The Relationship Between Accessory Maxillary Ostium and Sinonasal Region Variations

DOI: https://doi.org/10.21203/rs.3.rs-1784308/v1

Abstract

Purposes: The aim of this study is to evaluate the prevalence of accessory maxillary ostium (AMO) and its association with age, gender, sinus variation, pathological formations, status of dentition and tooth endodontic and periodontal status using cone-beam computed tomography (CBCT).

Methods : The study examined archived CBCT images of 390 patients at least 18 years old (232 females and 158 males) representing 790 regions of interest. The mean age of the female patients was 46.35 and that of the males was 48.62. All the CBCT images analyzed with sagittal, coronal and axial sections. The data were assessed using IBM SPSS 22. Significance was evaluated at the p <0.05 level.

Results:  The study observed that while the prevalence of primary maxillary ostium (PMO) on the right side was 94.9% and on the left side was 94.6% (for a total of 94.7%), the prevalence of accessory ostium on the right side was 33.1% and on the left was 35.4% (34.2% in total).

Conclusions: There was no significant difference in AMO prevalence related to age, presence of mucosal thickness, mucus retention cysts, maxillary sinusitis, sinonasal variation, status of dentition or periodontal status of posterior maxilla. However there was a relationship between AMO and both gender and endodontic status. 

Introduction

The maxillary sinus is the largest paranasal sinus and thus is an important and popular structure for both otolaryngology and dentistry [1].

The primary maxillary ostium (PMO) is a natural opening between the floor of the orbit and the medial wall of the maxillary sinus [1,2]. The PMO contributes to drainage from the sinuses towards the hiatus semilunaris, middle meatus, and nasal cavity, thus helping the maxillary sinus remain physiologically healthy [1,3].

Accessory maxillary ostium (AMO) is a relatively common anatomical variation observed in the maxillary sinus, its prevalence has been reported to be between 18% and 30% of the general population [4,5].

It is usually located in the fontanel, the membranous part of the lateral nasal wall that is covered with mucoperiosteum in the middle meatus, between the uncinate process and the inferior meatus. ITshould not be confused with the maxillary hiatus. The fontanel is divided into an anterior nasal fontanel (ANF) and a posterior nasal fontanel (PNF) by the uncinate process. An AMO is most often located in the PNF of the middle meatus and can be unilateral or bilateral [5–7].

Normally, an AMO takes a round or oval shape and is  parallel to the vertical plane of the lateral nasal wall. Unlike the PMO which is hidden behind the uncinate process,an AMO  can be easily seen in nasal endoscopic examinations [5].

It has not yet been determined whether an AMO is a congenital or an acquired structure. It is well known that some anatomical variations in the paranasal sinus can predispose individuals to sinus infections and may even complicate sinus surgery [8].

The presence of an AMO increases the ventilation rate of the maxillary sinus, but also leads to reverse drainage from the middle meatus to the sinus. This leads to decreased nitric oxide concentration in the sinus and results in mucus accumulation; this possibly contributes to the formation of pathological changes such as mucosal thickening, mucosal retention cyst formation, and maxillary sinusitis [1,7]. In one study, it was stated that 70-100% of antrochoanal polyps (ACPs)   originated from an accessory ostium [9].

Cone-beam computerized tomography (CBCT) is a safe, accurate, cost-effective, and relatively low-radiation three-dimensional (3D) imaging technique widely used in dentistry to obtain three-dimensional images of the jaw. In addition, it is frequently used in dentistry to allow three-dimensional examination of maxillary sinuses and adjacent structures [10]. In the literature, most studies evaluating the presence of an AMO use CBCT images. 

Many studies have investigated the causes and effects of AMO. Arslan et al analyzed the correlation between the presence of mucus retention cysts and ostemeatal complex obstruction, middle turbinate anomalies, AMO and nasal septal deviation. They reported that the presence of a mucus retention cyst is an indicator of  paranasal sinus anomalies [11].

Hung et al. evaluated AMO in 160 CBCT images and detected the presence of it at a rate of 47%. They argued that pathological formations in the maxillary sinus had an effect on AMOs [1].

Yenigün et al. investigated the incidence of AMO with mucus retention cysts, mucosal thickening, maxillary sinusitis, agger nasi cells, Haller cells, nasal septal deviation, inferior concha hypertrophy, and middle turbinate pneumatization.  They stated that the presence of AMO increased the possibility of mucus retention cysts approximately three-fold (48.6%), and the possibility of mucosal thickening two fold (43.0%) and maxillary sinusitis (29.1%) also two-fold [7].

Finallyi Bani-Ata et al. evaluated the incidence of AMO in the CIBT images of 928 patients and found the frequency to be 27.5%. They conluded that the presence of AMO contributes to the formation of maxillary and ethmoid sinusitis [6]. 

While many studies of AMO exist, few have focused specifically on  the Turkish subpopulation. Therefore the aim of our study is to investigate the incidence of AMO in this subpopulation. To the best of our knowledge, ours is the first study to use CBCT to analyze the prevalence of AMO and its association with age, gender, sinus variation, pathological formations, status of dentition and tooth endodontic and periodontal status. 

Method and Material

This study examined data from patients referred to the Department of Oral and Maxillofacial Radiology, Faculty of Dentistry at Altınbaş University. From these, 390 patients aged 18 years and older were selected as the study group. These patients had been referred  for various reasons including impacted teeth, temporomandibular disorder, and implant or orthodontic planning. 

The study’s inclusion criteria included these items: sufficient image quality and the absence of artifacts, the absence of a history of maxillofacial fracture in CBCT images including bilateral maxillary sinuses, images not containing any  pathological structure or deformation, and the patient has not undergone previous surgical intervention in the relevant area. Patients with maxillofacial fractures, pathological structures in the relevant region, and a history of previous trauma, surgical intervention or deformation in the maxillofacial area were not included. The study was conducted in full accordance with the 2013 Declaration of Helsinki and was approved by the Altınbaş University Faculty of Dentistry Ethical Committee (study protocol: 2021/47)

CBCT images of all patients were obtained informed consent in compliance with the Helsinki Declaration.

The all images were obtained with a NewTom VGİ evo (CeflaGroup, Verona, Italy) device and with operating parameters (1-32mA, 110kV and 0.3mm voxel size) specified by the manufacturer. During the exposure time, the patients were standing, with their heads, saggitals and vertical planes perpendicular to the ground, The orbitomeatal plane was positioned parallel to the ground, and the device made a single 360 ͦ rotation around the patient's head in each exposure. This ensured that it remained stable; in addition patients were given a special head band and chin support to prevent movement. 

The parameters were evaluated using the NNT Viewer version 8.0 computer program. In order to ensure an effective evaluation, the radiological images were evaluated on the Barco medical monitor screen with high 22 " image quality by an Oral and Maxillofacial Radiology specialist in a dark, quiet room.  Observer analyzed the images of the  25% of the sample and then the same observer, blind to the results of the first assessment, repeated the assessment four weeks later. 

Images were evaluated twice by a radiologist with five years of experience and were examined with coronal, axial, sagittal and cross sections. As the Kappa coefficients for all parameters are found to be close to 1.000 and 1.000, it is seen that the intra-observer agreement is quite high. Section thickness was evaluated as 0.3mm and filter application was not used.

Using DICOM format, these items were investigated  in the nasal and maxillary sinus regions: PMO, AMO, mucus retention cysts, mucosal thickening (more than 2mm), maxillary sinusitis, agger nasi cells, Haller cells, middle turbinate pneumatization (concha bullosa), inferior turbinate hypertrophy, paradoxical middle turbinate, nasal septal spur and nasal septal deviation existence (Fig.1, 2, 3 and 4).

CBCT images evaluated in the study according to the dentition status in the posterior maxilla (from the distal of the canine) were recorded as ; 

1. Dentate- 2. Partially edentulous- 3. Completely edentulous-

If there were teeth of the maxilla posterior, the conditions of these teeth were evaluated to investigate dental origin endodontic or periodontal pathology that could affect the maxillary sinus. The endodontic status of teeth in the respective posterior maxilla was classified into-

1. Absence of endodontic pathology or treatment-

2. Endodontic treatment(s) without visible pathology-

3. Apical lesion(s) with or without visible endodontic treatment(s), based on Hung et al and Yeung et al.’s study [1,12].

Teeth with periodontal pathology were classified into-

1. Absence of periodontal lesions-

2. Horizontal and/or vertical periodontal bone lesions deeper than the midlevel of the respective root without furcation involvement-

3. Periodontal bone lesions with furcation involvement-

 The endodontic/periodontal status was categorized into healthy (1) or pathological (2, 3), based on Hung et al. and Yeung et al.’s study [1,12]. 

Statistical Analysis 

For the statistical analysis, the IBM SPSS Statistics 22 (SPSS IBM in Armonk, NY.) program were used. The suitability of the parameters to the normal distribution was evaluated by the Kolmogorov-Smirnov test; the age was found to be suitable for the normal distribution. Descriptive statistical methods (average, standard deviation and frequency) were used. as well as one-way ANOVA test to compare the parameters between the groups in  comparison of the quantitative data. In addition Tamhane's T2 test was  used to determine the group that caused the difference. A Student’s t-test was used to make comparisons of the parameters between the two groups. To examine the qualitative data, the study also used a Chi-Square test, Fisher's Freeman Halton test and Continuity (Yates) Correction. Cohen Kappa coefficient of agreement was calculated for intra-observer agreement

Significance was evaluated at the p < 0.05 level . 

Results

In the present study, 780 sinuses from a total of 390 CBCT scans were analyzed. Overall, 158 patients (40.5% of total) were male and 232 were female (59.5% of total). The age of patients ranged between 18 and 86 years old with an average age of 47.27 ± 16.84. The ages of the male patients ranged from 19 to 85 years, with an average age of 48.62 ± 16.55 years. The ages of the female patients ranged from 18 and 86, with an average of 46.35 ± 17.01 years.

Incidence of PMO on the right side was 94.9% and on the left side 94.6%, bringing the total to 94.7%.  Incidence of AMO on the right side was 33.1% and on the left 35.4%, giving a total of and 34.2%. Incidence of pathological formation and sinonasal variations are presented in Table 1. 

Table 1

 Distribution of parameters (right-left-total)



Right

Left

Total

 

 

n (%)

n (%)

n (%)

Primary Maxillary Ostium

Presence

370 (94,9%)

369 (94,6%)

739 (94,7%)


Absence

20 (5,1%)

21 (5,4%)

41 (5,3%)

Accessory maxillary ostium

Presence

129 (33,1%)

138 (35,4%)

267 (34,2%)

 

Absence

261 (66,9%)

252 (64,6%)

513 (65,8%)

Sinonasal Pathology

Absence

193 (49,5%)

198 (50,8%)

391 (50,1%)

 

Maxillary sinusitis

29 (7,4%)

29 (7,4%)

58 (7,4%)

 

Mucosal thickening

131 (33,6%)

124 (31,8%)

255 (32,7%)

 

Mucus retention cysts

37 (9,5%)

39 (10%)

76 (9,7%)

Agger Nasi Cells

Presence

341 (87,4%)

346 (88,7%)

687 (88,1%)

 

Absence

49 (12,6%)

44 (11,3%)

93 (11,9%)

Haller cells

Presence

130 (33,3%)

119 (30,5%)

249 (31,9%)


Absence

260 (66,7%)

271 (69,5%)

531 (68,1%)

Concha bullosa

Presence

187 (47,9%)

208 (53,3%)

395 (50,6%)


Absence

203 (52,1%)

182 (46,7%)

385 (49,4%)

Inferior concha

hypertrophy

Presence

132 (33,8%)

131 (33,6%)

263 (33,7%)

 

Absence

258 (66,2%)

259 (66,4%)

517 (66,3%)

Paradoxical middle turbinate

Presence

47 (12,1%)

38 (9,7%)

85 (10,9%)

 

Absence

343 (87,9%)

352 (90,3%)

695 (89,1%)

Nasal septal spur

Presence

 

 

130 ( 33,3%)

 

Absence

 

 

 

Nasal septal deviation

Presence

 

 

243 ( 62,3%)

 

Absence

 

 

 

Dentition status

Completely edentulous

52 (13,3%)

58 (14,9%)

110 (14,1%)


Partially edentulous

171 (43,8%)

175 (44,9%)

346 (44,4%)


Dentate

167 (42,8%)

157 (40,3%)

324 (41,5%)

Endodontic Status

Absence of endodontic pathology or treatment

216 (64,1%)

229 (69,0%)

445 (66,5%)

 

Endodontic treatment(s) without visible pathology

44 (13,1%)

33 (9,9%)

77 (11,5%)

 

Apical lesion(s) with or without visible endodontic treatment(s)

77 (22,8%)

70 (21,1%)

147 (22,0%)

Periodontal Status

Absence of periodontal lesions

253 (75,1%)

245 (73,8%)

498 (74,4%)

 

Horizontal and/or vertical periodontal bone lesions deeper than the midlevel of the respective root without furcation involvement

30 (8,9%)

33 (9,9%)

63 (9,4%)

 

Periodontal bone lesions with furcation involvement

54 (16,0%)

54 (16,3%)

108 (16,1%)

On the right side, there was no statistically significant relationship between the presence of AMO and pathological formation (p> 0.05). While 5.4% of the cases with AMO had maxillary sinusitis, 35.7% had mucosal thickening and 7.8% had retention cysts Of the cases without AMO, maxillary sinusitis was observed in 8.4%, mucosal thickening in 32.6%, and retention cysts in 10.3%.

On the left side, there was no statistically significant relationship between the presence of the AMO and pathological formation (p > 0.05). Maxillary sinusitis was observed in 4.3% of the cases with AMO, mucosal thickening in 31.9% and retention cysts in 13%. Of the cases without AMO, maxillary sinusitis was observed in 9.1%, mucosal thickening in 31.7%, and retention cysts in 8.3%.

There was no statistically significant relationship between the presence of AMO and pathological formation in all individuals (p > 0.05). Maxillary sinusitis was observed in 4.9% of the cases with AMO, mucosal thickening in 33.7% and retention cyst in 10.5%. Of the cases without AMO, maxillary sinusitis was observed in 8.8%, mucosal thickening in 32.2%, and retention cyst in 9.4% (Table 2).

In addition There was no statistically significant difference between the incidence of AMO and the incidence of agger nasi cells, Haller cells, concha bullosa, i.conca hypertrophy and paradoxical middle turbinate, spur formation and nasal septal deviation(p = 0,846, p = 0,351, p = 0,905, p = 0,109, p = 0,344, p =0,819, p = 0,421 respectively) (Table 2).

Table 2

 Relationship between maxillary accessory ostium and sinonasal pathology, sinonasal variation , endodontic and periodontal status, 

 

 

Right

 

Left

 

Total

 

 

Accessory Ostium

 

Accessory Ostium

 

Accessory Ostium

 


Presence 

Absence

 

Presence

Absence

 

Presence

Absence

 

 

n (%)

n (%)

p

n (%)

n (%)

p

n (%)

n (%)

p

Sinonasal Pathology

 

 

 

 

 

 

 

 

 

 

 

 

Maxillary sinusitis

7 (5,4%)

22 (8,4%)

 

20,570

6 (4,3%)

23 (9,1%)

 

20,104

13 (4,9%)

45 (8,8%)

 

20,261

Mucosal thickening

46 (35,7%)

85 (32,6%)

 

 

44 (31,9%)

80 (31,7%)

 

 

90 (33,7%)

165 (32,2%)

 

 

Mucus retention cysts

10 (7,8%)

27 (10,3%)

 

 

18 (13%)

21 (8,3%)

 

 

28 (10,5%)

48 (9,4%)

 

 

Endodontic status

 

 

 

 

 

 

 

 

 

Absence of endodontic pathology or treatment

79 (71,2%)

137 (60,6%)

20,066

90 (75%)

139 (65,6%)

20,117

169 (73,2%)

276 (63%)

20,007*

Endodontic treatment(s) without visible pathology

15 (13,5%)

29 (12,8%)

 

12 (10%)

21 (9,9%)

 

27 (11,7%)

50 (11,4%)

 

Apical lesion(s) with or without visible endodontic treatment

17 (15,3%)

60 (26,5%)

 

18 (15%)

52 (24,5%)

 

35 (15,2%)

112 (25,6%)

 

Periodontal status

 

 

 

 

 

 

 

 

 

Absence of periodontal lesions

84 (75,7%)

169 (74,8%)

20,262

96 (80%)

149 (70,3%)

20,154

180 (77,9%)

318 (72,6%)

20,183

Horizontal and/or vertical periodontal bone lesions deeper than the midlevel of the respective root without furcation involvement

13 (11,7%)

17 (7,5%)

 

9 (7,5%)

24 (11,3%)

 

22 (9,5%)

41 (9,4%)

 

Periodontal bone lesions with furcation involvement

14 (12,6%)

40 (17,7%)

 

15 (12,5%)

39 (18,4%)

 

29 (12,6%)

79 (18%)

 

Variation

 

 

 

 

 

 

 

 

 

Agger nasi cells

116 (89,9%)

225 (86,2%)

10,379

120 (87%)

226 (89,7%)

10,518

236 (88,4%)

451 (87,9%)

10,846

Haller cells

49 (38%)

81   (31%)

20,171

42 (30,4%)

77 (30,6%)

20,980

91 (34,1%)

158 (30,8%)

10,351

Concha bullosa

64 (49,6%)

123 (47,1%)

20,644

72 (52,2%)

136 (54%)

20,734

136 (50,9%)

259 (50,5%)

10,905

Inferior concha hypertrophy

37 (28,7%)

95 (36,4%)

20,130

43 (31,2%)

88 (34,9%)

20,452

80 (30%)

183 (35,7%)

10,109

Paradoxical middle turbinate

20 (15,5%)

27 (10,3%)

10,191

13 (9,4%)

25 (9,9%)

11,000

33 (12,4%)

52 (10,1%)

10,344

Nasal septal spur

-

-

-

-

-

-

44 (34,1%)

86 (33,0%)

20,819

Nasal septal deviation

 

 

 

 

 

 

 

84 (65,1%)

159 (60,9%)

20,421

1Continuity (yates) correction     2Chi-Square test 

The relationship of the AMO with the endodontic and periodontal conditions of the teeth in the posterior maxilla is presented in Table 2.

There was no statistically significant relationship between the presence of AMO and the endodontic status of the teeth on both the right and left sides (p > 0.05). In total, the rate of endodontic treatment or absence of pathology (73.2%) in patients with AMO was significantly higher than in patients without AMO (63%). There was no statistically significant relationship between the presence of AMO and periodontal status (p> 0.05).

While there was no statistically significant difference between the mean age in terms of the presence of AMO (p> 0.05), the rate of AMO in males (38.3%) was more statistically significant than that of the females (31.5%) (p: 0.049; p < 0.05).

Discussion

The present study assessed frequency of AMO in 780 maxillary sinuses from 390 CBCT images, examining them in terms of age, gender, its association with sinus variation, pathological formations, status of the dentition, and endodontic and periodontal pathology.

In the literature, the prevalence of AMO in humans is reported to be in the range of 0-43%. Detailed radiological evaluation of the presence of AMO before surgical interventions in the sinus area is normally recommended, and takes the form of functional endoscopic sinus surgeries, maxillary sinus floor elevation, apical surgery, and extraction of impacted teeth in the posterior maxilla [1,7].

In the present study, while there was no statistically significant difference between the mean age in terms of the presence of AMO, the frequency of AMO in males (38.3%) was more statistically significant than in females (31.5%). 

The literature varies regarding the amount of mucosal thickening that is accepted as pathology.

Rak et al. noted that a mucosal thickening of>3mm may not cause symptoms in the patient [13] and Phothikhun et al. concluded that 5mm mucosal thickening does not accompany clinical symptoms in most cases [14]. In our study, we used the criteria of Capelli et al., Maillet et al., and Lu et al., which argues that thickening of the mucosa greater than 2mm is considered pathological [15–17].

Mucus retention cysts are usually located in the maxillary sinus and their prevalence in the general population has been reported to be approximately 9-22%. On CBCT scans, they appear as well-circumscribed hypodense masses [7]. In the literature, it is unclear whether chronic sinusitis causes the formation of AMO or whether the presence of AMO causes chronic sinusitis by recirculation of mucus secretions [6]. While some studies state that 30% of patients diagnosed with chronic maxillary sinusitis have AMO, the rate of AMO in healthy individuals is 10-20% [18,19]. Some studies state that there is a strong relationship between chronic maxillary sinusitis and AMO [7,20]. The present study showed that there is no statistically significant relationship between the presence of AMO and pathological formation in all individuals. This result is in line with the three previous CBCT studies which reported AMO was not associated with the morphological changes of the sinus mucosa[1,12,15] and chronic sinusitis [18,19]. 

Haller cells play a possible obstructive role in sinus drainage. It has been reported in the literature that the prevalence of Haller cells is highly variable between 2.7% and 45.1%. Ali et al. suggested that sinusitis caused by Haller cells may cause the development of AMO [8]. In contrast, Mathew et al. stated that there was no statistically significant association between the existence and size of Haller cells and maxillary sinusitis [21].

Özcan et al. stated that there was no significant relationship between maxillary sinuses with Haller cells and the presence of AMO [22]. In the present study we found that there was no statistically significant difference between the incidence of AMO and, Haller cells which is in line with Özcan et al.s’ study. 

The middle turbinate plays an important role in the drainage of the maxillary sinus. While extreme nasal septal deviation may occlude the osteomeatal unit, the role of minimal or moderately abnormal middle turbinate and nasal septal deviation in the etiology of inflammation in the paranasal region is controversial. Similarly, sinonasal variations such as concha bullosa, i. concha hypertrophy, pneumatization of the middle concha , septal spur and septal deviation may cause narrowing or obstruction of the osteomeatal unit, by reducing the normal airflow and mucociliary clearance of the sinuses [23]. Yenigün et al assessed frequency of AMO, simultaneous occurrence of AMO and agger nasi cells, concha bullosa, i. concha hypertrophy, pneumatization of the middle concha and septal deviation. Their research concluded that there was no statistical significance for the simultaneous occurrence of AMO and these sinonasal variations [7]. Similarly, in our study, we found that there was no statistically significant difference between the incidence of AMO and agger nasi cells, concha bullosa, i. concha hypertrophy, paradoxical middle turbinate, septal spur, or nasal septal deviation. 

Hung et al. stated that AMO was observed more in sinuses not associated with endodontic pathology in their study [1].Similarly, Yeung et al revealed that endodontic pathology did not have a significant influence on AMO presence [12]. In the current study, although there was no statistically significant relationship between the presence of AMO and endodontic status on the right and left sides (p> 0.05), in total, there was a statistically significant difference between the presence of the AMO and the endodontic state (p 0.007; p <0.05). The absence of endodontic treatment or pathology in AMO cases (73.2%) was significantly higher than in cases without AMO (63%), which is in line with Hung et al.

In addition, Lu et al. found that the prevalence and severity of maxillary sinus mucosal thickening was positively correlated with the degree of apical periodontitis [17]. Phothiknun et al. reported that sinuses adjacent to teeth with severe periodontal bone loss were 3 times more likely to have mucosal thickening [14]. Hung et al. evaluated AMO and periodontal pathology and reported that having periodontal pathology seems to be a factor associated with a decrease in length of the AMO long axis and AMO surface [1]. In the present study, we found that there is no statistically significant relationship between the presence of AMO and periodontal status.

Also Dedeoglu et al. concluded that the frequency of AMO was increased in the elderly, especially regarding edentulism [24].  But contrary to Dedeoğlu et al.’s arguments, Hung et al. demonstrated that dentition did not have a significant effect on the presence of AMO. They also stated that the dentition of the posterior maxilla had a significant effect on the shape of AMO.[1] In the present study we detected that there was no significant difference between the incidence of AMO according to the dentation, which is in line with Hung et al.s’ study (p > 0.05). 

To the best of our knowledge, this is the first study using CBCT images to assess relationship between the status of the dentition in the posterior maxilla with AMO presence in Turkish subpopulation. It has had some limitations, including small samples size used. Further studies are needed on larger groups in this area.

Conclusion

We concluded that while there was no observed relationship between AMO and age, presence of mucosal thickness, mucus retention cysts, maxillary sinusitis, sinonasal variation, status of the dentition or periodontal status of posterior maxilla, there was in fact a relationship between AMO and gender and endodontic status. We suggest a detailed radiological assessment to determine the presence of AMO before surgical interventions in the sinonasal region. CBCT is a useful technic for the evaluations. 

Declarations

Author contributions:  ÖO: Data collection and analysis. GAŞ:  Project development and manuscript writing

Funding: The authors did not receive support from any organization for the submitted work. 

Declarations 

Conflict of interest:  The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the local ethics committee (Non-Invasive Clinical Research Ethics Committee, Altınbas University Faculty of Dentistry; Date:2021  Number: 47).

Consent to participate 

Informed consent was obtained from all individual participants included in the study. Consent to publish Patients signed informed consent regarding publishing their data.

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