Durham Anthropology Journal
Volume 12(2-3) Copyright © 2005, Andrzej Wojtowicz, Katarzyna Sporniak-Tutak, Andrea Montella, Pasquale Bandiera, Maciej Dijakiewicz, Iwona Kochanowska and Kazimierz Ostrowski

The Influence of Human Maxillary Sinus Mucosa on Maxillary Bone Resorption During Pneumatisation Proces

Andrzej Wojtowicz(1), Katarzyna Sporniak-Tutak(2), Andrea Montella(3), Pasquale Bandiera(3), Maciej Dijakiewicz(4), Iwona Kochanowska(5) and Kazimierz Ostrowski(6)*

1. Department of Oral Surgery, Medical University of Warsaw

2. Department of Oral Surgery, Pomeranian Medical University, Szczecin

3. Universitá degli Studi di Sassari, Dipartimento di Scienze Biomediche. Sezione di Anatomia, Umana, Italia

4. Department of Oral Surgery, Medical University of Gdańsk

5. Institute for Immunology, Polish Academy of Sciences, Wrocľaw

6. *Department of Histology, Medical University of Warsaw, 02-004 Chaľubińskiego 5, Poland.


* Address for correspondence

Summary: The aim of this study was an immunohistological investigation of the TGFß (transforming growth factor), BMP6 (bone morphogenetic protein), MMPs 1-3 (metalloproteinases) and TIMP-1 (tissue inhibitors of metalloproteinases) in the following tissue compartments: maxillary sinus epithelium-mucosa - maxillary bone - oral mucosa as well as a radiometric assessment of the anterior and posterior segments of maxillary bone. We were able to confirm the involvement of epithelium- mucosa in the growth and formation of maxillary sinuses and their pneumatisation in physiological conditions as well as in chronic allergic sinusitis. This is connected with the intense synthesis of MMP proteases, which, like in bones, regulates the turnover and rebuilding process of surrounding soft tissues. This is true for the control samples as well as for the samples taken from the cases of allergic maxillary sinusitis during surgery.

The amount of resorbed bone is different in the anterior and posterior part of maxillary bone. This is influenced by growth of maxillary sinus in the posterior part of maxilla and bone resorption from both sides - sinus and oral lumens, mainly in edentulous patients. In consequence this is important for loss of teeth and for decisions in treatment of chronic sinusitis as well as in residual ridge augmentation in dental implantology. Radiological morphometry (Kreisler and Schultze 2000) is supporting the above-mentioned mechanism.

Key words: Maxillary sinus - BMPs - TGFß - MMPs -TIMP - radiometry - embryogenesis - chronic allergic sinusitis

1. Introduction:

1.1. The mechanism of formation of maxillary sinuses is not known, although the morphology of embryogenesis is well described (Helms and Schneider 2003). In the prenatal period, the pneumatisation hypothesis is not valid. There have been numerous hypotheses about the regulatory mechanisms of maxillary bone remodelling in prenatal and postnatal life. As the molecular approach to this problem is not easy, we decided to use few immunohistochemical reactions to analyse the synthesis of selected important molecules involved in the remodeling process of tissues (Brew et al. 2000, Coffin 1905, Furuta et al. 1997, Gurdon and Bourillot 2001, Helms et al. 1998, Nakashima et al. 1998, Niehrs 2001, Overall et al. 1989, Vidić 1971).

1.2. The aim of this study was an immunohistological assessment of the TGFß, BMP6, MMPs 1-3 and TIMP1 in the following tissue compartments: maxillary sinus mucosa-maxillary bone-oral mucosa as well as a radiometric assessment of the anterior and posterior segments of maxillary bone.

1.3. The progress of sinus pneumatisation and maxillary bone remodelling is carried on through the whole life of an individual. The mechanism of pneumatisation in postnatal period is connected with bone resorption and enlargement of the sinusoidal space. A similar mechanism is observed in the process of allergic maxillary sinusitis (Braun and Stammberger 2003, Lee et al. 2003, Prott 1977, Schaeffer 1910, Schaeffer 1916, Torriginani 1914, Vedova 1908, Vidić 1971).

1.4. About 200 factors are described which influence bone turnover. The list constructed by NIH contains cytokins, hormones, vitamins, and proteins active in the frames of immunological system. Because of this, nobody was able to construct the scheme describing all existing and possible interactions connected with maxillary bone remodelling process (Fujii et al. 1999, Galter et al. 1999, Hughes et al. 1995, Imai et al. 1997, Sato et al. 1999, Yamaguchi et al. 1996).

1.5. The maxillary sinuses are developed during the prenatal period, and their growth and pneumatisation is observed during life span. Apart from few theories on sinus growth, the bone resorption stimulated by the cytokines released by both oral mucosa and sinus mucosa seems to be crucial in physiology and in chronic allergic sinusitis. The knowledge of these mechanisms is important for success in disease treatment as well as in residual ridge augmentation necessary in dental implantology. It seems also that the some cytokines ( i.e., TGFß [transforming growth factor], BMPs [bone morphogenetic proteins] and system of metalloprotease enzymes MMPs and their inhibitors TIMP) play an important role in this mechanism. The above-mentioned tissue enzymes participate in the sinus embryogenesis and maxillary bone resorption (Gulisano et al. 1922, Ishino et al. 2003, Overall et al. 1991, Solloway et al. 1998, Stetler-Stevenson et al. 1989, Vidić 1971).

1.6. The aim of this study was to evaluate the prenatal expression of several factors in oral and sinus mucosa, involved in bone resorption: i.e., metalloproteinases MMPs1-3, their tissue inhibitor TIMP1, TGFß and expression of these factors in foetal and adult maxillary sinus and in chronic allergic sinusitis. Although BMP6 is not a regulator of bone metabolism, we decided to evaluate its expression in prenatal oral and sinus mucosa, as well as in sinus mucosa in chronic allergic sinusitis. The reason is that BMP6 is over-expressed in the cases with high epithelial turnover, such as in epithelial tissue in psoriasis or cancer of oesophagus (Clement et al. 1999, Galter et al. 1999, Hahn et al. 1992, Heikinheimo et al. 1999, Raida et al. 1999, Solloway et al. 1998, Vidić 1971).

1.7. The investigation of residual ridge resorption of the anterior and lateral parts of maxillary bone was performed using radiometric analysis in partially dented men and women.

2. Material and Methods:

2.1. The evaluated samples included 12 tissue biopsies collected from the alveolar recessus area of patients with good general health as a control and of 10 patients with chronic allergic sinusitis. The patients underwent maxillary bone surgeries as a result of injuries or gnathic defects and modified Caldwell-Luc surgery. The age of control healthy and suffering chronic allergic sinusitis patients was 45 - 55 years, and they have similar dental status - partially dented with physiologic occlusion.

2.2. For comparison, evaluation of epithelium covering the oral mucosa of five 15-week-old human foetuses from the collection of the Dept of Anatomy, Universita degli Studi di Sassari, was preformed.

2.3. The hematoxylin-eosin staining and the immunohistochemical reactions for detection of MMPs1-3, one of their inhibitor TIMP1, TGFß and BMP6 were evaluated on paraffin sectioned samples (Dochety and Murphy 1990, Greene et al. 1996, Halinen et al. 1996). The enumerated factors are cited in the literature as the main ones that regulate the tissue remodelling in developmental processes as well as in physiological metabolisms and regeneration (Adler et al. 1999, Helms and Schneider 2003, Inada et al. 1999).

2.4. The immunohistochemical reactions allow for reasoning on the basis of the localisation of their product and intensity of the reaction. We are aware that true quantification of the results of enumerated these reactions is not possible.

2.5. Residual ridge resorption in the maxilla bone was evaluated on panoramic radiographs using methodology proposed by Kresisler et al. (2000). It was defined against the reference areas in the maxilla on digitised radiographs obtained from 75 normal healthy partially dented individuals, and 35 patients suffering chronic allergic sinusitis (20 men and 15 women). Maxillary anterior and posterior bone areas were measured with an integrated planimetry program Vix Win 2000. The Student t- test (x± SD) was used for statistics (Kresisler and Schiltze 2000).

3. Results:

3.1. Immunohistochemical methods were used to assess the TGFß, BMP6, MMP 1, 2, 3 and TIMP-1 expression in paraffin-embedded tissue sections. The presence of mono and polynuclear cells was proved by means of the HE staining

3.2. An intense positive reaction for MMPs1,2 and 3 in the mucosal epithelium in the human foetuses was found. Similar intensity of MMPs expression were found in adult maxillary mucosa, and even stronger expression in chronic allergic sinusitis (Fig. 1and 2)

4. Radiometry

4.1. The methodology applied is applicable to a number of clinical diagnoses, and it could contribute to a better understanding of maxillary bone remodelling and resorption in physiology and pathology, as well as in implanto-prostodontics planning treatment. Pantomographs are most useful pictures in dentistry and the proposed methodology allows for retrospective and prospective analysis (Rzymski et al. 1999).

4.2. The frontal maxillary area in men was 460±21 mm2, in women was 405±14 mm2, posterior area was 960±38 mm2 and 430±38 mm2 in men and women respectively. Patients suffering chronic allergy sinusitis have significantly lower value of bone area measured on pantomographs: in men 265±32 mm2 in front area and 360± 39 mm2 on posterior maxillary area, in women 260±28 and 300±21 mm2 respectively (Fig. 3).

5. Discussion and Conclusion:

5.1. The idea of this project was to look for the presence of synthesis of some cytokines, growth factors and/or other molecules (e.g., some enzymes and their inhibitors) known for their interaction with the connective tissue ECM surrounding bone of maxilla. The localisation and intensity of expression of immunohistochemical reaction for MMPs in the 15 week-old, developing human foetuses seems to indicate that developing epithelium of oral cavity might be involved in the formation of lumens of this cavity as well as surrounding bone. The mechanism is most probably based on the influence on the turnover and rebuilding process of ECM driven by the high enzymatic activity of MMPs, contained in the epithelium covering the oral cavity ( Halinen et al. 1996, Killian 1895, Mayer 1906, Perr et al. 1999).

5.2. Strong reaction of MMPs and weak reaction of TIMP, observed in human maxillary sinus mucosa development, matured sinus mucosa and overgrowing sinus mucosa, seems to be one of the strongest factors involved into pneumatisation process of sinuses. Strong reaction of MMPs observed in human mature healthy sinus mucosa, but even stronger reaction in the course of allergic sinusitis, connected with higher bone resorption, may limitate long-term satisfactory result of sinus lift procedure and dental implants procedures. Such reaction was observed in mature healthy mucosa, but the intensity of this reaction is stronger in the epithelium of sinuses in foetuses. The increase in the intensity of the reaction for MMPs is parallel to the differentiation of the simple cuboidal epithelium into mature simple columnar ciliated epithelium, intercalated by the goblet cells and some adjacent small serous glands (Wojtowicz et al. 2002). Strong activity of TGFß, weak expression of BMP6, both members of the same superfamily of transforming growth factors, found in embryonic and adult tissues, seem to show that TGFß is expressed "everywere" during organogenesis, tissue remodelling/regeneration processes as well as in pathology, but BMP6 regulates only slightly epithelial tissue metabolism and growth during organogenesis and is more expressed in mucosal-epithelial pathology (Gitelman et al. 1997, Halinen et al. 1996, Howard et al. 1991, Innis et al. 1997, Iwasaki et al. 1997, Kubota et al. 1998, Okada et al. 1990, Olavesen et al. 1997, Solloway et al. 1998).

5.3. The results of radiometric analysis of the height of alveolar ridge resorption in allergic sinusitis correspond to the intensity of metaloproteases involved into bone resorption. The relative change of evaluated alveolar bone area, the effect of residual ridge resorption is probably also connected with the tooth loss and bone resorption from oral mucosa side of maxillary bone. The reason of higher maxillary bone loss of posterior area than in frontal area is that resorption from sinus mucosa is overlapped with bone resorption from oral mucosa. In a control group of women, the frontal and posterior bone area was significantly higher than in sinusitis mucosa. The perimenopausal effect of deficiency of estrogen, an important factor of bone loss, was parallel to the enzymatic activation in sinusitis, what was observed in healthy control women too. In men suffering allergy sinusitis, the posterior bone resorption was stronger than in the front area for about 50% and 25% respectively in comparison with the group of healthy men. Highest loss of maxillary alveolar bone height was found in the posterior part in comparison with frontal teeth area. Frontal teeth area is more refractory for bone resorption because maxillary bone resorption in posterior part is bilateral both from the direction of sinus and oral mucosa (Fig. 4).


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