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The morphology of Sella Turcica in individuals with different skeletal malocclusions – A cephalometric study
Translational Research in Anatomy 18 (2020) 100054
Contents lists available at ScienceDirect
Translational Research in Anatomy journal homepage: www.elsevier.com/locate/tria
The morphology of Sella Turcica in individuals with different skeletal malocclusions – A cephalometric study
T
Suraj Sinha, Akhil Shetty∗, Krishna Nayak A R T I C LE I N FO
A B S T R A C T
Keywords: Sella turcica Morphology Skeletal malocclusion
Aims: The aim of the study was to analyze the morphology and expedient the linear dimensions of Sella Turcica among Indian individuals having Skeletal Class I, Class II and Class III pattern, and then to determine if differences exist with different skeletal patterns. Methods and material: The lateral cephalogram of 150 patients (75 males and 75 females), aged 18–30 years who reported for various treatments of malocclusions were studied. Statistical analysis used: Analysis were done by ANOVA with Tukey's t-test, SPSS version 17.0 was used. P < 0.05 was considered as significant. Results: The normal morphology of the sella turcica were seen in 85 of the 150 individuals which was highest (56.66%) in the study group, an oblique anterior wall was present in 11.33% of the subjects, an irregular dorsum sella and sella turcica bridge were seen in 10% of the subjects, pyramidal shaped sella were seen in 6.66% and 5.33% of the subjects had double-contoured sella turcica. No significant difference between males or females in terms of diameter, depth or length was evident. A significant difference was observed among different skeletal patterns and the diameter of sella. Conclusions: The normal morphology of the sella turcica was seen in approximately 57% of the individuals. The larger diameter values were seen in the skeletal Class III subjects, while the smaller diameter values were observed in the Class II subjects.
1. Introduction A lateral cephalometric radiographic assessment of the craniofacial structures is one of the essential diagnostic tools of the orthodontic treatment diagnosis. The identification of various landmarks during the tracing of the radiographs are essential, as these points help in analyzing the relative positions of that of the maxilla and the mandible in relation to themselves or to the cranium. These reference points assist the orthodontist during diagnosis and in the estimation of orthodontic treatment results by superimposition of the reference points [1]. Sella point, the center of the Sella Turcica which gives shelter to the pituitary gland situated in the cranium, is one among the most commonly used cranial cephalometric landmarks for tracing the radiographs. The common morphology of Sella Turcica is studied beforehand for assessment of any unusual appearance present in the Sella region. As we know that there is high chance of different morphology to be seen from one individual to other, the findings of average standards help in classifying the presence of any anomaly in one of the significant region of the cranium [1]. The morphological shape of the Sella was classified into five
∗
different variant other than that of the normal. They are named as: double contour of the floor of Sella, oblique anterior wall, pyramidal shape of dorsum Sella, irregularity in the posterior part of the dorsum Sella and the Sella bridging [2]. Hence, the aim of the study was to analyze the morphology and evaluate the linear dimensions of Sella among Indian individuals having Skeletal Class I, Class II and Class III pattern, and then to determine if differences exist with different skeletal patterns. 2. Methods 150 patients (50 patients from each group of Skeletal Class I, Class II and Class III) were included in the study with equal proportion of males and females. The inclusion criteria were that the patient should be of age 18–30 years with no previous orthodontic, orthopedic or surgical treatment, no craniofacial trauma, no congenital anomalies and no neurologic disturbances. The exclusion criteria included such patients who were not willing to be a part of the study; the patient's whose radiographs were not clear for interpretation and the patients' with major illness or medical conditions.
Corresponding Author. E-mail addresses: [email protected] (S. Sinha), [email protected] (A. Shetty).
https://doi.org/10.1016/j.tria.2019.100054 Received 28 June 2019; Received in revised form 11 October 2019; Accepted 14 November 2019 Available online 22 November 2019 2214-854X/ © 2019 The Author(s). Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Translational Research in Anatomy 18 (2020) 100054
S. Sinha, et al.
The standardized lateral cephalograms used for the study were taken from the orthodontic departmental archives. These digital lateral skull radiographs were taken with Planmeca Promax (Helsinki, Finland). This radiographic system uses a charge coupled device sensor chip as an image receptor. The exposure parameters for the digital cephalograms were 68 KV, 5 mA and 18.7 s. The lateral cephalograms were traced on 0.003-inch acetate paper with 2H lead pencil under optical illumination. All tracings were done by the same operator in order to avoid the inter-operator errors. All the studied sample size was classified into the various skeletal malocclusions of Class I, Class II and Class III, categorized on ANB angle. This simply showed the moment of the skeletal jaw discrepancy, irrespective of the fact that which apical base has foible. The Skeletal pattern classification was classified by keeping the ANB angle as follows for different categories: Skeletal Class I with ANB angle between 0 and 4°; Skeletal Class II group with ANB angle of more than 4°; and the Skeletal Class III with ANB angle less than 0°. The tuberculum and dorsum Sella, the floor of Sella Turcica and posterior and anterior clinoid processes were drawn. The methods of Silverman [3] and Kisling [4] were used to measure the direct measurements such as, diameter, depth and length of Sella. Distance from the tip of the dorsum (DS) to the tuberculum (TS) was measured and defined as the length (L) of Sella. Perpendicular drawn through the above defined line towards the floor of Sella was measured and defined as the depth (D) of the Sella Turcica. The third line was drawn from the tuberculum to the point which is furthest located on the posterior inner wall of the fossa and this was measured as the anteroposterior diameter (APD) of the Sella (Fig. 1).
Table 1 Frequency distribution of Sella Turcica shapes. SELLA TYPE
CLASS I
CLASS II
CLASS III
n
%
Normal sella turcica Oblique anterior wall Sella turcica bridge Double contour Irregular dorsum sella Pyramidal shape Total
28 4 7 2 5 4 50
25 6 7 1 7 4 50
32 7 1 5 3 2 50
85 17 15 8 15 10 150
56.66 11.33 10 5.33 10 6.66 100
patterns are presented in Table 2. The largest measurement was that of the diameter of the Sella Turcica (14 mm), which was seen in skeletal Class I and Class III with the mean of 10.52 mm and 10.88 mm respectively, as compared to 10.02 mm of Class II. A remarkable disparity was observed among different skeletal patterns and the diameter of Sella. The diameter of the Sella had higher values in the skeletal Class III and lesser in the Class II individuals. Tukey Post hoc test revealed a significant difference between skeletal Class II and Class III subjects (Table 3). Among genders, the comparison of the measurements of Sella showed no significant differences between males or females in terms of diameter, depth or length (Tables 4–6). However, the length and the diameter were more for males than females in contrast to the depth. On analyzing each gender groups (Table 5), the male group of the studied subjects, the length of Sella Turcica was maximum for Class I and minimum for Class II; the depth and the diameter was maximum for Class III and minimum for Class II. Hence, the skeletal Class II had the minimum value of all the linear (diameter, depth and length) measurements of the Sella. In the female group, length was maximum for Class III and minimum for Class I. However, the depth and the diameter were maximum for Class III and minimum for Class II. On assessing each skeletal pattern (Table 6), the male populations of Class I pattern were found to have increased values of length and diameter of Sella Turcica with equal measurements of depth. The female population in Class II pattern had increased depth and diameter, whereas, the male had increased length of the Sella. In the Class III pattern, length and depth were equal for both male and female but the diameter was found to be more for male than female.
3. Results The normal morphology of the Sella Turcica were seen in 85 of the 150 individuals which was highest (56.66%) in the study group, irrespective to gender or skeletal type (Table 1, Graph 1). The different variations in the morphology were seen in the other 65 individuals; an oblique anterior wall was present in 11.33% of the subjects, an irregular dorsum Sella and Sella Turcica bridge were seen in 10% of the subjects, pyramidal shaped Sella were seen in 6.66% and 5.33% of the subjects had double-contoured Sella Turcica. The presence of Sella Turcica bridging was seen equally in skeletal Class I and Class II population, however, skeletal Class III population had only 1 out of 50 who had bridging. The presence of double contour Sella was the least in the sample group, in which the skeletal Class II had only 1 out of 50, whereas, Class III had 5 and Class I had 2. The linear dimensions of Sella Turcica with different skeletal
4. Discussion Based on the skeletal pattern of Class I, Class II and Class III, the lateral cephalometric radiographs of 50 patients (25 males and 25 females) from each group (150 patients) with the age range of 18–30 years were studied. The analyses of each lateral cephalometric radiograph were done and the Sella Turcica was measured to determine the shape as well as the linear dimensions of diameter, depth and length. This study showed that the normal morphology of the Sella Turcica was seen in the majority of the sample group followed by an oblique anterior wall Sella. The Sella Turcica with irregular dorsum Sella and bridging Sella were next in the order of frequency which were seen in equal proportion followed by the pyramidal shaped Sella and the least frequency was seen that of double contoured Sella. Many researchers in the past have reported the variations in the shape of the Sella Turcica (Bell and Gordon [5], Camp [6], Teal [7], Norton and Kantor [8], Kantor and Tetradis [9]). The Saucer shaped or flattened, oval and circular are different morphological classifications of Sella Turcica which were given by Bell and Gordon after examining children's radiographs of age of 1–12 years. Their study showed that the majority of the Sella Turcica were either an Oval-shaped Sella or a Circular Sella. The morphological shape of Sella Turcica as ‘J-shaped Sella’ was explained by Epstein and Davidoff [10] whereas Denizet and Fournier [11] introduced the term ‘Omega Sella’. However, Kier [12] referred these terminologies as radiological myths. The various other
Fig. 1. Normal sella turcica morphology and reference lines used for measuring sella size: TS, tuberculum sella; DS, dorsum sella; BPF, base of the pituitary fossa; black line, length of sella; dashed line, diameter of sella; dotted line, depth of sella. 2
Translational Research in Anatomy 18 (2020) 100054
S. Sinha, et al.
Graph 1. Pie chart distribution of morphology of Sella Turcica Table 2 Comparison of length, depth and diameter between the skeletal patterns. Class
N
Mean
SD
Minimum
Maximum
Table 4 Comparison of length, depth and diameter between the gender groups.
ANOVA F
p-value
0.23
0.80
Length Length
Depth
Diameter
I II III I II III I II III
50 50 50 50 50 50 50 50 50
5.94 5.68 6.00 6.80 6.62 6.96 10.52 10.02 10.88
2.77 2.63 2.11 1.43 1.32 1.23 1.97 1.64 1.49
0 0 0 4 4 4 3 7 7
10 11 10 10 10 9 14 13 14
Depth 0.82
0.44
3.18
0.04*
Diameter
I II
Class (J)
II III III
Mean Difference (IJ)
0.50 −0.36 −0.86
Std. Error
0.34 0.34 0.34
p-value
0.31 0.55 0.04*
N
Mean
SD
Mean Difference (95% CI)
t
df
p-value
Male Female Male Female Male Female
75 75 75 75 75 75
6.12 5.63 6.76 6.83 10.55 10.40
2.30 2.69 1.45 1.20 1.81 1.67
0.49 (−0.31, 1.30) −0.07 (−0.50, 0.36) 0.15 (−0.42, 0.71)
1.21
148
0.23
−0.31
148
0.76
0.52
148
0.61
Table 5 Comparison of length, depth and diameter between the skeletal patterns in each gender groups.
Table 3 Pairwise comparison of diameter between the skeletal patterns. Class (I)
Gender
Gender
95% Confidence Interval Lower Bound
Upper Bound
−0.31 −1.17 −1.67
1.31 0.45 −0.05
Male
Class
Length
Depth
Diameter
Female
morphology of Sella were given on the presence of either the concavity or the flatness of the silhouette of the floor of the Sella, the angles produced by the outline of the tuberculum Sella, the shape of both the clinoid processes and their fusion which is often known as ‘Sella Turcica Bridge’ [13,14]. The current study showed that the majority of the Class I population had normal morphology of Sella, followed by Sella Turcica bridge, irregular dorsum Sella, oblique anterior wall, pyramidal shaped Sella and
Length
Depth
Diameter
3
I II III I II III I II III I II III I II III I II III
N
25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
Mean
6.64 5.72 6.00 6.80 6.52 6.96 10.72 9.92 11.00 5.24 5.64 6.00 6.80 6.72 6.96 10.32 10.12 10.76
SD
2.252 2.441 2.198 1.500 1.358 1.513 2.092 1.470 1.708 3.099 2.856 2.062 1.384 1.308 .889 1.865 1.810 1.268
Min
1 0 0 4 5 4 3 7 7 0 1 3 4 4 5 6 7 8
Max
10 10 10 10 10 9 14 12 14 10 11 10 10 9 9 13 13 13
ANOVA F
p-value
1.05
0.36
0.58
0.56
2.49
0.09
0.49
0.61
0.25
0.78
0.96
0.39
Translational Research in Anatomy 18 (2020) 100054
S. Sinha, et al.
Table 6 Comparison of length, depth and diameter between the gender groups in each skeletal patterns. Class I
Length Depth Diameter
II
Length Depth Diameter
III
Length Depth Diameter
Gender
N
Mean
SD
Mean Difference (95% CI)
t
df
p-value
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
6.64 5.24 6.80 6.80 10.72 10.32 5.72 5.64 6.52 6.72 9.92 10.12 6.00 6.00 6.96 6.96 11.00 10.76
2.25 3.10 1.50 1.38 2.09 1.87 2.44 2.86 1.36 1.31 1.47 1.81 2.20 2.06 1.51 0.89 1.71 1.27
1.40 (−0.14, 2.94)
1.83
48
0.07
0.00 (−0.82, 0.82)
0.00
48
1.00
0.40 (−0.73, 1.53)
0.71
48
0.48
0.08 (−1.43, 1.59)
0.11
48
0.92
−0.20 (−0.96, 0.56)
−0.53
48
0.60
−0.20 (−1.14, 0.74)
−0.43
48
0.67
0.00 (−1.21, 1.21)
0.00
48
1.00
0.00 (−0.71, 0.71)
0.00
48
1.00
0.24 (−0.62, 1.10)
0.564
48
0.58
had bridging of Sella Turcica. The finding of pyramidal shaped Sella was 6.66% of the individuals as compared to 11.1% by Valizadeh et al. [17], 5% by Axelsson et al. [2], 3.84% by Yassir et al. [20] and 2.8% by Alkofide [1]. The least frequency was that of the double contoured Sella which was present in 5.33% of the individuals compared to 8.9% reported by Alkofide [1], 8.46% by Yassir et al. [20], 7% by Chauhan et al. [19] and 3% by Axelsson et al. [2]. This value was almost similar to that of by Valizadeh et al. [17] who had 5.6% of the population with double contoured Sella. A difference between the linear measurements of Sella i.e. diameter, depth and length between various skeletal pattern was seen. In this study, the female with Class II pattern had increased values of depth and diameter of Sella; the male and female had equal linear measurements of depth in Class I pattern and that of length and depth in Class III pattern. The male group had increased measurements in all other groups. However, the difference between the male and female group were non-significant. The similar non-significant results among the gender were reported by Alkofide [1], Axelsson [2], Israel [23]. Various studies have revealed that Sella in males are generally larger than that of in females [3]. However, Hass [24] has reported that the female subjects of more than 17 years of age showed larger sella than that of the males of that age group. The linear measurements of all the mean of the current study were compared with the existing literature. The study done by Alkofide [1], Axelsson [2], Valizadeh et al. [17], Ouakinine et al. [25] had shown increased values for all the mean (of diameter, depth and length), and this could be attributed to the fact that the studies were done in different ethnic group. In the current study, the Sella's linear dimensions were compared with the skeletal pattern and a significant difference was evident. The significant difference was seen when the diameter of Sella was compared among Class II and Class III individuals. The higher values of diameter were seen more often in Class III subjects, whereas, the Class II subjects had smaller values of diameter in general. The similar findings were reported by Alkofide [1]. However, Shah et al. [18] and Yassir et al. [20] reported that no significant correlation can be seen between the skeletal pattern and the linear measurements of Sella. At the same time, Preston [26] had reported that there was non-significant relation between the mean area of Sella and the different facial/skeletal type. This could be attributed to the fact that Preston used mean area of Sella to assess the correlation and came to the conclusion instead of using linear parameters as taken in the current study. The results of this current study can be highly informative in assessing the skeletal pattern of adolescent by measuring the diameter of the Sella. However, there are a few limitations of the study. The higher
the least frequency was seen of that of double contoured Sella. However, the study done by Axelsson et al. [2] on Class I subjects showed different findings (but the maximum frequency was that of normal morphology of Sella only) as compared to the current study, which could be attributed to the fact that both the studies were done in different ethnic group. The Class II population had shown the similar pattern of frequency as that of Class I population in the studied group. The findings of the morphological shape of Sella Turcica in skeletal Class II population were in agreement to that of by Ani et al. [15], who said that almost 50% of these populations had normal Sella and approximately 15% had the bridging of Sella Turcica. Class III population also had majority of Sella Turcica with normal morphology but the least frequency was seen of Sella Turcica bridge. However, Meyer et al. [16] reported that 9.4% of Class I and 16.8% of Class III population had bridging of sella as compared to 14% and 2% of Class I and III respectively from the current study. Valizadeh et al. [17] also reported that 43.3% of Class III population had bridging of Sella. In this study, the majority of the subject had the normal shape of the Sella which was approximately seen in 57%, whereas the variation was observed in the remaining 43% of the subjects. This data is in close approximation to the study done by Alkofide [1], Axelsson et al. [2] and Shah et al. [18], where normal Sella Turcica was seen in approximately 67% of the individuals. However, Valizadeh et al. [17] and Chauhan et al. [19] reported it to be as low as 24.4% and 28% respectively and Yassir et al. [20] reported it to be as high as 76.15%. The presence of oblique anterior wall of the sella was seen in 11.33% of the subjects as compared to 3.84% by Yassir et al. [20], 9.4% of the individuals by Alkofide [1], 20% by Valizadeh et al. [17], 23% by Chauhan et al. [19] and 26% by Axelsson et al. [13]. The irregular dorsum Sella was found in 10% of the studied subjects against 5.38% by Yassir et al. [20], 11% as reported by Alkofide [1] and Axelsson et al. [2], 15.6% by Valizadeh et al. [17] and 18% by Chauhan et al. [19]. The bridging of Sella Turcica was also seen in 10% of the individuals, which is well within the range of 5.5–22% of the individuals as reported by Axelsson et al. [2], Chauhan et al. [19], Camp [6], Kantor and Norton [8] and Tetradis and Kantor [9] and 23.3% by Valizadeh et al. [17]. However, Alkofide [1] reported that only 1.1% and Yassir et al. [20] reported only 0.76% of the individuals had the bridging of Sella Turcica. Becktor et al. [13] reported that the increase in the frequency of the individuals with the Sella Turcica Bridge indicates deviations in the craniofacial morphology. Muller [21] examined 1040 radiographs to correlate the bridging of Sella with ophthalmological problems, and he reported only 7% of bridging with no significant relation between them. Leonardi et al. [22] reported that there is increased probability of dental anomaly to be seen in the adolescents who 4
Translational Research in Anatomy 18 (2020) 100054
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sample size would have given a more significant correlation between the measured parameters and the younger age group should have been included to study the age related changes in the morphology and size of Sella.
(1977) 111–174. [8] M.L. Kantor, L.A. Norton, Normal radiographic anatomy and common anomalies seen in cephalometric films, Am. J. Orthod. Dentofacial Orthop. 91 (5) (1987 May 1) 414–426. [9] S. Tetradis, M.L. Kantor, Prevalence of skeletal and dental anomalies and normal variants seen in cephalometric and other radiographs of orthodontic patients, Am. J. Orthod. Dentofacial Orthop. 116 (5) (1999 Nov 30) 572–577. [10] L.M. Davidoff, B.S. Epstein, The Abnormal Pneumoencephalogram, Lea and Febiger, Philadelphia, 1950. [11] A.M. Fournier, D. Denizet, Omega-shaped sella turcica, Marseille Med. 102 (6) (1964 Dec) 503–509. [12] E.L. Kier, “J” and “omega” shape of sella turcica. Anatomic clarification of radiologic misconceptions, Acta Radiol. Diagn. 9 (1969) 91. [13] J.P. Becktor, S. Einersen, I. Kjær, A sella turcica bridge in subjects with severe craniofacial deviations, Eur. J. Orthod. 22 (1) (2000 Feb 1) 69–74. [14] W.J. Choi, E.H. Hwang, S.R. Lee, The study of shape and size of normal sella turcica in cephalometric radiographs, Korean J. Oral Maxillofac. Radiol. 31 (1) (2001 Mar 1) 43–49. [15] S. Ani, J. James, S.P. Prasanth, Morphology of sella turcica in skeletal class II subjects, J. Res. Pract. Dent. (2015) h1–9 2015 Dec 1. [16] P. Meyer-Marcotty, T. Reuther, A. Stellzig-Eisenhauer, Bridging of the sella turcica in skeletal Class III subjects, Eur. J. Orthod. 32 (2) (2009 Sep 13) 148–153. [17] S. Valizadeh, S. Shahbeig, S. Mohseni, F. Azimi, H. Bakhshandeh, Correlation of shape and size of sella turcica with the type of facial skeletal class in an Iranian group, Iran. J. Radiol. 12 (3) (2015 Jul). [18] A.M. Shah, U. Bashir, T. Ilyas, The shape and size of the sella turcica in skeletal Class I, II and III in patients presenting at Islamic International Dental Hospital, Islamabad. Pak. Oral Dent. J. 31 (1) (2011 Jun 1). [19] P. Chauhan, S. Kalra, S.M. Mongia, S. Ali, A. Anurag, Morphometric analysis of sella turcica in North Indian population: a radiological study, Int. J. Res. Med. Sci. 2 (2) (2017 Jan 23) 521–526. [20] Y.A. Yassir, M. Nahidh, H.A. Yousif, Size and morphology of sella turcica in Iraqi adults, Mustansiria Dent. J. 7 (2010) 23–30. [21] F. Müller, Die bedeutung der sellabrücke für das auge, Klin. Monatsblätter Augenheilkd. 120 (1952) 298–302. [22] R. Leonardi, E. Barbato, M. Vichi, M. Caltabiano, A sella turcica bridge in subjects with dental anomalies, Eur. J. Orthod. 28 (6) (2006 Sep 5) 580–585. [23] H. Israel, Continuing growth in sella turcica with age, Am. J. Roentgenol. 108 (3) (1970 Mar) 516–527. [24] L.L. Haas, The size of the sella turcica by age and sex, Am. J. Roentgenol. Radium Ther. Nucl. Med. 72 (5) (1954 Nov) 754–761. [25] G.E. Ouaknine, J. Hardy, Microsurgical anatomy of the pituitary gland and the sellar region. 1. The pituitary gland, Am. Surg. 53 (5) (1987 May) 285–290. [26] C.B. Preston, Pituitary fossa size and facial type, Am. J. Orthod. 75 (3) (1979 Mar 1) 259–263.
5. Conclusion The normal morphology of the Sella Turcica was seen in approximately 57% of the individuals, irrespective of the genders and the skeletal Class patterns. There were no significant differences in the size of the Sella Turcica between the genders of the studied subjects. However, when the Sella size was compared with the skeletal type, a significant difference was found in the diameter size of the Sella Turcica between Class II and Class III subjects. The larger diameter values were seen in the skeletal Class III subjects, while the smaller diameter values were observed in the Class II subjects. The study signifies that the skeletal pattern of adolescent can be assessed by measuring the diameter of the Sella. Further studies with a bigger sample size, broader age group and in different ethnic group may be required to validate the results of the present study. References [1] E. Alkofide, The shape and size of the sella turcica in skeletal class I, class II and class III Saudi subjects, Eur. J. Orthod. 29 (5) (2007 Oct) 457–463. [2] S. Axelsson, K. Storhaug, I. Kjær, Post-natal size and morphology of the sella turcica. Longitudinal cephalometric standards for Norwegians between 6 and 21 years of age, Eur. J. Orthod. 26 (6) (2004 Dec 1) 597–604. [3] F.N. Silverman, Roentgen standards fo-size of the pituitary fossa from infancy through adolescence, Am. J. Roentgenol. Radium Ther. Nucl. Med. 78 (3) (1957 Sep) 451–460. [4] E. Kisling, Cranial Morphology in Down's Syndrome: A Comparative Roentgenencephalometric Study in Adult Males, Munksgaard, 1966. [5] M.B. Gordon, A.L. Bell, A roentgenographic study of sella turcica in 104 normal children, N.Y. State J. Med. 22 (1922) 54–59. [6] J.D. Camp, Normal and pathological anatomy of the sella turcica as revealed by roentgenograms, Am. J. Roentgenol. 12 (1924 Aug) 143–156. [7] J.S. Teal, Radiology of the adult sella turcica, Bull. Los Ang. Neurol. Soc. 42 (3–4)
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Translational Research in Anatomy journal homepage: www.elsevier.com/locate/tria
The morphology of Sella Turcica in individuals with different skeletal malocclusions – A cephalometric study
T
Suraj Sinha, Akhil Shetty∗, Krishna Nayak A R T I C LE I N FO
A B S T R A C T
Keywords: Sella turcica Morphology Skeletal malocclusion
Aims: The aim of the study was to analyze the morphology and expedient the linear dimensions of Sella Turcica among Indian individuals having Skeletal Class I, Class II and Class III pattern, and then to determine if differences exist with different skeletal patterns. Methods and material: The lateral cephalogram of 150 patients (75 males and 75 females), aged 18–30 years who reported for various treatments of malocclusions were studied. Statistical analysis used: Analysis were done by ANOVA with Tukey's t-test, SPSS version 17.0 was used. P < 0.05 was considered as significant. Results: The normal morphology of the sella turcica were seen in 85 of the 150 individuals which was highest (56.66%) in the study group, an oblique anterior wall was present in 11.33% of the subjects, an irregular dorsum sella and sella turcica bridge were seen in 10% of the subjects, pyramidal shaped sella were seen in 6.66% and 5.33% of the subjects had double-contoured sella turcica. No significant difference between males or females in terms of diameter, depth or length was evident. A significant difference was observed among different skeletal patterns and the diameter of sella. Conclusions: The normal morphology of the sella turcica was seen in approximately 57% of the individuals. The larger diameter values were seen in the skeletal Class III subjects, while the smaller diameter values were observed in the Class II subjects.
1. Introduction A lateral cephalometric radiographic assessment of the craniofacial structures is one of the essential diagnostic tools of the orthodontic treatment diagnosis. The identification of various landmarks during the tracing of the radiographs are essential, as these points help in analyzing the relative positions of that of the maxilla and the mandible in relation to themselves or to the cranium. These reference points assist the orthodontist during diagnosis and in the estimation of orthodontic treatment results by superimposition of the reference points [1]. Sella point, the center of the Sella Turcica which gives shelter to the pituitary gland situated in the cranium, is one among the most commonly used cranial cephalometric landmarks for tracing the radiographs. The common morphology of Sella Turcica is studied beforehand for assessment of any unusual appearance present in the Sella region. As we know that there is high chance of different morphology to be seen from one individual to other, the findings of average standards help in classifying the presence of any anomaly in one of the significant region of the cranium [1]. The morphological shape of the Sella was classified into five
∗
different variant other than that of the normal. They are named as: double contour of the floor of Sella, oblique anterior wall, pyramidal shape of dorsum Sella, irregularity in the posterior part of the dorsum Sella and the Sella bridging [2]. Hence, the aim of the study was to analyze the morphology and evaluate the linear dimensions of Sella among Indian individuals having Skeletal Class I, Class II and Class III pattern, and then to determine if differences exist with different skeletal patterns. 2. Methods 150 patients (50 patients from each group of Skeletal Class I, Class II and Class III) were included in the study with equal proportion of males and females. The inclusion criteria were that the patient should be of age 18–30 years with no previous orthodontic, orthopedic or surgical treatment, no craniofacial trauma, no congenital anomalies and no neurologic disturbances. The exclusion criteria included such patients who were not willing to be a part of the study; the patient's whose radiographs were not clear for interpretation and the patients' with major illness or medical conditions.
Corresponding Author. E-mail addresses: [email protected] (S. Sinha), [email protected] (A. Shetty).
https://doi.org/10.1016/j.tria.2019.100054 Received 28 June 2019; Received in revised form 11 October 2019; Accepted 14 November 2019 Available online 22 November 2019 2214-854X/ © 2019 The Author(s). Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
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The standardized lateral cephalograms used for the study were taken from the orthodontic departmental archives. These digital lateral skull radiographs were taken with Planmeca Promax (Helsinki, Finland). This radiographic system uses a charge coupled device sensor chip as an image receptor. The exposure parameters for the digital cephalograms were 68 KV, 5 mA and 18.7 s. The lateral cephalograms were traced on 0.003-inch acetate paper with 2H lead pencil under optical illumination. All tracings were done by the same operator in order to avoid the inter-operator errors. All the studied sample size was classified into the various skeletal malocclusions of Class I, Class II and Class III, categorized on ANB angle. This simply showed the moment of the skeletal jaw discrepancy, irrespective of the fact that which apical base has foible. The Skeletal pattern classification was classified by keeping the ANB angle as follows for different categories: Skeletal Class I with ANB angle between 0 and 4°; Skeletal Class II group with ANB angle of more than 4°; and the Skeletal Class III with ANB angle less than 0°. The tuberculum and dorsum Sella, the floor of Sella Turcica and posterior and anterior clinoid processes were drawn. The methods of Silverman [3] and Kisling [4] were used to measure the direct measurements such as, diameter, depth and length of Sella. Distance from the tip of the dorsum (DS) to the tuberculum (TS) was measured and defined as the length (L) of Sella. Perpendicular drawn through the above defined line towards the floor of Sella was measured and defined as the depth (D) of the Sella Turcica. The third line was drawn from the tuberculum to the point which is furthest located on the posterior inner wall of the fossa and this was measured as the anteroposterior diameter (APD) of the Sella (Fig. 1).
Table 1 Frequency distribution of Sella Turcica shapes. SELLA TYPE
CLASS I
CLASS II
CLASS III
n
%
Normal sella turcica Oblique anterior wall Sella turcica bridge Double contour Irregular dorsum sella Pyramidal shape Total
28 4 7 2 5 4 50
25 6 7 1 7 4 50
32 7 1 5 3 2 50
85 17 15 8 15 10 150
56.66 11.33 10 5.33 10 6.66 100
patterns are presented in Table 2. The largest measurement was that of the diameter of the Sella Turcica (14 mm), which was seen in skeletal Class I and Class III with the mean of 10.52 mm and 10.88 mm respectively, as compared to 10.02 mm of Class II. A remarkable disparity was observed among different skeletal patterns and the diameter of Sella. The diameter of the Sella had higher values in the skeletal Class III and lesser in the Class II individuals. Tukey Post hoc test revealed a significant difference between skeletal Class II and Class III subjects (Table 3). Among genders, the comparison of the measurements of Sella showed no significant differences between males or females in terms of diameter, depth or length (Tables 4–6). However, the length and the diameter were more for males than females in contrast to the depth. On analyzing each gender groups (Table 5), the male group of the studied subjects, the length of Sella Turcica was maximum for Class I and minimum for Class II; the depth and the diameter was maximum for Class III and minimum for Class II. Hence, the skeletal Class II had the minimum value of all the linear (diameter, depth and length) measurements of the Sella. In the female group, length was maximum for Class III and minimum for Class I. However, the depth and the diameter were maximum for Class III and minimum for Class II. On assessing each skeletal pattern (Table 6), the male populations of Class I pattern were found to have increased values of length and diameter of Sella Turcica with equal measurements of depth. The female population in Class II pattern had increased depth and diameter, whereas, the male had increased length of the Sella. In the Class III pattern, length and depth were equal for both male and female but the diameter was found to be more for male than female.
3. Results The normal morphology of the Sella Turcica were seen in 85 of the 150 individuals which was highest (56.66%) in the study group, irrespective to gender or skeletal type (Table 1, Graph 1). The different variations in the morphology were seen in the other 65 individuals; an oblique anterior wall was present in 11.33% of the subjects, an irregular dorsum Sella and Sella Turcica bridge were seen in 10% of the subjects, pyramidal shaped Sella were seen in 6.66% and 5.33% of the subjects had double-contoured Sella Turcica. The presence of Sella Turcica bridging was seen equally in skeletal Class I and Class II population, however, skeletal Class III population had only 1 out of 50 who had bridging. The presence of double contour Sella was the least in the sample group, in which the skeletal Class II had only 1 out of 50, whereas, Class III had 5 and Class I had 2. The linear dimensions of Sella Turcica with different skeletal
4. Discussion Based on the skeletal pattern of Class I, Class II and Class III, the lateral cephalometric radiographs of 50 patients (25 males and 25 females) from each group (150 patients) with the age range of 18–30 years were studied. The analyses of each lateral cephalometric radiograph were done and the Sella Turcica was measured to determine the shape as well as the linear dimensions of diameter, depth and length. This study showed that the normal morphology of the Sella Turcica was seen in the majority of the sample group followed by an oblique anterior wall Sella. The Sella Turcica with irregular dorsum Sella and bridging Sella were next in the order of frequency which were seen in equal proportion followed by the pyramidal shaped Sella and the least frequency was seen that of double contoured Sella. Many researchers in the past have reported the variations in the shape of the Sella Turcica (Bell and Gordon [5], Camp [6], Teal [7], Norton and Kantor [8], Kantor and Tetradis [9]). The Saucer shaped or flattened, oval and circular are different morphological classifications of Sella Turcica which were given by Bell and Gordon after examining children's radiographs of age of 1–12 years. Their study showed that the majority of the Sella Turcica were either an Oval-shaped Sella or a Circular Sella. The morphological shape of Sella Turcica as ‘J-shaped Sella’ was explained by Epstein and Davidoff [10] whereas Denizet and Fournier [11] introduced the term ‘Omega Sella’. However, Kier [12] referred these terminologies as radiological myths. The various other
Fig. 1. Normal sella turcica morphology and reference lines used for measuring sella size: TS, tuberculum sella; DS, dorsum sella; BPF, base of the pituitary fossa; black line, length of sella; dashed line, diameter of sella; dotted line, depth of sella. 2
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Graph 1. Pie chart distribution of morphology of Sella Turcica Table 2 Comparison of length, depth and diameter between the skeletal patterns. Class
N
Mean
SD
Minimum
Maximum
Table 4 Comparison of length, depth and diameter between the gender groups.
ANOVA F
p-value
0.23
0.80
Length Length
Depth
Diameter
I II III I II III I II III
50 50 50 50 50 50 50 50 50
5.94 5.68 6.00 6.80 6.62 6.96 10.52 10.02 10.88
2.77 2.63 2.11 1.43 1.32 1.23 1.97 1.64 1.49
0 0 0 4 4 4 3 7 7
10 11 10 10 10 9 14 13 14
Depth 0.82
0.44
3.18
0.04*
Diameter
I II
Class (J)
II III III
Mean Difference (IJ)
0.50 −0.36 −0.86
Std. Error
0.34 0.34 0.34
p-value
0.31 0.55 0.04*
N
Mean
SD
Mean Difference (95% CI)
t
df
p-value
Male Female Male Female Male Female
75 75 75 75 75 75
6.12 5.63 6.76 6.83 10.55 10.40
2.30 2.69 1.45 1.20 1.81 1.67
0.49 (−0.31, 1.30) −0.07 (−0.50, 0.36) 0.15 (−0.42, 0.71)
1.21
148
0.23
−0.31
148
0.76
0.52
148
0.61
Table 5 Comparison of length, depth and diameter between the skeletal patterns in each gender groups.
Table 3 Pairwise comparison of diameter between the skeletal patterns. Class (I)
Gender
Gender
95% Confidence Interval Lower Bound
Upper Bound
−0.31 −1.17 −1.67
1.31 0.45 −0.05
Male
Class
Length
Depth
Diameter
Female
morphology of Sella were given on the presence of either the concavity or the flatness of the silhouette of the floor of the Sella, the angles produced by the outline of the tuberculum Sella, the shape of both the clinoid processes and their fusion which is often known as ‘Sella Turcica Bridge’ [13,14]. The current study showed that the majority of the Class I population had normal morphology of Sella, followed by Sella Turcica bridge, irregular dorsum Sella, oblique anterior wall, pyramidal shaped Sella and
Length
Depth
Diameter
3
I II III I II III I II III I II III I II III I II III
N
25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
Mean
6.64 5.72 6.00 6.80 6.52 6.96 10.72 9.92 11.00 5.24 5.64 6.00 6.80 6.72 6.96 10.32 10.12 10.76
SD
2.252 2.441 2.198 1.500 1.358 1.513 2.092 1.470 1.708 3.099 2.856 2.062 1.384 1.308 .889 1.865 1.810 1.268
Min
1 0 0 4 5 4 3 7 7 0 1 3 4 4 5 6 7 8
Max
10 10 10 10 10 9 14 12 14 10 11 10 10 9 9 13 13 13
ANOVA F
p-value
1.05
0.36
0.58
0.56
2.49
0.09
0.49
0.61
0.25
0.78
0.96
0.39
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Table 6 Comparison of length, depth and diameter between the gender groups in each skeletal patterns. Class I
Length Depth Diameter
II
Length Depth Diameter
III
Length Depth Diameter
Gender
N
Mean
SD
Mean Difference (95% CI)
t
df
p-value
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
6.64 5.24 6.80 6.80 10.72 10.32 5.72 5.64 6.52 6.72 9.92 10.12 6.00 6.00 6.96 6.96 11.00 10.76
2.25 3.10 1.50 1.38 2.09 1.87 2.44 2.86 1.36 1.31 1.47 1.81 2.20 2.06 1.51 0.89 1.71 1.27
1.40 (−0.14, 2.94)
1.83
48
0.07
0.00 (−0.82, 0.82)
0.00
48
1.00
0.40 (−0.73, 1.53)
0.71
48
0.48
0.08 (−1.43, 1.59)
0.11
48
0.92
−0.20 (−0.96, 0.56)
−0.53
48
0.60
−0.20 (−1.14, 0.74)
−0.43
48
0.67
0.00 (−1.21, 1.21)
0.00
48
1.00
0.00 (−0.71, 0.71)
0.00
48
1.00
0.24 (−0.62, 1.10)
0.564
48
0.58
had bridging of Sella Turcica. The finding of pyramidal shaped Sella was 6.66% of the individuals as compared to 11.1% by Valizadeh et al. [17], 5% by Axelsson et al. [2], 3.84% by Yassir et al. [20] and 2.8% by Alkofide [1]. The least frequency was that of the double contoured Sella which was present in 5.33% of the individuals compared to 8.9% reported by Alkofide [1], 8.46% by Yassir et al. [20], 7% by Chauhan et al. [19] and 3% by Axelsson et al. [2]. This value was almost similar to that of by Valizadeh et al. [17] who had 5.6% of the population with double contoured Sella. A difference between the linear measurements of Sella i.e. diameter, depth and length between various skeletal pattern was seen. In this study, the female with Class II pattern had increased values of depth and diameter of Sella; the male and female had equal linear measurements of depth in Class I pattern and that of length and depth in Class III pattern. The male group had increased measurements in all other groups. However, the difference between the male and female group were non-significant. The similar non-significant results among the gender were reported by Alkofide [1], Axelsson [2], Israel [23]. Various studies have revealed that Sella in males are generally larger than that of in females [3]. However, Hass [24] has reported that the female subjects of more than 17 years of age showed larger sella than that of the males of that age group. The linear measurements of all the mean of the current study were compared with the existing literature. The study done by Alkofide [1], Axelsson [2], Valizadeh et al. [17], Ouakinine et al. [25] had shown increased values for all the mean (of diameter, depth and length), and this could be attributed to the fact that the studies were done in different ethnic group. In the current study, the Sella's linear dimensions were compared with the skeletal pattern and a significant difference was evident. The significant difference was seen when the diameter of Sella was compared among Class II and Class III individuals. The higher values of diameter were seen more often in Class III subjects, whereas, the Class II subjects had smaller values of diameter in general. The similar findings were reported by Alkofide [1]. However, Shah et al. [18] and Yassir et al. [20] reported that no significant correlation can be seen between the skeletal pattern and the linear measurements of Sella. At the same time, Preston [26] had reported that there was non-significant relation between the mean area of Sella and the different facial/skeletal type. This could be attributed to the fact that Preston used mean area of Sella to assess the correlation and came to the conclusion instead of using linear parameters as taken in the current study. The results of this current study can be highly informative in assessing the skeletal pattern of adolescent by measuring the diameter of the Sella. However, there are a few limitations of the study. The higher
the least frequency was seen of that of double contoured Sella. However, the study done by Axelsson et al. [2] on Class I subjects showed different findings (but the maximum frequency was that of normal morphology of Sella only) as compared to the current study, which could be attributed to the fact that both the studies were done in different ethnic group. The Class II population had shown the similar pattern of frequency as that of Class I population in the studied group. The findings of the morphological shape of Sella Turcica in skeletal Class II population were in agreement to that of by Ani et al. [15], who said that almost 50% of these populations had normal Sella and approximately 15% had the bridging of Sella Turcica. Class III population also had majority of Sella Turcica with normal morphology but the least frequency was seen of Sella Turcica bridge. However, Meyer et al. [16] reported that 9.4% of Class I and 16.8% of Class III population had bridging of sella as compared to 14% and 2% of Class I and III respectively from the current study. Valizadeh et al. [17] also reported that 43.3% of Class III population had bridging of Sella. In this study, the majority of the subject had the normal shape of the Sella which was approximately seen in 57%, whereas the variation was observed in the remaining 43% of the subjects. This data is in close approximation to the study done by Alkofide [1], Axelsson et al. [2] and Shah et al. [18], where normal Sella Turcica was seen in approximately 67% of the individuals. However, Valizadeh et al. [17] and Chauhan et al. [19] reported it to be as low as 24.4% and 28% respectively and Yassir et al. [20] reported it to be as high as 76.15%. The presence of oblique anterior wall of the sella was seen in 11.33% of the subjects as compared to 3.84% by Yassir et al. [20], 9.4% of the individuals by Alkofide [1], 20% by Valizadeh et al. [17], 23% by Chauhan et al. [19] and 26% by Axelsson et al. [13]. The irregular dorsum Sella was found in 10% of the studied subjects against 5.38% by Yassir et al. [20], 11% as reported by Alkofide [1] and Axelsson et al. [2], 15.6% by Valizadeh et al. [17] and 18% by Chauhan et al. [19]. The bridging of Sella Turcica was also seen in 10% of the individuals, which is well within the range of 5.5–22% of the individuals as reported by Axelsson et al. [2], Chauhan et al. [19], Camp [6], Kantor and Norton [8] and Tetradis and Kantor [9] and 23.3% by Valizadeh et al. [17]. However, Alkofide [1] reported that only 1.1% and Yassir et al. [20] reported only 0.76% of the individuals had the bridging of Sella Turcica. Becktor et al. [13] reported that the increase in the frequency of the individuals with the Sella Turcica Bridge indicates deviations in the craniofacial morphology. Muller [21] examined 1040 radiographs to correlate the bridging of Sella with ophthalmological problems, and he reported only 7% of bridging with no significant relation between them. Leonardi et al. [22] reported that there is increased probability of dental anomaly to be seen in the adolescents who 4
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sample size would have given a more significant correlation between the measured parameters and the younger age group should have been included to study the age related changes in the morphology and size of Sella.
(1977) 111–174. [8] M.L. Kantor, L.A. Norton, Normal radiographic anatomy and common anomalies seen in cephalometric films, Am. J. Orthod. Dentofacial Orthop. 91 (5) (1987 May 1) 414–426. [9] S. Tetradis, M.L. Kantor, Prevalence of skeletal and dental anomalies and normal variants seen in cephalometric and other radiographs of orthodontic patients, Am. J. Orthod. Dentofacial Orthop. 116 (5) (1999 Nov 30) 572–577. [10] L.M. Davidoff, B.S. Epstein, The Abnormal Pneumoencephalogram, Lea and Febiger, Philadelphia, 1950. [11] A.M. Fournier, D. Denizet, Omega-shaped sella turcica, Marseille Med. 102 (6) (1964 Dec) 503–509. [12] E.L. Kier, “J” and “omega” shape of sella turcica. Anatomic clarification of radiologic misconceptions, Acta Radiol. Diagn. 9 (1969) 91. [13] J.P. Becktor, S. Einersen, I. Kjær, A sella turcica bridge in subjects with severe craniofacial deviations, Eur. J. Orthod. 22 (1) (2000 Feb 1) 69–74. [14] W.J. Choi, E.H. Hwang, S.R. Lee, The study of shape and size of normal sella turcica in cephalometric radiographs, Korean J. Oral Maxillofac. Radiol. 31 (1) (2001 Mar 1) 43–49. [15] S. Ani, J. James, S.P. Prasanth, Morphology of sella turcica in skeletal class II subjects, J. Res. Pract. Dent. (2015) h1–9 2015 Dec 1. [16] P. Meyer-Marcotty, T. Reuther, A. Stellzig-Eisenhauer, Bridging of the sella turcica in skeletal Class III subjects, Eur. J. Orthod. 32 (2) (2009 Sep 13) 148–153. [17] S. Valizadeh, S. Shahbeig, S. Mohseni, F. Azimi, H. Bakhshandeh, Correlation of shape and size of sella turcica with the type of facial skeletal class in an Iranian group, Iran. J. Radiol. 12 (3) (2015 Jul). [18] A.M. Shah, U. Bashir, T. Ilyas, The shape and size of the sella turcica in skeletal Class I, II and III in patients presenting at Islamic International Dental Hospital, Islamabad. Pak. Oral Dent. J. 31 (1) (2011 Jun 1). [19] P. Chauhan, S. Kalra, S.M. Mongia, S. Ali, A. Anurag, Morphometric analysis of sella turcica in North Indian population: a radiological study, Int. J. Res. Med. Sci. 2 (2) (2017 Jan 23) 521–526. [20] Y.A. Yassir, M. Nahidh, H.A. Yousif, Size and morphology of sella turcica in Iraqi adults, Mustansiria Dent. J. 7 (2010) 23–30. [21] F. Müller, Die bedeutung der sellabrücke für das auge, Klin. Monatsblätter Augenheilkd. 120 (1952) 298–302. [22] R. Leonardi, E. Barbato, M. Vichi, M. Caltabiano, A sella turcica bridge in subjects with dental anomalies, Eur. J. Orthod. 28 (6) (2006 Sep 5) 580–585. [23] H. Israel, Continuing growth in sella turcica with age, Am. J. Roentgenol. 108 (3) (1970 Mar) 516–527. [24] L.L. Haas, The size of the sella turcica by age and sex, Am. J. Roentgenol. Radium Ther. Nucl. Med. 72 (5) (1954 Nov) 754–761. [25] G.E. Ouaknine, J. Hardy, Microsurgical anatomy of the pituitary gland and the sellar region. 1. The pituitary gland, Am. Surg. 53 (5) (1987 May) 285–290. [26] C.B. Preston, Pituitary fossa size and facial type, Am. J. Orthod. 75 (3) (1979 Mar 1) 259–263.
5. Conclusion The normal morphology of the Sella Turcica was seen in approximately 57% of the individuals, irrespective of the genders and the skeletal Class patterns. There were no significant differences in the size of the Sella Turcica between the genders of the studied subjects. However, when the Sella size was compared with the skeletal type, a significant difference was found in the diameter size of the Sella Turcica between Class II and Class III subjects. The larger diameter values were seen in the skeletal Class III subjects, while the smaller diameter values were observed in the Class II subjects. The study signifies that the skeletal pattern of adolescent can be assessed by measuring the diameter of the Sella. Further studies with a bigger sample size, broader age group and in different ethnic group may be required to validate the results of the present study. References [1] E. Alkofide, The shape and size of the sella turcica in skeletal class I, class II and class III Saudi subjects, Eur. J. Orthod. 29 (5) (2007 Oct) 457–463. [2] S. Axelsson, K. Storhaug, I. Kjær, Post-natal size and morphology of the sella turcica. Longitudinal cephalometric standards for Norwegians between 6 and 21 years of age, Eur. J. Orthod. 26 (6) (2004 Dec 1) 597–604. [3] F.N. Silverman, Roentgen standards fo-size of the pituitary fossa from infancy through adolescence, Am. J. Roentgenol. Radium Ther. Nucl. Med. 78 (3) (1957 Sep) 451–460. [4] E. Kisling, Cranial Morphology in Down's Syndrome: A Comparative Roentgenencephalometric Study in Adult Males, Munksgaard, 1966. [5] M.B. Gordon, A.L. Bell, A roentgenographic study of sella turcica in 104 normal children, N.Y. State J. Med. 22 (1922) 54–59. [6] J.D. Camp, Normal and pathological anatomy of the sella turcica as revealed by roentgenograms, Am. J. Roentgenol. 12 (1924 Aug) 143–156. [7] J.S. Teal, Radiology of the adult sella turcica, Bull. Los Ang. Neurol. Soc. 42 (3–4)
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