Original Articles ORTHODONTICS AN ASSOCIATION BETWEEN DIMENSIONS AND BRIDGING OF THE SELLA TURCICA AND DENTAL ANOMALIES

Abstract

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.

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Stoma Edu J. 2021;8(1):
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Original Articles
ORTHODONTICS
AN ASSOCIATION BETWEEN DIMENSIONS
AND BRIDGING OF THE SELLA TURCICA AND DENTAL
ANOMALIES
Seden Akan1a , Nevin Kaptan Akar2b
1Department of Orthodontics, Faculty of Dentistry, of the Altınbaș University, Bakırköy / İstanbul, Turkey
2Department of Orthodontics, İstanbul Medipol University Faculty of Dentistry, İstanbul, Turkey
aDDS, PhD, Assistant Professor; e-mail: sedenakandt@hotmail.com; ORCIDiD: https://orcid.org/0000-0001-7955-3086
bDDS, PhD, Assistant Professor; e-mail: nakar@medipol.edu.tr; ORCIDiD: https://orcid.org/0000-0003-1208-6369
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 inuence of
craniofacial growth) were used.
Results The frequency of complete calcication of the Sella was greater in the group with supernumerary
teeth (23%) and in the group with hypodontia (14.7%), while partial calcication 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 at Sella was rarely seen. In terms of the inuence of growth on the dimensions
of the Sella, there was no statistically signicant dierence between pre- and post-treatment radiographs.
Conclusion Signicant relationships were found between dental anomalies and bridging and shape of the
Sella. The Sella was also signicantly 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.
ABSTRACT
Sella Turcica Bridging; Hypodontia; Transposition; Supernumerary Tooth; Digital Radiography.
KEYWORDS
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):309-315.
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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1. INTRODUCTION
The Sella turcica is a depression in the middle line
of the upper surface of the sphenoid bone. For
orthodontists, the Sella is a well-known anatomical
structure on the scalp, because it is the central
reference landmark in the evaluation of craniofacial
morphology and the maxillomandibular relationship.
The name Sella turcica, Latin for “Turkish saddle,”
derives from the structure’s similarity in shape to a
saddle used by the Turks [1]. The anterior border of
the Sella turcica is marked by the tuberculum Sella
and the posterior border is marked by the dorsum
Sella [2]. The pituitary gland is located in the Sella
turcica, and two anterior and posterior clinoid
processes project over the pituitary fossa [2].
During the embryological period, the Sella turcica
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Akan S, et al.
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..
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is the key point for the migration of the neural crest
cells to the frontonasal and maxillary developmental
elds [3]. The neural crest cells are involved in the
formation and development of the Sella turcica
and the teeth [4]. Given this relationship between
the Sella turcica and the teeth, it has been argued
that anatomic deviations in the Sella turcica may be
related to dental alterations. Thus, the morphology
of the Sella has been studied in relation to skeletal
malocclusions [5,6], Down syndrome [7], cleft
subjects [8], and dental anomalies such as dental
transposition [9], absence of the second premolar
[10], and palatally displaced canines [10].
In lateral cephalometry, the Sella turcica is
U-shaped. The size of the Sella turcica has been
evaluated widely in the literature and ranges from
4 to 12 mm in depth and from 5 to 16 mm for the
anteroposterior diameter [11]. Three dierent shapes
of the Sella have been identied in the literature:
oval, round, and at. Of the three, the oval and
round types are more common. The Sella turcica
is divided into three segments: an anterior wall, a
oor, and a posterior wall [4]. Bridging of the Sella
turcica has been described as a bony union of the
anterior and posterior clinoid processes. Bridging
is regarded as an anatomical abnormality, and it
is particularly prevalent in craniofacial deviations
and developmental conditions such as basal cell
carcinoma, Williams syndrome, Rieger syndrome,
and other disorders [6]. The current study was
therefore performed to evaluate the dimensions of
the Sella turcica and the incidence of bridging of
the Sella turcica in patients with dental anomalies
(transpositions, hypodontia, and supernumerary
teeth), to compare them with the controls, and to
assess whether any signicant changes occurred
in the dimensions of the Sella during craniofacial
growth in patients with dental anomalies.
2. MATERIALS AND METHODS
2.1. Study Population
This retrospective radiographic study, approved by
the institutional ethical board (ref.10840098-604),
was carried out on the cephalometric radiographs of
25 patients (21females and four males) with dental
transposition, 88 patients (55 females and 33 males)
with hypodontia, and 26 patients (13 females and 13
males) with supernumerary teeth. Only patients with
good-quality lateral cephalometric and panoramic
radiographs were included in the study. The exclusion
criteria were as follows: presence of any syndrome or
systemic disease, previous orthodontic treatment,
excess craniofacial deviations, and history of trauma.
Group
Transposition Hypodontia Supernumerary Control Total
Gender
Female/Male 21/4 55/33 13/13 33/19 122/69
Age (Mean±SD) 15.81±3.51 16.54±4.60 16.60±4.30 17.96±4.05 16.84±4.31
Table 1. Descriptive statistics and gender distribution of study groups.
P value for age was 0.143
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Sellar bridging and dental anomalies
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.
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The control group was created according to power
analysis (α = 0.05, f = 0.25, power = 0.80) and
consisted of 52 subjects (33 females and 19 males).
The same inclusion and exclusion criteria were used
as for the dental anomaly groups. The study groups
are described in TableI.
2.2. Cephalometric Analysis
Pre-treatment lateral cephalometric and panoramic
radiographs of all the patient groups and the
control group were taken according to the standard
technique for evaluating cranial structures, using a
Kodak Extraoral Imaging System machine (Kodak
9000, Carestream Health, Inc., Rochester, NY, USA)
and a cephalostat with a xed magnication factor.
Only radiographs with good-quality images of the
Sella turcica area were selected for analysis. The
region around the contour of the pituitary fossa from
the tip of the dorsum sellae to the tuberculum sellae
was traced on the lateral cephalometric images using
acetate paper and a 0.5 mm lead pencil. The tracing
and measurements were performed manually by
one observer (SA) under ideal lighting conditions.
Bridging of the Sella turcica was evaluated in
accordance with the standardized scoring scale
method of Leonardi et al. [10] A Sella was scored as
having “no calcication” when its length was greater
than or equal to three-fourths of its diameter, as
“partially calcied” when its length was less than
three-fourths of its diameter, and as “completely
calcied” when only the diaphragma sellae
could be seen radiographically (Fig. 1). The linear
characteristics of the Sella turcica were measured
in accordance with Silverman’s method [12]. The
length of the Sella turcica was measured from the
tuberculum sellae to the tip of the dorsum sellae.
Its depth was measured perpendicularly to this line
passing through the deepest point of the pituitary
fossa. Its diameter was measured in the sagittal
direction by drawing a line from the tuberculum
sellae to the most distant point on the posterior
inner wall of the fossa (Fig. 2). Morphologically, each
Sella turcica was classied as one of the three basic
types (round, oval, or at), in accordance with the
method of Jones et al. (Fig. 1) [13] .
2.3. Evaluation of Inuence of Craniofacial Growth
To assess the possible eects of craniofacial growth
on the size, shape, and bridging of the Sella, post-
treatment cephalometric radiographs of 15 patients
selected at random from the study groups were
compared to their pre-treatment radiographs. The
mean time period between pre- and post-treatment
radiographs was 3.21 ± 1.19 years.
2.4. Statistical Analysis
Analysis of the data was performed in the SPSS 16
package (SPSS for Windows, SPSS Inc., Chicago, IL,
USA). Means, standard deviations, and minimum and
maximum values were calculated, and the Shapiro–
Wilks normality test was applied to the data. One-
way analysis of variance (ANOVA) and a Tukey post
hoc test were used to assess dierences between the
linear dimensions of the groups, while nominal data
were tested using a chi-squared test. A T-test was
used to evaluate the inuence of craniofacial growth
on the measurements. To determine intra-rater
reliability, 20 cephalometric radiographs selected at
random were retraced after two weeks, and Pearson
correlation coecients were calculated (ranging
from 0.810 to 0.862). The statistical signicance was
set at p<0.05.
3. RESULTS
Table I shows the descriptive statistics and p-values
for the study groups and the control group. Table II
shows the distribution of the degree of calcication
of the Sella turcica in the study and control groups.
Complete calcication of the Sellawas more frequent
in the group with supernumerary teeth (23%) and
in the group with hypodontia (14.7%), while the
partial calcication of the Sella was more frequent
in the control group (77%) and in the group with
supernumerary teeth (73%) (p=0.025).
The average linear dimensions of the sella turcica in
the study groups and the control group are shown
in Table II. The depth of the sella was greatest in the
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Akan S, et al.
group with dental transposition, and the dierence
from the group with supernumerary teeth was
statistically signicant (p<0.05). The distribution
of the shape of the Sellaturcica in the study and
control groups is also shown in Table II. Oval and
round shapes were more frequent in all groups, and
a at sella was rarely seen (p=0.001). According to
the results of the T-test, there was no statistically
signicant dierence between the pre- and post-
treatment radiographs in terms of the inuence of
the growth on the dimensions and bridging of the
sella.
4. DISCUSSION
In this retrospective study, certain characteristics
and dimensions of the Sella turcica were analyzed
on pre-treatment standardized lateral cephalometric
radiographs. The aim was to assess the shapes,
dimensions, and the incidence of bridging of the
Sella turcica in subjects with dental anomalies
(transpositions, hypodontia, and supernumerary
teeth) compared to control subjects. These
parameters have not previously been studied in
Turkish orthodontic patients. The literature reports
Sella bridging, dened as ossication between
the anterior and posterior clinoid processes in
the dura mater, as a determinant factor for dental
anomalies. Although bridging is seen in healthy
subjects [14], it occurs more frequently in subjects
with craniofacial deviations (i.e. carcinomas [15],
syndromes [16], and skeletal malocclusions [17,18]).
From an embryologic point of view, the anterior
wall of the Sella turcica develops from neural crest
cells, as teeth do; thus, deviations in the anterior
wall are believed to be related to dental anomalies
[14]. In the present study, bridging of the Sella
turcica at the completely calcied level was seen
in 23.1% of the patients with supernumerary teeth,
in 14.7% of the patients with hypodontia, in 8% of
the patients with transposition, and in 3.8% of the
control patients (total frequency = 12%). Bridging
at the partially calcied level was seen in 73.1% of
the patients with supernumerary teeth, in 66% of
the patients with hypodontia, in 56% of the patients
with transposition, and in 77% of the control patients
(total frequency = 68.6%). The ndings of the present
study are dierent from those of comparable studies.
For example, in patients with supernumerary teeth,
bridging of the Sella turcica has previously been
reported at the partially calcied level in 53% of
the patients and at completely calcied level in
6% of the patients; in that study, the levels for the
control patients were 30% and 13%, respectively
[19]. In a study of patients with transposition, 42.9%
were at the partially calcied level and 23.8% at the
completely calcied level; the levels for the control
patients were 68.6% and 5.7%, respectively.9 In a
study of patients with supernumerary teeth, 21.7%
were at the partially calcied level and 21.7% were
at the completely calcied level; the levels for the
control patients were 19.4% and 5.6%, respectively
[20]. These dierences between previous studies
and the present ndings may be due to the number
of patients included in each study and the nature
of their existing malformations, as bridging of the
Sella turcica has been related in the literature to
craniofacial deviations. Many studies have reported
patients with Class III malocclusion as having a
greater proportion of bridging of the Sella than
ClassI patients [17,18,21]. The size of the Sella turcica
Group
Trasposition Hypodontia Supernumerary Control P
Bridging Type
n(%)
(x)
No Calcification 9 (36) 17 (19.3) 1 (3.8) 10 (19.2)
0.025*
Partially
Calcified 14 (56) 58 (66) 19 (73.1) 40 (77)
Completelly
Calcified 2 (8) 13 (14.7) 6 (23.1) 2 (3.8)
Linear
Dimensions
(Mean±SD)
(à)
Length 5.04±2.75 4.48±2.78 3.88±2.37 4.71±2.34 0.421
Depth 7.48±1.36 6.93±1.26 6.42±1.10 6.86±0.99 0.018*
Diamater 9.12±1.83 8.40±2.13 7.92±1.63 8.33±1.63 0.154
Shape of Sella
n(%)
(x)
Oval 5 (20) 10 (11.4) 13 (50) 19 (36.5)
0.001**
Round 18 (72) 69 (78.4) 13 (50) 27 (52)
Flat 2 (8) 9 (10.2) 0 6 (11.3)
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..
(x) means Chi square statistics, * P<0.05. (à) means ANOVA test * P<0.05. According to Tukey Post hoc test; a statistically signicant dierence was
found only between transposition and supernumerary groups P=0.009*
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Original Articles
Sellar bridging and dental anomalies
has been studied in detail in the literature, with
the linear measurements ranging from 4 to 12 mm
in depth and 5 to 16 mm in length [11,12]. In the
present study, there were no statistically signicant
dierences between the patient groups; lengths
ranged from 3.88 to 5.04 mm and diameters from
7.92 to 9.12 mm. There was a statistically signicant
dierence in the depth of the Sella between the
patients with transposition (7.48 mm) and those
with supernumerary teeth (6.42 mm) (p=0.018). The
dierence between the present ndings and the
measurements in the literature may be due to the
use of dierent landmarks and levels of radiographic
magnication. Some studies have revealed a
correlation between the linear dimensions of the
Sella and age and growth as factors associated
with bridging of the Sella [22], whereas others
have denied any association [23]. In the present
study, the eects of growth on the characteristics
of the Sella were evaluated by measuring the size,
shape, and bridging of the Sella on the pre- and
post-orthodontic cephalometric radiographs of
15 patients. No statistically signicant dierence
(p>0.05) was found in either the pre-treatment or
the post-treatment data; however, the correlation
between the Sella characteristics and age should be
analyzed on a larger sample of cephalograms. The
shape of the Sella turcica is aected by anatomical
structures: the pituitary gland, the extent of the
anterior and posterior intercavernous venous sinuses
[24], and the internal carotid artery [25]. The shape of
the Sella turcica is also determined genetically [26].
In the present study, the shape of the Sella turcica
was classied as oval, round, or at, in line with
the approach taken by Jones et al [13]. Although
Jones et al. [20] did not provide any data about the
prevalence of the dierent shapes, other studies
have shown the oval shape to be the most common
among Nigerian subjects [27]. In the present study,
consistent with the literature, the round shape was
the most common in all groups, followed by the oval
shape and then the at type. This study was limited
by a number of factors, including a lack of gender
discrimination between the groups. Some studies
have suggested that there is no gender correlation in
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
patients in the study groups was balanced. A further
limitation is that this study used two-dimensional
lateral cephalometric radiographs instead of three-
dimensional cone beam computerized tomography
images, which limited the capacity to determine the
characteristics of the sella turcica. Three-dimensional
images are more informative and reliable, but they
are no routine diagnostic tools in orthodontics for
the dental anomalies under study here.
The clinical relevance of the present study relates to
early diagnosis of dental anomalies. The ndings may
allow clinicians to provide preventive measures for
specic patient groups, especially with a diagnosis of
transposition and the possibility of supernumerary
teeth in the early period.
5. CONCLUSION
The ndings of the present study indicate that
bridging of the Sellaturcica was more frequent in
patients with supernumerary teeth and hypodontia.
The Sella was deeper in patients with transposition,
and in terms of shape, oval and round sellae were
the most frequent in all groups. Although the
study groups were not divided according to age,
the results of the growth evaluation showed no
signicant change in the dimensions of the Sella
during craniofacial growth in patients with dental
anomalies.
CONFLICT OF INTEREST
The authors declare no conict of interest.
ACKNOWLEDGMENTS
None.
AUTHOR CONTRIBUTIONS
SA: contributed to the concept and design of the study, the
acquisition, analysis and interpretation of the data and drafting
the article. NKA: participated by adding her patient records and
revising the article critically. All authors read and approved the
nal manuscript.
FUNDING
The authors declare that they have not received any funding.
COMPETING INTERESTS
The authors declare that they have no competing interests.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
A written informed consent containing all the information about
records and usage for study was obtained from all patients. All
procedures in this study were approved by the Ethical Board of the
Istanbul Medipol University (10840098-604) and complied with
the Code of Ethics of the World Medical Association (Declaration
of Helsinki).
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Stoma Edu J. 2021;8(1):
pISSN 2360-2406; eISSN 2502-0285
www.stomaeduj.com
Original Articles
Sellar bridging and dental anomalies
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.
Seden AKAN
Department of Orthodontics
Faculty of Dentistry
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 eect 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.
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