Prevalence, location and
morphology of maxillary sinus
septa: systematic review and
Pommer B, Ulm C, Lorenzoni M, Palmer R, Watzek G, Zechner W. Prevalence,
location and morphology of maxillary sinus septa: systematic review and meta-
analysis. J Clin Periodontol 2012; 39: 769–773. doi: 10.1111/j.1600-051X.2012.01897.x.
Aim: To gain further insights and resolve conflicting results in the literature
regarding prevalence, predominant location and morphologic variability of maxil-
lary sinus septa.
Material and Methods: Electronic and hand searching of English literature identi-
fied 33 investigations published from 1995 to 2011. Septa were defined as at least
2–4 mm in height.
Results: Septa were present in 28.4% of 8923 sinuses investigated (95% confi-
dence interval: 24.3–32.5%). Prevalence was significantly higher in atrophic
sinuses compared with dentate maxillae (p < 0.001). Septa were located in premo-
lar, molar and retromolar regions in 24.4%, 54.6% and 21.0% respectively. Ori-
entation of septa was transverse in 87.6%, sagittal in 11.1% and horizontal in
1.3% of cases. Septa height measured 7.5 mm on average. Complete septa (divid-
ing the sinus into two separate cavities) were found in only 0.3%. Other rare con-
ditions included multiple septa in one sinus (4.2%) and bilateral septa (17.2%).
Septa diagnosis using panoramic radiographs yielded incorrect results in 29% of
Conclusions: In view of their high overall prevalence and significant morphologic
variability, 3D radiographic imaging prior to sinus floor augmentation may help
to reduce complication rates in the presence of maxillary sinus septa.
Bernhard Pommer1, Christian Ulm2,
Martin Lorenzoni3, Richard Palmer4,
Georg Watzek1and Werner Zechner1
1Department of Oral Surgery, Vienna Medical
University, Vienna, Austria;2Department of
Periodontology, Vienna Medical University,
Vienna, Austria;3Department of
Prosthodontics, University Dental Clinic Graz,
Graz, Austria;4Department of Restorative
Dentistry, King’s College London, London,UK
Key words: dental implants; maxillary sinus
floor elevation; radiographic diagnosis; sinus
anatomy; sinus membrane perforation
Accepted for publication 15 April 2012
Maxillary sinus septa are barriers of
cortical bone that divide the maxil-
lary sinus floor into multiple com-
sinus anatomy is largely based on
the work of Austrian anatomist Emil
(Stammberger 1989); however, max-
illary sinus septa were first analysed
regarding their prevalence and char-
acteristics by Arthur S. Underwood,
an anatomist at King’s College Lon-
don, and are thus also referred to as
1910). Although sinus septa have
been considered clinically insignifi-
cant variations for decades, they
have gained practical relevance for
periodontists, oral and maxillofacial
surgeons as well as otolaryngologists
(Rysz & Bakon ´ 2009). Septa have
become increasingly important after
the introduction of sinus floor aug-
mentation surgery as their presence
may complicate both creation and
inversion of the access window in
the lateral sinus wall, as well as ele-
vation of the sinus membrane from
Conflict of interest and source of
The authors declare that they have no
conflict of interests.
No external funding was obtained.
© 2012 John Wiley & Sons A/S
J Clin Periodontol 2012; 39: 769–773 doi: 10.1111/j.1600-051X.2012.01897.x
the bony sinus floor (Betts & Miloro
septa ranges between 10% and 58%
in the literature (Yang et al. 2009,
Maestre-Ferrı´n et al. 2011). Recent
literature reviews on the topic identi-
fied conflicting study results regard-
ing not only overall prevalence but
also septa height,
septa location as well as prevalence
in edentulism (Katranji et al. 2008,
Maestre-Ferrı´n et al. 2010, Rossetti
et al. 2010). Therefore, the aim of
this investigation was to gain fur-
ther insights into prevalence, loca-
tion and morphology of maxillary
sinus septa using a meta-analytic
Material and Methods
Literature search and selection
A MEDLINE search of English lit-
erature (last search performed on 1
January 2012, key words: maxillary
sinus septa, antral septa, maxillary
sinus bone ridges, maxillary sinus
sinus and maxillary sinus crests) was
supplemented by hand searching rel-
evant journals including electronic
publications ahead of print (Clinical
Research, Implant Dentistry, Interna-
tional Journal of Oral and Maxillofa-
cial Implants, Journal of Clinical
Implantology, Journal of Oral and
Maxillofacial Surgery and Journal of
Periodontology) and reference lists of
retrieved papers as well as review
articles. Studies were considered if
they met the following inclusion cri-
teria: (1) trials investigating maxil-
lary sinus septa by 3D radiographic
adults, and (2) presenting data on
septa prevalence (primary outcome).
Reporting on secondary
height, septa integrity, septa orienta-
was not considered a criterion for
inclusion. After exclusion of 703
screened. Full texts of 566 papers
were obtained for further assessment
against the stated criteria: 512 did
not meet inclusion criterion 1 and 19
did not meet criterion 2 (Appen-
Data collection and validity assessment
data extraction and methodological
appraisal. Authors of seven studies
were contacted for clarification or
missing data (listed in Acknowledge-
Ottawa scale (NOS) was used as
quality assessment tool (Wells et al.
2001). Studies that received NOS
ratings ?7 stars (of nine possible
stars) were judged as high quality
(Chak et al. 2009) and included in
the analysis, whereas two studies
had to be excluded (NOS rating of
six stars): one study (Shibli et al.
2007) was allotted no star in NOS
category F (assessment of outcome)
due to retrospective evaluation of
et al. 2001) revealed shortcomings in
NOS category A (representativeness
of the exposed cohort) due to non-
consecutive recruitment of human
cadaver half-heads. The vast major-
ity of included studies, by contrast,
evaluated both sinuses of a subject
allowed data extraction for patient-
based statistical analysis.
Study characteristics and quantitative
tuted the final selection (Table 1)
tomographic images, 729 in patients
undergoing sinus surgery and 426 in
human cadavers. Twelve investiga-
tions regarded only septa higher
than 2–4 mm to exclude irregulari-
ties and uneven patches of the sinus
floor from the analysis, eight of
them used the threshold definition of
?2.5 mm proposed by Ulm et al.
(1995). Septa prevalence is given as
overall percentages with 95% confi-
means of septa height and 95% CIs
were computed. Comparison of sub-
groups was performed using Fisher’s
exact and independent two-sample
t-tests, for prevalence and height
(A + C)) and specificity (D/(B + D))
using computed tomography (CT) as
a reference standard were calculated
using absolute frequencies (A: septa
visible in both CT and PR, B: septa
visible in PR but not in CT, C: septa
D: septa not visible in both CT
and PR). All analyses were per-
formed using R 2.4.0 (R Foundation
for Statistical Computing, Vienna,
Prevalence of maxillary sinus septa
Septa were present in 28.4% of 8923
maxillary sinuses investigated in 33
patients featured septa in one sinus
only, whereas 17.2% showed them
bilaterally(n = 3731).
within the same sinus were observed in
3.7% [95% CI: 2.2–5.2], whereas only
0.5% [95% CI: 0.4–0.6] of sinuses had
three or more septa (n = 5323). Equal
numbers of septa were reported in
right (50.7%) and left (49.3%) sinuses
(n = 1986). Septa prevalence was sig-
nificantly lower in the Asian popula-
tion (22.9%, n = 1936, p < 0.001),
whereas no gender difference could
be observed (n = 1103, p = 0.207).
Location and height of maxillary sinus
The majority of septa (54.6% [95%
CI: 47.1–62.2]) were found in first or
whereas 24.4% [95% CI: 14.8–33.9]
and 21.0% [95% CI: 14.8–27.2] were
located in anterior (premolar) and
posterior (retromolar) sinus regions
respectively (Appendix S2).
prevalence was significantly higher in
dentate ridges (n = 1167, p < 0.001).
Septa distribution to anterior, mid-
dle and posterior regions showed sig-
nificant differences between dentate
(27.1%, 58.6%, 14.3%) and edentu-
lous ridges (12.6%, 69.5%, 17.9%)
molar regions following sinus pneuma-
tization (n = 339, p = 0.007).
septa height measured 7.5 mm (CI95%
6.7–8.4) (n = 1686) without differences
between dentate and edentulous ridges
(n = 339, p = 0.902).
© 2012 John Wiley & Sons A/S
Pommer et al.
Septa morphology and visualization on
The vast majority of sinus septa
(99.7% [95% CI: 99.1–100]) were
incomplete, whereas only 0.3% [95%
CI: 0.0–0.9] completely divided the
(n = 1825). Orientation of septa was
transverse (buccopalatal) in 87.6%
[95% CI: 78.4–96.7], sagittal (mesio-
distal) in 11.1% [95% CI: 2.1–20.2]
and horizontal (parallel to the sinus
floor) in 1.3% [95% CI: 0.0–3.6]
(n = 2038). Transverse septa demon-
strated significantly greater height at
their medial (palatal) insertion com-
aspect (6.9 mm
n = 299,p = 0.047).
sinus septa using panoramic radio-
graphs yielded incorrect results in
(n = 249). Using CT scans as the ref-
erence standard, panoramic radio-
graphs show a test sensitivity (true
positive rate) of 53.8% [95% CI:
37.3–70.4] and a test specificity (true
negative rate) of 80.4% [95% CI:
The overall prevalence of maxillary
sinus septa (28.4%) proved to be
only slightly lower than the fre-
quency of 33.3% reported one cen-
tury ago (Underwood 1910). The
septa (0.3%), saggital (11.1%) or
horizontal (1.3%) septa orientation,
multiple septa per sinus (4.2%) and
(17.2%). Conflicting results in con-
resolved: septa prevalence was found
to range between 24% and 33%
(four studies) in one review article
(Katranji et al. 2008) and from 13%
to 35% (11 studies) in a systematic
review that also considered investiga-
tions using panoramic radiographs
(Maestre-Ferrı´n et al. 2010). While
80% of included studies reported
more septa in partially edentulous
patients, a third review article con-
cluded that septa were more frequent
in edentulous jaws (Rossetti et al.
2010). In the present meta-analysis,
a significantly higher prevalence in
atrophic sinuses could be revealed.
results regarding predominant septa
location (55% in first or second
height (7.5 mm) could be settled.
Potential limitations may arise
from divergent criteria of septa defi-
studies. However, no significant dif-
ference in septa prevalence could be
found between threshold definitions
of <2.5 mm versus ?2.5 mm (27.9%
versus 27.1%, p = 0.786) as well as
Table 1. Prevalence of maxillary sinus septa per sinus in the 33 included studies as well as patient-based frequencies of uni- and bilateral
sinus septa: overall prevalence and 95% CIs (n.d. = no data)
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Becker et al. 2008
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Gosau et al. 2009
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Kasabah et al. 2002
Kasabah et al. 2003
Kfir et al. 2009
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Toscano et al. 2010
Ulm et al. 1995
van Zyl & van Heerden 2009
Vela ´ squez-Plata et al. 2002
Yang et al. 2009
Zijderveld et al. 2008
© 2012 John Wiley & Sons A/S
Meta-analysis on maxillary sinus septa
between studies with versus without
threshold definition (27.3% versus
29.2%, p = 0.277). Moreover, statis-
height reported in studies with versus
without threshold definition yielded
no significant difference (6.6 mm ver-
sus 7.7 mm,p = 0.301).
methodological issue that needs to
be considered is the risk of measure-
ment bias introduced by differences
in outcome assessment: septa evalua-
tion using 3D radiographic imaging
(7768 sinuses = 87%) versus direct
clinical observation (1155 sinuses =
15%), however, yielded no signifi-
cant different results (p = 0.102). As
radiographic investigations are fre-
patient groups like those referred for
implant treatment, recruitment bias
may be assumed (Selcuk et al. 2008).
This seems inevitable as radiation
tomography, diagnosis of sinus septa
yield incorrect results in 29% of
cases. Sinus septa showing a sagittal
orientation may not be diagnosable
at all using panoramic radiographs
and may thus lead to the false
assumption of narrow internal sinus
anatomy and subsequent non-aug-
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the sinus cavity. The necessity of
pre-operative radiographic imaging
should be judged on its therapeutic
consequences, in case of sinus floor
augmentation ranging from modifi-
cation in the surgical access strategy
(or window design) to change in
implant positions or total avoidance
of bone graft surgery. In view of the
high overall prevalence and signifi-
cant morphologic variability in sinus
septa seen in this investigation, 3D
radiography prior to sinus floor aug-
presence of maxillary sinus septa.
out in selected
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Additional Supporting Information
may be found in the online version
of this article:
Appendix S1. Flow chart for litera-
ture search and selection.
Appendix S2. Distribution of septa
to anterior, middle and posterior
sinus regions in 14 studies (overall
distribution [95% confidence inter-
Please note: Wiley-Blackwell are
not responsible for the content or
materials supplied by the authors.
Any queries (other than missing
material) should be directed to the
corresponding author for the article.
Department of Oral Surgery
Vienna Medical University
Scientific rationale for the study:
The presence of maxillary sinus
septa may be associated with a
higher risk of
sinus floor augmentation surgery
sinusitis and graft infection.
Principal findings: Septa are predom-
inantly found in first and second
molar regions. Most are incomplete
and show transverse (buccopalatal)
Practical implications: Therapeutic
consequences of sinus septa range
from modification in the surgical
access strategy (or window design)
to change in implant positions or
© 2012 John Wiley & Sons A/S
Meta-analysis on maxillary sinus septa