art-3-1-21
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ORTHODONTICS
AN ASSOCIATION BETWEEN DIMENSIONS
Original Articles
AND BRIDGING OF THE SELLA TURCICA AND DENTAL
ANOMALIES
Seden Akan1a , Nevin Kaptan Akar2b
Department of Orthodontics, Faculty of Dentistry, Altınbaș University, Bakırköy / İstanbul, Turkey
1
Department of Orthodontics, İstanbul Medipol University Faculty of Dentistry, İstanbul, Turkey
2
a
DDS, PhD, Assistant Professor; e-mail: sedenakandt@hotmail.com; ORCIDiD: https://orcid.org/0000-0001-7955-3086
b
DDS, PhD, Assistant Professor; e-mail: nakar@medipol.edu.tr; ORCIDiD: https://orcid.org/0000-0003-1208-6369
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(1).art. 3
Introduction The aim of this study was to determine the incidence of bridging of the sella turcica and the
dimensions of the Sella in subjects with dental anomalies (transpositions, hypodontia, and supernumerary
teeth) and to compare them to controls.
Methodology Lateral cephalograms from 25 patients with dental transposition, 88 with hypodontia, and
26 with supernumerary teeth were evaluated. The shape, length, depth, diameter, and bridging of the Sella
turcica were determined from radiographs and compared to those of control group (n=52). For statistical
analysis, one-way ANOVA, Tukey post-hoc test, chi-squared test and T-test (to evaluate the influence of
craniofacial growth) were used.
Results The frequency of complete calcification of the Sella was greater in the group with supernumerary
teeth (23%) and in the group with hypodontia (14.7%), while partial calcification of the Sella was more
frequent in the control group (77%) and in the group with supernumerary teeth (73%)(p<0.05). The depth
of the Sella was greater in the group with dental transposition. Oval and round Sella shapes were more
frequent in all groups, and a flat Sella was rarely seen. In terms of the influence of growth on the dimensions
of the Sella, there was no statistically significant difference between pre- and post-treatment radiographs.
Conclusion Significant relationships were found between dental anomalies and bridging and shape of the
Sella. The Sella was also significantly deeper in patients with dental transposition. The bridging and shape of
the Sella may be useful in the diagnosis of dental anomalies in early childhood.
KEYWORDS
Sella Turcica Bridging; Hypodontia; Transposition; Supernumerary Tooth; Digital Radiography.
1. INTRODUCTION derives from the structure’s similarity in shape to a
The sella turcica is a depression in the middle line saddle used by the Turks [1]. The anterior border of
of the upper surface of the sphenoid bone. For the sella turcica is marked by the tuberculum sella
orthodontists, the sella is a well-known anatomical and the posterior border is marked by the dorsum
structure on the scalp, because it is the central sella [2]. The pituitary gland is located in the sella
reference landmark in the evaluation of craniofacial turcica, and two anterior and posterior clinoid
morphology and the maxillomandibular relationship. processes project over the pituitary fossa [2].
The name sella turcica, Latin for “Turkish saddle,” During the embryological period, the sella turcica
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Akan S, Akar NK. An association between dimensions and bridging of the sella turcica and dental anomalies. Stoma Edu J. 2021;8(1):26-32.
Received: October 13, 2020; Revised: October 26, 2020; Accepted: November 13, 2020; Published: November 16, 2020
*Corresponding author: Dr. Seden Akan; Altınbaş Üniversitesi Diş Hekimliği Fakültesi Zuhuratbaba Mahallesi, İncirli Caddesi, No:11-A
34147 Bakırköy / İstanbul / Turkey.
Tel/Fax: 0090535 5113760; e-mail: sedenakandt@hotmail.com
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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Original Articles
Figure 1. Classification of the bridging and shapes of the sella turcica: a) no calcification, b) partially calcified, and c) completely calcified; d) oval, e) round,
and f) flat.
Table 1. Descriptive statistics and gender distribution of study groups.
Group
Transposition Hypodontia Supernumerary Control Total
Gender
21/4 55/33 13/13 33/19 122/69
Female/Male
Age (Mean±SD) 15.81±3.51 16.54±4.60 16.60±4.30 17.96±4.05 16.84±4.31
P value for age was 0.143
is the key point for the migration of the neural crest and developmental conditions such as basal cell
cells to the frontonasal and maxillary developmental carcinoma, Williams syndrome, Rieger syndrome, and
fields [3]. The neural crest cells are involved in the other disorders [6]. The current study was therefore
formation and development of the sella turcica performed to evaluate the dimensions of the sella
and the teeth [4]. Given this relationship between turcica and the incidence of bridging of the sella
the sella turcica and the teeth, it has been argued turcica in patients with dental anomalies (transpo-
that anatomic deviations in the sella turcica may be sitions, hypodontia, and supernumerary teeth),
related to dental alterations. Thus, the morphology to compare them with the controls, and to assess
of the sella has been studied in relation to skeletal whether any significant changes occurred in the
malocclusions [5,6], Down syndrome [7], cleft sub- dimensions of the sella during craniofacial growth in
jects [8], and dental anomalies such as dental trans- patients with dental anomalies.
position [9], absence of the second premolar [10],
and palatally displaced canines [10]. 2. MATERIALS AND METHODS
In lateral cephalometry, the sella turcica is
U-shaped. The size of the sella turcica has been 2.1. Study Population
evaluated widely in the literature and ranges from This retrospective radiographic study, approved by
4 to 12 mm in depth and from 5 to 16 mm for the the institutional ethical board (ref. 10840098-604),
anteroposterior diameter [11]. Three different shapes was carried out on the cephalometric radiographs of
of the sella have been identified in the literature: 25 patients (21 females and four males) with dental
oval, round, and flat. Of the three, the oval and transposition, 88 patients (55 females and 33 males)
round types are more common. The sella turcica with hypodontia, and 26 patients (13 females and 13
is divided into three segments: an anterior wall, a males) with supernumerary teeth. Only patients with
floor, and a posterior wall [4]. Bridging of the sella good-quality lateral cephalometric and panoramic
turcica has been described as a bony union of the radiographs were included in the study. The exclusion
anterior and posterior clinoid processes. Bridging criteria were as follows: presence of any syndrome or
is regarded as an anatomical abnormality, and it systemic disease, previous orthodontic treatment,
is particularly prevalent in craniofacial deviations excess craniofacial deviations, and history of trauma.
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Akan S, et al.
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Original Articles
Figure 1. Reference lines and measurements of the sella turcica: L =
length of the sella, D = depth of the sella, and Dia = greatest diameter of the
sella.
Figure 3. Sella bridging.
The control group was created according to power method of Jones et al. (Fig. 1) [13] .
analysis (α = 0.05, f = 0.25, power = 0.80) and
2.3. Evaluation of Influence of Craniofacial Growth
consisted of 52 subjects (33 females and 19 males).
The same inclusion and exclusion criteria were used To assess the possible effects of craniofacial growth
as for the dental anomaly groups. The study groups on the size, shape, and bridging of the sella, post-
are described in Table I. treatment cephalometric radiographs of 15 patients
selected at random from the study groups were
2.2. Cephalometric Analysis
compared to their pre-treatment radiographs. The
Pre-treatment lateral cephalometric and panoramic mean time period between pre- and post-treatment
radiographs of all the patient groups and the radiographs was 3.21 ± 1.19 years.
control group were taken according to the standard
2.4. Statistical Analysis
technique for evaluating cranial structures, using a
Kodak Extraoral Imaging System machine (Kodak Analysis of the data was performed in the SPSS 16
9000, Carestream Health, Inc., Rochester, NY, USA) package (SPSS for Windows, SPSS Inc., Chicago, IL,
and a cephalostat with a fixed magnification factor. USA). Means, standard deviations, and minimum and
Only radiographs with good-quality images of the maximum values were calculated, and the Shapiro–
Sella turcica area were selected for analysis. The Wilks normality test was applied to the data. One-
region around the contour of the pituitary fossa from way analysis of variance (ANOVA) and a Tukey post
the tip of the dorsum sellae to the tuberculum sellae hoc test were used to assess differences between the
was traced on the lateral cephalometric images using linear dimensions of the groups, while nominal data
acetate paper and a 0.5 mm lead pencil. The tracing were tested using a chi-squared test. A T-test was
and measurements were performed manually by used to evaluate the influence of craniofacial growth
one observer (SA) under ideal lighting conditions. on the measurements. To determine intra-rater
Bridging of the sella turcica was evaluated in reliability, 20 cephalometric radiographs selected at
accordance with the standardized scoring scale random were retraced after two weeks, and Pearson
method of Leonardi et al. [10] A sella was scored as correlation coefficients were calculated (ranging
having “no calcification” when its length was greater from 0.810 to 0.862). The statistical significance was
than or equal to three-fourths of its diameter, as set at p<0.05.
“partially calcified” when its length was less than
three-fourths of its diameter, and as “completely 3. RESULTS
calcified” when only the diaphragma sellae
could be seen radiographically (Fig. 1). The linear Table I shows the descriptive statistics and p-values
characteristics of the sella turcica were measured for the study groups and the control group. Table II
in accordance with Silverman’s method [12]. The shows the distribution of the degree of calcification
length of the sella turcica was measured from the of the sella turcica in the study and control groups.
tuberculum sellae to the tip of the dorsum sellae. Complete calcification of the Sellawas more frequent
Its depth was measured perpendicularly to this line in the group with supernumerary teeth (23%) and
passing through the deepest point of the pituitary in the group with hypodontia (14.7%), while the
fossa. Its diameter was measured in the sagittal partial calcification of the Sella was more frequent
direction by drawing a line from the tuberculum in the control group (77%) and in the group with
sellae to the most distant point on the posterior supernumerary teeth (73%) (p=0.025).
inner wall of the fossa (Fig. 2). Morphologically, each The average linear dimensions of the sella turcica in
sella turcica was classified as one of the three basic the study groups and the control group are shown
types (round, oval, or flat), in accordance with the in Table II. The depth of the sella was greatest in the
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Original Articles
Table 2. Distributions of the bridging types and the shapes of the sella, and average linear dimensions of the sella turcica in the study groups.
Group
Trasposition Hypodontia Supernumerary Control P
No Calcification 9 (36) 17 (19.3) 1 (3.8) 10 (19.2)
Bridging Type Partially
14 (56) 58 (66) 19 (73.1) 40 (77) 0.025*
n(%) Calcified
(x) Completelly
2 (8) 13 (14.7) 6 (23.1) 2 (3.8)
Calcified
Length 5.04±2.75 4.48±2.78 3.88±2.37 4.71±2.34 0.421
Linear
Dimensions
Depth 7.48±1.36 6.93±1.26 6.42±1.10 6.86±0.99 0.018*
(Mean±SD)
(à)
Diamater 9.12±1.83 8.40±2.13 7.92±1.63 8.33±1.63 0.154
Oval 5 (20) 10 (11.4) 13 (50) 19 (36.5)
Shape of Sella
n(%) Round 18 (72) 69 (78.4) 13 (50) 27 (52) 0.001**
(x)
Flat 2 (8) 9 (10.2) 0 6 (11.3)
(x) means Chi square statistics, * P<0.05. (à) means ANOVA test * P<0.05. According to Tukey Post hoc test; a statistically significant difference was
found only between transposition and supernumerary groups P=0.009*
group with dental transposition, and the difference believed to be related to dental anomalies [14]. In
from the group with supernumerary teeth was the present study, bridging of the sella turcica at the
statistically significant (p<0.05). The distribution of completely calcified level was seen in 23.1% of the
the shape of the sella turcica in the study and patients with supernumerary teeth, in 14.7% of the
control groups is also shown in Table II. Oval and patients with hypodontia, in 8% of the patients with
round shapes were more frequent in all groups, and transposition, and in 3.8% of the control patients
a flat sella was rarely seen (p=0.001). According to (total frequency = 12%). Bridging at the partially
the results of the T-test, there was no statistically calcified level was seen in 73.1% of the patients
significant difference between the pre- and post- with supernumerary teeth, in 66% of the patients
treatment radiographs in terms of the influence of with hypodontia, in 56% of the patients with
the growth on the dimensions and bridging of the transposition, and in 77% of the control patients
sella. (total frequency = 68.6%). The findings of the present
study are different from those of comparable studies.
4. DISCUSSION For example, in patients with supernumerary teeth,
bridging of the sella turcica has previously been
reported at the partially calcified level in 53% of
In this retrospective study, certain characteristics the patients and at completely calcified level in
and dimensions of the sella turcica were analyzed 6% of the patients; in that study, the levels for the
on pre-treatment standardized lateral cephalometric control patients were 30% and 13%, respectively
radiographs. The aim was to assess the shapes, [19]. In a study of patients with transposition, 42.9%
dimensions, and the incidence of bridging of the sella were at the partially calcified level and 23.8% at the
turcica in subjects with dental anomalies (transpo- completely calcified level; the levels for the control
sitions, hypodontia, and supernumerary teeth) patients were 68.6% and 5.7%, respectively [9]. In a
compared to control subjects. These parameters study of patients with supernumerary teeth, 21.7%
have not previously been studied in Turkish were at the partially calcified level and 21.7% were
orthodontic patients. The literature reports sella at the completely calcified level; the levels for the
bridging, defined as ossification between the control patients were 19.4% and 5.6%, respectively
anterior and posterior clinoid processes in the [20]. These differences between previous studies
dura mater, as a determinant factor for dental and the present findings may be due to the number
anomalies. Although bridging is seen in healthy of patients included in each study and the nature of
subjects [14], it occurs more frequently in subjects their existing malformations, as bridging of the sella
with craniofacial deviations (i.e. carcinomas [15], turcica has been related in the literature to cranio-
syndromes [16], and skeletal malocclusions [17,18]). facial deviations. Many studies have reported
From an embryologic point of view, the anterior wall patients with Class III malocclusion as having a grea-
of the sella turcica develops from neural crest cells, ter proportion of bridging of the sella than Class I
as teeth do; thus, deviations in the anterior wall are patients [17,18,21]. The size of the sella turcica has
Stoma Edu J. 2021;8(1): 26-32 pISSN 2360-2406; eISSN 2502-0285 29
Akan S, et al.
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been studied in detail in the literature, with the are no routine diagnostic tools in orthodontics for
Original Articles linear measurements ranging from 4 to 12 mm the dental anomalies under study here.
in depth and 5 to 16 mm in length [11,12]. In the The clinical relevance of the present study relates to
present study, there were no statistically significant early diagnosis of dental anomalies. The findings may
differences between the patient groups; lengths allow clinicians to provide preventive measures for
ranged from 3.88 to 5.04 mm and diameters from specific patient groups, especially with a diagnosis of
7.92 to 9.12 mm. There was a statistically significant transposition and the possibility of supernumerary
difference in the depth of the sella between the teeth in the early period.
patients with transposition (7.48 mm) and those
with supernumerary teeth (6.42 mm) (p=0.018). The 5. CONCLUSION
difference between the present findings and the
measurements in the literature may be due to the
The findings of the present study indicate that
use of different landmarks and levels of radiographic
bridging of the sella turcica was more frequent in
magnification. Some studies have revealed a corre-
patients with supernumerary teeth and hypodontia.
lation between the linear dimensions of the Sella
The sella was deeper in patients with transposition,
and age and growth as factors associated with
and in terms of shape, oval and round sellae were
bridging of the sella [22], whereas others have den-
the most frequent in all groups. Although the
ied any association [23]. In the present study, the
study groups were not divided according to age,
effects of growth on the characteristics of the sella
the results of the growth evaluation showed no
were evaluated by measuring the size, shape,
significant change in the dimensions of the sella
and bridging of the sella on the pre- and post-
during craniofacial growth in patients with dental
orthodontic cephalometric radiographs of 15 pati-
anomalies.
ents. No statistically significant difference (p>0.05)
was found in either the pre-treatment or the post- CONFLICT OF INTEREST
treatment data; however, the correlation between
the sella characteristics and age should be analyzed The authors declare no conflict of interest.
on a larger sample of cephalograms. The shape of
ACKNOWLEDGMENTS
the sella turcica is affected by anatomical structures:
the pituitary gland, the extent of the anterior and
None.
posterior intercavernous venous sinuses [24], and
the internal carotid artery [25]. The shape of the
AUTHOR CONTRIBUTIONS
sella turcica is also determined genetically [26]. In
the present study, the shape of the Sella turcica
SA: contributed to the concept and design of the study, the
was classified as oval, round, or flat, in line with
acquisition, analysis and interpretation of the data and drafting
the approach taken by Jones et al [13]. Although
the article. NKA: participated by adding her patient records and
Jones et al. [20] did not provide any data about the
revising the article critically. All authors read and approved the
prevalence of the different shapes, other studies
final manuscript.
have shown the oval shape to be the most common
among Nigerian subjects [27]. In the present study,
FUNDING
consistent with the literature, the round shape was
the most common in all groups, followed by the oval
The authors declare that they have not received any funding.
shape and then the flat type. This study was limited
by a number of factors, including a lack of gender
COMPETING INTERESTS
discrimination between the groups. Some studies
have suggested that there is no gender correlation in
The authors declare that they have no competing interests.
terms of the linear dimensions of the sella [6,28,29].
In the present study, gender data were taken into
account, and thus the ratio of female to male ETHICS APPROVAL AND CONSENT TO PARTICIPATE
patients in the study groups was balanced. A further
limitation is that this study used two-dimensional A written informed consent containing all the information about
lateral cephalometric radiographs instead of three- records and usage for study was obtained from all patients. All
dimensional cone beam computerized tomography procedures in this study were approved by the Ethical Board of the
images, which limited the capacity to determine the Istanbul Medipol University (10840098-604) and complied with
characteristics of the sella turcica. Three-dimensional the Code of Ethics of the World Medical Association (Declaration
images are more informative and reliable, but they of Helsinki).
30 Stoma Edu J. 2021;8(1): 26-32 pISSN 2360-2406; eISSN 2502-0285
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Akan S, et al.
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Original Articles Seden AKAN
Department of Orthodontics
Faculty of Dentistry
Altınbaș University
Bakırköy / İstanbul, Turkey
CV
Seden Akan graduated from the Hacettepe University, Faculty of Dentistry, Ankara, Turkey in 2003. She enrolled for her PhD
degree in 2004 and she was awarded her PhD degree by the Hacettepe University in 2010.
Since 2018, she has been working as an Assistant Professor at the Department of Orthodontics within the Faculty of Dentistry
of the Altınbaș University, Bakırköy / İstanbul, Turkey.
Questions
1. What is the key point for seeking a relationship between the Sella turcica and dental
malocclusions?
qa. The anterior wall of the Sella turcica and teeth share in common the involvement of neural crest cells;
qb. Their close neighborhood;
qc. The effect of pituitary gland secretion;
qd. The shape of the sphenoid bone.
2. In the present study, the shapes of the Sella turcica identified in:
qa. Round;
qb. Oval;
qc. Flat;
qd. Answers a-d are correct.
3. Sella turcica bridging is especially seen in the following cases:
qa. Craniofacial deviations;
qb. Developmental conditions;
qc. Skeletal malocclusions;
qd. Answers a-d are correct.
4. According to the present study results, the complete calcification of the Sella was
shown in the…
qa. Transposition group;
qb. Hypodontia group;
qc. Supernumerary teeth group;
qd. Impacted teeth group.
32 Stoma Edu J. 2021;8(1): 26-32 pISSN 2360-2406; eISSN 2502-0285