|Year : 2014 | Volume
| Issue : 4 | Page : 151-158
Sella turcica shape, linear dimensions, and cervical vertebrae staging in preorthodontic patients in Benin City, Nigeria
Idia N Ize-Iyamu
Department of Preventive Dentistry, University of Benin Teaching Hospital, University of Benin, Benin City, Edo State, Nigeria
|Date of Web Publication||11-Dec-2014|
Idia N Ize-Iyamu
P.O. Box 7022, Benin City, Edo State
Background: The sella turcica is one of the commonly used orthodontic landmarks in determining and diagnosing various problems of the facial skeleton; with the shape and linear dimensions found to vary in different types of skeletal classes especially during puberty where significant changes of the sella turcica occur. These pubertal changes can be assessed using the stage of maturation of the cervical vertebrae and a method; the Cervical vertebrae Maturation (CVM) method which could aid in the clinical determination of optimal treatment modalities. Materials and Methods: The sella turcica and first six cervical vertebrae were assessed on the cephalometric radiographs of 106 untreated orthodontic patients. Correlations between variables were determined by using the SPSS (version 16) software. Results: A normal sella turcica shape was the most frequently occurring in 65 (61.3%) of the total sample population. Skeletal Class II was the most predominant craniofacial problem in 53 (50%) and in 13 (46.4%) in CVM Stage 3, with a significant difference in the diameter, P < 0.05 in females with a skeletal Class I pattern. Maxillary prognathism with an increased sella-nasion-maxillary point A (SNA) value >90° was highest in 50 (47.2%). There was a significant difference in the diameter of the sella turcica among gender with skeletal Class II. The largest diameter of 18 mm was observed in females and in CVM Stage 4. The mean area of the sella turcica is the same for both CVM Stages 1 and 5 (74.07 mm 2 ). The difference in the area of the sella turcica was highest in the transition between Stages 1 and 2 (8.81 mm 2 ) and similar between Stages 2, 3, and 4 (2.38 mm 2 ). The mean area of the sella turcica demonstrated a sequential increase from CVM Stages 2-6. Conclusion: The CVM stages may be utilized as a diagnostic tool in the clinic to differentiate the pubertal growth spurt and determining the best time for treating certain orthodontic problems. The linear dimensions of the sella turcica cannot be used as a diagnostic tool in determining skeletal classes.
Keywords: Cervical vertebrae maturation, dimensions, sella turcica shape
|How to cite this article:|
Ize-Iyamu IN. Sella turcica shape, linear dimensions, and cervical vertebrae staging in preorthodontic patients in Benin City, Nigeria. Sahel Med J 2014;17:151-8
|How to cite this URL:|
Ize-Iyamu IN. Sella turcica shape, linear dimensions, and cervical vertebrae staging in preorthodontic patients in Benin City, Nigeria. Sahel Med J [serial online] 2014 [cited 2020 Feb 20];17:151-8. Available from: http://www.smjonline.org/text.asp?2014/17/4/151/146821
| Introduction|| |
The lateral cephalometric radiograph is used routinely in orthodontics to determine diagnosis, treatment planning, growth and development of the facial skeleton and pre and postoperative assessment changes of treatment. , The uniqueness of cephalometric analysis is that it not only depends on various reference points and landmarks of which the sella turcica is one of the most commonly used cranial landmarks, , but also the degree of maturation of the cervical vertebrae, which has been closely related with the onset of puberty and growth. , The advantage of this single investigative tool is that it can be used to determine the orthodontic problem and simultaneously indicate the stage of skeletal maturation by assessing and analyzing the second to the sixth cervical vertebrae in one film. ,,,,
The sella turcica is a saddle shaped area of bone located in the middle cranial fossa with the shape established in early embryonic life  with studies describing various shapes and morphologies for different populations. ,, Other studies ,,,,, had identified variations as circular, oval, flat, shallow and "j" shaped. Studies have recently identified different morphological shapes for the sella turcica and include a normal shape, an oblique anterior wall, a sella turcica bridge, double contour of the floor, irregularities of the posterior part of the dorsum sella and a pyramidal shape of the dorsum sella. ,, During puberty, growth changes occur which may alter the shape and size of the sella turcica and affect orthodontic diagnosis and treatment. ,, Functional appliances have been found to be beneficial in the treatment of skeletal Classes II and III during and prior to the pubertal growth spurt respectively, with the cervical vertebrae used as the identifying factor.  As the patient approaches puberty, the second to sixth cervical vertebrae exhibit different anatomical changes observed in the concavity of the lower border, height and shape of the vertebral body. ,,,, Six shapes have been identified and correlated to six stages of skeletal maturation on the cervical vertebra and to the pubertal growth spurt ,,,, for different racial groups and populations. It is important therefore to investigate in our environment if these pubertal changes as exhibited by changes in the cervical vertebrae would affect the sella turcica shape and linear dimensions, thereby determining the optimal time for the commencement of treatment of orthodontic patients.
Various studies have determined the linear dimensions of the sella turcica to include the length, depth and diameter. ,,,,, While these studies identified the linear dimensions for various populations and gender, ,, studies by Udoaka and Bassey  determined the mean length and depth of the sella turcica to be 10.8 + 1.7 mm and 8.2 + 1.6 mm, respectively in adult jaws of Nigerians in the Niger Delta region with no significant gender variation. Other studies on Asians  identified the mean length, depth and diameter to be 11.3, 9.9 and 13.8 mm, respectively with mild variations between genders. Studies have also found that variations exist between the skeletal classes and the linear dimensions of the sella turcica  with a significant difference between the diameter of the sella turcica in skeletal Classes II and III.  Other studies have identified orthodontic problems of the facial skeleton to also vary with linear dimensions of the sella turcica. , There however appear to be no studies in our environment investigating the relationship between the linear dimensions of the sella turcica and the skeletal classes or mal relationship of the bones of the facial skeleton, which would aid in the diagnosis and treatment planning of patients with varying clinical problems.
This study therefore aimed to determine if there is a correlation between the various stages of skeletal maturation of the cervical vertebrae and the linear dimension and shapes of the sella turcica in untreated orthodontic patients in Benin City, Nigeria.
| Materials and methods|| |
This cross-sectional analytical study was carried out on 106 pretreatment standardized digital cephalometric radiographs of 1 st time orthodontic patients of the University of Benin Teaching Hospital. All the radiographs from January 2012 to January 2013 were entered into an X-ray book and systematic random sampling was carried out with every second radiograph selected. Patients with congenital anomalies, medical conditions or illnesses were excluded from the study. Children below the age of 7 years were also excluded from the study. All the patients' radiographs were taken by the same radiographic technician in a standardized manner using a digital cephalometric machine (Planmeca Proline XC with Dimax 3 X-ray, 2006 model) set at ×1.25 magnification as recommended by the manufacturer. The images generated were stored directly in the computer data base created using the manufacturer's software (Dimaxis Pro version 4.1.4; Planmeca, Helsinki, Finland). Conventional measurements were taken using hard-copy printouts of the digital radiographs. Although a previous study found that slight enlargement may occur when printing hard copies of digital cephalograms, the size difference is minimal and regarded as clinically acceptable. , Only radiographs with the clearest reproduction of the sella turcica and the cervical vertebrae were analyzed.
Tracing of sella turcica
The contour of the sella turcica was traced manually on matte acetate paper 0.003 inches thick using a 0.05 mm lead pencil placed over the printed image. Morphological shapes were identified as described by Axelsson et al. 
Measurement of sella turcica dimensions
The linear measurements of length, depth, and diameter were done using the method described by Silverman.  The following were determined as below:
- Length: The distance between the tuberculum sella to the tip of the dorsum sella.
- Depth: Was determined by a perpendicular drawn from the line drawn from the tuberculum sella to the tip of the dorsum sella to the deepest point on the floor of the sella turcica.
- Diameter: This was done anteroposteriorly with a line drawn from the tuberculum sella to the most posterior point on the posterior wall of the sella turcica.
Intra operator reliability was assessed by randomly selecting 20 lateral cephalometric radiographs 2 weeks after the initial analysis and remeasuring the linear dimensions of the sella turcica. A k =0.84 was obtained indicating an almost perfect agreement.
Determination of orthodontic problems
Cephalometric analysis was also carried out to determine the orthodontic problems (sella-nasion-maxillary points A; mandibular point B [SNA, SNB], and ANB were assessed) using the Steiner analysis. 
SNA-(the innermost and concave part of the bony maxilla) to determine maxillary prognathism or retrognathism
- Nigerian values  of 82-89° were regarded as a normal maxilla.
- Values of < 81° were regarded as a retrusive maxilla and > 90° as maxillary prognathism. 
SNB-(the innermost and concave part of the bony mandible) to determine mandibular prognathism or retrognathism.
- Nigerian values of 79.5-85.9° were regarded as a normal mandible. 
- Values of < 79.4° were regarded as a retrusive mandible and > 86° as mandibular prognathism. 
ANB-point A to nasion to point B representing the skeletal pattern.
- Nigerian values of 2-4° represent skeletal pattern I. 
- < 1° skeletal pattern III and > 5° skeletal pattern II. 
Analysis of cervical vertebrae shape
Maturation stages were determined by the method described by Hassel and Farman.  Visual analysis consisted of viewing the morphology of the 2 nd -6 th cervical vertebrae [C2, C3 C4, C5, and C6 - [Figure 1] and [Figure 2] by one investigator (The author) under the same conditions and at two different intervals. The k =0.88 obtained gave a good intra-examiner interpretation. The most posterior, anterior and deepest parts of the lower border of the bodies of C2, C3 C4, C5, and C6 were traced on the radiograph and examined for the presence or absence of a concavity at the lower border of the bodies. They were also examined for the following shapes: trapezoid, wedge shaped C3 and nearly rectangular C4; rectangular horizontal, square and rectangular vertical to help in identifying the various CVM stages [Figure 2].
Data obtained was tested and analyzed with a Statistical Package for Social Sciences Software version 15.0 (SPSS Inc, IBM 2009). The Student's t-test was used to calculate the differences in the linear dimension of the sella turcica. A one-way analysis of variance (ANOVA) was carried out to determine if there was any association between the diameter and different sella turcica shapes and cervical vertebral maturation. The confidence level was set at 95% and probability values (P values) of P < 0.05 were regarded as significant.
| Results|| |
The study population comprised of 106 untreated orthodontic patients aged 7 to 32 years The 7-14 year old age group was seen in 36.8%, 15-25 years old in 50.9% and the ≥26 years old in 12.3%. The sella turcica in females showed a mean length, depth, and diameter of 9.93, 7.18, and 9.28 mm, respectively. Males showed a mean length, depth, and diameter of 10.48, 6.90, and 9.12 mm. There was an almost equal gender distribution with 50.9% females and 49.1% male.
Maxillary and mandibular prognathism or retrognathism were present using the SNA and SNB values for Nigerians.  Maxillary prognathism was the highest craniofacial problem in 47.2% and also in CVM Stage 3. Skeletal Classes I, II, and III were seen in CVM Stages 1-6 with Classes II and III demonstrating the highest and the lowest number in 50% and 14.2%, respectively. Skeletal Class II and CVM Stage 3 recorded the highest number with 46.4%.
The mean area (length × depth) of the sella turcica was 74.07 mm 2 in CVM Stages 1 and 5, with Stages 2, 3, 4, and 6 recording values of 65.26 mm 2 , 67.43 mm 2 , 69.81 mm 2 , and 79.95 mm 2 , respectively.
[Table 1] shows the distribution of the sella turcica linear dimensions with the 15-25 years old age group demonstrating the largest mean sella turcica depth with 7.23 mm. The standard error of estimate in the various age groups was higher in the length depth and diameter in the 25-32 years old.
|Table 1: Distribution of the mean length, depth and diameter of the sella turcica according to age |
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[Table 2] shows a one-way ANOVA of cervical vertebra maturation on the length, depth and diameter of the sella turcica with the lowest length of the sella turcica seen in Stage 4 as 9.93 mm. The standard error of estimate in the linear dimensions ranged from 0.25 in Stage 3 to 0.89 in Stage 4 with errors smaller in diameter and length when compared with the depth.
|Table 2: One-way ANOVA of cervical maturation on the length, depth and diameter of the sella turcica |
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[Table 3] shows the distribution of the various skeletal classes with the linear dimensions of the sella turcica according to gender with a significant difference in diameter in skeletal Class I, P < 0.05.
|Table 3: Skeletal class distribution of the mean length, depth and diameter of the sella turcica according to gender |
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[Table 4] shows the relationship between the cephalometric analysis of the facial skeleton and its relationship with the shape of the sella turcica.
|Table 4: Cephalometric analysis of the facial skeleton and of the shape of the sella turcica |
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[Figure 1] and [Figure 2] demonstrate the different morphological shapes of the sella turcica and the 2 nd -6 th cervical vertebrae, respectively. [Figure 3] shows the diagrammatic representation of the six stages of the cervical vertebrae.
|Figure 3: Diagrammatic representation of the six stages of cervical vertebral maturation as traced from cephalometric radiographs|
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The cervical vertebrae showed an equal gender distribution in Stage 1. CVM Stages 3 and 5 were seen in the highest number in 26.4% and 22.7%, respectively. There were more girls in Stages 2 (66.7%) and 3 (33.3%) than boys in 33.3% and 35.7%, respectively. Stages 4 and 5 were demonstrated more in boys with 73.3% and 58.3% when compared with girls in 26.7% and 41.7% [Figure 4].
[Figure 5] shows a comparative analysis of the different morphological shapes of the sella turcica and the six CVM stages. A normal sella turcica was most prevalent in all the six CVM stages and the irregular dorsum sellae variant was absent in Stages 2 and 4. There was a highly significant difference, P < 0.05 between the shape and maxillary prognathism, but no significant differences between the SNB values and the various skeletal classes.
|Figure 5: Comparative analysis of sella turcica shapes and CVM stages (P > 0.05)|
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| Discussion|| |
The morphology and linear dimensions of the sella turcica in relation to growing subjects has gained increasing importance in the orthodontic management of patients with various skeletal and craniofacial morphologies. The planning, initiation, progression, and post treatment evaluation of various treatment modalities can be determined using these variables and correlating them to each other. The objective of this present investigation was to determine the relationship between the shape and linear dimension of the sella turcica and the various stages of skeletal maturation of the cervical vertebrae in untreated orthodontic patients in Benin City, Nigeria.
This current study demonstrated that 61.3% of the subjects had a normal sella turcica with a distribution of the other variants in 38.7%. This is close to values from other studies ,, where 66-67% also had a normal sella turcica shape with variations in 33-34%. While this study showed a sella turcica bridge in 2.8% of subjects, other studies  demonstrated a range of 5.5-22% which included participants with cranial morphologies and other studies showing no evidence of bridging of the sella turcica.  When comparing shape variations from different studies, this study showed a much higher value in the oblique anterior wall in 18.9% when compared with 4% and 9.4% in other studies , and was much lower in studies by Axelsson et al.  in 26%. Furthermore, this study showed a lower value in the irregular dorsum sella shape in 6.6% when compared with values from other studies of 11%, 11.1%, and 16.7%, respectively. ,, Similarly, the double contour and pyramidal shapes were lower in this present study when compared with other studies. , However, the pyramidal shape was lower in this study when compared with 2.8% in another study.  A comparative analysis of the differences in the values from these other studies ,, with this present study could be as a result of racial and ethnic variations. While this present study was carried out in Africans, the other studies were in Europeans, Arabs, and Asians. ,, Skeletal Class II was highest in 50% in this study and showed a high prevalence in the normal morphological variant (60%). The oblique anterior wall variant was also high in 45%. The sella turcica bridge was not demonstrated in skeletal Class III in this study, but present in 66.7% in skeletal Class I and 33.3% in skeletal Class II. This is in contrast with other studies ,,, where there was an increased incidence of bridging of the sella in 18%  in skeletal Class III but in agreement with studies by Shah et al.  where the sella turcica bridge was absent in skeletal Class III. This variation could be as a result of the variations in the incidence of sella turcica bridging among various populations. ,,,
The SNA and SNB angles identified maxillary prognathism (SNA > 90°) as being highest in the normal, oblique anterior wall, irregular dorsum sellae and the pyramidal morphological variants. This is consistent with cephalometric norms for the Nigerian population with an increased incidence of maxillary prognathism. 
Studies have identified the various stages of skeletal maturation across various age groups from 6 to 17 years of age , with other studies also demonstrating shape variation in different age groups. , While the shape and size of the sella turcica in patients above 15 years of age was demonstrated by Shah et al.,  the mean length depth and diameter of the sella was also investigated in other studies ,,, in new born children and subjects as old as 42 years of age. , This present study was also carried out on a wide age range from 7 to 32 years to determine the linear dimensions of the sella turcica over diverse age groups as orthodontic treatment commences from as early as 7 years of age with no age limit. While other studies ,,, showed a linear increase in the length of the sella turcica across all age groups with variations ranging from 0.1 mm  to 1.0 mm,  this present study demonstrated variations with an increase in length in 0.20-0.37 mm with the greater increase in the 15-25 year old age groups. The depth and diameter across all age groups in other studies ,,, also demonstrated a linear increase, but this study showed the largest measurements in depth in the 15-25 year olds. This implies that the length of the sella turcica from this study is longer in the 26-42 year old age group but deeper in the 15-25 year old age group, which is in agreement with studies by Lopez et al.  and Acheson and Archer  where there is an increase in depth in this age group.
Gender has been shown to have differences in the linear dimension of the sella turcica with studies identifying variations between male and female for different races. ,,, While some studies identified no gender differences in shape and linear dimensions of the sella turcica, ,, this present study showed that the mean sella depth and diameter was longer in females by 0.28 and 0.16 mm, but the mean length was longer in males by 0.55 mm. This is however in contrast with studies by Alkofide  and Choi et al.  who demonstrated an almost equal size in the length, depth, and diameter in both genders, but in agreement with another study  where the mean length and depth of the sella turcica was greater in males that in females. While our study differed in depth and diameter of the sella turcica across gender with another study,  this could be due to the fact that there is an increase in the depth of the sella turcica during the prepubertal growth spurt, which varies among gender for different races. ,,,
The one-way ANOVA from this present study demonstrated no significant differences in the mean length, depth, and diameter of the sella turcica for the various cervical vertebral stages. While this study showed Stage 4 of the cervical maturation stage to have the shortest mean length of 9.93 mm, Stage 6 demonstrated the longest mean length of 10.52 mm. The mean length of the total sample from this present study was 10.20 mm, which is in agreement with studies by Acheson and Archer  and close to the results of a similar study where the mean length was 10.80,  but at variance with other studies where the mean length was 11 mm and 11.4 mm, respectively. , This study showed a variation in the linear dimensions of the sella turcica when compared with other studies. ,, While this present study demonstrated a mean length, depth and diameter of 10.20, 9.08, and 9.20 mm, respectively, studies by Quakinine et al.  and Axelsson et al.  showed an average length, depth and diameter of 12, 6, and 8 mm, respectively. While their study was carried out on Caucasians, studies by Alkofide  in Saudi's demonstrated larger sizes with a mean difference of 0.22-5.10 mm with the higher values seen in the diameter. Other studies , identified the diameter as larger in Class III subjects and smaller in Class II subjects, which is in agreement with this present study where Class III demonstrated an increase in length and the diameter, but Class II skeletal pattern exhibited the greatest increase in depth. However, this study also showed a significant increase in diameter in females with skeletal Class I. This clearly demonstrates that the size of the sella turcica varies for different skeletal classes from other races and populations.
This study demonstrated no significant differences in the various cervical vertebral stages, SNA, SNB, and the size of the sella turcica. While dramatic changes have been shown in the sella turcica during puberty,  studies have identified CVM Stages 3 and 4 to be the ideal time for the onset of functional jaw orthopedics for patients with mandibular deficiency ( < SNB).  While Stages 3 and 4 recorded the lowest mean length and depth of the sella turcica, Stages 1 and 5 had the smallest diameter of the sella in participants in this present study. Previous studies have identified the prepubertal growth spurt to be 11-13 years of age with Stages 3 and 4 being most prevalent. ,,,, Other studies , have identified mean lengths and depths in 11-13 year olds as 7.1 and 6.1 mm in Greeks  , 9.8 and 7.5 mmin British subjects  , respectively which is at variance with this present study where the mean length and depth for Stages 3 and 4 is 6.73 and 7.03 mm, respectively. Other studies , found out that there is a positive linear tendency in the length, depth and diameter of the sella turcica until 25 years of age. This is in agreement with this present study where the largest dimensions in the sella turcica were seen in patients in the older age groups who are past the pubertal growth spurt.
| Conclusion|| |
Approximately 61.3% of the subjects in this study had a normal sella turcica shape. The sella length is larger in males, while the depth and diameter are larger in females. The depth of the sella depth is deeper in CVM Stages 3 and 4, which is the pubertal growth spurt. No significant difference was found between the linear dimensions of the sella turcica and skeletal Classes I-III. Maxillary prognathism with SNA > 90° was the most prevalent orthodontic problem in the six morphological variants of the sella turcica shape. The results of this present study may be used when evaluating younger male and female patients in the pubertal growth spurt to determine the optimal time of treatment for the use of functional jaw appliances in Nigerians.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]