Analysis digital panoramic radiograph about positions root of maxillary posterior teeth with maxillary sinus floor

Introduction: Maxillary sinus floor is a part of the alveolar bone adjacent to the apex of the posterior maxillary teeth that often causes complications in dentistry. Anatomical relationship between the maxillary posterior tooth root and the maxillary sinus floor can be obtained by panoramic radiograph. The purpose of this study is to analysis digital panoramic radiograph about positions root of maxillary posterior teeth’s with maxillary sinus floor by age and gender using. Methods: Research method is descriptive with purposive sampling technique. Study population was taken from archives of patient’s digital panoramic radiograph in Radiography Installation from January to March 2016. 88 samples were obtained from 207 digital panoramic radiographs archives. Results: The result showed that type 3 was dominated by P1 (86.8% right, 88.2% left), type 2 is dominated by P2 (24.7% right, 21% left), type 1 is dominated by M2 in the right (31.2%) and M1 in the left (38.1%). Conclusion: This study concludes that overall, the most commonly found was type 3. Based on the age, type 1 majority occurs in age group of above 49 years old; type 2 in age group of 40-49 years old; and type 3 in age group 30-39 years old, 40-49 years old, and above 49 years old. By gender, type 1 and type 2 are more common in males, while type 3 is more common in female.


INTRODUCTION
The maxillary sinus is a pyramid-shaped air space and known as the largest sinus which located on both sides of the maxilla.The maxillary sinus floor is a part of the alveolar bone tends to be close to the apex of the maxillary posterior teeth with different spaces.
Based on research conducted by Ok (2014) against the population of the Turkish people using the radiograph Cone-Beam Computed Tomography (CBCT), the first and second maxillary premolars tend not to relate to the maxillary sinus floor as compared with the first and second molar.Around 63,4-67.6% of second molar's root was penetrated into maxillary sinus which shows the percentage of the posterior teeth is larger than others.No significant difference was found between the left and right side, but the difference was found on gender and age variables.Tooth root penetration into the maxillary sinus floor is more prevalent in men than women and the prevalence tends to decrease along the increase number of age.The roots of the molar teeth which penetrated into the maxillary sinus has found and increased on the first, second and third decade.The study also found that the molar root penetration into the maxillary sinus has increases after the age of 60 years.
The correlation between maxillary sinus and root of posterior teeth become one of the reason of the complication occurence of maxillary sinus during the treatment, including extraction that can lead to the formation of oroantral communication.If it becomes chronic, it will cause sinusitis maxillaris.Root canal treatment procedure can cause perforation to maxillary sinus so the dental material will reach into maxillary sinus.Orlay (1966) in Ok (2014) reported the occurrence of extrusion of root canal sealer N2 into the maxillary sinus while doing the obsturation procedure, caused a heavy pain in trigeminal area and aspergillosis sinus 2,3 A deep understanding of the anatomical relationship between the apex of the maxillary posterior teeth and the maxillary sinus is a crucial thing for an operator.This can help to avoid or minimize the complication after extraction or root canal treatment. 2,4e description of the anatomical relationship between the posterior maxillary teeth roots and the maxillary sinus floor can be obtained through panoramic radiography.Panoramic radiography is an extraoral radiography that relatively fast and easy to used, especially by the general practitioner.Panoramic radiography is able to interpret the facial structure of the maxillary and mandible dental arch and its supporting structure.The maxillary sinus is usually have a good visualization through panoramic radiograph. 5

METHODS
The research is a descriptive research using method of the survey.The population used in this study is taken from the archives of the panoramic radiograph that provides an overview of the maxilla and mandible and its surrounding structures and stored digitally in Installation Radiology RSGM Padjadjaran University in the period March 2016 with total 207 radiograph.
The sample of the research done by purposive sampling technique based on inclusion criteria include: (1) the panoramic radiograph with good quality and ideal, (2) the panoramic radiograph of patients who have an overview of the posterior maxillary permanent teeth with apical root which has been closed or the formation of teeth's root perfectly without any pathological condition on both of the regio (right and left), (3) the panoramic radiograph patients showed a good maxillary sinus condition, characterized by a thin cortical bone radiography which is visible as a smooth, thin, and continous radioopak line.
In addition, the selection of the sample is done by considering the exclusion criteria periapical abscesses, cysts, periapical granuloma, condensing osteitis, hypersementosis, sclerotic bone, periodontal disorders, sinus approximation.After the selection is done according with the criteria of the required samples, it has been elected 88 panoramic radiographs as objects of research.
The position of the posterior maxillary teeth roots against maxillary sinus floor was the location of the root apical posterior maxillary permanent teeth against the maxillary sinus floor.If the tooth has more than one root, it is seen as the nearest root apical teeth to maxillary sinus floor in two dimensions.
The posterior maxillary teeth which being examined is the teeth with apical root which has experienced the closure perfectly is characterized by the absence of radiolusen area limited in apeks, there is a thin and clear line of radiolusen around the root, the root is not a funnel-shaped, the root canal is clearly visible from the room of pulp until the apical root and the apical foramen has opened.
The position of the posterior maxillary teeth roots against the maxillary sinus floor is grouped by the classification which stated by Ok (2014).If the root apical penetrated into the maxillary sinus floor and lamina dura and periodontal membrane are not visible on the superimposition description of the tooth root with maxillary sinus, it will be classified as the type 1 position.If apical root contacts with the maxillary sinus floor, it will be classified as a type 2 position.If apical root is below the maxillary sinus floor which the lamina dura and periodontal membrane looked as intake at superimposition description of root teeth with the maxillary sinus, then it will be classified in a type 3 position .Overall, the number of female gender's radiograph are about 53 radiographs, while males's readiograph are about 35 radiographs.Table 1 shows the results of the study of maxillary posterior tooth root's position towards the maxillary sinus floor as a whole in the period March 2016.Based on the table, it shows that the type 3 (root is below the maxillary sinus floor) happens most on the first premolar, either at right region (86.8%) and at left region (88.2%).The type 2 (the root is contacted to the maxillary sinus floor) is dominated by second premolars, both at the right region (24.7%) and at the left region (21%).Based on gender, type 1 and 2 positions are dominated by men, while the position of the type 3 are dominated by women.

DISCUSSION
Based on research results on table 1 which presents the overall results of the study, the maxillary first premolars showed the greatest percentage for type 3 (86.8%and 88.2%) and least for type 1 (1.3%).The results of this study in accordance with the results of previous research suggests that the maxillary first premolars is not penetrated into the maxillary sinus floor.
Different with the first premolar, maxillary have the frequency distribution of thpe 1 (6.2%) and type 2 (24.7% and 21%).The results of this study in accordance with similar research conducted by Ok (2014)   Besides that, Huang et al case reports (2011) also stated that the root of the maxillary first molar has a higher risk of perforation to maxillary sinus than another maxillary posterior teeth related to anatomy and morphology of the maxillary sinus.
However in the right region, type 1 is dominated by the second molar for about 31.2% 7 .This is in accordance with similar research conducted by Hassan (2010) and Shokri (2014) which States that the penetration of the posterior maxillary teeth against the maxillary sinus floor is dominated by the second and first molar.
According to Kwak (2004) in his research towards the population of Korea society, the findings above can occur due to anatomically, the topography of the inferior wall of the maxillary sinus has the farthest distance towards the apex in the first premolars area with cortical bone thickness.The apex of the maxillary second premolars have a distance closer to the maxillary sinus if is compared with first premolars.While molar area, especially the second molar has the shortest distance.
The first left molar is 0.1-0.52 mm against the maxillary sinus floor.The second molar on the left region is 0.31-0.78mm against the maxillary sinus floor.In other words, the first molar on the left region has a close distance with the maxillary sinus than second molar.Whereas the first molar on the right region is a 0.7-1.86 mm against the maxillary sinus floor, the second molar is 0.25-1.06mm against the maxillary sinus floor.On the right region, the second molar has a closer distance with the maxillary sinus than the first molar.
Age is being one of the factors that influence the relationship betwwen maxillary posterior teeth's apex and the maxillary sinus floor related with the pneumatitation of maxillary sinus 4,11.The maxillary sinus began to form from the intrauterin stage.The growth continues rapidly until the age of 3 and then slows down.The growth of the sinus will be back quickly at the age of 7 and continued until the 4-5 years later.The pneumatitation of maxillary sinus progresses most rapidly between the ages of 7-12 years and reach maximum size at the age of 18 12.Based on the age group, the type 1 is mostly occurred on the fifth decade.
This can happen because at this age group, almost all of the samples that have been examined, suffered a loss of one or more of the posterior teeth.According to Malik   (2008), the maxillary sinus will extend to prosesus alveolaris which was left after the loss of one or more of the maxillary posterior teeth.A wide pneumatitation occurred after loses second molar teeth or extraction of more that one maxillary posterior teeth 13,14 .
After the loss of teeth, the Schneiderian periosteum membrane shows an increase in the activity of the osteoclasts which caused the resorption of sinus floor and resulted the expansion of the maxillary sinus.The side of the maxillary sinus which having the greatest expansion was at the sinus floor because this side have associated with the teeth.The extraction or tooth loss in this area will cause an increasing in pressure or functional force.Prosessus alveolaris depends on the mandible teeth are there or not, regardless of whether the teeth still active doing a mastication or not.The process of bone apositon decreases as a result of the loss of functional stimulation 15.The type 2 mostly occurred in four decades, while type 3 mostly occurred in the decade of the third, fourth, and fifth.This finding is in accordance with the results of previous studies which concluded that the prevalence of tooth penetration into the maxillary sinus floor tends to decreases along the increasing of age.This can occur because the average distance of maxillary posterior teeth's apex against the limit of maxillary sinus floor will grow in the line with increasing number of age.
Overall, the difference between the left and right regions is caused by the difference in size of the maxillary sinus.Research conducted by Mattar et al (2010)   found significant differences between the relationship of the maxillary posterior teeth root against \ the maxillary sinus floor in the left and right region.According to him, although it is small, the human maxillary sinus is asimetric 16 .
If it is reviewed based on gender, type 1 and type 2 mostly happened on men, the type 3 mostly found in women.These findings are similar with previous research done by Ok (2014) who discovered the existence of frequency distribution variation on each type of gender.The research was supported by the theory that stated that the length and height of the maxillary sinus on men was larger than women 17.The men need a larger respiratory tract to support organs and muscles which is relatively larger, start from the nose and nasopharynx.Thus, the physiological changes in the size and shape of the nasal cavity is a direct result of the respiratory needs and the maxillary sinus is a cavity which located in the complex of nasomaksilaris 18 .In addition, the growth of the maxillary sinus continued until the third decade on the men and women in the second decade.Therefore, the size of the maxillary sinus on men is larger than on women will cause a closer relationship between the apex of maxillary posterior teeth towards the maxillary sinus floor.

CONCLUSION
Based on the results of the research, it can be descriptively inferred that are : 1.The position of the maxillary posterior teeth towards the maxillary sinus floor which shown on a panoramic digital radiograph is under the maxillary sinus floor (type 3). 3. Based on the gender, in all the teeth (premolars and molars) type 1 and type 2 is more prevalent in males, whereas type 3 mostly found in women.

Type 1 (
the root penetrates into the maxillary sinus floor) shows the difference between the left and right of the region.The type 1 at the right region dominated by second molar (31.2%), whereas in the left region dominated by the first molar (38.1%).

Diagram 1 .Diagram 3 .
The distribution of maxillary posterior tooth root's position (type 1) frequent against the maxillary sinus floor based on gender Diagram 2. The distribution of maxillary posterior tooth root's position (type 2) frequent against the maxillary sinus floor based on gender The distribution of maxillary posterior tooth root's position (type 3) frequent against the maxillary sinus floor based on gender

2.
Based on age, the maxillary posterior roots which penetrated into the maxillary sinus (type 1)are found on the age group of > 49 years; the roots of the maxillary posterior teeth affecting the maxillary sinus floor (type 2) are found in the age group 40-49 years; the roots of the maxillary posterior teeth that is outside of the maxillary sinus (type 3) are found in the age group 30-39 years, 40-49years and > 49 years.

Table I .
The position of the posterior maxillary teeth Roots toward the maxillary sinus floor in General Based on age, the type 1 most often occurs on the fifth decade (at 100% of the M1 from the total number of M1 on the age group); type 2 is much going on its fourth decade (in M3 of 100% of total M3 on the age group); many of type 3 occur in the decade of the third, fourth, and fifth (at P1, P2, M3 amounted to 100% of the total amount of each tooth on the age group).