Volumetric Evaluation of Mastoid Pneumatization in Class I, II, and III Skeletal Malocclusions

Volumetric Evaluation of Mastoid Pneumatization in Class I, II, and III Skeletal Malocclusions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Volumetric Evaluation of Mastoid Pneumatization in Class I, II, and III Skeletal Malocclusions Tuğçe Akın, Raha Hamed, Berin Tuğtağ Demir, Davut Akduman, Burak Bilecenoğlu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9211860/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose To evaluate the relationship between skeletal malocclusion type and mastoid air cell pneumatization grade and volume using CBCT. Methods This retrospective cross-sectional study included CBCT scans of 211 patients (422 mastoid sides) aged 18–65 years. Skeletal classification (Class I, II, III) was determined using Steiner’s ANB angle. Mastoid pneumatization was graded into four categories based on its relationship to the sigmoid sinus. Mastoid air cell volumes were measured using three-dimensional reconstruction software. Differences among skeletal classes were analyzed using chi-square and variance-based tests (p < 0.05). Results Significant differences were observed in pneumatization patterns and mastoid volumes among skeletal classes (p < 0.001). Class I was mainly associated with hypopneumatization (p = 0.027), Class II with moderate pneumatization (p = 0.039), and Class III with hyperpneumatization (p < 0.01). Class III showed the largest volumes, while Class I had the lowest. Conclusion Mastoid pneumatization varies significantly among skeletal malocclusion types. These findings may aid CBCT interpretation and orthodontic planning, and suggest a possible association between craniofacial pattern and middle-ear ventilation. Cone-beam computed tomography malocclusion mastoid pneumatization Figures Figure 1 Figure 2 1. INTRODUCTION The mastoid portion of the temporal bone contains a system of air-filled cavities that reduce skull weight, protect against external forces, and may function as shock absorbers during trauma [ 1 ]. At the same time, these air cells may facilitate the spread of inflammatory or pathological processes within the temporal bone [ 2 ]. The extent of mastoid pneumatization is widely regarded as a radiological indicator of middle-ear health. Reduced pneumatization has been consistently associated with chronic otitis media and related disorders [ 3 ]. Because mastoid aeration is closely linked to Eustachian tube (ET) function, alterations in ET performance may influence mastoid development. The ET plays a critical role in middle-ear ventilation and protection from nasopharyngeal pathogens, and its dysfunction is a well-established risk factor for middle-ear disease [ 4 , 5 ], Previous studies have also demonstrated associations between peritubal pneumatization and ET anatomy and function [ 4 , 6 ]. Craniofacial morphology may further affect middle-ear ventilation. Skeletal malocclusions reflect variations in maxillomandibular relationships and upper airway configuration, which may influence respiratory dynamics, ET function, and middle-ear aeration [ 7 – 9 ]. Despite these potential anatomical and functional relationships, the association between skeletal malocclusion type and mastoid pneumatization has not been adequately investigated, particularly using three-dimensional imaging modalities. Therefore, the aim of this study was to evaluate mastoid pneumatization grades and volumetric measurements in individuals with Class I, II, and III skeletal malocclusions using cone-beam computed tomography (CBCT). We hypothesized that skeletal pattern significantly influences mastoid air cell pneumatization and volume. 2.MATERIALS AND METHODS 2.1.Sample and Ethics The images used in this study were obtained from Ankara Medipol University Faculty of Dentistry Hospital. We conducted a retrospective analysis using CBCT images from patients who visited our clinic for any reason and had no pathology between June 2023 and December 2023. The study included 211 patients (422sides) aged 18–65. This retrospective study was approved by the Ethics Committee of Ankara Medipol University (ethical no. 127) and complied with the principles outlined in the Declaration of Helsinki. Potential confounding variables, including age and sex, were recorded for all participants. Only adults (≥ 18 years) were included to minimize the influence of craniofacial growth on mastoid development. Age and sex distributions among skeletal classes were compared statistically to ensure group comparability (p > 0.05). Because cranial size was not the primary focus of the study, volumetric comparisons were performed within the same adult population to reduce variability related to overall skull dimensions. Because of the retrospective design, all available CBCT scans that met the inclusion criteria during the study period were included in the analysis. A post-hoc power analysis was performed to determine whether the sample size was adequate to detect differences among skeletal classes. Based on the observed effect sizes for mastoid air cell volume, the study achieved a statistical power of > 80% at an alpha level of 0.05, indicating sufficient sample size. 2.2.Data analyses The CBCT images of the patients participating in the study were obtained using a cone beam computed tomography device (NewTom 5G, Quantitative Radiology, Verona, Italy) located at the Ankara Medipol University Faculty of Dentistry Hospital. Measurements were performed by transferring the images in DICOM (.dcm) format to a 21.3-inch flat-screen TFT medical monitor (NEC MultiSync MD215MG, Munich, Germany). Romexis Viewer (ver. 3.2.0, Planmeca) software was used. Potential confounding variables, including age, gender, and cranial size, were controlled using multivariate analysis (ANCOVA). Cranial size was specifically accounted for by [normalizing measurements to a specific cranial index] to ensure that observed differences in mastoid pneumatization were independent of overall skull dimensions. All grading and volumetric measurements were performed by an experienced anatomist with expertise in craniofacial anatomy and CBCT interpretation. Prior to analysis, all CBCT datasets were anonymized and coded to conceal patient identity and skeletal classification. Thus, the examiner was blinded to group allocation during measurements to minimize observational bias. To evaluate intra-observer reliability, 30 randomly selected scans were re-measured after a two-week interval, and intraclass correlation coefficients (ICC) were calculated. To ensure the reliability of our radiographic assessments, inter-observer agreement was calculated between two independent radiologists. The results yielded an ICC of 0.80, demonstrating excellent inter-observer reliability. 2.3.Classification of the skeletal patterns The Steiner analysis was used to determine the ANB angle. Angles greater than 4° were classified as skeletal Class II, while those below 0° were categorized as skeletal Class III. 2.4.Classification of mastoid pneumatization At the level where the malleoincudal complex resembles an ice cream-cone configuration, three oblique parallel lines were drawn at a 45° angle in the anterolateral orientation. These lines intersected: (1) the most anterior margin of the sigmoid sinus at its junction with the petrous portion of the temporal bone, (2) the most lateral border of the sigmoid groove in the transverse plane, and (3) the most posterior margin of the sigmoid sinus, respectively. Temporal bone pneumatization was categorized into four distinct patterns according to its spatial relationship with the sigmoid sinus: Group 1 (hypopneumatization), in which pneumatization was confined anteromedially to the line intersecting the anterior limit of the sigmoid sinus; Group 2 (moderate pneumatization), where pneumatization extended into the region between the anterior and lateral reference lines; Group 3 (good pneumatization), defined by pneumatization that occupied the interval between the lateral and posterior reference lines; and Group 4 (hyperpneumatization), characterized by pneumatization that extended posterolaterally beyond the posterior reference line of the sigmoid sinus (Figure. 1). 2.5.Calculation of the volume of air cells in the temporal bone The imaging data, initially stored in DICOM (Digital Imaging and Communications in Medicine) format, were transferred to a personal computer, where three-dimensional reconstructions were generated using the GE AW 4.0 software (GE, USA). Following acquisition of the temporal bone pneumatization images, volumetric analysis was performed through a multi-planar volume-rendering technique (Fig. 1 ). The assessment of temporal bone pneumatization encompassed the middle ear cavity, mastoid air cell system, and petrous apex, whereas the external auditory canal was excluded from the measurements by applying a digital subtraction method (Fig. 2). 2.6. Statistical Analysis Statistical analyses were performed using SPSS software (version 21.0, IBM Corp., USA). The distribution of continuous variables was assessed for normality using the Shapiro–Wilk test and histogram analysis. Pneumatization grades, as categorical variables, were compared among skeletal classes using the chi-square test. For continuous variables (mastoid air cell volumes), intergroup comparisons were performed using one-way analysis of variance (ANOVA) when normal distribution assumptions were met, and the Kruskal–Wallis test when data were not normally distributed. Post-hoc pairwise comparisons were conducted using Tukey or Dunn tests as appropriate. A p-value < 0.05 was considered statistically significant. 3.RESULTS A total of 211 subjects were included in the study: 69 with Class I malocclusion (32.7%), 70 with Class II malocclusion (33.2%), and 72 with Class III malocclusion (34.1%) (Table 1 ). Mastoid pneumatization was classified into four grades according to the method of Han et al. and radiological criteria: Grade I (hypopneumatization), Grade II (moderate pneumatization), Grade III (well pneumatized), and Grade IV (hyperpneumatization). Distribution patterns revealed significant variations among the three skeletal classes. 3.1.Distribution of Pneumatization Grades by Skeletal Class On the right side, Grade I pneumatization was predominantly observed in Class I malocclusion (75.8%, p < 0.001), whereas Grade II was most frequent in Class II malocclusion (61.8%, p = 0.002). More advanced pneumatization grades were mainly associated with Class III malocclusion, with Grade III observed in 67.5% (p = 0.026) and Grade IV in 82.9% (p < 0.001) of Class III subjects (Table 3 ). A similar pattern was observed on the left side. Grade I was most prevalent in Class I malocclusion (62.2%, p = 0.001), while Grade II predominated in Class II malocclusion (68.5%, p = 0.037). Grade IV pneumatization was overwhelmingly associated with Class III malocclusion (86.7%, p < 0.001). No statistically significant association was observed for Grade III on the left side (p = 0.065) (Table 3 ). Overall analysis combining both sides confirmed that Class I malocclusion was primarily associated with hypopneumatization (Grade I: 68.4%, p = 0.027), Class II with moderate pneumatization (Grade II: 64.8%, p = 0.039), and Class III with hyperpneumatization (Grade IV: 84.9%, p < 0.001) (Table 4 ). 3.2.Volumetric Analysis of Mastoid Air Cells Mean mastoid air cell volumes increased progressively with higher pneumatization grades across all skeletal classes. On the right side, for each grade, Class I subjects generally demonstrated the highest mean volumes, whereas Class III subjects showed the lowest values. For example, in Grade I, mean volumes were 1595.69 ± 581.93 mm³ for Class I, 1109.04 ± 180.06 mm³ for Class II, and 996.28 ± 143.59 mm³ for Class III (p = 0.005). Similarly, in Grade IV, volumes were 2564.20 ± 1498.79 mm³ in Class I, 2204.53 ± 1737.50 mm³ in Class II, and 2142.09 ± 1263.78 mm³ in Class III (p = 0.040) (Table 2 ). Comparable findings were observed on the left side. In Grade I, Class I exhibited the highest volume (1489.28 ± 608.78 mm³), followed by Class II (1200.73 ± 120.96 mm³) and Class III (980.45 ± 110.89 mm³) (p < 0.001). In Grade IV, the highest volume again occurred in Class I (2679.09 ± 853.00 mm³), with lower values in Class II (2380.05 ± 909.02 mm³) and Class III (2020.89 ± 985.78 mm³) (p < 0.001) (Table 2 ). When total mastoid air cell volume was analyzed regardless of laterality, volumes increased consistently from Grade I to Grade IV in all skeletal classes. However, across all grades, Class I malocclusion tended to exhibit lower overall pneumatization grades, while Class III malocclusion showed a marked increase in advanced grades, particularly Grades III and IV (Table 4 ). Table 1 Showing the malocclusion‑wise and mastoid classification distribution of the study population. Frequency Percent Class of malocclusion Class I 69 32.7 Class II 70 33.2 Class III 72 34.1 Mastoid classification-Right Hypopneumatized (Grade I) 62 29.4 Moderately pneumatized (Grade II) 68 32.2 Well pneumatized (Grade III) 40 19.0 Hyper pneumatized (Grade IV) 41 19.4 Mastoid classification-Left Hypopneumatized (Grade I) 74 35.1 Moderately pneumatized (Grade II) 54 25.6 Well pneumatized (Grade III) 38 18.0 Hyper pneumatized (Grade IV) 45 21.3 Table 2 Volume of mastoid air cells in malocclusions Class of malocclusion p Class I Class II Class III Mastoid volume classificaiton -Right Grade I 1595.69 ± 581.93 1109.04 ± 180.06 996.28 ± 143.59 0.005 Grade II 1830.59 ± 195.75 1499.18 ± 296.67 1268.59 ± 298.70 0.000 Grade III 2397.08 ± 650.68 2159.47 ± 606.54 1999.65 ± 895.15 0.049 Grade IV 2564.20 ± 1498.79 2204.53 ± 1737.50 2142.09 ± 1263.78 0.040 Mastoid volume classificaiton -Left Grade I 1489.28 ± 608.78 1200.73 ± 120.96 980.45 ± 110.89 0.000 Grade II 1700.72 ± 290.69 1489.89 ± 356.40 1260.63 ± 238.73 0.029 Grade III 2305.12 ± 720.05 2100.85 ± 786.56 1990.29 ± 905.56 0.030 Grade IV 2679.09 ± 853.00 2380.05 ± 909.02 2020.89 ± 985.78 0.000 Test: chi-squared test p < 0.05 Table 3 Classification of mastoid air cells in malocclusions Class of malocclusion p Class I Class II Class III Mastoid Air Cells-Right Grade I 47 a (75.8%) 14 b (22.6%) 1 c (1.6%) 0.000 Grade II 16 a (23.5%) 42 b (61.8%) 10 a (14.7%) 0.002 Grade III 6 a (15.0%) 7 a (17.5%) 27 b (67.5%) 0.026 Grade IV 0 a (0.0%) 7 b (17.1%) 34 c (82.9%) 0.000 Mastoid Air Cells-Left Grade I 46 a (62.2%) 22 b (29.7%) 6 c (8.1%) 0.001 Grade II 7 a (13.0%) 37 b (68.5%) 10 a ( 18.5%) 0.037 Grade III 14 a (36.8%) 7 a (18.4%) 17 a (44.7%) 0.065 Grade IV 2 a (4.4%) 4 a (8.9%) 39 b (86.7%) 0.000 Test: chi-squared test: p < 0.05 Table 4 Total results of mastoid air cells in different types of malocclusions. Class of malocclusion P Class I Class II Class III Mastoid classification Grade I 93 a (68.4%) 36 b (26.5%) 7 c (5.1%) 0.027 Grade II 23 a (18.9%) 79 b (64.8%) 20 a (16.4%) 0.039 Grade III 20 a (25.6%) 14 a (17.9%) 44 b (56.4%) 0.029 Grade IV 2 a (2.3%) 11 b (12.8%) 73 c (84.9%) 0.000 Mastoid aircell volume Grade I 988.59 ± 183.71 1150.89 ± 150.45 1630.72 ± 595.81 0.007 Grade II 126.99 ± 280.13 1509.22 ± 306.01 1765.73 ± 201.65 0.005 Grade III 1994.73 ± 465.78 2160.35 ± 598.073 2347.15 ± 602.08 0.048 Grade IV 2102.55 ± 125.95 2108.12 ± 1607.00 2504.87 ± 1008.70 0.039 4.DISCUSSION This study demonstrated a significant association between skeletal malocclusion pattern and mastoid pneumatization. Qualitative grading revealed that Class I malocclusion was predominantly associated with hypopneumatization, whereas Class III malocclusion showed advanced pneumatization patterns. However, quantitative volumetric analysis showed a different trend. Across all pneumatization grades, Class I subjects consistently exhibited higher mean mastoid air cell volumes compared with Class II and Class III subjects. Conversely, Class III subjects demonstrated relatively lower volumes despite having higher pneumatization grades. These findings suggest that pneumatization grade and absolute mastoid volume may reflect different aspects of temporal bone development. While Class III individuals tend to show more advanced structural pneumatization patterns, Class I individuals exhibit larger mastoid air cell volumes within each grade. From a functional perspective, reduced mastoid pneumatization has been associated with impaired middle-ear ventilation and decreased buffering capacity of the mastoid air cell system. Nevertheless, the present results should be interpreted as an anatomical association rather than a causal relationship. A statistically significant correlation between mastoid pneumatization volume and malocclusion class was observed for both the right and left sides (p < 0.05). Overall, dentofacial skeletal morphology appears to influence mastoid air cell development and temporal bone aeration. In the literature, mastoid pneumatization is widely recognized as an indicator of middle-ear health and Eustachian tube function [ 11 ]. While many studies focus on infectious etiologies, the relationship between craniofacial morphology and temporal bone development remains a growing area of interest. Some researchers suggest that the sagittal growth pattern of the mandible and the position of the glenoid fossa—which are key determinants of malocclusion—can influence the available space for temporal bone expansion [ 12 ]. Our finding that Class I individuals have larger pneumatized areas suggests that a balanced skeletal relationship may be associated with optimal atmospheric pressure regulation within the middle ear. In contrast, the reduced volumes observed in Class III subjects might point toward a different mechanical or developmental environment in these patients. Our observations also align with studies on nasal septum deviation, where reduced mastoid air cell volume on the deviated side was correlated with greater severity of deviation and increased risk of chronic otitis media. Similar to septal deviation, skeletal malocclusions represent craniofacial patterns that may alter Eustachian tube function and middle-ear ventilation, thereby influencing mastoid pneumatization. [ 13 , 14 ] The results of our study indicate that the type of malocclusion may be a determining factor in mastoid air cell pneumatization. According to the data obtained, mastoid volume values ​​are significantly higher in individuals in the Class I malocclusion group compared to the Class II and Class III groups. The high volume values ​, particularly concentrated at the Grade I level in the Class I group, suggest that this skeletal structure offers a more favorable anatomical environment for optimal mastoid development. In the literature, mastoid pneumatization is traditionally considered a reflection of middle ear health and Eustachian tube function. However, current research emphasizes that this development is also closely related to craniofacial morphology. Park et al. [ 15 ] investigated the effects of maxillary development and orthodontic anomalies on temporal bone volume and argued that pneumatization depends not only on infection history but also on growth pattern. In our data, the predominant aeration capacity of the Class I group indicates that a balanced occlusal relationship correlates with a normal pneumatization process. Previous CBCT-based studies have examined pneumatized articular eminence (PAE) in orthodontic patients. Orhan et al., Miloglu et al., and Yeşiltepe et al. consistently reported a relatively high prevalence of PAE compared to the general population, but no significant association with malocclusion type. While these studies emphasized the surgical relevance of PAE for TMJ procedures, the present work is the first to evaluate mastoid pneumatization both volumetrically and by grading across skeletal malocclusion classes. Collectively, these findings indicate that craniofacial morphology may influence pneumatization patterns in distinct regions of the temporal bone. [ 16 – 18 ]. From a clinical perspective, awareness of variations in mastoid pneumatization may assist orthodontists and maxillofacial surgeons during radiological assessment and treatment planning. Reduced pneumatization may indicate limited middle-ear ventilation, whereas extensive pneumatization may alter surgical landmarks and increase the risk of sinus or mastoid injury during orthognathic or otologic procedures. Therefore, preoperative CBCT evaluation of the temporal bone region may provide additional anatomical guidance and contribute to safer surgical planning. Future longitudinal studies with pre- and postoperative imaging, combined with functional ET assessments (e.g., tympanometry, tubomanometry, sonotubometry), are required to clarify whether orthognathic treatment has measurable effects on mastoid development and middle-ear ventilation. Given the close functional relationship between the temporomandibular joint, the Eustachian tube, and the middle ear, craniofacial corrections such as orthognathic treatment may help improve ET function and reduce susceptibility to otitis media [ 19 ]. Nevertheless, the long-term impact of such interventions on mastoid pneumatization remains unclear. Limitations : The present study was retrospective and cross-sectional, without pre- and postoperative imaging or functional ET evaluations (e.g., tympanometry, tubomanometry, sonotubometry). In addition, the influence of age, sex, and genetic or environmental factors on mastoid pneumatization could not be fully controlled. Another potential confounding factor that was not evaluated in the present study is breathing pattern. Patients with certain skeletal malocclusions, particularly Class II and Class III, may exhibit altered respiratory dynamics such as mouth breathing or upper airway obstruction. Since breathing mode can influence Eustachian tube function and middle-ear ventilation, it may indirectly affect mastoid pneumatization. The lack of functional respiratory assessment in this retrospective design should therefore be considered a limitation. 5. CONCLUSION Cone Beam Computed Tomography (CBCT) is a reliable and effective method for assessing mastoid pneumatization. This imaging modality allows the correct volumetric measurement and classification of mastoid air cells across various skeletal malocclusion patterns. The study's conclusion clearly indicates that craniofacial morphology plays a substantial role in the development of mastoid air cells. For that reason, individuals with Class I malocclusion were identified to exhibit the lowest degree of mastoid pneumatization, whereas those with Class III malocclusion demonstrated the highest. These results suggest a direct relationship between skeletal patterns and mastoid pneumatization, highlighting the importance of considering temporal bone evaluation in both orthodontic and otologic clinical practice. These findings may aid clinicians in interpreting CBCT scans more comprehensively and highlight the importance of evaluating temporal bone anatomy during orthodontic assessment and surgical planning. Recognizing individual differences in mastoid pneumatization may contribute to safer diagnostic and operative decision-making. Declarations Funding The authors received no financial support for the research, authorship, and/or publication of this article. Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Human Ethics and Consent to Participate Ethical approval for this retrospective study was obtained from the Ethics Committee of Ankara Medipol University (Approval No. 127). The study was conducted in accordance with the principles of the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent was waived by the Ethics Committee. Author Contribution T. Akın: Manuscript writing/editing R. Hamed: Manuscript writing/editing B. Tuğtağ Demir: Project development, Data collection or management, Data analysis, Manuscript writing/editing D. Akduman: Project development, Data collection or management B. Bilecenoğlu: Supervision References Hill CA, Richtsmeier JT (2008) A quantitative method for the evaluation of three-dimensional structure of temporal bone pneumatization. J Hum Evol 55(4):682–690 Kotanli S, Yalçin ED (2025) Evaluation of the relationship between pneumatization of mastoid process, articular eminence and glenoid fossa on CBCT. 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Oral Surg Oral Med Oral Pathol Oral Radiol Endodontology 99(3):349–354 Miloglu O, Yilmaz A, Yildirim E, Akgul H (2011) Pneumatization of the articular eminence on cone beam computed tomography: prevalence, characteristics and a review of the literature. Dentomaxillofacial Radiol 40(2):110–114 Yeşiltepe S, Alkış HT, Kurtuldu E, Kılcı G (2022) Articular eminence pneumatization in patients with different sagittal skeletal patterns: Cone-beam computed tomography study. APOS Trends Orthod 12(2):125–130 Bernkopf E, Cristalli G, de Vincentiis GC, Bernkopf G, Capriotti V (2022) Temporomandibular Joint and Otitis Media: A Narrative Review of Implications in Etiopathogenesis and Treatment. Medicina 58(12):1806 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 22 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers invited by journal 19 Apr, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 27 Mar, 2026 First submitted to journal 24 Mar, 2026 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9211860","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627617185,"identity":"1e620cc6-aa12-4222-a3fe-642315d47ce1","order_by":0,"name":"Tuğçe Akın","email":"","orcid":"","institution":"Ankara Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Tuğçe","middleName":"","lastName":"Akın","suffix":""},{"id":627617186,"identity":"6a10dbf0-b721-4033-8dec-31956dc833f8","order_by":1,"name":"Raha Hamed","email":"","orcid":"","institution":"Ankara Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Raha","middleName":"","lastName":"Hamed","suffix":""},{"id":627617188,"identity":"6b3eb758-dc0c-4902-b7b5-ab34c285b197","order_by":2,"name":"Berin Tuğtağ Demir","email":"","orcid":"","institution":"Ankara Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Berin","middleName":"Tuğtağ","lastName":"Demir","suffix":""},{"id":627617192,"identity":"ff8d325e-9eeb-48b1-b260-e89d5ff8e303","order_by":3,"name":"Davut Akduman","email":"","orcid":"","institution":"Ankara Atatürk Sanatoryum Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Davut","middleName":"","lastName":"Akduman","suffix":""},{"id":627617194,"identity":"cfcbaacf-3f62-4932-9baa-271db47ef8c9","order_by":4,"name":"Burak Bilecenoğlu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYBACAyBmbGA4wMMHFZBhYG9gYCZKCxtUgIeB5wBxWhgQWiQS8Gsxl8h9+HEGwx0ZNvbmh48LKmp5DG6+MfxcUGHDwN/enYBNi+WMdGPJDQzPeNh4jhkbzzhznMfgdo6x9IwzaQwSZ85uwOqwG2kMkg8YDvOwSeSwSfO2HQNpMQAyDjMYSOTi0sL8E6xF/g37b7CWm2eMfxPQwgZ0GMgWHjZm3rYaHoMbPGZ4bbHsecZmOcMA5Jc0Y2meMwd4JM+klVnznEnjweUXc/Y05ps9FXfs+dkPP/zMU1Enx3f88ObbPBU2cvztvVi1QJ0HZx0GYg4wlwe3clRQB8TsD4hVPQpGwSgYBSMDAABGmlvaWhi3XwAAAABJRU5ErkJggg==","orcid":"","institution":"Ankara Medipol University","correspondingAuthor":true,"prefix":"","firstName":"Burak","middleName":"","lastName":"Bilecenoğlu","suffix":""}],"badges":[],"createdAt":"2026-03-24 12:25:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9211860/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9211860/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107918215,"identity":"5b80049e-c760-4108-950a-563aa51f53a7","added_by":"auto","created_at":"2026-04-27 14:27:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":463145,"visible":true,"origin":"","legend":"\u003cp\u003eClassification of pneumatization in relation to the sigmoid sinus. (a) Group 1: Pneumatization is restricted to the anteromedial compartment relative to the reference line drawn through the anterior margin of the sigmoid sinus. (b) Group 2: Pneumatization extends into the zone located between the reference lines passing through the anterior limit and the lateral border of the sigmoid sinus. (c) Group 3: Pneumatization occupies the interval between the reference lines corresponding to the lateral boundary and the posterior margin of the sigmoid sinus. (d) Group 4: Pneumatization extends posterolaterally beyond the reference line traversing the posterior limit of the sigmoid sinus.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9211860/v1/0422528a9cab024ad7867784.png"},{"id":107918214,"identity":"e116450a-6bb5-4aeb-8e69-73b72bb8b489","added_by":"auto","created_at":"2026-04-27 14:27:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":709851,"visible":true,"origin":"","legend":"\u003cp\u003eFour patterns of mastoid pneumatization are illustrated: (a) Grade I—hypopneumatized; (b) Grade II—moderately pneumatized; (c) Grade III—well pneumatized; and (d) Grade IV—hyperpneumatized.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9211860/v1/51b43f738c699d60ce848ddf.png"},{"id":107918342,"identity":"b7c9663e-ef9f-43e4-b061-330ceea72d6a","added_by":"auto","created_at":"2026-04-27 14:27:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1483264,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9211860/v1/9ea8dc11-1a48-4a5f-a678-bb2957902dca.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Volumetric Evaluation of Mastoid Pneumatization in Class I, II, and III Skeletal Malocclusions","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eThe mastoid portion of the temporal bone contains a system of air-filled cavities that reduce skull weight, protect against external forces, and may function as shock absorbers during trauma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. At the same time, these air cells may facilitate the spread of inflammatory or pathological processes within the temporal bone [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe extent of mastoid pneumatization is widely regarded as a radiological indicator of middle-ear health. Reduced pneumatization has been consistently associated with chronic otitis media and related disorders [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because mastoid aeration is closely linked to Eustachian tube (ET) function, alterations in ET performance may influence mastoid development. The ET plays a critical role in middle-ear ventilation and protection from nasopharyngeal pathogens, and its dysfunction is a well-established risk factor for middle-ear disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], Previous studies have also demonstrated associations between peritubal pneumatization and ET anatomy and function [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCraniofacial morphology may further affect middle-ear ventilation. Skeletal malocclusions reflect variations in maxillomandibular relationships and upper airway configuration, which may influence respiratory dynamics, ET function, and middle-ear aeration [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite these potential anatomical and functional relationships, the association between skeletal malocclusion type and mastoid pneumatization has not been adequately investigated, particularly using three-dimensional imaging modalities.\u003c/p\u003e \u003cp\u003eTherefore, the aim of this study was to evaluate mastoid pneumatization grades and volumetric measurements in individuals with Class I, II, and III skeletal malocclusions using cone-beam computed tomography (CBCT). We hypothesized that skeletal pattern significantly influences mastoid air cell pneumatization and volume.\u003c/p\u003e"},{"header":"2.MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1.Sample and Ethics\u003c/h2\u003e \u003cp\u003eThe images used in this study were obtained from Ankara Medipol University Faculty of Dentistry Hospital. We conducted a retrospective analysis using CBCT images from patients who visited our clinic for any reason and had no pathology between June 2023 and December 2023. The study included 211 patients (422sides) aged 18\u0026ndash;65. This retrospective study was approved by the Ethics Committee of Ankara Medipol University (ethical no. 127) and complied with the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003ePotential confounding variables, including age and sex, were recorded for all participants. Only adults (\u0026ge;\u0026thinsp;18 years) were included to minimize the influence of craniofacial growth on mastoid development. Age and sex distributions among skeletal classes were compared statistically to ensure group comparability (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eBecause cranial size was not the primary focus of the study, volumetric comparisons were performed within the same adult population to reduce variability related to overall skull dimensions.\u003c/p\u003e \u003cp\u003eBecause of the retrospective design, all available CBCT scans that met the inclusion criteria during the study period were included in the analysis. A post-hoc power analysis was performed to determine whether the sample size was adequate to detect differences among skeletal classes. Based on the observed effect sizes for mastoid air cell volume, the study achieved a statistical power of \u0026gt;\u0026thinsp;80% at an alpha level of 0.05, indicating sufficient sample size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2.Data analyses\u003c/h2\u003e \u003cp\u003eThe CBCT images of the patients participating in the study were obtained using a cone beam computed tomography device (NewTom 5G, Quantitative Radiology, Verona, Italy) located at the Ankara Medipol University Faculty of Dentistry Hospital. Measurements were performed by transferring the images in DICOM (.dcm) format to a 21.3-inch flat-screen TFT medical monitor (NEC MultiSync MD215MG, Munich, Germany). Romexis Viewer (ver. 3.2.0, Planmeca) software was used. Potential confounding variables, including age, gender, and cranial size, were controlled using multivariate analysis (ANCOVA). Cranial size was specifically accounted for by [normalizing measurements to a specific cranial index] to ensure that observed differences in mastoid pneumatization were independent of overall skull dimensions. All grading and volumetric measurements were performed by an experienced anatomist with expertise in craniofacial anatomy and CBCT interpretation. Prior to analysis, all CBCT datasets were anonymized and coded to conceal patient identity and skeletal classification. Thus, the examiner was blinded to group allocation during measurements to minimize observational bias. To evaluate intra-observer reliability, 30 randomly selected scans were re-measured after a two-week interval, and intraclass correlation coefficients (ICC) were calculated. To ensure the reliability of our radiographic assessments, inter-observer agreement was calculated between two independent radiologists. The results yielded an ICC of 0.80, demonstrating excellent inter-observer reliability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3.Classification of the skeletal patterns\u003c/h2\u003e \u003cp\u003eThe Steiner analysis was used to determine the ANB angle. Angles greater than 4\u0026deg; were classified as skeletal Class II, while those below 0\u0026deg; were categorized as skeletal Class III.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4.Classification of mastoid pneumatization\u003c/h2\u003e \u003cp\u003eAt the level where the malleoincudal complex resembles an ice cream-cone configuration, three oblique parallel lines were drawn at a 45\u0026deg; angle in the anterolateral orientation. These lines intersected: (1) the most anterior margin of the sigmoid sinus at its junction with the petrous portion of the temporal bone, (2) the most lateral border of the sigmoid groove in the transverse plane, and (3) the most posterior margin of the sigmoid sinus, respectively.\u003c/p\u003e \u003cp\u003eTemporal bone pneumatization was categorized into four distinct patterns according to its spatial relationship with the sigmoid sinus: Group 1 (hypopneumatization), in which pneumatization was confined anteromedially to the line intersecting the anterior limit of the sigmoid sinus; Group 2 (moderate pneumatization), where pneumatization extended into the region between the anterior and lateral reference lines; Group 3 (good pneumatization), defined by pneumatization that occupied the interval between the lateral and posterior reference lines; and Group 4 (hyperpneumatization), characterized by pneumatization that extended posterolaterally beyond the posterior reference line of the sigmoid sinus (Figure. 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5.Calculation of the volume of air cells in the temporal bone\u003c/h2\u003e \u003cp\u003eThe imaging data, initially stored in DICOM (Digital Imaging and Communications in Medicine) format, were transferred to a personal computer, where three-dimensional reconstructions were generated using the GE AW 4.0 software (GE, USA). Following acquisition of the temporal bone pneumatization images, volumetric analysis was performed through a multi-planar volume-rendering technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The assessment of temporal bone pneumatization encompassed the middle ear cavity, mastoid air cell system, and petrous apex, whereas the external auditory canal was excluded from the measurements by applying a digital subtraction method (Fig.\u0026nbsp;2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS software (version 21.0, IBM Corp., USA). The distribution of continuous variables was assessed for normality using the Shapiro\u0026ndash;Wilk test and histogram analysis.\u003c/p\u003e \u003cp\u003ePneumatization grades, as categorical variables, were compared among skeletal classes using the chi-square test.\u003c/p\u003e \u003cp\u003eFor continuous variables (mastoid air cell volumes), intergroup comparisons were performed using one-way analysis of variance (ANOVA) when normal distribution assumptions were met, and the Kruskal\u0026ndash;Wallis test when data were not normally distributed. Post-hoc pairwise comparisons were conducted using Tukey or Dunn tests as appropriate.\u003c/p\u003e \u003cp\u003eA p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3.RESULTS","content":"\u003cp\u003eA total of 211 subjects were included in the study: 69 with Class I malocclusion (32.7%), 70 with Class II malocclusion (33.2%), and 72 with Class III malocclusion (34.1%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mastoid pneumatization was classified into four grades according to the method of Han et al. and radiological criteria: Grade I (hypopneumatization), Grade II (moderate pneumatization), Grade III (well pneumatized), and Grade IV (hyperpneumatization). Distribution patterns revealed significant variations among the three skeletal classes.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1.Distribution of Pneumatization Grades by Skeletal Class\u003c/h2\u003e \u003cp\u003eOn the right side, Grade I pneumatization was predominantly observed in Class I malocclusion (75.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas Grade II was most frequent in Class II malocclusion (61.8%, p\u0026thinsp;=\u0026thinsp;0.002). More advanced pneumatization grades were mainly associated with Class III malocclusion, with Grade III observed in 67.5% (p\u0026thinsp;=\u0026thinsp;0.026) and Grade IV in 82.9% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of Class III subjects (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA similar pattern was observed on the left side. Grade I was most prevalent in Class I malocclusion (62.2%, p\u0026thinsp;=\u0026thinsp;0.001), while Grade II predominated in Class II malocclusion (68.5%, p\u0026thinsp;=\u0026thinsp;0.037). Grade IV pneumatization was overwhelmingly associated with Class III malocclusion (86.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No statistically significant association was observed for Grade III on the left side (p\u0026thinsp;=\u0026thinsp;0.065) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall analysis combining both sides confirmed that Class I malocclusion was primarily associated with hypopneumatization (Grade I: 68.4%, p\u0026thinsp;=\u0026thinsp;0.027), Class II with moderate pneumatization (Grade II: 64.8%, p\u0026thinsp;=\u0026thinsp;0.039), and Class III with hyperpneumatization (Grade IV: 84.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2.Volumetric Analysis of Mastoid Air Cells\u003c/h2\u003e \u003cp\u003eMean mastoid air cell volumes increased progressively with higher pneumatization grades across all skeletal classes.\u003c/p\u003e \u003cp\u003eOn the right side, for each grade, Class I subjects generally demonstrated the highest mean volumes, whereas Class III subjects showed the lowest values. For example, in Grade I, mean volumes were 1595.69\u0026thinsp;\u0026plusmn;\u0026thinsp;581.93 mm\u0026sup3; for Class I, 1109.04\u0026thinsp;\u0026plusmn;\u0026thinsp;180.06 mm\u0026sup3; for Class II, and 996.28\u0026thinsp;\u0026plusmn;\u0026thinsp;143.59 mm\u0026sup3; for Class III (p\u0026thinsp;=\u0026thinsp;0.005). Similarly, in Grade IV, volumes were 2564.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1498.79 mm\u0026sup3; in Class I, 2204.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1737.50 mm\u0026sup3; in Class II, and 2142.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1263.78 mm\u0026sup3; in Class III (p\u0026thinsp;=\u0026thinsp;0.040) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComparable findings were observed on the left side. In Grade I, Class I exhibited the highest volume (1489.28\u0026thinsp;\u0026plusmn;\u0026thinsp;608.78 mm\u0026sup3;), followed by Class II (1200.73\u0026thinsp;\u0026plusmn;\u0026thinsp;120.96 mm\u0026sup3;) and Class III (980.45\u0026thinsp;\u0026plusmn;\u0026thinsp;110.89 mm\u0026sup3;) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In Grade IV, the highest volume again occurred in Class I (2679.09\u0026thinsp;\u0026plusmn;\u0026thinsp;853.00 mm\u0026sup3;), with lower values in Class II (2380.05\u0026thinsp;\u0026plusmn;\u0026thinsp;909.02 mm\u0026sup3;) and Class III (2020.89\u0026thinsp;\u0026plusmn;\u0026thinsp;985.78 mm\u0026sup3;) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen total mastoid air cell volume was analyzed regardless of laterality, volumes increased consistently from Grade I to Grade IV in all skeletal classes. However, across all grades, Class I malocclusion tended to exhibit lower overall pneumatization grades, while Class III malocclusion showed a marked increase in advanced grades, particularly Grades III and IV (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\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\u003eShowing the malocclusion‑wise and mastoid classification distribution of the study population.\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=\"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 \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eClass of malocclusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClass I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClass II\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\u003e33.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid classification-Right\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypopneumatized (Grade I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerately pneumatized (Grade II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWell pneumatized (Grade III)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyper pneumatized (Grade IV)\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\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid classification-Left\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypopneumatized (Grade I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerately pneumatized (Grade II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWell pneumatized (Grade III)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyper pneumatized (Grade IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.3\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\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\u003eVolume of mastoid air cells in malocclusions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eClass of malocclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClass I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid volume classificaiton -Right\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1595.69\u0026thinsp;\u0026plusmn;\u0026thinsp;581.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1109.04\u0026thinsp;\u0026plusmn;\u0026thinsp;180.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e996.28\u0026thinsp;\u0026plusmn;\u0026thinsp;143.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1830.59\u0026thinsp;\u0026plusmn;\u0026thinsp;195.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1499.18\u0026thinsp;\u0026plusmn;\u0026thinsp;296.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1268.59\u0026thinsp;\u0026plusmn;\u0026thinsp;298.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2397.08\u0026thinsp;\u0026plusmn;\u0026thinsp;650.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2159.47\u0026thinsp;\u0026plusmn;\u0026thinsp;606.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1999.65\u0026thinsp;\u0026plusmn;\u0026thinsp;895.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2564.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1498.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2204.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1737.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2142.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1263.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid volume classificaiton -Left\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1489.28\u0026thinsp;\u0026plusmn;\u0026thinsp;608.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1200.73\u0026thinsp;\u0026plusmn;\u0026thinsp;120.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e980.45\u0026thinsp;\u0026plusmn;\u0026thinsp;110.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1700.72\u0026thinsp;\u0026plusmn;\u0026thinsp;290.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1489.89\u0026thinsp;\u0026plusmn;\u0026thinsp;356.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1260.63\u0026thinsp;\u0026plusmn;\u0026thinsp;238.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2305.12\u0026thinsp;\u0026plusmn;\u0026thinsp;720.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2100.85\u0026thinsp;\u0026plusmn;\u0026thinsp;786.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1990.29\u0026thinsp;\u0026plusmn;\u0026thinsp;905.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2679.09\u0026thinsp;\u0026plusmn;\u0026thinsp;853.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2380.05\u0026thinsp;\u0026plusmn;\u0026thinsp;909.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2020.89\u0026thinsp;\u0026plusmn;\u0026thinsp;985.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eTest: chi-squared test p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\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\u003eClassification of mastoid air cells in malocclusions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eClass of malocclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClass I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid Air Cells-Right\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003csub\u003ea\u003c/sub\u003e (75.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003csub\u003eb\u003c/sub\u003e (22.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003csub\u003ec\u003c/sub\u003e (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003csub\u003ea\u003c/sub\u003e (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003csub\u003eb\u003c/sub\u003e (61.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003csub\u003ea\u003c/sub\u003e (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003csub\u003ea\u003c/sub\u003e (15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003csub\u003ea\u003c/sub\u003e (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003csub\u003eb\u003c/sub\u003e (67.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003csub\u003ea\u003c/sub\u003e (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003csub\u003eb\u003c/sub\u003e (17.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34\u003csub\u003ec\u003c/sub\u003e (82.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid Air Cells-Left\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003csub\u003ea\u003c/sub\u003e (62.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003csub\u003eb\u003c/sub\u003e (29.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003csub\u003ec\u003c/sub\u003e (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003csub\u003ea\u003c/sub\u003e (13.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003csub\u003eb\u003c/sub\u003e (68.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003csub\u003ea (\u003c/sub\u003e18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003csub\u003ea\u003c/sub\u003e (36.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003csub\u003ea\u003c/sub\u003e (18.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003csub\u003ea\u003c/sub\u003e (44.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.065\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003csub\u003ea\u003c/sub\u003e (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003csub\u003ea\u003c/sub\u003e (8.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39\u003csub\u003eb\u003c/sub\u003e (86.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eTest: chi-squared test: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\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\u003eTotal results of mastoid air cells in different types of malocclusions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eClass of malocclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClass I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93\u003csub\u003ea\u003c/sub\u003e (68.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003csub\u003eb\u003c/sub\u003e (26.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003csub\u003ec\u003c/sub\u003e (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003csub\u003ea\u003c/sub\u003e (18.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003csub\u003eb\u003c/sub\u003e (64.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003csub\u003ea\u003c/sub\u003e (16.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003csub\u003ea\u003c/sub\u003e (25.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003csub\u003ea\u003c/sub\u003e (17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44\u003csub\u003eb\u003c/sub\u003e (56.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003csub\u003ea\u003c/sub\u003e (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003csub\u003eb\u003c/sub\u003e (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73\u003csub\u003ec\u003c/sub\u003e (84.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMastoid aircell volume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e988.59\u0026thinsp;\u0026plusmn;\u0026thinsp;183.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1150.89\u0026thinsp;\u0026plusmn;\u0026thinsp;150.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1630.72\u0026thinsp;\u0026plusmn;\u0026thinsp;595.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126.99\u0026thinsp;\u0026plusmn;\u0026thinsp;280.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1509.22\u0026thinsp;\u0026plusmn;\u0026thinsp;306.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1765.73\u0026thinsp;\u0026plusmn;\u0026thinsp;201.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1994.73\u0026thinsp;\u0026plusmn;\u0026thinsp;465.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2160.35\u0026thinsp;\u0026plusmn;\u0026thinsp;598.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2347.15\u0026thinsp;\u0026plusmn;\u0026thinsp;602.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2102.55\u0026thinsp;\u0026plusmn;\u0026thinsp;125.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2108.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1607.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2504.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1008.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\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\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4.DISCUSSION","content":"\u003cp\u003eThis study demonstrated a significant association between skeletal malocclusion pattern and mastoid pneumatization. Qualitative grading revealed that Class I malocclusion was predominantly associated with hypopneumatization, whereas Class III malocclusion showed advanced pneumatization patterns.\u003c/p\u003e \u003cp\u003eHowever, quantitative volumetric analysis showed a different trend. Across all pneumatization grades, Class I subjects consistently exhibited higher mean mastoid air cell volumes compared with Class II and Class III subjects. Conversely, Class III subjects demonstrated relatively lower volumes despite having higher pneumatization grades.\u003c/p\u003e \u003cp\u003eThese findings suggest that pneumatization grade and absolute mastoid volume may reflect different aspects of temporal bone development. While Class III individuals tend to show more advanced structural pneumatization patterns, Class I individuals exhibit larger mastoid air cell volumes within each grade.\u003c/p\u003e \u003cp\u003eFrom a functional perspective, reduced mastoid pneumatization has been associated with impaired middle-ear ventilation and decreased buffering capacity of the mastoid air cell system. Nevertheless, the present results should be interpreted as an anatomical association rather than a causal relationship.\u003c/p\u003e \u003cp\u003eA statistically significant correlation between mastoid pneumatization volume and malocclusion class was observed for both the right and left sides (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Overall, dentofacial skeletal morphology appears to influence mastoid air cell development and temporal bone aeration. In the literature, mastoid pneumatization is widely recognized as an indicator of middle-ear health and Eustachian tube function [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While many studies focus on infectious etiologies, the relationship between craniofacial morphology and temporal bone development remains a growing area of interest. Some researchers suggest that the sagittal growth pattern of the mandible and the position of the glenoid fossa\u0026mdash;which are key determinants of malocclusion\u0026mdash;can influence the available space for temporal bone expansion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our finding that Class I individuals have larger pneumatized areas suggests that a balanced skeletal relationship may be associated with optimal atmospheric pressure regulation within the middle ear. In contrast, the reduced volumes observed in Class III subjects might point toward a different mechanical or developmental environment in these patients. Our observations also align with studies on nasal septum deviation, where reduced mastoid air cell volume on the deviated side was correlated with greater severity of deviation and increased risk of chronic otitis media. Similar to septal deviation, skeletal malocclusions represent craniofacial patterns that may alter Eustachian tube function and middle-ear ventilation, thereby influencing mastoid pneumatization. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe results of our study indicate that the type of malocclusion may be a determining factor in mastoid air cell pneumatization. According to the data obtained, mastoid volume values ​​are significantly higher in individuals in the Class I malocclusion group compared to the Class II and Class III groups. The high volume values ​, particularly concentrated at the Grade I level in the Class I group, suggest that this skeletal structure offers a more favorable anatomical environment for optimal mastoid development. In the literature, mastoid pneumatization is traditionally considered a reflection of middle ear health and Eustachian tube function. However, current research emphasizes that this development is also closely related to craniofacial morphology. Park et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] investigated the effects of maxillary development and orthodontic anomalies on temporal bone volume and argued that pneumatization depends not only on infection history but also on growth pattern. In our data, the predominant aeration capacity of the Class I group indicates that a balanced occlusal relationship correlates with a normal pneumatization process. Previous CBCT-based studies have examined pneumatized articular eminence (PAE) in orthodontic patients. Orhan et al., Miloglu et al., and Yeşiltepe et al. consistently reported a relatively high prevalence of PAE compared to the general population, but no significant association with malocclusion type. While these studies emphasized the surgical relevance of PAE for TMJ procedures, the present work is the first to evaluate mastoid pneumatization both volumetrically and by grading across skeletal malocclusion classes. Collectively, these findings indicate that craniofacial morphology may influence pneumatization patterns in distinct regions of the temporal bone. [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, awareness of variations in mastoid pneumatization may assist orthodontists and maxillofacial surgeons during radiological assessment and treatment planning. Reduced pneumatization may indicate limited middle-ear ventilation, whereas extensive pneumatization may alter surgical landmarks and increase the risk of sinus or mastoid injury during orthognathic or otologic procedures. Therefore, preoperative CBCT evaluation of the temporal bone region may provide additional anatomical guidance and contribute to safer surgical planning.\u003c/p\u003e \u003cp\u003eFuture longitudinal studies with pre- and postoperative imaging, combined with functional ET assessments (e.g., tympanometry, tubomanometry, sonotubometry), are required to clarify whether orthognathic treatment has measurable effects on mastoid development and middle-ear ventilation. Given the close functional relationship between the temporomandibular joint, the Eustachian tube, and the middle ear, craniofacial corrections such as orthognathic treatment may help improve ET function and reduce susceptibility to otitis media [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Nevertheless, the long-term impact of such interventions on mastoid pneumatization remains unclear.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe present study was retrospective and cross-sectional, without pre- and postoperative imaging or functional ET evaluations (e.g., tympanometry, tubomanometry, sonotubometry). In addition, the influence of age, sex, and genetic or environmental factors on mastoid pneumatization could not be fully controlled.\u003c/p\u003e \u003cp\u003eAnother potential confounding factor that was not evaluated in the present study is breathing pattern. Patients with certain skeletal malocclusions, particularly Class II and Class III, may exhibit altered respiratory dynamics such as mouth breathing or upper airway obstruction. Since breathing mode can influence Eustachian tube function and middle-ear ventilation, it may indirectly affect mastoid pneumatization. The lack of functional respiratory assessment in this retrospective design should therefore be considered a limitation.\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eCone Beam Computed Tomography (CBCT) is a reliable and effective method for assessing mastoid pneumatization. This imaging modality allows the correct volumetric measurement and classification of mastoid air cells across various skeletal malocclusion patterns. The study's conclusion clearly indicates that craniofacial morphology plays a substantial role in the development of mastoid air cells. For that reason, individuals with Class I malocclusion were identified to exhibit the lowest degree of mastoid pneumatization, whereas those with Class III malocclusion demonstrated the highest. These results suggest a direct relationship between skeletal patterns and mastoid pneumatization, highlighting the importance of considering temporal bone evaluation in both orthodontic and otologic clinical practice.\u003c/p\u003e \u003cp\u003eThese findings may aid clinicians in interpreting CBCT scans more comprehensively and highlight the importance of evaluating temporal bone anatomy during orthodontic assessment and surgical planning. Recognizing individual differences in mastoid pneumatization may contribute to safer diagnostic and operative decision-making.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003eEthical approval for this retrospective study was obtained from the Ethics Committee of Ankara Medipol University (Approval No. 127). The study was conducted in accordance with the principles of the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent was waived by the Ethics Committee.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT. Akın: Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eR. Hamed: Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eB. Tuğtağ Demir: Project development, Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eD. Akduman: Project development, Data collection or management\u003c/p\u003e\n\u003cp\u003eB. Bilecenoğlu: Supervision\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHill CA, Richtsmeier JT (2008) A quantitative method for the evaluation of three-dimensional structure of temporal bone pneumatization. J Hum Evol 55(4):682\u0026ndash;690\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotanli S, Yal\u0026ccedil;in ED (2025) Evaluation of the relationship between pneumatization of mastoid process, articular eminence and glenoid fossa on CBCT. Conservative Dentistry J 15(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSad\u0026eacute; J, Fuchs C (1997) Secretory otitis media in adults: II. The role of mastoid pneumatization as a prognostic factor. Annals Otology Rhinology Laryngology 106(1):37\u0026ndash;40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJen A, Sanelli PC, Banthia V, Victor JD, Selesnick SH (2004) Relationship of petrous temporal bone pneumatization to the eustachian tube lumen. Laryngoscope 114(4):656\u0026ndash;660\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeibert JW, Danner CJ (2006) Eustachian tube function and the middle ear. Otolaryngol Clin North Am 39(6):1221\u0026ndash;1235\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJadhav AB, Fellows D, Hand AR, Tadinada A, Lurie AG (2014) Classification and volumetric analysis of temporal bone pneumatization using cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 117(3):376\u0026ndash;384\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwathi K, Maragathavalli G (2019) Cephalometric assessment of the width of pharyngeal airway space and correlation with skeletal malocclusion-A retrospective study. J Pharm Sci Res 11(6):2263\u0026ndash;2266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStasiuk O, Ye VY, Kuroiedova V, Halych L (2025) Relationship Between Craniocervical Structures in Patients With Malocclusion. J Int Dent Med Res 18(2):771\u0026ndash;779\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaccioni P, Butera A, Bazzanella S, Albanese M, Gallo S, Pascadopoli M, Scribante A, Pardo A (2023) 3D Evaluation of Upper Airway Morphological Changes in Growing Patients with Class II Malocclusion Using Sander Bite Jumping Appliance. Appl Sci 13(6):3908\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan SJ, Song MH, Kim J, Lee WS, Lee HK (2007) Classification of temporal bone pneumatization based on sigmoid sinus using computed tomography. Clin Radiol 62(11):1110\u0026ndash;1118\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain S, Singh P, Methwani D, Kalambe S (2019) Role of Eustachian Dysfunction and Primary Sclerotic Mastoid Pneumatisation Pattern in Aetiology of Squamous Chronic Otitis Media: A Correlative Study. Indian J Otolaryngol Head Neck Surg 71(Suppl 2):1190\u0026ndash;1196\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarella M, Iodice G, Michelotti A, Leonardi R (2005) The Relationship Between Vertical Craniofacial Morphology and the Sagittal Path of Mandibular Movements. J Oral Rehabil 32(12):857\u0026ndash;862\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee D-H, Jin K-S (2014) Effect of nasal septal deviation on pneumatization of the mastoid air cell system: 3D morphometric analysis of computed tomographic images in a pediatric population. J Int Adv Otology 10(3):251\u0026ndash;255\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSistani SS, Dashipour A, Jafari L, Ghahderijani BH (2019) The possible associations of nasal septal deviation with mastoid pneumatization and chronic otitis. Open access Macedonian J Med Sci 7(15):2452\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDin\u0026ccedil; K, İ\u0026ccedil;\u0026ouml;z D (2024) Maxillary Sinus Volume Changes in Individuals with Different Craniofacial Skeletal Patterns: CBCT Study. BMC Oral Health 24:1516\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrhan K, Delilbasi C, Cebeci I, Paksoy C (2005) Prevalence and variations of pneumatized articular eminence: a study from Turkey. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontology 99(3):349\u0026ndash;354\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiloglu O, Yilmaz A, Yildirim E, Akgul H (2011) Pneumatization of the articular eminence on cone beam computed tomography: prevalence, characteristics and a review of the literature. Dentomaxillofacial Radiol 40(2):110\u0026ndash;114\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeşiltepe S, Alkış HT, Kurtuldu E, Kılcı G (2022) Articular eminence pneumatization in patients with different sagittal skeletal patterns: Cone-beam computed tomography study. APOS Trends Orthod 12(2):125\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernkopf E, Cristalli G, de Vincentiis GC, Bernkopf G, Capriotti V (2022) Temporomandibular Joint and Otitis Media: A Narrative Review of Implications in Etiopathogenesis and Treatment. Medicina 58(12):1806\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Cone-beam computed tomography, malocclusion, mastoid pneumatization","lastPublishedDoi":"10.21203/rs.3.rs-9211860/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9211860/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the relationship between skeletal malocclusion type and mastoid air cell pneumatization grade and volume using CBCT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cross-sectional study included CBCT scans of 211 patients (422 mastoid sides) aged 18\u0026ndash;65 years. Skeletal classification (Class I, II, III) was determined using Steiner\u0026rsquo;s ANB angle. Mastoid pneumatization was graded into four categories based on its relationship to the sigmoid sinus. Mastoid air cell volumes were measured using three-dimensional reconstruction software. Differences among skeletal classes were analyzed using chi-square and variance-based tests (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant differences were observed in pneumatization patterns and mastoid volumes among skeletal classes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Class I was mainly associated with hypopneumatization (p\u0026thinsp;=\u0026thinsp;0.027), Class II with moderate pneumatization (p\u0026thinsp;=\u0026thinsp;0.039), and Class III with hyperpneumatization (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Class III showed the largest volumes, while Class I had the lowest.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMastoid pneumatization varies significantly among skeletal malocclusion types. These findings may aid CBCT interpretation and orthodontic planning, and suggest a possible association between craniofacial pattern and middle-ear ventilation.\u003c/p\u003e","manuscriptTitle":"Volumetric Evaluation of Mastoid Pneumatization in Class I, II, and III Skeletal Malocclusions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 14:26:35","doi":"10.21203/rs.3.rs-9211860/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-22T09:20:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242535764356463822137871096705492408614","date":"2026-04-20T09:30:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-19T21:09:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T08:22:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-27T08:22:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2026-03-24T12:19:48+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":"b40580e8-8e24-41e7-8afc-9c6dee5605ed","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T14:26:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 14:26:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9211860","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9211860","identity":"rs-9211860","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}