6 3.87a
Large 2.55 6 3.11 2.33 6 2.32b 3.13 6 2.59b 3.42 6 3.78b 3.88 6 2.67b 4.39 6 2.56b 2.81 6 3.63b
ANOVA 0.052 0.008y 0.006y 0.014* 0.001z 0.003y 0.039*
P value
Different characters represent statistical difference.
5, Second premolar; 6, first molar; 7, second molar; DB, distobuccal; MB, mesiobuccal; P, palatal.
*P \0.05; yP #0.01; zP #0.001.

sample of Jung and Cho were younger, less than 20 years
and less than 30 years, respectively, than the sample in
the study of Kilic et al, with a mean age of about 40 years.
The age-related characteristic of sinus dimensions may
also explain why the older group (20-28 years) tended
to have more protrusion of the roots into the sinus
than the younger group (10-20 years), although signif-
icant differences were found only at the distobuccal
and palatal roots of the first molars and the palatal roots
of the second molars (Table V). The mean differences
were approximately 1 mm. Because the contact ratio
was comparatively high, especially in the older age
group, clinicians should be aware of this when making
a plan for intrusion of the maxillary molars.
This study showed that the mesiobuccal roots of the
second molars had the greatest protrusion into the sinus

December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Ahn and Park
in both the right and left sides with averages of –2.64
and –2.54 mm, respectively (Table III). This finding is
similar to the results of many previous
studies,6,8,10,22,24,25 although some studies found that
the distances to the sinus floor was shortest for the
distobuccal roots of the second molars, followed by
the mesiobuccal roots of the second molars.7,9 On the
other hand, the root tips of the second premolars and
the palatal roots of the second molars were the
farthest from the sinus or had the least protrusion into
the sinus, and this is consistent with other
studies.6-10,22,24,25 The left second premolar roots were
significantly more protruded into the sinus than the
right (Table III). This was not consistent with other
studies that showed no significant difference between
sides.9,22,26
As for sex, all roots of the maxillary posterior teeth in
the male group were more protruded into the sinus than
those in the female group (Table IV). This observation
may be explained by the fact that the size of the maxil-
lary sinus on average in males is larger than that in fe-
males.27-29 This result agreed with the studies of Ok
et al,22 Kang et al,25 and von Arx et al.26 A contrary
view was expressed by Kilic et al,9 who found no signif-
icant difference between male and female groups.
In recent years, microimplants, used as an orthodon-
tic anchorage unit, have frequently been placed in the
posterior alveolar bone region of the maxilla. Before mi-
croimplants, intrusion of the molars was a real challenge
with traditional anchorage, but now it is possible.11,30,31
However, the maxillary sinus may cause some difficulties
in orthodontic tooth movement and implant placement.
Moving teeth into the sinus leads to tipping and
periapical root resorption histologically and even
radiographically.12,13,32-35 Moreover, Laursen et al36
found an increased risk of damaging the sinus by angled
placement of microimplants. Therefore, knowledge
about the proximity of maxillary posterior root apices
to the sinus floor is important for preventing problems
such as perforation of the sinus and root resorption dur-
ing molar intrusion.
Regarding vertical relationships, patients with a nor-
modivergent skeletal pattern had significantly greater
distances from the first molar root tips to the sinus floor,
or less protrusion of the root into the sinus, compared
with patients in hyperdivergent group. The hyperdiver-
gent patients seemed to have the smallest distances be-
tween the roots and the sinus floor, or more protrusion
of the root into the sinus (Table VII). In addition, all roots
of patients with a large gonial angle showed a signifi-
cantly closer relationship to the sinus floor or more pro-
trusion of the roots into the sinus than the roots of
patients in the normal and small gonial angle groups,
American Journal of Orthodontics and Dentofacial Orthopedics
817
and the mean differences were greater than 1 mm
(Table IX). Proffit et al37 showed that long-face adults
had 2 to 3 times smaller occlusal forces than those
with a normal face. Other studies also found a negative
correlation between bite force and mandibular angle and
gonial angle.38,39 The lighter bite force in hyperdivergent
and large gonial angle patients might lead to a shift in
remodeling process toward bone resorption according
to Wolff's law and result in an increase of sinus
volume.40 Intrusion of the maxillary molars is essential
for the treatment of open-bite and hyperdivergent pa-
tients, but it might be a difficult movement because of
the proximity of the sinus or more surface contact with
the sinus wall.11,30,31,33,41 A light intrusion force may
be required to minimize root resorption in patients
with a large gonial angle. Clinicians should take this
into account when determining the amount and
direction of the orthodontic forces.
Patients with a normal cant of the PP have more pro-
trusion of the roots into the maxillary sinus than do
those with an up-canted PP. Since intrusion of the
maxillary posterior teeth is required for controlling the
vertical dimension in hyperdivergent patients who
commonly have an up-canted PP, the intrusion may
not be more difficult than in patients with a normal PP
cant and a normodivergent skeletal pattern.
Hyperdivergent male patients from 20 to 30 years
with a large gonial angle had an increased chance of
the roots to be in contact with the sinus floor, or to
have more protrusion of the roots into the sinus. There-
fore, if orthodontic maxillary molar intrusion is planned
for them, more caution is needed to avoid the risk of root
resorption.
One limitation of our study was sample selection. Our
subjects were patients visiting the orthodontic depart-
ment for treatment. Therefore, the results may not be
the same for the general population. Further studies
with general populations may elucidate more clearly.
CONCLUSIONS
To evaluate the relationships of maxillary posterior
root apices to the inferior wall of the maxillary sinus,
the 3D CBCT images of each root were checked, and
the distances between the root tips and the sinus wall
were measured along the true vertical axis in 118 pa-
tients (63 male, 55 female) aged 10 to 28 years. The dif-
ferences in distances among the subgroups classified by
age, sex, and skeletal pattern were assessed.
1. More than two thirds of the maxillary posterior roots
had contact with the sinus floor.
2. The mesiobuccal root tips of the second molars were
closest to the sinus floor or more protruded into the
December 2017  Vol 152  Issue 6
818
sinus, whereas the second premolar and
second molar distobuccal root apices were farthest
from the sinus floor.
3. The distances in the male and older age groups were
significantly smaller than the distances in the female
and younger age groups.
4. The anteroposterior relationship had no significant
correlation with the distances between the maxillary
root tips and the sinus floor.
5. Regarding vertical relationships, the distances be-
tween root apices and the sinus floor were shorter
or more protruded into sinus in subjects with hyper-
divergent facial patterns and a large gonial angle.
Intrusion of the maxillary molars in these conditions
might be difficult and slow because of the pneumatized
maxillary sinus.
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