J F O

Journal Name
1 6 4 2
Manuscript No. B Dispatch: 4.12.10
Author Received:
Journal: JFO CE: Valarmathi
No. of pages: 6 PE: Karpagavalli
J Forensic Sci, 2010
doi: 10.1111/j.1556-4029.2010.01642.x
PAPER Available online at: onlinelibrary.wiley.com
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3 GENERAL; ANTHROPOLOGY AND ODONTOLOGY
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Asmaa T. Uthman,1 B.D.S., M.Sc.; Natheer H. Al-Rawi,1 B.D.S., M.Sc., Ph.D.;
8 Ahmed S. Al-Naaimi,2 M.B.Ch. B., M.Sc., Ph.D.; and Jalal F. Al-Timimi.3 B.D.S., M.Sc.
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10
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12 Evaluation of Maxillary Sinus Dimensions
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in Gender Determination Using Helical
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CT Scanning
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21 ABSTRACT: Gender determination is an important step in identification in forensic medicine. CT measurements of maxillary sinuses may be
22 useful to support gender identification. This study was undertaken to study the accuracy and reliability of maxillary sinus dimensions measurement in
23 gender classification through the use of reconstructed helical CT images. Eighty-eight patients (43 men and 45 women) with age range from 20 to
49 years were selected in this study. The width, the length, and the height of the maxillary sinuses in addition to the total distance across both sinuses
24 were measured. Data were subjected to discriminant analysis for gender using multiple regression analysis. Maxillary sinus height was the best discri-
25 minant parameter that could be used to study sexual dimorphism with an overall accuracy of 71.6%. Using multivariate analysis, 74.4% of male
26 sinuses and 73.3% of female sinuses were sexed correctly. The overall percentage for sexing maxillary sinuses correctly was 73.9%. It can be con-
27 cluded that reconstructed CT image can provide valuable measurements for maxillary sinuses and could be used for sexing when other methods of
28 sexing are not conclusive.
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KEYWORDS: forensic science, maxillary sinus, CT scan, reconstructed image, dimensional accuracy, sexing
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32 The study of anthropometric characteristics is of fundamental together can be used for gender determination when the whole
33 importance to solve problems related to identification. Craniometri- skeleton is not available (7). This study was designed to determine
34 cal features are included among these characteristics which are clo- the reliability and accuracy of maxillary sinus dimensions measure-
35 sely connected to forensic dentistry, because they can be used to ment as a method for gender identification of unknown persons.
36 aid in identifying an individual from a skull found detached from
37 its skeleton (1). Skeletal remains have been used for sexing the
Patients and Methods
38 individual as bones of the body are last to perish after death, next
39 to enamel of teeth (2). Radiography is used in forensic pathology The sample consisted of 88 patients (43 men and 45 women)
40 for the identification of humans especially in cases where the body with age range from 20 to 49 years. They were referred to Radiol-
41 is decomposed, fragmented, or burned (3). The skull, pelvis, and ogy Department in Al-Najaf Teaching Hospital for the purpose of
42 femora are the most useful for the radiological determination of paranasal sinuses imaging. All participants were supplied with
43 gender. Radiology can assist in giving accurate dimensions for informed consent, and the study protocol was approved by Local
44 which certain formulae can be applied to determine gender (4). It Ethics Committee of Al-Najaf General Teaching Hospital. To
45 has been reported that maxillary sinuses remain intact, although the determine the reliability and reproducibility of the maxillary sinus
46 skull and other bones may be badly disfigured in victims who are measurements, an inter-and intra-examiner calibrations were carried
47 incinerated, and therefore, that maxillary sinuses can be used for out. This calibration was carried out by comparing the greatest
48 identification (5). CT scans are an excellent imaging modality used measurements of the randomly selected 10 radiographs by the same
49 to evaluate the sino-nasal cavities. They provide an accurate assess- radiologist (JF) after 2 weeks from the first reading for intra-exam-
50 ment of the paranasal sinuses, craniofacial bones, as well as the iner calibration and by another senior general radiologist (MT) for
51 extent of pneumatization of the sinuses (6). Gender determination inter-examiner calibration. The radiographs were examined on the
52 is an important step in identification in forensic medicine. CT mea- computer in dim light room. Comparison of the two measurements
53 surements of maxillary sinuses may be useful to support gender showed statistical nonsignificant difference (p > 0.05) when paired
54 determination. The width, the length, and height of maxillary sinus t-test applied. Maxillary sinus measurements (width, length, height,
55 and total distance across both sinuses) were measured from recon-
56 1
Department of Oral and Craniofacial Health Science, College of structed axial and coronal sections (5-mm slice thickness) helical
57 Dentistry, University of Sharjah, Sharjah, UAE. CT scan (Somatom Emotion, Siemens 2000).The greatest measure-
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58 Department of Community, College of Medicine, University of Baghdad, ments were taken after going through different slices in axial and
59 Baghdad, Iraq.
3
Department of Oral Diagnosis, College of Dentistry, University of
coronal sections. Edentulous patients or patients who had history of
60 Baghdad, Baghdad, Iraq. trauma, surgery, or pathological lesions in maxillofacial region
61 Received 29 Nov. 2009; and in revised form 5 Jan. 2010; accepted 6 Feb. were not included in this study. The maxillary sinus width was
62 2010. measured from axial reconstructed image section that was parallel
63
 2010 American Academy of Forensic Sciences 1
 2 JOURNAL OF FORENSIC SCIENCES
Colour online, B&W in print

Colour online, B&W in print

1

LOW RESOLUTION FIG

LOW RESOLUTION FIG
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19 FIG. 3—Total distance across both sinuses measured from the recon- 6
20 FIG. 1—The width and length of the maxillary sinus measured from the 4 structed axial CT section.
21 reconstructed CT axial section.
22
23
Colour online, B&W in print

Maxillary Sinus Width

24
LOW RESOLUTION FIG

25 The mean value for the maximum width of maxillary sinus for
26 male group was (24.7 € 4 mm) for the right side and (25.6 €
27 4.4 mm) for the left side. Female group had statistically significant
28 lower values for both right and left sides (22.7 € 3.2 and 23 €
29 4 mm), respectively (p < 0.05) (Table 1). Right and left side differ-
30 ences were significant for only male group as shown in Table 2.
31
32
Maxillary Sinus Length
33
34 The mean value for maximum length of maxillary sinus for male
35 group was (39.3 € 3.8 mm) for the right side and (39.4 € 3.7 mm)
36 for the left side which was greater than that recorded for female
37 group (36.9 € 3.8 mm) for the right and (37 € 4 mm) for the left
38 side and with statistically significant difference (p < 0.05)
39 (Table 1). Nonstatistically significant side difference was seen for
40 both gender as shown in Table 3.
41
42 FIG. 2—The height of the maxillary sinus measured from the recon- 5
Maxillary Sinus Height
43 structed coronal CT sections.
44 The mean value for the maximum sinus height recorded for male
45 to the hard palate as a distance from the outermost point of the group was (43.3 € 4.8 mm) for the right side and (45.1 € 4.1) for
46 lateral wall of maxillary sinus to the medial wall. The length was the left side which was significantly greater than that recorded for
47 also measured from axial reconstructed image as the longest length female group which was (39.9 € 5.2 mm) for the right side and
48 antero-posteriorly (Fig. 1). The height of maxillary sinus was repre- (40 € 4.8 mm) for the left side (Table 1). A statistically significant
49 sented by the distance measured from the uppermost point of the side difference was seen for only male group (Table 4).
50 superior wall of the sinus to the lowest point of the inferior wall.
51 The measurement was obtained from reconstructed coronal section
Total Distance Across Both Sinuses
52 that was perpendicular to the hard palate (Fig. 2). The total distance
53 across both sinuses was measured from reconstructed axial section The mean value of this parameter was (82.4 € 7.7) mm for male
54 as a distance from the outermost point of one maxillary sinus to group and (77.9 € 6.2 mm) for female group. A significant gender
55 the outermost point of the opposite sinus (Fig. 3). All data were difference was recorded regarding this parameter (Table 1).
56 subjected to descriptive and discriminate analyses using the SPSS Multiple regression equations have been used in this study; the
57 2 package (version 17). variable (gender) has been given a value (0 for women and 1 for
58 men). The classification variables were the maxillary sinus mea-
59 surements. The equation provided by the model calculates the 3
Results
60 discriminate score ‘‘D’’, which aids in the prediction process of
61 The total studied sample composed of 88 patients; the results gender by substituting the value of the specific measurement(s) in
62 were based on two study group: the male group (composed of 43 the equation. The resulting value of ‘‘D’’ is compared with a refer-
63 patients) and female group (composed of 45 patients). ence value (also provided by the model). If a value of calculated
 UTHMAN ET AL • EVALUATION OF MAXILLARY SINUS DIMENSIONS IN GENDER DETERMINATION 31

1 TABLE 1—Gender differences for maxillary sinus (MS) measurements.

2
3 Female Male
4 Parameters Range Mean SD SE Range Mean SD SE p (t-test)
5
6 Right MS width (mm) 13.4–29.4 22.7 3.2 0.48 16.2–35 24.7 4 0.61 0.009
Right MS length (mm) 24.1–44.1 36.9 3.8 0.56 30.5–50.4 39.3 3.8 0.57 0.004
7 Right MS height (mm) 26.5–51.7 39.9 5.2 0.78 30.2–52.1 43.3 4.8 0.73 0.002
8 Left MS width (mm) 14.3–31.5 23 4 0.6 16.2–34 25.6 4.4 0.67 0.004
9 Left MS length (mm) 25.9–44.2 37 4 0.59 31.3–49.8 39.4 3.7 0.56 0.005
10 Left MS height (mm) 26.2–47.9 40 4.8 0.71 38.4–52.7 45.1 4.1 0.62 <0.001
11 Total distance across both sinuses (mm) 63.8–88.7 77.9 6.2 0.92 66–96.2 82.4 7.7 1.17 0.003
12
13
14 TABLE 2—Side difference of maxillary sinus (MS) width measurements. TABLE 4—Side difference of maxillary sinus (MS) height measurements.
15
Right–Left MS Right–MS
16 Right MS Left MS Width (mm) Right MS Left MS Height (mm)
17 Width (mm) Width (mm) Difference p (paired t-test) Height (mm) Height (mm) Difference p (paired t-test)
18
Female Female
19 Range 13.4 to 29.4 14.3 to 31.5 )4.8 to 7.4 Range 26.5 to 51.7 26.2 to 47.9 )6.9 to 9.4
20 Mean 22.7 23 )0.3 0.49[NS] Mean 39.9 40 )0.1 0.88 [NS]
21 SD 3.2 4 2.7 SD 5.2 4.8 3.3
22 SE 0.48 0.6 0.4 SE 0.78 0.71 0.49
N 45 45 45 N 45 45 45
23 Male Male
24 Range 16.2 to 35 16.2 to 34 )9.6 to 5.8 Range 30.2 to 52.1 38.4 to 52.7 )10.8 to 5
25 Mean 24.7 25.6 )0.9 0.033 Mean 43.3 45.1 )1.8 0.002
26 SD 4 4.4 2.6 SD 4.8 4.1 3.5
27 SE 0.61 0.67 0.39 SE 0.73 0.62 0.53
N 43 43 43 N 43 43 43
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32 TABLE 3—Side difference of maxillary sinus (MS) length measurements. between men and women. For each cutoff value, the positive pre-
33 dictive value (a 50% pretest probability) was calculated to show
34 Right–Left the confidence in male determination (positive test results). Among
35 Right MS Left MS MS (mm) cutoff points with highest sensitivity, the left maxillary sinus height
Length (mm) Length (mm) Difference p (paired t-test)
36 is the best; it is associated with lowest false positive rate among all
37 Female similar cutoff values of remaining parameters (Table 9).
38 Range 24.1 to 44.1 25.9 to 44.2 )7.3 to 8.7
Mean 36.9 37 )0.1 0.79 [NS]
39 SD 3.8 4 3 Discussion
40 SE 0.56 0.59 0.44
41 N 45 45 45 Identification on skeletal and decomposing human remains is
42 Male one of the most difficult skills in forensic medicine. Sex determina-
43 Range 30.5 to 50.4 31.3 to 49.8 )8.1 to 3.8 tion is also an important problem in the identification. When the
Mean 39.3 39.4 )0.1 0.78 [NS]
44 SD 3.8 3.7 2.3 skeleton exists completely, sex can be determined with 100% accu-
45 SE 0.57 0.56 0.35 racy. This estimation rate is 98% in existence of pelvis and cra-
46 N 43 43 43 nium, 95% with only pelvis and long bones, and 80–90% with
47 only long bones. However, in explosions, warfare and other mass
48 disasters like aircraft crashes, identification, and sex determination
49 are not an easy task (8,9). Next to the pelvis, the skull is the most
50 ‘‘D’’ is greater than reference D, it indicates we are dealing with a easily sexed portion of the skeleton, but the determination of the
51 male gender, and if ‘‘D’’ value is less than the reference values, this sex from the skull is not reliable well until after puberty. Sex esti-
52 indicates dealing with female gender. The more extreme the calcu- mation can be accomplished using either morphological or metric
53 lated ‘‘D’’ from the reference value, the higher the probability that methodologies. Statistical methods utilizing metric traits are becom-
54 the predicted gender is really true as seen in Tables 5 and 6. ing more popular, with most of the bones having been subjected to
55 Among all maxillary sinus measurements, the left maxillary sinus linear discriminate classification (10). The result of the present
56 height was the best discriminate parameter (overall accu- investigation showed that the maxillary sinus exhibits anatomic var-
57 racy = 71.6%) (Table 7). By combining the right and the left sinus iability between genders. A significant sex difference was found in
58 measurements, the overall classification accuracy was improved to relation to maxillary sinus width, length, and height. Among these
59 73.9% (Table 8). Receiver operating characteristic (ROC) analysis parameters, the left maxillary sinus height was the best discriminate
60 was also used to assess the validity of the tested variables. For each variable between genders (Wilk’s lambda is 0.745 with overall
61 measurement, three cutoff values were selected. The optimum cut- accuracy 71.6%). Teke et al. (7) found in their study about gender
62 off value was associated with highest accuracy rate in classifying determination from CT measurements of maxillary sinus that the
63 subjects according to the gender and provides the best separation overall accuracy rate for left maxillary sinus height measurement
 4 JOURNAL OF FORENSIC SCIENCES

1 TABLE 5—Discriminate analysis using right maxillary sinus measurements to discriminate between males and females.
2
3 Right maxillary sinus width (RMSW)
4 7 D = )6.535 + 0.276 · RMSW
5 Wilks’ Lambda = 0.923 p = 0.009
Female Male Overall
6
7 Percent accurately predicted group membership 55.6% 60.5% 58%
8
Classified as Male if D>
9
10 Functions at group centroids )0.279 0.292 0.006
11 Right maxillary sinus length (RMSL)
12 D = )10.123 + 0.266 · RMSL
13 Wilks’ Lambda = 0.908 p = 0.004
14 Overall
15
Percent accurately predicted group membership 53.3% 62.8% 58%
16
17 Classified as Male if D>
18 Functions at group centroids )0.307 0.322 0.008
19 Right maxillary sinus height (RMSH)
20
21 D = )8.256 + 0.199 · RMSH
Wilks’ Lambda = 0.894 p = 0.002
22 Overall
23
24 Percent accurately predicted group membership 64.4% 60.5% 62.5%
25 Classified as Male if D>
26
27 Functions at group centroids )0.334 0.349 0.007
28 Total distance across both sinuses (TDABS)
29 D = )11.53 + 0.144 · TDABS
30 Wilks’ Lambda = 0.905 p = 0.003
31 Overall
32 Percent accurately predicted group membership 62.2% 58.1% 60.2%
33
Classified as Male if D>
34
35 Functions at group centroids )0.314 0.328 0.007
36
37
38 TABLE 6—Discriminate analysis using left maxillary sinus (LMS) measurements to discriminate between males and females.
39
40 Left maxillary sinus width (LMSW)
41 D = )5.768 + 0.238 · LMSW
42 Wilks’ Lambda = 0.908 p = 0.004
43 Female Male Overall
44
45 Percent accurately predicted group membership 60% 62.8% 61.4%
Classified as Male if D>
46
47 Functions at group centroids )0.308 0.323 0.008
48 Left maxillary sinus length (LMSL)
49 D = )9.937 + 0.26 · LMSL
50 Wilks’ Lambda = 0.913 p = 0.005 Overall
51
52 Percent accurately predicted group membership 64.4% 67.4% 65.9%
53 Classified as Male if D>
54
Functions at group centroids )0.298 0.312 0.007
55 Left maxillary sinus height (LMSH)
56
57 D = )9.566 + 0.225 · LMSH
58 Wilks’ Lambda = 0.745 p < 0.001
Overall
59
60 Percent accurately predicted group membership 71.1% 72.1% 71.6%
61 Classified as Male if D>
62
63 Functions at group centroids )0.566 0.592 0.013
 UTHMAN ET AL • EVALUATION OF MAXILLARY SINUS DIMENSIONS IN GENDER DETERMINATION 51

1 TABLE 7—Discriminate analysis using right and left maxillary sinus measurements to discriminate between males and females.
2
3 Standardized Coefficient
4 RMSW 0.171
5 RMSL 0.393
6 RMSH 0.597
Wilks’ Lambda = 0.874 p = 0.01
7 Female Male Overall
8
9 Predicted group membership 64.4% 60.5% 62.5%
10 D = )10.024 + (0.047 · RMSW) + (0.105 · RMSL) + (0.119 · RMSH)
11 Classified as Male if D>
12 Functions at group centroids )0.368 0.385 0.009
13
14 LMSW )0.046
15 LMSL )0.156
LMSH 1.117
16 Wilks’ Lambda = 0.741 p < 0.001
17 Overall
18
19 Predicted group membership 68.9% 74.4% 71.6%
20 D = )8.874 + ()0.011 · LMSW) + ()0.041 · LMSL) + (0.252 · LMSH)
Classified as Male if D>
21
22 Functions at group centroids )0.572 0.598 0.013
23
24
25
26 TABLE 8—Discriminate analysis using both right and left maxillary sinus measurements to discriminate between males and females.
27
Standardized coefficient
28
29 Right maxillary sinus width (RMSW) 0.093
30 Right maxillary sinus length (RMSL) 0.042
Right maxillary sinus height (RMSH) )0.437
31 Left maxillary sinus width (LMSW) )0.171
32 Left maxillary sinus length (LMSL) )0.178
33 Left maxillary sinus height (LMSH) 1.422
34 Wilks’ Lambda = 0.727 p < 0.001
35 Predicted group membership Female Male Overall
36 73.3% 74.4% 73.9%
37 D = )8.271 + (0.026 · RMSW) + (0.011 · RMSL) + ()0.087 · RMSH) +
38 ()0.041 · LMSW) + ()0.046 · LMSL) + (0.32 · LMSH)
39 Functions at group centroids Classified as Male if D>
40 )0.592 0.62 0.014
41
42
43 was only 63.8%. On the other hand, the present study recorded the Fernandes (11) performed gender-discriminate analysis using
44 accuracy rate for both sinuses measurements to be 74.4% for men maxillary sinus measurements in addition to nasal cavity width,
45 and 73.3% for women with overall accuracy of 73.9%. Teke et al. total distance across the sinuses, head circumference, head width,
46 (7) reported lower accuracy rates for the same measurements, bizygomatic width at the zygion, glabellar ⁄ nasion ⁄ nasal bone angle,
47 which was 69.3% for men and 69.4% for women with overall and left and right lateral canthal angle. He found that 79.2% of the
48 accuracy of 69.3%. This 3.9–4.6% rate difference between the two skulls were correctly classified. Another study (2) tested 16 param-
49 studies could be attributed to the different measurement techniques eter for gender assessment including maxillary sinus measurements;
50 used, especially for maxillary sinus height. Teke et al. (7) measured they found that the average accuracy reached 80–87%. In the field
51 the height by marking the first and last scene of the sinus in of forensic identification, maxillary sinus measurements can be
52 CT scan and the number of the sections between them was taken with high speed and accuracy on the CT machine and stan-
53 determined, then the number of sections obtained was multiplied dard instruments of measures. The results of the present study pro-
54 by slice thickness (3 mm) to find out the height of the sinus. vided average accuracies that were comparable to those obtained
55 This method is considered less accurate than that used in the using more complex techniques and parameters.
56 present study.
57 Multiple regression equations were applied in this study to test
Conclusion
58 the accuracy rate in sex classification; if values of width, length,
59 and height were substituted to the following formula, the accuracy Maxillary sinus dimensions measurements are valuable in study-
60 rate of sex prediction will be about 74% ing sexual dimorphism. They tend to stabilize after second decade
61 D = )8.271 + (0.026 · right sinus width) + (0.011 · right sinus of life, and the reconstructed CT images could provide adequate
62 length) + ()0.087 · right sinus height) + ()0.041 · left sinus measurements for maxillary sinuses that cannot be approached by
63 width) + ()0.046 · left sinus length) + (0.32 · left sinus height). other means.
 6 JOURNAL OF FORENSIC SCIENCES

1 TABLE 9—Validity parameters of 3 cutoff values for each test when used to predict male gender differentiating it from females.
2
3 PPV at Pretest
Positive if ‡ Cut-off Value Sensitivity Specificity Accuracy Probability = 50%
4
5 Right maxillary sinus width (mm)
6 16.1 (highest sensitivity) 100.0 4.4 51.1 51.1
26.2 (Optimal cut-off value) 34.9 91.1 63.6 79.7
7 29.5 (highest specificity) 18.6 100.0 60.2 100.0
8 Right maxillary sinus length (mm)
9 30.5 (highest sensitivity) 100.0 6.7 52.3 51.7
10 39.5 (Optimal cutoff value) 51.2 82.2 67.1 74.2
11 45.5 (highest specificity) 4.7 100.0 53.4 100.0
Right maxillary sinus height (mm)
12 30.0 (highest sensitivity) 100.0 8.9 53.4 52.3
13 42.5 (Optimal cutoff value) 53.5 75.6 64.8 68.7
14 51.9 (highest specificity) 2.3 100.0 52.3 100.0
15 Left maxillary sinus width (mm)
16.2 (highest sensitivity) 100.0 6.7 52.3 51.7
16 24.5 (Optimal cut-off value) 62.8 62.2 62.5 62.4
17 32.1 (highest specificity) 11.6 100.0 56.8 100.0
18 Left maxillary sinus Length (mm)
19 31.2 (highest sensitivity) 100.0 11.1 54.5 52.9
20 38.3 (Optimal cut-off value) 67.4 64.4 65.9 65.4
44.6 (highest specificity) 7.0 100.0 54.6 100.0
21 Left maxillary sinus height (mm)
22 38.2 (highest sensitivity) 100.0 33.3 65.9 60.0
23 42.0 (Optimal cut-off value) 76.7 68.9 72.7 71.2
24 48.1 (highest specificity) 32.6 100.0 67.1 100.0
Total distance across both sinuses (mm)
25 65.4 (highest sensitivity) 100.0 6.7 52.3 51.7
26 83.6 (Optimal cut-off value) 51.2 82.2 67.1 74.2
27 89.2 (highest specificity) 20.9 100.0 61.3 100.0
28
29
References 8. Krogman WM, Iscan MY. The human skeleton in forensic medicine,
30 2nd edn. Springfield, IL: Charles C. Thomas Publishing, 1986.
31 1. Ono I, Ohura T, Narumi E, Kawashima K, Matsuno I, Nakamura S, 9. Badger K, Craft RS, Jensen L. Age and gender differences in
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dimensional computed tomography. J Craniomaxillofac Surg 1992;20(2): e1–5.
33 49–60. 10. Ramanlal DM, Ariyo BM. Discriminating sex in South Africa blacks
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299–305. Asmaa T. Uthman, B.D.S., M.Sc.
40 5. Lerno P. Identification Per le sinus maxillaire. Odontol Leg 1983;216: Assistant Professor
41 39–40. Department of Oral and Craniofacial Health Science
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42 skull. A new technique. Naturwissenschaften 1989;76(7):325–7.
College of Dentistry, University of Sharjah, UAE
43 PO Box 27272
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44 measuring the size of the maxillary sinuses in computed tomography E-mail: asmaatahseen69@yahoo.com
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all characters to be deleted
Substitute character or
through letter or new character or
substitute part of one or
more word(s) through characters new characters
Change to italics under matter to be changed
Change to capitals under matter to be changed
Change to small capitals under matter to be changed
Change to bold type under matter to be changed
Change to bold italic under matter to be changed
Change to lower case B
Encircle matter to be changed
or
‘superior’ character
Insert superscript through character or under character
under character
where required e.g.
Insert subscript e.g.overorcharacter
Insert ‘inferior’ character (As above) e.g.
over character
Insert full stop (As above)
Insert comma (As above)
Insert single quotation marks (As above)
or and/or
Insert double quotation marks (As above)
or
Insert hyphen (As above)
Start new paragraph
Transpose
Close up linking characters

Insert or substitute space through character or

between characters or words where required
Reduce space between between characters or
characters or words words affected