Evaluation of clinical and radiographic warning signs for prediction of oroantral communication following tooth extractions

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Preoperative prediction of OAC can reduce treatment duration and prepare both operators and patients for the procedure. This study aims to identify alarming radiographic and clinical indicators that can predict OAC. Methods In this retrospective case-control study, a control group twice the size of the OAC group was established. Clinical data were collected, and measurements were conducted separately by two blinded observers on digital panoramic radiographs. Inter-rater reliability was assessed. The correlation between OAC and demographic data (age, sex), as well as various factors assessed on panoramic radiographs (including, but not limited to, the length of the root, root projection into the sinus, bone width, presence of mesial and distal adjacent teeth), was statistically evaluated. Results Inter-rater reliability was found to be excellent. Several factors were identified as potential predictors of OAC. According to our model, the strongest predictors were the distance between the cemento-enamel junction and marginal bone, extent of root projection into the sinus, presence of sinus recess around the roots, angulation, and absence of the mesial adjacent tooth. Conclusions Well-defined measurements on panoramic radiographs may aid in predicting OAC. Further prospective investigations are necessary to confirm these indicators and address factors related to clinical examination and operation. Maxillary Sinus Tooth Extraction Intraoperative Complications Oroantral Fistula Orthopantomography panoramic radiograph Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Oroantral communication (OAC) is a relatively common complication of maxillary tooth extractions[ 1 – 3 ] and other interventions such as sinus lifts and implant placement [ 4 ]. The highest incidence of OAC is reported in cases of maxillary first and second molar extractions [ 1 ], although canine and premolar extractions may also result in OAC. Well-known risk factors predisposing individuals to this complication include the extraction of the last remaining tooth from the arch or a tooth with periapical inflammation [ 1 , 4 , 5 ]. Morphometric studies have highlighted the importance of the size, shape, and extent of the maxillary sinus, as well as the relationship between the roots of maxillary teeth and the floor of the sinus [ 6 – 16 ]. These works provide essential insights into the anatomical variability of the maxillary sinus and highlight the benefits of analysing cone beam computed tomography (CBCT) over orthopantomography (OPG)[ 6 , 9 – 11 , 13 , 16 – 18 ]. However, these studies do not provide clinical guidance. Potential risk factors of OAC were examined most broadly in relation to upper wisdom tooth removal [ 17 , 19 – 22 ] and mostly reported the superiority of CBCT analysis over panoramic radiographs in the prediction. While cone beam computed tomography (CBCT) has been shown to provide valuable insights into these anatomical considerations, panoramic radiographs remain a more commonly selected diagnostic tool due to their lower cost and reduced radiation exposure.[ 23 ] [ 24 ] Unlike in case of impaction, OAC during routinely performed extractions can significantly extend the treatment duration, as it will require additional interventions such as raising a flap, which can lead to further potential complications. Our study aims to assess and identify potential clinical and panoramic radiographic warning signs that could predict the occurrence of OAC during maxillary tooth extractions. Such risk assessment could benefit both patients and dentists by improving time management, aiding in decision-making, enhancing informed consent processes, and facilitating treatment planning for more favourable long-term outcomes. Materials and methods In our retrospective case-control study, approved by the regional ethics committee (8577-PTE 2020), a database search was conducted in the archives of the University of Pécs, Clinical Centre, Department of Dentistry, Oral and Maxillofacial Surgery. All cases in which closure of Oroantral Communication (OAC) was performed between 2019 and 2021 were collected. The cases were then categorised based on the inclusion and exclusion criteria outlined in Table 1 . Two controls were matched to each OAC case solely based on the type of tooth (canine, first premolar, second premolar, first/second or third molar). Table 1 Inclusion and exclusion criteria (OAC-oroantral communication, OPG- orthopantomographic image, C-canine, PM1/PM2- first or second premolar, M1/M2/M3- first, second or third molar) Inclusion criteria- case Exclusion criteria- case • OAC after tooth extraction of a maxillary canine, premolar or molar tooth. • OAC was not the result of tooth extraction, • tooth extraction was not performed at on University of Pécs, Clinical Centre, Department of Dentistry, Oral and Maxillofacial Surgery (referred patients), • lack of OPG prior to extraction, • OPG was older than 6 months or surgical interventions (extractions, implantation) were carried out in the quadrant within the time span between the OPG was taken and the OAC developed, • multiple extractions were performed in the same quadrant (localisation of OAC and relationship to adjacent extraction was unknown), • uninterpretable OPG. Inclusion criteria- control Exclusion criteria- control • 2 controls for each case with the same type of extraction (C, PM1, PM2, M1/M2/M3) without OAC after extraction. • no prior OPG, • uninterpretable OPG, • multiple extractions from the same quadrant. Two independent interpreters, blinded to the case/control status, evaluated the panoramic radiographs according to a predefined criteria system (see Appendix 1). All X-rays were captured at the university clinic using the same X-ray machine (VATECH, PCH-2500, Korea) and following the manufacturer’s recommended positioning for each patient. The panoramic radiographs were assessed using EasyDentV4 (Vatech Co., Ltd., version: 4.1.3.2, Data Tec, Inc., Johannesburg, South Africa) software. The measurements conducted on the images are depicted in Fig. 1 . Statistical Analysis The interrater reliability was determined using Cohen's Kappa. In cases where discrete variables did not align between the two interpreters, the results of a third interpreter's evaluation were utilised for further analysis. Similarly, the results of the third interpreter were considered in instances where the interrater κ was < 0.8 (indicating less than strong agreement) for continuous variables. Exploratory analyses were conducted using Wilcoxon rank sum tests, Pearson’s Chi-squared tests, and Fisher’s exact tests. Given the high number of variables relative to the sample size, a random forest algorithm was employed for variable selection to identify potential predictor factors for OAC. Variable correlation for continuous variables was assessed to identify correlated and independent variables. A model comprising only independent factors potentially influencing OAC was developed based on the outcomes of the variable selection and correlation. Decision tree and binary logistic regression analyses were performed using this model. Results A total of 241 cases of oroantral communication (OAC) were evaluated, of which 97 cases were ultimately included in the study. The process of case selection is depicted in Fig. 2 . The selected cases and controls, as well as the demographic data (age, sex) of the patients and factors related to tooth extraction (tooth position), were collated in a single table (Table 2 ) Table 2 Demographic and clinical data of the study population Case Control n 97 194 Female 54 99 Male 43 95 Average age (years) 43 ± 18 42 ± 18 C 2 4 PM1 3 6 PM2 7 14 M1 46 92 M2 26 52 M3 13 26 In the case of all categorical variables, there was a near-perfect agreement between the interpreters (κ > 0.81). In instances of disagreement, a third independent interpreter's decision was utilized for further assessment. The only exception was the measurement of the vertical width of the periapical defect, which demonstrated less than perfect agreement (κ = 0.68) Among the factors examined, several were identified as potential predictors of OAC. A statistically significant correlation was observed with impaction (p = 0.001), the distance from the cementoenamel junction (CEJ) to the marginal bone on the distal (p = 0.002) and mesial sides (p = 0.002), maximal root projection mesially (p < 0.001) and distally (p = 0.001), and the vertical bone width mesially (p = 0.002) and distally (p = 0.009) (Table 3 ). Table 3 Results of Wilcoxon rank sum tests, Pearson’s Chi-squared tests and Fisher’s exact tests V * -vertical, M ** -mesial, D *** -distal, SD **** -standard deviation. Bold p values are significant. All measured parameters given in millimetre. Case Control p Max. root projection 2.9 ± 3.5 1.1 ± 3.0 < 0.001 Distance between CEJ and marginal bone on the distal side (average ± SD) 2.19 ± 2.80 3.39 ± 2.15 0.002 Distance between CEJ and marginal bone on the mesial side (average ± SD) 1.71 ± 2.83 3.04 ± 2.05 0.002 Vertical bone width distally (average ± SD) 6.6 ± 3.1 7.5 ± 3.1 0.009 Maximal root projection mesially 1.46 ± 3.03 0.05 ± 2.83 < 0.001 Maximal root projection distally -0.20 ± 2.63 0.99 ± 2.62 0.001 Vertical bone width mesially (average ± SD) 6.4 ± 3.1 7.8 ± 3.6 0.002 Distal adjacent tooth present 43 95 0.455 Mesial adjacent tooth present 53 121 0.205 Length of root mesially (average ± SD **** ) 8.90 ± 3.06 8.49 ± 2.55 0.358 Caries present 74 164 0.086 Distal sinus recession present 8 8 0.146 Angulation V * :65 M ** :21 D *** :11 142 35 17 0.540 Root canal treated tooth 20 29 0.223 Interdental space distally coronally (average ± SD) 6.50 ± 6.40 5.70 ± 6.70 0.175 Interdental space mesially apically(average ± SD) 9.00 ± 10.00 7.00 ± 7.00 0.271 Periapical lesion reaches/penetrates the base of the sinus 28 60 0.718 Interruption in the basal line of maxillary sinus 13 17 0.220 Interdental space mesially coronally (average ± SD) 7.00 ± 10.00 5.00 ± 7.00 0.197 Periapical bone resorption present 30 73 0.260 Interdental space distally apically(average ± SD) 7.20 ± 6.60 6.80 ± 6.90 0.498 Maximal mesio-distal width of periapical defect 1.92 ± 3.14 1.91 ± 2.81 0.588 Multiple roots 80 165 0.570 Mesial sinus recession present 19 25 0.133 Impaction 6 0 0.001 Length of root distally (average ± SD) 8.05 ± 2.82 7.56 ± 2.68 0.211 Maximal depth of vertical bone defect (average ± SD) 0.48 ± 1.20 0.58 ± 1.28 0.733 Restoration in tooth present 36 70 0.863 Relation of apex(es) to base of maxillary sinus root projects into the sinus: 67 in contact: 13 no contact: 17 122 26 46 0.467 Vertical bone loss present 20 41 0.919 Maximal vertical width of periapical defect 0.77 ± 1.57 0.76 ± 1.49 0.532 Interdental space distally coronally (average ± SD) 6.50 ± 6.40 5.70 ± 6.70 0.175 Vertical bone width mesially (average ± SD) 6.4 ± 3.1 7.8 ± 3.6 0.002 A random forest analysis for variable selection identified 13 factors potentially related to OAC (Fig. 3 ). As anticipated, the correlation of variables revealed several interacting factors (Fig. 4 ). A model based on the gathered information was constructed and utilized for further evaluation. Binary logistic regression analysis revealed three factors that significantly influenced OAC: maximal root projection (p < 0.001; odds ratio [OR] = 1.22), the distance from the CEJ or the most coronal portion of the root to the marginal bone on the mesial side (p = 0.011, OR = 0.721), and the presence of an adjacent mesial tooth (p = 0.032, OR = 0.495) (Table 4 ). Table 4 Results of binary logistic regression analysis. Bold p-values indicate significant correlation. OR-odds ratio, CI-confidence interval. Variable OR1 95% CI1 p-value maximal root projection 1.22 1.11, 1.35 < 0.001 distance between CEJ and marginal bone on the distal side 1.02 0.802, 1.28 0.899 distance between CEJ and marginal bone on the mesial side 0.721 0.555, 0.923 0.011 adjacent tooth mesially not present 1.00 — present 0.495 0.257, 0.938 0.032 adjacent tooth distally not present 1.00 — present 1.05 0.454, 2.48 0.905 presence of caries not present 1.00 — present 0.613 0.299, 1.27 0.183 interdental space distally coronally 1.02 0.959, 1.09 0.492 maximal length of root mesially 0.919 0.811, 1.04 0.176 presence of sinus recession not present 1.00 — present 1.80 0.918, 3.50 0.085 angulation vertical 1.00 — mesial 0.956 0.453, 1.98 0.905 distal 1.45 0.489, 4.15 0.492 According to the decision tree analysis, four branching factors were identified: distance from the CEJ or the most coronal portion of the root to the marginal bone on the mesial side, maximal root projection, presence of sinus recess, and angulation (Fig. 5 .). Discussion OAC associated with maxillary tooth extractions is a relatively common complication Both the planning and timely intervention in the treatment of OAC can pose challenges for clinicians. Panoramic radiographs are commonly used for the prediction of inferior alveolar nerve exposure during wisdom tooth surgeries [ 25 – 27 ], failure of condylar neck osteosynthesis[ 28 ], impaction of maxillary canines [ 29 ], growth changes associated with orthodontic therapy [ 30 ] nd the diagnosis of atheromatous plaque formation in the carotid artery [ 31 ]. Panoramic radiographs are generally accepted as diagnostic tools and, in many cases, provide sufficiently reliable measurements [ 23 ]. The relationship between the roots of maxillary teeth and the sinus has been evaluated using both panoramic radiographs and CBCT scans [ 6 – 9 , 11 – 13 , 15 , 16 , 18 ]. Although most studies emphasize the superiority of CBCT over panoramic radiographs in assessing the real correlation between the roots and the sinus floor, they do not provide a prediction of the occurrence of post-extraction OAC. Regnstrand et al. reported that approximately 70% of upper first molar roots are in contact with the sinus, with up to a fifth of the root surface (for the palatal root) being involved [ 7 ]. However, Punwutikorn et al. found that the incidence of OAC related to upper first molar extractions was only 0.61% [ 1 ] suggesting that anatomical observations do not directly translate to clinical findings. According to Sharan & Madjar, the projection of maxillary teeth roots into the sinus is overestimated on panoramic radiographs in both occurrence and length [ 11 ]. Jung & Cho reported that, contrary to the appearance of wisdom tooth roots projecting into the sinus on panoramic radiographs, CBCT scans showed that the sinus floor is often located buccally to the roots, mimicking root projection on panoramic images [ 16 ]. he risk of OAC during upper wisdom tooth removal has been examined in detail by several studies [ 17 , 19 – 22 ], both panoramic radiographs and CBCTs were evaluated, along with clinical parameters. Iwata et al. concluded that the usefulness of CT evaluation as an adjunct to panoramic radiographs in predicting OAC following upper wisdom tooth removal is limited [ 19 ]. In addition to root projection into the sinus and depth of impaction, other factors such as a single-rooted tooth, pericoronitis, and "remarkable hemorrhage" were associated with an increased risk of OAC. Hasegawa et al. [ 20 ] reported similar outcomes related to the depth of impaction and the root projection, additionally mesioangular position and incision were raised as risk factors. reported similar outcomes related to the depth of impaction and root projection, adding mesioangular position and incision as risk factors. Further risk factors, such as older age and intraoperative root fracture, were reported by Rothamel et al.[ 22 ]. A systemic review by Lewusz-Butkiewicz et al.[ 5 ] concluded that the relationship between the root of the wisdom tooth and the maxillary sinus can be an important predictive factor, along with older age, mesioangular position, and performed osteotomy during tooth removal. Our study was not conducted focusing solely on wisdom teeth, as the occurrence of OAC is more common and may be a more troublesome consequence when extracting other teeth. Similarly to these articles, "depth," represented in our study by the distance between the cementoenamel junction and the marginal bone, was an important predicting factor for OAC. In cases of impaction and severely destructed teeth with remaining roots below the marginal bone level, negative values of this parameter indicated a higher chance for the formation of an oroantral communication. Angulation other than vertical and the length of root projection into the sinus (maximal root projection) also proved to be significant. Unfortunately, in our retrospective study, operational parameters such as excessive use of an elevator, osteotomy, and excessive bleeding were difficult to address; however, they could have had a remarkable impact. As we examined OAC related to the extractions of canines, premolars, and molars as well, the number of cases is higher (97 OAC) than in those studies that focus on wisdom tooth surgeries (7–46), except for a prospective multicenter study by Rothamel et al.[ 22 ]. In a recent study by Vollmer et al.[ 32 ], several deep learning models were employed to determine if OAC could be predicted based on preoperative panoramic radiographs. They assessed both expert performance and artificial intelligence (AI) performance in predicting OAC without a preset criteria system. From the 100 OAC cases and 200 controls, they concluded that the prediction of OAC by AI is not yet feasible and that expert agreement on the same matter is poor. In contrast, our study demonstrated excellent expert agreement, which may be the result of a defined, preset evaluation criteria system (see Appendix 1). Our investigation revealed that neither the presence nor the size of periapical inflammation significantly influences the occurrence of oroantral communication (OAC). This finding may be attributable to the preservation of the cortical bone at the sinus base during bone resorption or to local thickening of the Schneiderian membrane induced by inflammation. Both factors potentially diminish the risk of creating a pronounced, direct connection during tooth extraction. Furthermore, disruptions in the basal contour of the maxillary sinus or the presence of root projections in relation to the sinus base did not demonstrate a significant impact. The results of our study identified several potential indicators on panoramic radiographs predictive of OAC formation. Both decision tree analysis and binary logistic regression revealed significant correlations with two parameters: the distance between the marginal bone and the cementoenamel junction mesially, and the maximal root projection. While the decision tree offers a clinically relevant heuristic for decision-making, it is important to note that the initial braching point (mesial CEJ to marginal bone distance) provides limited interpretive value, as a negative distance may denote either an impacted tooth or a a root remnant. The depth of impaction or, alternatively, the extent of destruction (distance from the marginal bone to the CEJ or the most coronal part of the root) may affect the development of OAC. This relationship is corroborated by our binary logistic regression analysis, which indicated a 0.721-fold decrease in OAC risk for every millimeter increase in the mesial distance from the CEJ to the bone. The significance of this measure may extend beyond the relative depth of the tooth/root, suggesting that the removal of a root remnant or impacted tooth may necessitate osteotomy or intensive use of elevators, both of which are likely contributory to OAC formation. These potential contributing factors were beyond the scope of this study. Another significant determinant of OAC, identified by both analytical approaches, was the maximal root projection. A one-millimeter increase in maximal root projection was associated with a 1.22-fold increase in OAC risk, with the decision tree threshold set at 3.3 mm. This finding is consistent with prior research by Madjar et al.[ 11 ], who demonstrated that root projection into the sinus is overestimated on panoramic radiographs compared to cone-beam computed tomography (CBCT), emphasizing the significance of the extent, rather than the mere presence, of root projection. Sinus recess and mesial or distal angulation of the tooth were also identified as significant factors by the decision tree. The relevance of sinus recess is underscored by Regnstrand et al.[ 7 ] who observed that the roots may contact the sinus across a larger surface area, not limited to the socket's most apical portion. Mesial angulation has been highlighted as a risk factor by other studies [ 5 , 20 ]. It is noteworthy that teeth with distal angulation were relatively infrequent (n = 11) in our cohort, suggesting the need for further investigation into their significance. The binary logistic regression analysis also identified the loss of mesial contact as a significant OAC risk factor. The presence of a mesial adjacent tooth was associated with a 0.495-fold reduction in OAC risk. This factor is inherently related to mesial angulation and sinus recess on the mesial side; tooth loss can lead to mesialization and sinus pneumatisation over time. The interplay among these factors adds complexity to the analysis. Our findings advocate for the consideration of various clinical and radiographic indicators on panoramic radiographs when predicting the likelihood of OAC in association with upper tooth extractions. To the best of our knowledge, this is one of the inaugural studies to evaluate the incidence of OAC following tooth extractions using routine panoramic radiographs, with a particular focus beyond the upper wisdom teeth. Our interrater reliability was good to excellent, validating the effectiveness of our predefined criteria and the reliability of the study's results. Nonetheless, certain limitations of the study warrant mention. Panoramic radiography only allows for semi-standardized settings. Given the retrospective nature of the study, specific clinical data—such as periodontal probing depth surrounding the tooth, tooth mobility, precise localization of OAC within the alveolar socket, or detailed accounts of the instruments used and the difficulty of the extraction procedure—could not be collected. Additionally, the variability in operator technique was not addressed due to the involvement of numerous dentists in the extractions. While CBCT remains the superior imaging modality for predicting OAC during dental extractions, its use is constrained by cost, radiation exposure, and environmental impact. A prospective clinical study incorporating comprehensive preoperative examinations, meticulously documented interventions, and precise measurements taken from well-aligned periapical radiographs using the parallel technique could yield additional valuable data for the prediction of post-extraction OAC. Declarations Funding Declaration We report no funding. Data Availability All data supporting the findings of this study are available within the paper and its Supplementary Information. Competing Interests We report no competing interests. References Punwutikorn J, Waikakul A, Pairuchvej V (1994) Clinically significant oroantral communications - a study of incidence and site. 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Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 23 Oct, 2024 Read the published version in Clinical Oral Investigations → Version 1 posted Editorial decision: Revision requested 09 Jul, 2024 Reviews received at journal 01 Jul, 2024 Reviews received at journal 01 Jul, 2024 Reviews received at journal 25 Jun, 2024 Reviewers agreed at journal 21 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviewers agreed at journal 19 Jun, 2024 Reviewers invited by journal 06 May, 2024 Editor assigned by journal 25 Apr, 2024 Submission checks completed at journal 25 Apr, 2024 First submitted to journal 24 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4319954","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":296619560,"identity":"93a43b1b-ca23-49b1-b30a-7cdccf35306f","order_by":0,"name":"Alexandra Jurasek","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Jurasek","suffix":""},{"id":296619561,"identity":"5f3c91be-2cde-4b72-a283-aa9864817e2f","order_by":1,"name":"Nelli Farkas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYFAC5sYDCQxyDAw8QPYHBgYDsCBjAz4tjA1ALcZgLYwzwFqYidDCANXCzEOMFnP2xoYDDxgM5M17Dj/+bFNjY8wg3X/wAeOOwzi1WPYcBDnMwHDO2TYz6ZxjaWYMMoeZDRjP4NZicCMRpOUP4wx+BjPmHLbDNgwSyWwSjG14tNx/CLbFfgY/++fPFv/AWth/4NVyAxxiBokzeHsMpIEqzUC2MODVcgbkMAOD5Bk8Z8oke/vSjNlkDhtLJLal49Zy/PDBhz8qDGxn8KRv/vDjm41hv3Tjww8f26xxaoFqRGKzSQCJBAIa0IAEacpHwSgYBaNg+AMAxFpT/bGiZ4IAAAAASUVORK5CYII=","orcid":"","institution":"University of Pecs","correspondingAuthor":true,"prefix":"","firstName":"Nelli","middleName":"","lastName":"Farkas","suffix":""},{"id":296619562,"identity":"00631838-1627-469a-a087-ee91f7518709","order_by":2,"name":"Dorottya Frank","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Dorottya","middleName":"","lastName":"Frank","suffix":""},{"id":296619563,"identity":"c5fd40cc-be15-4e55-a2b1-494b749a11cb","order_by":3,"name":"Bela Kolarovszki","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Bela","middleName":"","lastName":"Kolarovszki","suffix":""},{"id":296619564,"identity":"c2aa0944-7c3f-4da4-bcb7-496bc92d0fbc","order_by":4,"name":"Balazs Sandor","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Balazs","middleName":"","lastName":"Sandor","suffix":""},{"id":296619565,"identity":"e5b84da4-4fad-48e3-a85c-54206f9aefb3","order_by":5,"name":"Andrea Radacsi","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Radacsi","suffix":""},{"id":296619574,"identity":"59f7c157-fc61-4de9-9bd4-63bba846b65b","order_by":6,"name":"Ildiko Szanto","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Ildiko","middleName":"","lastName":"Szanto","suffix":""},{"id":296619577,"identity":"ecd39ca8-657d-4915-87f1-3c6d67f305ba","order_by":7,"name":"Krisztian Katona","email":"","orcid":"","institution":"University of Pecs","correspondingAuthor":false,"prefix":"","firstName":"Krisztian","middleName":"","lastName":"Katona","suffix":""}],"badges":[],"createdAt":"2024-04-24 18:25:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4319954/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4319954/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00784-024-06000-x","type":"published","date":"2024-10-23T15:57:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55639623,"identity":"98d18e55-098c-4fcc-b30f-058da2e2ab30","added_by":"auto","created_at":"2024-04-30 22:10:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":336931,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of the measurements conducted on the orthopantomographic images: \u003cem\u003e\u003cstrong\u003eA \u003c/strong\u003e\u003c/em\u003eand\u003cem\u003e\u003cstrong\u003e B\u003c/strong\u003e\u003c/em\u003e- length of the root measured mesially and distally from the coronal level of the bone to the apex; \u003cem\u003e\u003cstrong\u003eC \u003c/strong\u003e\u003c/em\u003e\u003cem\u003eand\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e D\u003c/strong\u003e\u003c/em\u003e- distance between the cemento-enamel junction (CEJ) and the coronal bone level on the mesial (C) and distal (D) sides. In cases of crown restoration, the most apical point of the crown was used instead of the CEJ. For severely destructed teeth (root remnant) below the bone level (C', D') or in cases of impacted teeth, this value is negative; \u003cem\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003c/em\u003eand \u003cem\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/em\u003e- interdental space measured coronally on the mesial and distal sides, at the coronal bone level or, in the case of an impacted tooth, at the most coronal point of the crown. If no more tooth was present in the quadrant, the distal measurement point was designated at the distal side of the maxillary tuber and the mesial at the median sagittal suture; \u003cem\u003e\u003cstrong\u003eG\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003eH\u003c/strong\u003e\u003c/em\u003e- interdental space measured apically on the mesial and distal sides at the level of the sinus base, or if the root did not reach this, then at the most apical point of the root (G' \u0026amp; H'). In cases of completely missing distal or mesial teeth in the quadrant, the same approach was used as previously described; \u003cstrong\u003eI\u003c/strong\u003e-sinus recession on the mesial side (or the distal side); \u003cem\u003e\u003cstrong\u003eK\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003eL\u003c/strong\u003e\u003c/em\u003e-root projection into the sinus, on the mesial and/or distal side: distance between the level of the sinus base and the apex on the mesial and distal side, note that if the apex does not reach the level of the sinus base this value is negative; \u003cem\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/em\u003e- maximal root projection- the length between the base of the sinus and the apex of the root with the most protrusion into the sinus. If the root(s) do not reach the base of the sinus, the distance between the base and the closest root was measured and indicated by a negative value; \u003cem\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/em\u003e-depth of vertical bone loss: distance between coronal level of bone and most apical point of vertical defect; \u003cem\u003e\u003cstrong\u003eO\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/em\u003e- mesiodistal (O) and vertical (P) diameter of periapical defect; \u003cem\u003e\u003cstrong\u003eQ\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003eR\u003c/strong\u003e\u003c/em\u003e- vertical bone width on the mesial and distal sides, measuring the distance between the coronal bone level and the base of the sinus on the mesial and distal sides of the analyzed tooth, respectively.\u003c/p\u003e","description":"","filename":"Figure1anonym.png","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/0019aecaf5b14931d2cd3aac.png"},{"id":55639622,"identity":"dcdb754e-f7c0-48f2-aab3-6b6c233a3931","added_by":"auto","created_at":"2024-04-30 22:10:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":91395,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of case selection, OAC. oroantral communication, OPG-orthopantomographic image\u003c/p\u003e","description":"","filename":"Figure2.flowchart.png","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/1fbcb7701a6ad3fcb7b2ddd0.png"},{"id":55639783,"identity":"73f7b05f-a406-4a1b-bdf1-2c578ae39160","added_by":"auto","created_at":"2024-04-30 22:18:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16021,"visible":true,"origin":"","legend":"\u003cp\u003eResults of random forest analysis. Each column represents a variable (1-39), factors above the line (1-13) were identified as potential predictors of oroantral communication: \u003cstrong\u003e1\u003c/strong\u003e- maximal and \u003cstrong\u003e2\u003c/strong\u003e-average root projection, \u003cstrong\u003e3\u003c/strong\u003e- distance between cementoenamel junction and marginal bone on the distal and \u003cstrong\u003e4\u003c/strong\u003e- mesial side, , \u003cstrong\u003e5\u003c/strong\u003e-vertical bone width distally, \u003cstrong\u003e6\u003c/strong\u003e- maximal root projection mesially, \u003cstrong\u003e7\u003c/strong\u003e- maximal root projection distally, \u003cstrong\u003e8\u003c/strong\u003e- vertical bone width mesially, \u003cstrong\u003e9-\u003c/strong\u003epresence of distal adjacent tooth, \u003cstrong\u003e10\u003c/strong\u003e- extent of caries lesion, \u003cstrong\u003e11\u003c/strong\u003e- presence of mesial adjacent tooth, \u003cstrong\u003e12\u003c/strong\u003e-length of root mesially, \u003cstrong\u003e13-\u003c/strong\u003epresence of caries, \u003cstrong\u003e14\u003c/strong\u003e-distal sinus recession present, \u003cstrong\u003e15-\u003c/strong\u003eangulation, \u003cstrong\u003e16-\u003c/strong\u003epresence of sinus recession, \u003cstrong\u003e17-\u003c/strong\u003eroot canal treatment (yes/no), \u003cstrong\u003e18\u003c/strong\u003e-interdental space distally coronally, \u003cstrong\u003e19\u003c/strong\u003e-age of patient (years), \u003cstrong\u003e20-\u003c/strong\u003einterdental space mesially apically, \u003cstrong\u003e21-\u003c/strong\u003e relation of periapical lesion to the base of the sinus \u003cstrong\u003e22-\u003c/strong\u003e interruption in the basal line of maxillary sinus, \u003cstrong\u003e23-\u003c/strong\u003einterdental space mesially coronally, \u003cstrong\u003e24-\u003c/strong\u003epresence of periapical radiolucency, \u003cstrong\u003e25\u003c/strong\u003e- interdental space distally apically, \u003cstrong\u003e26-\u003c/strong\u003emaximal mesio-distal width of periapical defect, \u003cstrong\u003e27-\u003c/strong\u003esingle or multiple roots, \u003cstrong\u003e28-\u003c/strong\u003epresence of mesial sinus recession, \u003cstrong\u003e29\u003c/strong\u003e-impaction, \u003cstrong\u003e30\u003c/strong\u003e-root length distally, \u003cstrong\u003e31\u003c/strong\u003e-depth of vertical bone defect, \u003cstrong\u003e32\u003c/strong\u003e-type of tooth, \u003cstrong\u003e33\u003c/strong\u003e-presence of restoration, \u003cstrong\u003e34\u003c/strong\u003e- extent of restoration, \u003cstrong\u003e35\u003c/strong\u003e-relation of apex(es) to base of maxillary sinus, \u003cstrong\u003e36\u003c/strong\u003e-sex, \u003cstrong\u003e37\u003c/strong\u003e-presence of vertical bone defect, \u003cstrong\u003e38\u003c/strong\u003e-maximal vertical width of periapical defect, \u003cstrong\u003e39\u003c/strong\u003e-notation of tooth (FDI)\u003c/p\u003e","description":"","filename":"Figure3.randomforest.png","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/0473fd35bed95414e9d2f69f.png"},{"id":55639624,"identity":"56835ba5-3712-457c-b85a-dee7185ebc2b","added_by":"auto","created_at":"2024-04-30 22:10:36","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":80084,"visible":true,"origin":"","legend":"\u003cp\u003eResults of variable correlation: values closer to 0 indicate no correlation while values closer to 1 or -1 indicate strong positive and negative correlation respectively.\u003c/p\u003e","description":"","filename":"Figure4.variablecorrelation.png","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/463a128b00d7f3754ed4aeb8.png"},{"id":55639625,"identity":"38962c35-e85a-4709-b156-4ab58b4f11cd","added_by":"auto","created_at":"2024-04-30 22:10:36","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":56424,"visible":true,"origin":"","legend":"\u003cp\u003eDecision tree for oroantral communication occurrence\u003c/p\u003e","description":"","filename":"Figure5..png","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/6ce60876349028214939b31d.png"},{"id":67681908,"identity":"712ed4c7-74c9-4fb1-aaa0-a31fdebd9173","added_by":"auto","created_at":"2024-10-28 16:11:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1104657,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/abdfd8ef-e6a0-4185-b124-b2e2676ec7d6.pdf"},{"id":55639620,"identity":"db9486c0-152d-4b75-8cbc-8482cbc2f0c2","added_by":"auto","created_at":"2024-04-30 22:10:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19273,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4319954/v1/40cf3a63adb17bdc2b838fbc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of clinical and radiographic warning signs for prediction of oroantral communication following tooth extractions","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOroantral communication (OAC) is a relatively common complication of maxillary tooth extractions[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and other interventions such as sinus lifts and implant placement [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The highest incidence of OAC is reported in cases of maxillary first and second molar extractions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], although canine and premolar extractions may also result in OAC. Well-known risk factors predisposing individuals to this complication include the extraction of the last remaining tooth from the arch or a tooth with periapical inflammation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Morphometric studies have highlighted the importance of the size, shape, and extent of the maxillary sinus, as well as the relationship between the roots of maxillary teeth and the floor of the sinus [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These works provide essential insights into the anatomical variability of the maxillary sinus and highlight the benefits of analysing cone beam computed tomography (CBCT) over orthopantomography (OPG)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, these studies do not provide clinical guidance. Potential risk factors of OAC were examined most broadly in relation to upper wisdom tooth removal [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and mostly reported the superiority of CBCT analysis over panoramic radiographs in the prediction. While cone beam computed tomography (CBCT) has been shown to provide valuable insights into these anatomical considerations, panoramic radiographs remain a more commonly selected diagnostic tool due to their lower cost and reduced radiation exposure.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Unlike in case of impaction, OAC during routinely performed extractions can significantly extend the treatment duration, as it will require additional interventions such as raising a flap, which can lead to further potential complications.\u003c/p\u003e \u003cp\u003eOur study aims to assess and identify potential clinical and panoramic radiographic warning signs that could predict the occurrence of OAC during maxillary tooth extractions. Such risk assessment could benefit both patients and dentists by improving time management, aiding in decision-making, enhancing informed consent processes, and facilitating treatment planning for more favourable long-term outcomes.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eIn our retrospective case-control study, approved by the regional ethics committee (8577-PTE 2020), a database search was conducted in the archives of the University of P\u0026eacute;cs, Clinical Centre, Department of Dentistry, Oral and Maxillofacial Surgery. All cases in which closure of Oroantral Communication (OAC) was performed between 2019 and 2021 were collected. The cases were then categorised based on the inclusion and exclusion criteria outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Two controls were matched to each OAC case solely based on the type of tooth (canine, first premolar, second premolar, first/second or third molar).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and exclusion criteria (OAC-oroantral communication, OPG- orthopantomographic image, C-canine, PM1/PM2- first or second premolar, M1/M2/M3- first, second or third molar)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion criteria- case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExclusion criteria- case\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; OAC after tooth extraction of a maxillary canine, premolar or molar tooth.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; OAC was not the result of tooth extraction,\u003c/p\u003e \u003cp\u003e\u0026bull; tooth extraction was not performed at on University of P\u0026eacute;cs, Clinical Centre, Department of Dentistry, Oral and Maxillofacial Surgery (referred patients),\u003c/p\u003e \u003cp\u003e\u0026bull; lack of OPG prior to extraction,\u003c/p\u003e \u003cp\u003e\u0026bull; OPG was older than 6 months or surgical interventions (extractions, implantation) were carried out in the quadrant within the time span between the OPG was taken and the OAC developed,\u003c/p\u003e \u003cp\u003e\u0026bull; multiple extractions were performed in the same quadrant (localisation of OAC and relationship to adjacent extraction was unknown),\u003c/p\u003e \u003cp\u003e\u0026bull; uninterpretable OPG.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInclusion criteria- control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eExclusion criteria- control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; 2 controls for each case with the same type of extraction (C, PM1, PM2, M1/M2/M3) without OAC after extraction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; no prior OPG,\u003c/p\u003e \u003cp\u003e\u0026bull; uninterpretable OPG,\u003c/p\u003e \u003cp\u003e\u0026bull; multiple extractions from the same quadrant.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwo independent interpreters, blinded to the case/control status, evaluated the panoramic radiographs according to a predefined criteria system (see Appendix 1). All X-rays were captured at the university clinic using the same X-ray machine (VATECH, PCH-2500, Korea) and following the manufacturer\u0026rsquo;s recommended positioning for each patient. The panoramic radiographs were assessed using EasyDentV4 (Vatech Co., Ltd., version: 4.1.3.2, Data Tec, Inc., Johannesburg, South Africa) software. The measurements conducted on the images are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe interrater reliability was determined using Cohen's Kappa. In cases where discrete variables did not align between the two interpreters, the results of a third interpreter's evaluation were utilised for further analysis. Similarly, the results of the third interpreter were considered in instances where the interrater κ was \u0026lt;\u0026thinsp;0.8 (indicating less than strong agreement) for continuous variables.\u003c/p\u003e \u003cp\u003eExploratory analyses were conducted using Wilcoxon rank sum tests, Pearson\u0026rsquo;s Chi-squared tests, and Fisher\u0026rsquo;s exact tests. Given the high number of variables relative to the sample size, a random forest algorithm was employed for variable selection to identify potential predictor factors for OAC. Variable correlation for continuous variables was assessed to identify correlated and independent variables. A model comprising only independent factors potentially influencing OAC was developed based on the outcomes of the variable selection and correlation. Decision tree and binary logistic regression analyses were performed using this model.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 241 cases of oroantral communication (OAC) were evaluated, of which 97 cases were ultimately included in the study. The process of case selection is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe selected cases and controls, as well as the demographic data (age, sex) of the patients and factors related to tooth extraction (tooth position), were collated in a single table (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical data of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the case of all categorical variables, there was a near-perfect agreement between the interpreters (κ\u0026thinsp;\u0026gt;\u0026thinsp;0.81). In instances of disagreement, a third independent interpreter's decision was utilized for further assessment. The only exception was the measurement of the vertical width of the periapical defect, which demonstrated less than perfect agreement (κ\u0026thinsp;=\u0026thinsp;0.68)\u003c/p\u003e \u003cp\u003eAmong the factors examined, several were identified as potential predictors of OAC. A statistically significant correlation was observed with impaction (p\u0026thinsp;=\u0026thinsp;0.001), the distance from the cementoenamel junction (CEJ) to the marginal bone on the distal (p\u0026thinsp;=\u0026thinsp;0.002) and mesial sides (p\u0026thinsp;=\u0026thinsp;0.002), maximal root projection mesially (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and distally (p\u0026thinsp;=\u0026thinsp;0.001), and the vertical bone width mesially (p\u0026thinsp;=\u0026thinsp;0.002) and distally (p\u0026thinsp;=\u0026thinsp;0.009) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Wilcoxon rank sum tests, Pearson\u0026rsquo;s Chi-squared tests and Fisher\u0026rsquo;s exact tests V\u003csup\u003e*\u003c/sup\u003e-vertical, M\u003csup\u003e**\u003c/sup\u003e-mesial, D\u003csup\u003e***\u003c/sup\u003e-distal, SD\u003csup\u003e****\u003c/sup\u003e-standard deviation. Bold p values are significant. All measured parameters given in millimetre.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMax. root projection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDistance between CEJ and marginal bone on the distal side (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDistance between CEJ and marginal bone on the mesial side (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.04\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVertical bone width distally (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMaximal root projection mesially\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMaximal root projection distally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u0026thinsp;\u0026plusmn;\u0026thinsp;2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVertical bone width mesially (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDistal adjacent tooth present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.455\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMesial adjacent tooth present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.205\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLength of root mesially (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003csup\u003e****\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.90\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.358\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCaries present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDistal sinus recession present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eV\u003csup\u003e*\u003c/sup\u003e:65\u003c/p\u003e \u003cp\u003eM\u003csup\u003e**\u003c/sup\u003e:21\u003c/p\u003e \u003cp\u003eD\u003csup\u003e***\u003c/sup\u003e:11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e142\u003c/p\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoot canal treated tooth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInterdental space distally coronally (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterdental space mesially apically(average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriapical lesion reaches/penetrates the base of the sinus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterruption in the basal line of maxillary sinus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterdental space mesially coronally (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePeriapical bone resorption present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInterdental space distally apically(average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.20\u0026thinsp;\u0026plusmn;\u0026thinsp;6.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;6.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.498\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMaximal mesio-distal width of periapical defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.91\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple roots\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMesial sinus recession present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eImpaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of root distally (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMaximal depth of vertical bone defect (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestoration in tooth present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelation of apex(es) to base of maxillary sinus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eroot projects into the sinus: 67\u003c/p\u003e \u003cp\u003ein contact: 13\u003c/p\u003e \u003cp\u003eno contact: 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertical bone loss present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal vertical width of periapical defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterdental space distally coronally (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertical bone width mesially (average\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA random forest analysis for variable selection identified 13 factors potentially related to OAC (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs anticipated, the correlation of variables revealed several interacting factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA model based on the gathered information was constructed and utilized for further evaluation. Binary logistic regression analysis revealed three factors that significantly influenced OAC: maximal root projection (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; odds ratio [OR]\u0026thinsp;=\u0026thinsp;1.22), the distance from the CEJ or the most coronal portion of the root to the marginal bone on the mesial side (p\u0026thinsp;=\u0026thinsp;0.011, OR\u0026thinsp;=\u0026thinsp;0.721), and the presence of an adjacent mesial tooth (p\u0026thinsp;=\u0026thinsp;0.032, OR\u0026thinsp;=\u0026thinsp;0.495) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of binary logistic regression analysis. Bold p-values indicate significant correlation. OR-odds ratio, CI-confidence interval.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emaximal root projection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11, 1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edistance between CEJ and marginal bone on the distal side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.802, 1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edistance between CEJ and marginal bone on the mesial side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.555, 0.923\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eadjacent tooth mesially\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enot present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.257, 0.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eadjacent tooth distally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enot present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.454, 2.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epresence of caries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enot present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.299, 1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einterdental space distally coronally\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.959, 1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emaximal length of root mesially\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.811, 1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epresence of sinus recession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enot present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.918, 3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eangulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evertical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emesial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.453, 1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edistal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.489, 4.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the decision tree analysis, four branching factors were identified: distance from the CEJ or the most coronal portion of the root to the marginal bone on the mesial side, maximal root projection, presence of sinus recess, and angulation (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOAC associated with maxillary tooth extractions is a relatively common complication Both the planning and timely intervention in the treatment of OAC can pose challenges for clinicians. Panoramic radiographs are commonly used for the prediction of inferior alveolar nerve exposure during wisdom tooth surgeries [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], failure of condylar neck osteosynthesis[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], impaction of maxillary canines [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], growth changes associated with orthodontic therapy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] nd the diagnosis of atheromatous plaque formation in the carotid artery [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Panoramic radiographs are generally accepted as diagnostic tools and, in many cases, provide sufficiently reliable measurements [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The relationship between the roots of maxillary teeth and the sinus has been evaluated using both panoramic radiographs and CBCT scans [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although most studies emphasize the superiority of CBCT over panoramic radiographs in assessing the real correlation between the roots and the sinus floor, they do not provide a prediction of the occurrence of post-extraction OAC. Regnstrand et al. reported that approximately 70% of upper first molar roots are in contact with the sinus, with up to a fifth of the root surface (for the palatal root) being involved [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, Punwutikorn et al. found that the incidence of OAC related to upper first molar extractions was only 0.61% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] suggesting that anatomical observations do not directly translate to clinical findings. According to Sharan \u0026amp; Madjar, the projection of maxillary teeth roots into the sinus is overestimated on panoramic radiographs in both occurrence and length [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Jung \u0026amp; Cho reported that, contrary to the appearance of wisdom tooth roots projecting into the sinus on panoramic radiographs, CBCT scans showed that the sinus floor is often located buccally to the roots, mimicking root projection on panoramic images [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. he risk of OAC during upper wisdom tooth removal has been examined in detail by several studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], both panoramic radiographs and CBCTs were evaluated, along with clinical parameters. Iwata et al. concluded that the usefulness of CT evaluation as an adjunct to panoramic radiographs in predicting OAC following upper wisdom tooth removal is limited [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition to root projection into the sinus and depth of impaction, other factors such as a single-rooted tooth, pericoronitis, and \"remarkable hemorrhage\" were associated with an increased risk of OAC. Hasegawa et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported similar outcomes related to the depth of impaction and the root projection, additionally mesioangular position and incision were raised as risk factors. reported similar outcomes related to the depth of impaction and root projection, adding mesioangular position and incision as risk factors. Further risk factors, such as older age and intraoperative root fracture, were reported by Rothamel et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A systemic review by Lewusz-Butkiewicz et al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] concluded that the relationship between the root of the wisdom tooth and the maxillary sinus can be an important predictive factor, along with older age, mesioangular position, and performed osteotomy during tooth removal. Our study was not conducted focusing solely on wisdom teeth, as the occurrence of OAC is more common and may be a more troublesome consequence when extracting other teeth. Similarly to these articles, \"depth,\" represented in our study by the distance between the cementoenamel junction and the marginal bone, was an important predicting factor for OAC. In cases of impaction and severely destructed teeth with remaining roots below the marginal bone level, negative values of this parameter indicated a higher chance for the formation of an oroantral communication. Angulation other than vertical and the length of root projection into the sinus (maximal root projection) also proved to be significant. Unfortunately, in our retrospective study, operational parameters such as excessive use of an elevator, osteotomy, and excessive bleeding were difficult to address; however, they could have had a remarkable impact. As we examined OAC related to the extractions of canines, premolars, and molars as well, the number of cases is higher (97 OAC) than in those studies that focus on wisdom tooth surgeries (7\u0026ndash;46), except for a prospective multicenter study by Rothamel et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a recent study by Vollmer et al.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], several deep learning models were employed to determine if OAC could be predicted based on preoperative panoramic radiographs. They assessed both expert performance and artificial intelligence (AI) performance in predicting OAC without a preset criteria system. From the 100 OAC cases and 200 controls, they concluded that the prediction of OAC by AI is not yet feasible and that expert agreement on the same matter is poor. In contrast, our study demonstrated excellent expert agreement, which may be the result of a defined, preset evaluation criteria system (see Appendix 1).\u003c/p\u003e \u003cp\u003eOur investigation revealed that neither the presence nor the size of periapical inflammation significantly influences the occurrence of oroantral communication (OAC). This finding may be attributable to the preservation of the cortical bone at the sinus base during bone resorption or to local thickening of the Schneiderian membrane induced by inflammation. Both factors potentially diminish the risk of creating a pronounced, direct connection during tooth extraction. Furthermore, disruptions in the basal contour of the maxillary sinus or the presence of root projections in relation to the sinus base did not demonstrate a significant impact.\u003c/p\u003e \u003cp\u003eThe results of our study identified several potential indicators on panoramic radiographs predictive of OAC formation. Both decision tree analysis and binary logistic regression revealed significant correlations with two parameters: the distance between the marginal bone and the cementoenamel junction mesially, and the maximal root projection. While the decision tree offers a clinically relevant heuristic for decision-making, it is important to note that the initial braching point (mesial CEJ to marginal bone distance) provides limited interpretive value, as a negative distance may denote either an impacted tooth or a a root remnant. The depth of impaction or, alternatively, the extent of destruction (distance from the marginal bone to the CEJ or the most coronal part of the root) may affect the development of OAC. This relationship is corroborated by our binary logistic regression analysis, which indicated a 0.721-fold decrease in OAC risk for every millimeter increase in the mesial distance from the CEJ to the bone. The significance of this measure may extend beyond the relative depth of the tooth/root, suggesting that the removal of a root remnant or impacted tooth may necessitate osteotomy or intensive use of elevators, both of which are likely contributory to OAC formation. These potential contributing factors were beyond the scope of this study. Another significant determinant of OAC, identified by both analytical approaches, was the maximal root projection. A one-millimeter increase in maximal root projection was associated with a 1.22-fold increase in OAC risk, with the decision tree threshold set at 3.3 mm. This finding is consistent with prior research by Madjar et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], who demonstrated that root projection into the sinus is overestimated on panoramic radiographs compared to cone-beam computed tomography (CBCT), emphasizing the significance of the extent, rather than the mere presence, of root projection.\u003c/p\u003e \u003cp\u003eSinus recess and mesial or distal angulation of the tooth were also identified as significant factors by the decision tree. The relevance of sinus recess is underscored by Regnstrand et al.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] who observed that the roots may contact the sinus across a larger surface area, not limited to the socket's most apical portion. Mesial angulation has been highlighted as a risk factor by other studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It is noteworthy that teeth with distal angulation were relatively infrequent (n\u0026thinsp;=\u0026thinsp;11) in our cohort, suggesting the need for further investigation into their significance. The binary logistic regression analysis also identified the loss of mesial contact as a significant OAC risk factor. The presence of a mesial adjacent tooth was associated with a 0.495-fold reduction in OAC risk. This factor is inherently related to mesial angulation and sinus recess on the mesial side; tooth loss can lead to mesialization and sinus pneumatisation over time. The interplay among these factors adds complexity to the analysis.\u003c/p\u003e \u003cp\u003eOur findings advocate for the consideration of various clinical and radiographic indicators on panoramic radiographs when predicting the likelihood of OAC in association with upper tooth extractions. To the best of our knowledge, this is one of the inaugural studies to evaluate the incidence of OAC following tooth extractions using routine panoramic radiographs, with a particular focus beyond the upper wisdom teeth. Our interrater reliability was good to excellent, validating the effectiveness of our predefined criteria and the reliability of the study's results.\u003c/p\u003e \u003cp\u003eNonetheless, certain limitations of the study warrant mention. Panoramic radiography only allows for semi-standardized settings. Given the retrospective nature of the study, specific clinical data\u0026mdash;such as periodontal probing depth surrounding the tooth, tooth mobility, precise localization of OAC within the alveolar socket, or detailed accounts of the instruments used and the difficulty of the extraction procedure\u0026mdash;could not be collected. Additionally, the variability in operator technique was not addressed due to the involvement of numerous dentists in the extractions.\u003c/p\u003e \u003cp\u003eWhile CBCT remains the superior imaging modality for predicting OAC during dental extractions, its use is constrained by cost, radiation exposure, and environmental impact. A prospective clinical study incorporating comprehensive preoperative examinations, meticulously documented interventions, and precise measurements taken from well-aligned periapical radiographs using the parallel technique could yield additional valuable data for the prediction of post-extraction OAC.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding Declaration\u003c/p\u003e\n\u003cp\u003eWe report no funding.\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eAll data supporting the findings of this study are available within the paper and its Supplementary Information.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eWe report no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePunwutikorn J, Waikakul A, Pairuchvej V (1994) Clinically significant oroantral communications - a study of incidence and site. Int J Oral Maxillofac Surg 23:19\u0026ndash;21. https://doi.org/10.1016/S0901-5027(05)80320-0\u003c/li\u003e\n\u003cli\u003eMiclotte I, Agbaje JO, Spaey Y, et al (2018) Incidence and treatment of complications in patients who had third molars or other teeth extracted. British Journal of Oral and Maxillofacial Surgery 56:388\u0026ndash;393. https://doi.org/10.1016/j.bjoms.2018.02.001\u003c/li\u003e\n\u003cli\u003eKiencało A, Jamka-Kasprzyk M, Panaś M, Wyszyńska-Pawelec G (2021) Analysis of complications after the removal of 339 third molars. Dent Med Probl 58:75\u0026ndash;60. https://doi.org/10.17219/dmp/127028\u003c/li\u003e\n\u003cli\u003eShahrou R, Sha P, Withana T, et al (2021) Oroantral communication, its causes, complications, treatments and radiographic features: A pictorial review. Imaging Sci Dent 51:1\u0026ndash;5. https://doi.org/10.5624/ISD.20210035\u003c/li\u003e\n\u003cli\u003eLewusz-Butkiewicz K, Kaczor K, Nowicka A (2018) Risk factors in oroantral communication while extracting the upper third molar: Systematic review. Dent Med Probl 55:69\u0026ndash;74. https://doi.org/10.17219/dmp/80944\u003c/li\u003e\n\u003cli\u003eLopes LJ, Gamba TO, Bertinato JVJ, Freitas DQ (2016) Comparison of panoramic radiography and CBCT to identify maxillary posterior roots invading the maxillary sinus. Dentomaxillofacial Radiology 45:. https://doi.org/10.1259/dmfr.20160043\u003c/li\u003e\n\u003cli\u003eRegnstrand T, Ezeldeen M, Shujaat S, et al (2022) Three-dimensional quantification of the relationship between the upper first molar and maxillary sinus. Clin Exp Dent Res 8:750\u0026ndash;756. https://doi.org/10.1002/cre2.561\u003c/li\u003e\n\u003cli\u003eTian XM, Qian L, Xin XZ, et al (2016) An analysis of the proximity of maxillary posterior teeth to the maxillary sinus using cone-beam computed tomography. J Endod 42:371\u0026ndash;377. https://doi.org/10.1016/j.joen.2015.10.017\u003c/li\u003e\n\u003cli\u003eThemkumkwun S, Kitisubkanchana J, Waikakul A, Boonsiriseth K (2019) Maxillary molar root protrusion into the maxillary sinus: a comparison of cone beam computed tomography and panoramic findings. Int J Oral Maxillofac Surg 48:1570\u0026ndash;1576. https://doi.org/10.1016/j.ijom.2019.06.011\u003c/li\u003e\n\u003cli\u003eKirkham-Ali K, La M, Sher J, Sholapurkar A (2019) Comparison of cone-beam computed tomography and panoramic imaging in assessing the relationship between posterior maxillary tooth roots and the maxillary sinus: A systematic review. J Investig Clin Dent 10:1\u0026ndash;7. https://doi.org/10.1111/jicd.12402\u003c/li\u003e\n\u003cli\u003eSharan A, Madjar D (2006) Correlation between maxillary sinus floor topography and related root position of posterior teeth using panoramic and cross-sectional computed tomography imaging. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology 102:375\u0026ndash;381. https://doi.org/10.1016/j.tripleo.2005.09.031\u003c/li\u003e\n\u003cli\u003eElsayed SA, Alolayan AB, Alahmadi A, Kassim S (2019) Revisited maxillary sinus pneumatization narrative of observation in Al-Madinah Al-Munawwarah, Saudi Arabia: A retrospective cross-sectional study. Saudi Dental Journal 31:212\u0026ndash;218. https://doi.org/10.1016/j.sdentj.2018.11.002\u003c/li\u003e\n\u003cli\u003eJung YH, Cho BH (2015) Assessment of maxillary third molars with panoramic radiography and cone-beam computed tomography. Imaging Sci Dent 45:233\u0026ndash;240. https://doi.org/10.5624/isd.2015.45.4.233\u003c/li\u003e\n\u003cli\u003eYamaguchi K, Munakata M, Kataoka Y, et al (2022) Effects of missing teeth and nasal septal deviation on maxillary sinus volume: a pilot study. Int J Implant Dent 8:0\u0026ndash;6. https://doi.org/10.1186/s40729-022-00415-5\u003c/li\u003e\n\u003cli\u003eKhojastepour L, Movahhedian N, Zolghadrpour M, Mahjoori-Ghasrodashti M (2021) Assessment of the relationship between the maxillary sinus and the canine root tip using cone beam computed tomography. BMC Oral Health 21:1\u0026ndash;8. https://doi.org/10.1186/s12903-021-01700-2\u003c/li\u003e\n\u003cli\u003eJung YH, Cho BH, Hwang JJ, Jung YH (2020) Comparison of panoramic radiography and cone-beam computed tomography for assessing radiographic signs indicating root protrusion into the maxillary sinus. Imaging Sci Dent 50:309\u0026ndash;318. https://doi.org/10.16995/OLH.486\u003c/li\u003e\n\u003cli\u003eSingh A, Kodali MVRM, Pentapati KC, et al (2023) Role of CBCT in Prediction of Oro-antral Communication Post Third Molar Extraction: A Retrospective Study. Eur J Dent. https://doi.org/10.1055/s-0043-1760720\u003c/li\u003e\n\u003cli\u003eThemkumkwun S, Kitisubkanchana J, Waikakul A, Boonsiriseth K (2019) Maxillary molar root protrusion into the maxillary sinus: a comparison of cone beam computed tomography and panoramic findings. Int J Oral Maxillofac Surg 48:1570\u0026ndash;1576. https://doi.org/10.1016/j.ijom.2019.06.011\u003c/li\u003e\n\u003cli\u003eIwata E, Hasegawa T, Kobayashi M, et al (2021) Can CT predict the development of oroantral fistula in patients undergoing maxillary third molar removal? Oral Maxillofac Surg 25:7\u0026ndash;17. https://doi.org/10.1007/s10006-020-00878-z\u003c/li\u003e\n\u003cli\u003eHasegawa T, Tachibana A, Takeda D, et al (2016) Risk factors associated with oroantral perforation during surgical removal of maxillary third molar teeth. Oral Maxillofac Surg 20:369\u0026ndash;375. https://doi.org/10.1007/s10006-016-0574-1\u003c/li\u003e\n\u003cli\u003eLim AAT, Wong CW, Allen JC (2012) Maxillary third molar: Patterns of impaction and their relation to oroantral perforation. Journal of Oral and Maxillofacial Surgery 70:1035\u0026ndash;1039. https://doi.org/10.1016/j.joms.2012.01.032\u003c/li\u003e\n\u003cli\u003eRothamel D, Wahl G, d\u0026rsquo;Hoedt B, et al (2007) Incidence and predictive factors for perforation of the maxillary antrum in operations to remove upper wisdom teeth: Prospective multicentre study. British Journal of Oral and Maxillofacial Surgery 45:387\u0026ndash;391. https://doi.org/10.1016/j.bjoms.2006.10.013\u003c/li\u003e\n\u003cli\u003eEliasova H, Dostalova T, Prochazka A, et al (2021) Comparison of 2D OPG image versus orthopantomogram from 3D CBCT from the forensic point of view. Leg Med 48:. https://doi.org/10.1016/j.legalmed.2020.101802\u003c/li\u003e\n\u003cli\u003eChoi JW (2011) Assessment of panoramic radiography as a national oral examination tool: Review of the literature. Imaging Sci Dent 41:1\u0026ndash;6. https://doi.org/10.5624/isd.2011.41.1.1\u003c/li\u003e\n\u003cli\u003eSzalma J, Lempel E, Jeges S, Olasz L (2012) Digital Versus Conventional Panoramic Radiography in Predicting Inferior Alveolar Nerve Injury After Mandibular Third Molar Removal. Journal of Craniofacial Surgery 23:e155\u0026ndash;e158. https://doi.org/10.1097/SCS.0b013e31824cdca8\u003c/li\u003e\n\u003cli\u003eSzalma J, Vajta L, Lov\u0026aacute;sz BV, et al (2020) Identification of Specific Panoramic High-Risk Signs in Impacted Third Molar Cases in Which Cone Beam Computed Tomography Changes the Treatment Decision. Journal of Oral and Maxillofacial Surgery 78:1061\u0026ndash;1070. https://doi.org/10.1016/j.joms.2020.03.012\u003c/li\u003e\n\u003cli\u003eJanovics K, So\u0026oacute;s B, T\u0026oacute;th \u0026Aacute;, Szalma J (2021) Is it possible to filter third molar cases with panoramic radiography in which roots surround the inferior alveolar canal? A comparison using cone-beam computed tomography. Journal of Cranio-Maxillofacial Surgery 49:971\u0026ndash;979. https://doi.org/10.1016/j.jcms.2021.05.003\u003c/li\u003e\n\u003cli\u003eSeemann R, Undt G, Lauer G, et al (2011) Is failure of condylar neck osteosynthesis predictable based on orthopantomography? Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology 111:362\u0026ndash;371. https://doi.org/10.1016/j.tripleo.2010.11.028\u003c/li\u003e\n\u003cli\u003eAlqerban A, Storms AS, Voet M, et al (2016) Early prediction of maxillary canine impaction. Dentomaxillofacial Radiology 45:. https://doi.org/10.1259/dmfr.20150232\u003c/li\u003e\n\u003cli\u003eVit\u0026aacute;lyos G, Tak\u0026aacute;cs A, Borbasn\u0026eacute; KF, et al (2018) Comparison of the effect of premolar extraction and non-extraction on the position and developmental changes of the lower third molars. Int Orthod 16:470\u0026ndash;485. https://doi.org/10.1016/j.ortho.2018.06.007\u003c/li\u003e\n\u003cli\u003eBarona-Dorado C, Gutierrez-Bonet C, Leco-Berrocal I, Fern\u0026aacute;ndez-C\u0026aacute;liz F (2016) Relation between diagnosis of atheromatous plaque from orthopantomographs and cardiovascular risk factors. A study of cases and control subjects. Med Oral Patol Oral Cir Bucal 21:e66\u0026ndash;e71. https://doi.org/10.4317/medoral.20183\u003c/li\u003e\n\u003cli\u003eVollmer A, Saravi B, Vollmer M, et al (2022) Artificial Intelligence-Based Prediction of Oroantral Communication after Tooth Extraction Utilizing Preoperative Panoramic Radiography. Diagnostics 12:1406. https://doi.org/10.3390/diagnostics12061406\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Maxillary Sinus, Tooth Extraction, Intraoperative Complications, Oroantral Fistula, Orthopantomography, panoramic radiograph","lastPublishedDoi":"10.21203/rs.3.rs-4319954/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4319954/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eOroantral communication (OAC) is a relatively common and mild complication of maxillary tooth extractions. Preoperative prediction of OAC can reduce treatment duration and prepare both operators and patients for the procedure. This study aims to identify alarming radiographic and clinical indicators that can predict OAC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this retrospective case-control study, a control group twice the size of the OAC group was established. Clinical data were collected, and measurements were conducted separately by two blinded observers on digital panoramic radiographs. Inter-rater reliability was assessed. The correlation between OAC and demographic data (age, sex), as well as various factors assessed on panoramic radiographs (including, but not limited to, the length of the root, root projection into the sinus, bone width, presence of mesial and distal adjacent teeth), was statistically evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eInter-rater reliability was found to be excellent. Several factors were identified as potential predictors of OAC. According to our model, the strongest predictors were the distance between the cemento-enamel junction and marginal bone, extent of root projection into the sinus, presence of sinus recess around the roots, angulation, and absence of the mesial adjacent tooth.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWell-defined measurements on panoramic radiographs may aid in predicting OAC. Further prospective investigations are necessary to confirm these indicators and address factors related to clinical examination and operation.\u003c/p\u003e","manuscriptTitle":"Evaluation of clinical and radiographic warning signs for prediction of oroantral communication following tooth extractions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-30 22:10:31","doi":"10.21203/rs.3.rs-4319954/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-09T13:42:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-01T15:22:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-01T11:59:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-26T02:28:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74312468344929829895376907436400399274","date":"2024-06-21T15:45:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316538582192629618441013037363205786797","date":"2024-06-20T20:05:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99173171852296172706503903532108193442","date":"2024-06-20T03:03:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-06T20:12:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-25T09:15:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-25T09:15:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2024-04-24T18:20:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a7d5d408-55ec-4db3-8e07-66fbdb98ab44","owner":[],"postedDate":"April 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:03:10+00:00","versionOfRecord":{"articleIdentity":"rs-4319954","link":"https://doi.org/10.1007/s00784-024-06000-x","journal":{"identity":"clinical-oral-investigations","isVorOnly":false,"title":"Clinical Oral Investigations"},"publishedOn":"2024-10-23 15:57:48","publishedOnDateReadable":"October 23rd, 2024"},"versionCreatedAt":"2024-04-30 22:10:31","video":"","vorDoi":"10.1007/s00784-024-06000-x","vorDoiUrl":"https://doi.org/10.1007/s00784-024-06000-x","workflowStages":[]},"version":"v1","identity":"rs-4319954","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4319954","identity":"rs-4319954","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}