ORIGINAL ARTICLE

Association between sella turcica

bridging and the impaction severity of
palatally displaced canines:
A retrospective study
Genta Agani Sabaha,b and Banu Dinçerc
Izmir, Turkey

Introduction: This retrospective study aimed to investigate the association between the extent of the bridging
and dimensions of sella turcica and the impaction severity of palatally displaced canines. Secondarily, any
possible association between skeletal age and gender was evaluated. Methods: Panoramic and cephalometric
radiographs of 94 patients (63 female, 31 male; 19 pre-peak, 75 post-peak) with palatally displaced canines were
evaluated. Sector classification and a angle were used to determine the impaction severity of palatally displaced
canines on panoramic radiographs. The distance from the cusp tip of the palatally displaced canines to the
occlusal plane (d) and the extent of the bridging and dimensions of the sella turcica were evaluated on cepha-
lometric radiographs. Results: Sella turcica bridging and dimensions did not vary regarding the impaction
severity of palatally displaced canines, but a significant association was found between sella turcica bridging
and skeletal age (P 5 0.038). Class II (33.3%) and Class III (12.0%) bridging was higher in postpubertal patients.
No differences between females and males were detected for the extent of bridging and dimensions of the sella
turcica. Conclusions: These findings indicate no association between sella turcica bridging and dimensions
and the impaction severity of palatally displaced canines. Sella turcica bridging is more frequent in the postpu-
bertal period, whereas gender does not influence sella turcica bridging. More studies are needed to evaluate if
the extent of sella turcica bridging may be indicative of severely impacted palatal canines, which in turn would
allow for careful monitoring of patients from an early age and for the clinician to take preventive measures. (Am J
Orthod Dentofacial Orthop 2023;164:567-74)

L
ateral cephalometric radiographs are widely used
in orthodontics to evaluate skeletal and dental
structures, in addition to growth and develop-
ment. They also provide important diagnostic findings
regarding the skull, facial structures and upper cervical
vertebrae.1 Pathologic findings and various anatomical
variations of these structures discovered incidentally
a
Department of Orthodontics, Faculty of Dentistry, Izmir Tinaztepe University,
Izmir, Turkey.
b ital anomalies such as cleft lip and palate,9 and certain
Department of Oral and Dental Health, Vocational School of Health Services,
Izmir Tinaztepe University, Izmir, Turkey.
c
Department of Orthodontics, Faculty of Dentistry, Ege University, Izmir,
Turkey.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Genta Agani Sabah, Department of Orthodontics,
Faculty of Dentistry, Izmir Tinaztepe University, Aydogdu, 1267/1. Sk. No. 4,
35400 Buca, Izmir, Turkey; e-mail, genta.agani@gmail.com.
Submitted, September 2022; revised and accepted, March 2023.
0889-5406/$36.00
Ó 2023.
https://doi.org/10.1016/j.ajodo.2023.03.016
on cephalometric radiographs have been reported in
the literature.2 Some of these studies have described
“bridging of the sella turcica,” which is formed by the
abnormal calcification of the interclinoid ligament
(ICL) of the sella turcica between the anterior and poste-
rior clinoid processes.2-5
In cephalometric studies, sella turcica bridging has
been reported between 3.8% and 13.0% of the general
population,1,5-7 with an increased prevalence in
patients with severe craniofacial deviations,4,7,8 congen-
dental anomalies.1,10-12 It has been suggested that this
relationship may be due to the common embryologic
origin from the neural crest cells of the anterior wall of
the sella turcica and the maxillary and frontonasal
areas.13
Several studies have suggested an association be-
tween sella turcica bridging and palatally displaced ca-
nines (PDC).1,10,12,14,15 However, to our knowledge, no
previous study has evaluated the relationship between

567
568
sella turcica bridging and the impaction severity of PDC.
Therefore, the primary aim of this retrospective study
was to evaluate whether the impaction severity of PDC
is related to the extent of the bridging and dimensions
of sella turcica. The secondary aim was to evaluate any
association between the extent of the bridging and di-
mensions of sella turcica with skeletal age and gender.
The null hypothesis was that there is no correlation be-
tween the extent of the bridging of sella turcica and the
impaction severity of PDC.
MATERIAL AND METHODS
This study was approved by the Clinical Research
Ethics Committee of the Faculty of Medicine at Ege Uni-
versity (No. 20-6.1T/61, June 24, 2020).
The sample size calculation (version 3.1.9.4, G*Po-
wer; Kiel University, Kiel, Germany) was performed using
a significance level of 5% and a sample power of 80% to
detect Pearson’s correlation coefficient of r 5 0.3.16 Ac-
cording to this calculation, a minimum of 84 subjects
were required. In this study, treatment records of 94 pa-
tients (63 female and 31 male) with a diagnosis of a PDC
were randomly selected from the archive of patients
treated in the last 10 years in the Department of Ortho-
dontics, Ege University, starting from the most recent re-
cords until the required sample size was achieved.
Maxillary canine teeth that did not erupt at their
physiological eruption time were considered impacted.
The bucco-palatal position of impacted canines was
determined by cone beam computed tomography, and
PDC with any depth, position, or impaction severity
were included.
Records of patients with cleft lip and/or palate,
craniofacial anomaly or syndrome, systemic disease, his-
tory of facial trauma and/or multi-agent chemotherapy
treatment history, supernumerary teeth, congenital
missing teeth other than third molars, peg lateral teeth,
patients requiring orthognathic surgery, patients with a
history of previous orthodontic treatment and radio-
graphs that were of poor quality were not included in
the study. The type of malocclusion was not considered
an exclusion criterion.
Patients were divided into groups according to
gender and skeletal age. Skeletal age was determined ac-
cording to the cervical vertebral maturation (CVM)
method, and patients were divided into pre-peak (cervi-
cal stage [CS] 1, CS 2, and CS 3) and post-peak (CS 4, CS
5, and CS 6) groups.17
Measurements on panoramic and cephalometric ra-
diographs were made using Onyx Ceph 3 (version
3.2.51; Image Instruments, Chemnitz, Germany).
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Agani Sabah and Dinçer
Sector classification by Ericson and Kurol18 was used
to determine the impaction severity of PDC on pano-
ramic radiographs. The medial crown position of the
PDC in sectors 1 to 5 (s1-s5) and the a angle between
the long axis of the PDC and the midline constructed
from the anterior nasal spine and the intermaxillary su-
ture were evaluated (Fig 1).
Cephalometric radiographs were imported into the
cephalometric analysis software and were calibrated us-
ing the ruler placed on it. A perpendicular line was used
to measure the millimetric distance from the cusp tip of
the PDC to the occlusal plane (d). The occlusal plane was
determined as the horizontal plane passing through the
incisal edge of the maxillary central incisor and the
maxillary first molar cusp (Fig 2).
After the standard tracing of the sella turcica, the
tuberculum sellae (TS), the dorsum sellae (DS), the
most posterior point of the inner wall of the sella tur-
cica (sella posterior [SP]) and the deepest point of the
sella turcica (sella base [SB]) were determined. The
length of the sella turcica was measured as the distance
between TS and DS (which also corresponds to the po-
sition of diaphragma sellae). The antero-posterior
greatest diameter of the sella turcica was measured
from TS to SP. The depth of the sella turcica was
measured as a perpendicular line from the length of
the sella turcica to SB (Fig 3).19
The standardized scoring scale established by Leo-
nardi et al1 was used to determine the extent of sella tur-
cica bridging. According to this scoring scale, if the
length of the sella turcica was greater than or equal to
three-quarters of the diameter, bridging was scored as
Class I (no calcification) (Fig 4); if less than or equal to
three-fourths (ICL partially calcified) as Class II (Fig 5);
and Class III for a radiographically visible diaphragma
sellae (ICL completely calcified) (Fig 6).
To ensure intra-rater reliability, the same evaluator
(G.A.S.) repeated all measurements twice with 1-month
intervals to determine any possible errors. During statis-
tical analysis, the weighted kappa coefficient (k) was
used for categorical data, and the intraclass correlation
coefficient was used for numerical data.
Statistical analysis
Descriptive statistics were summarized for all numer-
ical and categorical variables (mean, standard deviation,
median and range). The relationship between sella tur-
cica bridging and the impaction severity of PDC was eval-
uated using Fisher’s exact test and Kruskal-Wallis test.
Spearman’s correlation coefficient (r) was used to mea-
sure the degree of association between these variables.
Agani Sabah and Dinçer
Fig 1. A, The medial crown position of the maxillary canine in sectors s1-s5; B, a angle between the
long axis of the PDC and the midline.
Fig 2. Distance (d) of the cusp tip of the maxillary canine
from the occlusal line.
Pearson’s chi-square test was used to evaluate the
relationship of sella turcica bridging with gender and
skeletal age. For the dimensions of the sella turcica, an
independent samples t test or a Mann-Whitney U test
was used, depending on the distribution of the data as
assessed by the Shapiro-Wilk test.
If not otherwise specified, all tests were 2-tailed, and
the statistical significance was set at the P \0.05 level.
Calculations were made using SPSS (version 25.0, IBM,
Armonk, NY).
American Journal of Orthodontics and Dentofacial Orthopedics
569
Fig 3. Sella measurements: TS, tuberculum sellae; DS,
dorsum sellae; SP, sella posterior; SB, sella base.
Length, continuous; Diameter, dashed; Depth, dotted.
RESULTS
Regarding the error of the method, excellent intra-
observer reliability of the measurements was observed
for all variables (k, .0.999; intraclass correlation
coefficient, .0.933).
Descriptive statistics (mean, standard deviation, me-
dian and range) were calculated for a angle, d, and sella
turcica measurements (Table I). Frequencies and distri-
butions were calculated for sectors and the classification
of ICL calcification (Table II).
The relationship between sella turcica bridging and
the sector classification (P 5 0.921), a angle (P 5
0.579) and d (P 5 0.058) of PDC was not found to be
significant, suggesting that the severity of impaction
did not change according to the degree of ICL
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570 Agani Sabah and Dinçer

Fig 4. A, Schematic fig of Class I calcification of ICL; B, Section of a lateral cephalometric radiograph

from a patient with a Class I calcification of ICL.

Fig 5. A, Schematic figure of Class II calcification of ICL; B, Section of a lateral cephalometric radio-
graph from a patient with a Class II calcification of ICL.

Fig 6. A, Schematic fig of Class III calcification of ICL; B, Section of a lateral cephalometric radiograph
from a patient with a Class III calcification of ICL.

calcification (Table III). Spearman’s rank correlation be-

Table I. Descriptive statistics of a angle, d and sella tween sella turcica bridging and the sector classification
turcica linear measurements among subjects (r 5 0.08; P 5 0.444), a angle (r 5 0.046; P 5 0.659)
and d (r 5 0.067; P 5 0.519) of PDC was not signif-
Variables Mean 6 SD Median Range
icant with a weak correlation (Table IV).
PDC
a angle ( ) 39.5 6 14.9 36.3 60.9 The evaluation of the relationship between sella tur-
d (mm) 8.8 6 2.7 8.3 15.6 cica bridging and skeletal age showed a difference be-
Sella turcica tween the 2 skeletal age groups (P 5 0.038). A Class II
Length (mm) 8.3 6 3.4 9.1 13.8 calcification of the ICL was observed in 33.3%, and a
Diameter (mm) 10.3 6 4.0 11.4 14.7
Class III calcification in 12% of the post-peak skeletal
Depth (mm) 7.9 6 1.1 7.9 6.5
age group (Table V). However, there was no difference
SD, standard deviation. between skeletal age and the length (P 5 0.406),

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Agani Sabah and Dinçer
Table II. Frequencies and distributions of sectors and
ICL calcification among subjects
Classification Frequency Distribution (%)
Sector
s1 5 5.3
s2 17 18.1
s3 20 21.3
s4 34 36.2
s5 18 19.1
ICL
I 57 60.6
II 26 27.7
III 11 11.7
diameter (P 5 0.448) and depth (P 5 0.080) of the sella
turcica (Table VI).
The extent of the bridging of sella turcica for males
was similar to that for females (P 5 0.073), and differ-
ences in the length (P 5 0.111), diameter (P 5 0.581)
and depth (P 5 0.396) between males and females
were not significant, suggesting no relationship of sella
turcica bridging and dimensions according to gender.
DISCUSSION
The development of craniofacial structures is a
complex process, with cranial neural crest cells coordi-
nating a series of morphogenetic steps.20 These cells
form the anterior wall of sella turcica, whereas progen-
itor cells of dental epithelium differentiate by
sequential and reciprocal interaction with the neural
crest-derived mesenchymal tissue.13,21 Sella turcica is
a key area of the migration of neural crest cells toward
the frontonasal and maxillary fields, and mutations in
the homeobox (HOX) and sonic hedgehog (SHH) genes
can have a negative effect on the development of parts
of the sella turcica, midface and teeth, which may
result in excessive ossification of the dura mater be-
tween the anterior and posterior clinoidal processes
of the sphenoid bone leading to the formation of a
sella turcica bridge.5,13,22
Regarding PDC, theories about why these teeth are
impacted are generally divided into the genetic and
guidance theory. According to the genetic theory, PDC
arise as a result of developmental dislocation of the
maxillary canine to the palatal site resulting in
impaction.23,24 PDC are usually detected in individuals
from the same family, their prevalence is similar to
certain dental anomalies with a genetic origin, and
they often occur together with other genetically related
dental anomalies.25,26 The fact that PDC are 2 times
more common in females than males and that they occur
2-3 times more in European individuals supports the
American Journal of Orthodontics and Dentofacial Orthopedics
571
genetic factor of this anomaly.25-27 In contrast, the
guidance theory emphasizes the importance of local
factors in the ectopic position of the maxillary canines.
According to this theory, in dentitions with small-sized
or missing maxillary lateral incisors, there are no guiding
structures during the eruption of the canine due to
excess space formed in the apical part of the maxilla.
The frequent occurrence of palatal impacted canines
and small-sized or missing maxillary lateral incisors sup-
ports this theory.28,29
Previous studies in the literature have reported an
increased prevalence of sella turcica bridging in patients
with PDC,1,10,12,14,15 which can be explained by the com-
plex developmental processes and the common embryo-
logic origin of these structures. As a result,
malformations in the frontonasal, maxillary and palatal
areas are thought to be associated with malformations
in the anterior wall of the sella turcica.13 Sella turcica
bridging, in turn, may reflect developing pathologic
conditions of the oral cavity. Therefore, the rationale
of this study originated from the conjecture that a
deeper connection behind the relationship between sella
turcica bridging and PDC may exist, where a completely
calcified ICL could be associated with more severely
impacted PDC. Nonetheless, this study failed to reject
the null hypothesis and no correlation was found be-
tween the extent of the bridging of sella turcica and
the impaction severity of PDC.
Since there is a large variability in the timing and
amount of physical growth between individuals, mea-
sures of physiological maturity have been researched in
preference to chronological age for the evaluation of in-
dividual development.30 Therefore, when evaluating the
extent of the bridging and dimensions of the sella turcica
according to age, skeletal age classification according to
the CVM method was used in this study.17 Although the
length, diameter and depth differences between the
skeletal age groups were not significant, an increased
prevalence of Class II and Class III ICL calcification was
found in the post-peak group. The reason for this could
be that even though physiological intracranial calcifica-
tions such as calcification of the ICL are not fully under-
stood, it is presumed that they are related to aging and
degenerative changes.31
Leonardi et al1 and Cederberg et al5 showed a signif-
icant, albeit weak positive correlation between calcifica-
tion of the ICL and chronological age, suggesting a
slightly increased degree of ICL calcification for
increased age. In contrast, Scribante et al32 compared
the linear dimensions of 18 randomly selected patients
from the study group before and after treatment, in or-
der to evaluate the effect of growth on the extent of the
bridging of sella turcica. According to the results of this
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Table III. ICL classification according to sector, a angle, and d

ICL classification

Variables I II III df P value

Sector, n (%) 8 0.921y
s1 3 (5.3) 2 (7.7) 0 (0.0)
s2 11 (19.3) 3 (11.5) 3 (27.3)
s3 13 (22.8) 5 (19.2) 2 (18.2)
s4 21 (36.8) 10 (38.5) 3 (27.3)
s5 9 (15.8) 6 (23.1) 3 (27.3)
a angle ( ) 2 0.579z
n 57 26 11
Mean 6 SD 39.8 6 15.2 40.5 6 14.6 35.4 6 14.1
Median 35.9 41.3 30.3
Range 70.9 57.1 47.1
d (mm) 2 0.058z
n 57 26 11
Mean 6 SD 9.0 6 2.7 8.0 6 2.6 9.6 6 2.5
Median 8.5 7.3 9.1
Range 14.8 13.3 9.6
SD, standard deviation; df, degrees of freedom.
y
Fisher’s exact test; zKruskal-Wallis H test (Ha 5 1.094; Hd 5 5.697).

Table IV. Correlation between ICL classification and Table VI. Sella turcica dimensions among skeletal age
sector, a angle, and d groups
Sector a angle ( ) d (mm) Skeletal Age
ICL calcification Spearman’s 0.08 0.046 0.067
Sella turcica Pre-peak Post-peak P value
correlation
coefficient (r) Length (mm) 0.406y
P value 0.444 0.659 0.519 Mean 6 SD 8.85 6 3.65 8.18 6 3.44
Median 9.07 9.13
Range 13.00 13.80
Diameter (mm) 0.448y
Mean 6 SD 10.2 6 3.93 10.34 6 4.05
Table V. ICL classification among skeletal age groups Median 10.90 11.53
Range 14.77 14.73
ICL calcification Depth (mm) 0.080z
Mean 6 SD 7.49 6 1.06 8.00 6 1.12
Variables I II III df P value Median 0.56 8.00
Skeletal age 2 0.038* Range 4.03 6.53
Pre-peak 16 (84.2) 1 (5.3) 2 (10.5)
SD, standard deviation.
Post-peak 41 (54.7) 25 (33.3) 9 (12.0) y
Mann-Whitney U test (Ulength 5 624.5; Udiameter 5 632.0);
z
Note. Values are presented as n (% within age). Independent samples t test (t 51.769).
df, degrees of freedom.
*Statistically significant at P \ 0.05 (Pearson's chi-squared test [c2
5 6.529]). the results of these studies are not comparable with
the present research due to the division of the subjects
into age groups according to chronological age.
study, no significant correlation was found between age Studies in the literature report inconsistent findings
and calcification of the ICL. However, the authors regarding the relationship of sella turcica bridging and
emphasize the need for further studies with larger sam- dimensions according to gender. In accordance with
ples of cephalometric radiographs to evaluate the corre- the studies of Leonardi et al,1 Cederberg et al,5 Meyer-
lation between sella turcica bridging and age. Regarding Marcotty et al,8 Ali et al,14 Alkofide33 and Tepedino
the dimensions of the sella turcica, several studies show a et al.34 the data from this research showed no relation-
steady increase in the length, diameter and depth of the ship of sella turcica bridging and dimensions according
sella turcica with chronological age.6,19,33,34 However, to gender. Contrary to our findings, in the longitudinal

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Agani Sabah and Dinçer
study conducted by Axelsson et al,6 the length of the
sella turcica was larger in males, and this difference
was significant in the 12-, 15-, and 18-year-old age
groups. These results are supported by the study of Sil-
verman,19 who reported larger sella turcica sizes in males
than in females. In contrast, Francis35 found that the
length of the sella turcica from 9 months to 18 years
was greater in girls than boys. However, at 18 years
old, the length of the sella turcica was the same in the
male and female groups, and there was no difference be-
tween the genders after this age. This finding is similar to
the study of Axelsson et al,6 which showed no significant
difference regarding length between genders in the
adult group with a mean age of 21 years. The overall re-
sults for the depth and diameter of the sella turcica were
similar between the 2 genders in all age groups.6,35
Regarding the limitations of this study, the conjecture
that PDC impaction severity could be related to the extent
of sella turcica bridging can only be partially explained
since an association between these 2 structures also re-
quires the involvement of the posterior part of the sella
turcica, which has a different embryologic origin from
the notochord.12,13 Another limitation is the use of
2-dimensional as opposed to 3-dimensional imaging
techniques to determine the extent of sella turcica
bridging. Higher incidences of bridging of the sella turcica
are reported in studies using cephalometric radiographs
than in anatomical studies.1,5-7,36-38 These differences
have been attributed to the numerous variations in the
size and shape of the clinoid processes, especially the
anterior clinoid processes, which on lateral cephalograms
may appear as short blunt structures or as elongated
processes extending toward the posterior clinoid
processes with which they occasionally unite.6 Superimpo-
sition of the overlapping clinoid processes on
cephalometric radiographs may also contribute to the
appearance of a bridge-type union between the bony pro-
cesses.6,8 Although more precise and accurate information
about the sella turcica area can be obtained with 3-dimen-
sional imaging, because of the higher exposure to radia-
tion, computed tomography is not routinely used in
orthodontics, and therefore cephalometric radiographs
are the standard diagnostic tools for evaluating the sella
turcica region in orthodontic patients.8
Sella turcica bridging has been associated with
various diseases and syndromes.3,8,39,40 Therefore, early
diagnostic findings that may indicate developmental
anomalies and their severity are of great importance.
Orthodontists must be familiar with the normal anat-
omy of the sella turcica and be able to recognize any
morphological deviations that may reflect pathologic
conditions. Accordingly, inclusion of the sella turcica
American Journal of Orthodontics and Dentofacial Orthopedics
573
in the standard evaluation of cephalometric radio-
graphs is recommended.
CONCLUSIONS
The degree of calcification of the ICL did not vary ac-
cording to the impaction severity of PDC, but a signifi-
cant association between the degree of calcification of
the ICL and skeletal age was apparent.
ACKNOWLEDGMENTS
The authors express their endless gratitude to Profes-
sor Enver Yetkiner and Professor Pelin G€ uneri for their
valuable contributions to this study.
AUTHOR CREDIT STATEMENT
Genta Agani Sabah contributed to conceptualization,
methodology, investigation, resources, and original
draft preparation; Banu Dinçer contributed to conceptu-
alization, manuscript review and editing, supervision,
and project administration.
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Agani Sabah and Dinçer
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