|Year : 2019 | Volume
| Issue : 5 | Page : 616-625
3-D mapping of cortical bone thickness in subjects with different face form and arch form: A CBCT analysis
S Chaturvedi, MA Alfarsi
Department of Prosthetic Dentistry, College of Dentistry, King Khalid University, Abha, Saudi Arabia
|Date of Acceptance||29-Jan-2019|
|Date of Web Publication||15-May-2019|
Dr. S Chaturvedi
Assistant Professor, Department of Prosthodontics, College of Dentistry, King Khalid University, Abha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To determine the relationship between face form (FF), arch form (AF), and cortical bone thickness in anterior and posterior region of the mandibular jaws, using cone beam computed tomography (CBCT). Patients and Methods: Total 90 subjects were selected. For each subject FF (euryprosopic, mesoprosopic, and leptoprosopic) was determined using Prosopic Index. CBCT scans were done for each subject to determine mandibular AF (as tapered, oval, or square in horizontal sections) and cortical bone thickness (at two vertical levels 4 and 7 mm from the alveolar crest in the anterior and posterior region of mandible in sagittal sections). Numerical data so obtained were analyzed using descriptive statistics, analysis of variance followed by Tukey HSD (honestly significant difference) test at a statistical significance level of 5%. Results: Significant difference in thickness of cortical bone was noted between various AF and face. In square AF, mean value of thickness of cortical bone was highest both at 4 and 7 mm vertical level and tapered AF had minimum mean values at 4 mm and oval at 7 mm in anterior region and posterior region on buccal and lingual sides, in all the three-FF. Conclusion: Significant effects of FF and AF on cortical bone thickness were seen both on buccal and lingual side and the effect of AF was more compared to FF. The availability of the cortical bone in euryprosopic FF and square AF patients was more; therefore, implants with a shorter length may be used in these clinical cases.
Keywords: Cone beam computed tomography, dental implant stability, Prosopic Index
|How to cite this article:|
Chaturvedi S, Alfarsi M A. 3-D mapping of cortical bone thickness in subjects with different face form and arch form: A CBCT analysis. Niger J Clin Pract 2019;22:616-25
|How to cite this URL:|
Chaturvedi S, Alfarsi M A. 3-D mapping of cortical bone thickness in subjects with different face form and arch form: A CBCT analysis. Niger J Clin Pract [serial online] 2019 [cited 2020 May 27];22:616-25. Available from: http://www.njcponline.com/text.asp?2019/22/5/616/258287
| Introduction|| |
The anatomy of the stomatognatic system is under the influence of the genomes and decided during the embryonic period. Conversely, functional requirements direct its growth and development specially the circumferential areas of craniofacial regions. It has been proved previously that (FF) is meticulously moderated by the surrounding musculatures, i.e. facial, masticatory muscles. The facial bony skeleton and related muscles result in a particular type of growth pattern, and their association is well documented in literature. The muscular functional loading alters the cortical bone thickness (CBT) in the alveolar bone of the tooth-bearing interface of the maxillary and mandibular jaws. Consequently, through this phenomenon, the thickness of the cortical bone can elucidate proportionality of the forces it experiences which could diverge in individual with different FF. FF can be classified as leptoprosopic, euryprosopic, and mesoprosopic depending on the facial indices. Preceding literatures substantiate a complex relationship between CBT and the facial type. But still differences in opinion exists regarding the exact relationship.
The teeth-bearing area of the jaw is arranged in the form of arches and are classified as tapered, oval, or square.,, Arch form (AF) basically refers to the overall configuration of the dental arch, and this considers the symmetry, roundness, elongation, and convexity. It is a guideline provided by nature to replace missing teeth and its dimensions are related to individuals and to evolutionary factors.
The AF and FF are determined during the embryonic period and both has a complex embryonic relationship with cortical bone. It has been illustrated that development of cortical bone starts with the development of AF. But, up to now, we had not found any firm justifications in indexed data search engines which directly relate AF and FF with CBT. Individual studies had been performed but direct correlation have not been assessed, despite of the fact, it has a very important role during diagnosis and treatment planning not only in prosthodontics but also in implantology and orthodontics. In prosthetic dentistry, facial measurements and AF play a vital role in success of any dental prosthesis. They are used as a guide for selection and arrangement of the teeth., This is considered true not only in complete dentures where the denture teeth should follow the AF of the natural precursors but also for the conventional and implant retained dental prostheses. During replacement of missing anterior teeth with fixed dental prosthesis the AF along with the above-mentioned guidance also dictates the number of abutments used. This is for the reason that additional/secondary abutments are needed in tapered AF to counteract the torsional forces produced by the increased distance of pontics from the abutments. Whereas, the square and oval arches may only need the primary abutments. Similarly, when designing a prosthesis on implants, the size and shape of the dental arches have a considerable effect on treatment planning, space availability, stability of prosthesis, esthetics, number of implants (more for tapering arches), A–P length, and cantilever length all are influenced by AF., In orthodontics, the pragmatic shift from the natural AF may hamper the posttreatment occlusal stability., AF provides a reliable guideline about the position into which the teeth can be moved. Orthodontic relapse occurs when teeth are placed outside the soft tissue envelope.
It has also been demonstrated in clinical and basic research that initial implant stability is of utmost importance for overall success.,,, Along with other factors, the quality and quantity of regional bone influences primary implant fixation. The study on quantitative imaging and biomechanical evaluations of cortical bone clearly demonstrated that CBT strongly increased implant stability in humans. It had also been proved that the amount of cancellous bone did not increase implant stability at the time of surgery, but it is the cortical bone.,,, Thus, CBT has significant influence in endosseous implants stability as well as the stability of mini implants placed in orthodontics for anchorage. Accordingly, preoperative examination of the host bone is essential for treatment certainty. Clinically, computed tomography (CT) is currently the only and most appropriate diagnostic imaging technique that allows for determination of the CBT, density and structures of the jawbones surrounding the implant site.,
Based on these premises, the aim of the study was to determine relationship between FF and AF and CBT of anterior and posterior region of the mandibular jaws in different subjects, using cone beam CT. This would provide reference data for clinicians placing dental implants for replacement of missing teeth as well as mini-implants for orthodontic anchorage. The null hypothesis was formulated that there would be no statistically significant differences in CBT of anterior and posterior region of the mandibular jaws, among subjects with different face and AFs. forms.
| Patients and Methods|| |
This study was conducted following all ethical standards and approval was taken from the ethical committee of the institute (SRC/REG/2017-2018/42) and written informed consent was obtained from all participants.
The samples were collected from the KKUCOD, outpatient department (OPD), in a period of 6 months (February 2018–July 2018). During this period, all patients reporting to the OPD were checked by a single examiner. The examiner selected the samples only on the basis of inclusion and exclusion criteria from the pool of patients in OPD with the age range of 25–45 years. A total of 90 samples were collected. Participants receiving previous or current orthodontic treatment, evident periodontal disease (determined from radiographic signs of bone loss), missing permanent teeth (excluding third molars), who have taken bisphosphonate for more than 3 years, evidence of previous trauma, muscle dystrophy, or related bone disorder and any pathologies of maxillofacial region, uncontrolled systemic diseases were excluded. For each subject FF was determined through Banister's classification as euryprosopic, mesoprosopic, and leptoprosopic. For this, bizygomatic width and facial length [Nasion to Gnathion (N-Gn)] was measured using digital sliding caliper. Then, FF was determined on the basis of values so obtained using the formulae.[Table 1], [Figure 1] - Facial index = N-Gn/bizygomatic width × 100.
|Figure 1: Various face forms on basis of Banister's classification [Points used to measure were-bizygomatic width and facial length [Nasion to Gnathion (N-Gn)], (a) Euryprosopic face form, (b) Mesoprosopic face form, (c) Leptoprosopic face form|
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Following this, for all participants cone beam computed tomography (CBCT) scan was obtained by Veraviewepocs 3D CBCT scanner (Veraviewepocs 3DF40 J. Morita MFG CORP. Kyoto, Japan) with the following settings: 90 kVp at 3 mA for a total scan time of 7 s, with a voxel size 0.3 mm (all protection protocol was followed while making scans according to ethical standards). The three-dimensional image was reconstructed by Veraviewepocs 3D™ software and saved in digital imaging and communications in medicine (DICOM) format.
The mandibular AF was determined by using same software. In horizontal sections of CBCT, the occlusal view of the arch was located. Then, the measuring tools of the software were used to join the following reference points: incisal edges of the incisors, cuspids tips of the canines, and the buccal cuspids tips of the premolars and molars, to obtain the dental AF. [Figure 2]. These images of the dental arches were used to classify the arches as square, oval, or tapered, by the main researcher and coresearcher. Correlation between examiners in classifying the morphology of the dental arch was evaluated by applying the modified Kappa test.
|Figure 2: Various arch forms in horizontal section of CBCT (Points joined are-incisal edges of the incisors, cuspids tips of the canines, and the buccal cuspids tips of the premolars and molars, to obtain the dental AF), (a) Square Arch Form, (b) Oval Arch Form, (c) Tapered Arch Form|
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Now in these classified participants using same software, through each contact area 0.3 mm thick sections were created. Orientation of each site in all three planes of space was carried out before measurement. The interradicular areas in the anterior (between canine and lateral incisor) and posterior (between second premolar and first molar) were located on the sagittal sections. Then, the selected section was oriented so that the interradicular space was intersected by the vertical reference line and was parallel to the long axes of the roots. Alignment of the axial section was then used to ensure that the horizontal reference line bisected the interradicular area and traversed the thinnest area of cortical bone. The horizontal reference line was moved to establish the measurement level in relation to the alveolar crest as seen on the coronal section [Figure 3].
For each selected interradicular space in the mandible, the following measurements were done:
- Buccal and lingual, CBT at 4 and 7 mm apical to the crest of the alveolar bone. It was defined as the thickness of the buccal and lingual cortical plate measured perpendicular to the bone surface, respectively.
For each participant, either the right or left quadrant of the mandible was randomly chosen for the measurement. Only one side was measured because it has been previously shown that there are no differences in cortical thickness between sides of the jaws.,,
To reduce variations in measurement, in this study, the chief researcher made all measurements. The intraoperator error was assessed by remeasuring the eight randomly selected participants at an interval of 1 week by the same observer. Also, interoperator error measurements were done by asking a trained prosthodontist to take measurements on the same participants. The intraoperator and interoperator error were assessed using the intraclass correlation coefficient. High correlation was found for both intraoperator (r = 0.91) and interoperator (r = 0.89) error.
Numerical data so obtained after recording were estimated for normal distribution. It was analyzed using descriptive statistics and comparisons were made between FF and AF for CBT. For multiple comparisons, two-way analysis of variance (ANOVA) was used to detect effects of various FF and AF and their interactions. ANOVA was followed by Tukey HSD test for paired comparisons of the means. All tests were calculated with a statistical significance level of 5% and confidence interval of 95%. Statistical analysis was performed with IBM SPSS Statistics Version 20 for Windows (IBM Corporation, NY, USA. SPSS, Inc., an IBM Company).
| Results|| |
The statistical analysis of the data showed that in the anterior region, buccal and lingual cortical plate thickness of the square AF had highest mean value both at 4 and 7 mm vertical level and tapered AF had minimum mean values at 4 mm and oval at 7 mm. in all the three FFs. Similar results were seen in the posterior region [Table 2]a and [Table 2]b.
The critical observation of average thickness of the buccal and lingual cortical plate of different FFs in the anterior region, revealed that at 4 mm vertical level, euryprosopic FF had the highest value 2.12 ± 0.30 and 2.43 ± 0.30 respectively, while leptoprosopic FF had the lowest value 1.78 ± 0.09 and 2.12 ± 0.17 respectively, among all three FFs. At 7 mm vertical level euryprosopic FF had the highest value 2.69 ± 0.34 and 3.11 ± 0.26 respectively, while leptoprosopic FF had the lowest value 2.39 ± 0.27 and 2.76 ± 0.21 respectively, among all three FFs. Similar observations were noted in posterior region [Table 2]a and [Table 2]b.
On comparing the CBT among various FFs and AFs at 4 and 7 mm vertical level in anterior region it was found that on both the sides viz. buccal and lingual, there was significant effect of FF and AF on CBT (P < 0.001 and P < 0.005, respectively) but no interaction effect of FF and AF was seen. However, the effect of AF was more than the effect of FF. Similar observations were noted in posterior region except that there was significant interaction effect between FF and AF [Table 2]a and [Table 2]b.
The comparison of CBT between various FFs in the anterior and posterior regions at 4 and 7 mm vertical level is shown in [Figure 4] and [Figure 5], the maximum mean difference was found between euryprosopic and leptoprosopic forms and minimum mean difference was found between mesoprosopic and leptoprosopic forms. Similar comparison between various AFs is shown in [Figure 6] and [Figure 7].
|Figure 4: Bigroup comparisons of cortical bone thickness between various groups of face forms and arch forms at 4 mm vertical level in anterior region|
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|Figure 5: Bigroup comparisons of cortical bone thickness between various groups of face forms and arch forms at 7 mm vertical level in anterior region|
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|Figure 6: Bigroup comparisons of cortical bone thickness between various groups of face forms and arch forms at 4 mm vertical level in posterior region|
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|Figure 7: Bigroup comparisons of cortical bone thickness between various groups of face forms and arch forms at 7 mm vertical level in posterior region|
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At buccal and lingual sides the estimated ranges with 95% confidence of CBT for various groups of FFs and AFs at 4 and 7 mm. Vertical level in anterior and posterior regions is shown in the [Table 3] and can be used as a reference normal ranges for people of various categories regarding FFs and AFs.
|Table 3: Estimated range with 95% confidence of cortical bone thickness for various groups of face forms and arch forms at 4 and 7 mm vertical level in anterior and posterior region|
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| Discussion|| |
In the present study, clinical data and radiomorphometric data by CBCT revealed that CBT has a definite relation with the FF and mandibular AF and cortical bone is commonly thicker in the posterior region compared to anterior, thus we reject the null hypothesis. The study was conducted in meticulously selected young age group individuals deprived of any condition affecting the bone thickness, consequently results of this study provided reference data of normal ranges of CBT for participants of different FFs and AFs [Table 3].
This will be useful for clinicians who are involved in rehabilitation of patients with fixed or removable, conventional or implant supported prosthesis, who places endosseous dental implants and miniimplant (in orthodontics for anchorage), also it provides the insight of CBT during extraction and disimpaction of teeth, autogenous bone graft harvesting for various purposes from the mandible in participants with varying FF and AF.
It is always difficult to properly assess bone condition preoperatively due to a lack of rationality and reliability of measurement methods. Bone quality is often referred in the literature as the amount of cortical and cancellous bone. In the present study, the cortical bone was measured using CBCT, which allowed a three-dimensional visualization of bone, especially in the buccolingual direction, which was not visible in conventional panoramic images. It also provided comprehensive data at a very low radiation dose compared to CT scans thus making it as a standard tool for studying the intraoral bony anatomical structures, for dental implant placement and various intraoral surgical procedure.,
CBT can be described as the thickness from periosteum to the cortical–trabecular interface. CBT is mainly dependent on mechanical stimuli, but it is also influenced by a wide range of genetic and nongenetic factors. It is documented that the primary purpose of cortical bone is to resist deformation in response to internal (muscular) and external forces, so it must be sufficiently stiff to resist breakage and should be dynamic and adaptive. Furthermore, CBT is the key determinant of initial stability of endosseous dental implants and miniimplants. Recent findings by Miyamoto et al. suggest that CBT plays greater role in implant stability than the length of dental implants. Furthermore, for miniimplants, thin cortical bone increases the risk failure on the contrary thick cortical bone can increase the risk of miniimplant breakage and bone micro-fractures.
Thus, the above evident facts make it essential that the clinicians should perceive the type of bone and specifically CBT available in the area of concern, before any related procedures. As sated earlier that this may not be possible without detailed, expensive, time-taking investigations, and failing to do so may impede the initial diagnosis and treatment planning moreover the therapeutic success of treatment will be questionable. To reduce the chance of this error, the current study related the FF and AF with CBT both in buccal and lingual side at 4 and 7 mm vertical level. Similar to this study, Ozdemir et al. measured CBT at 4 mm from the alveolar crest and Mais Medhat Sadek et al. measured CBT at 4 and 7 mm. These vertical levels appears to correspond to the attached gingiva and was important for the endosseous implant primary stability at cervical and apical region, also it was reported to be a favorable area for miniimplant placement in orthodontics. Likewise, only one side assessment was made as it was documented previously by Deguchi et al. and many other authors that there are no differences in cortical thickness between sides of the jaws.,,
Over the years, the human dental AF is recognized to be variable in shape and size. Its shape is influenced by many factors in which basic skeletal morphology is of paramount importance and this skeletal morphology is basically predisposal of the surrounding soft tissues and other additional environmental factors. Thus, the interrelationship between FF, AF, and CBT is complex but definite and very important.
The FF in this study was categorized as euryprosopic, mesoprosopic, and leptoprosopic, based on the ration described by the Banister. The human face, along with its bony and muscular support, presents peculiar characteristics. Facial configuration is under the influence of various factors, such as race, gender, heredity, genetics, environment, and the character of craniofacial growth. The facial growth, with the exception of the mandible, is concluded relatively early: 60% of craniofacial development occurs during the first 4 years of life and, by age 12, is 90% completed. Although facial appearance is established in early childhood, it presents some changes during the growth, especially in mesofacial participants. The mandible grows until maturity, when the surface acquires its final dimension. Growth preserves the dental (intraoral) and facial (extraoral) morphological features in both normal and abnormal occlusion. Therefore, in the present study the Banister method was adopted to determine the FF of the participants with age range of 25–45 years because by this time the complete growth would have been completed and face would have acquired its final form.
The AF described in the glossary of prosthodontic terms as “the geometric shape of the dental arch when viewed from the horizontal plane.” Failure to maintain the AF during treatment may results in loss of stable, functional, and esthetic outcome. Classic studies classified AF on the basis of its shapes, few authors used mathematical formulae to classify AF. In the present study, the arch from was classified as square, tapered, and oval by visual examination of the outline obtained in the horizontal slice of mandibular arch CBCT image. This method of classifying arches was considered above the mathematical functional methods because the mathematical methods of evaluation involve measurement of distances between specific reference points and use of various algebraic functions to analyze the AF and have described four to five different shapes. These quantitative methods result in vast data requiring intricate adjustments with sophisticated apparatus. Some authors argue that anatomical structures could not be reduced to the mathematical precision of geometrical terms. Visual analysis method of classification of the dental arch was also used by other authors like Felton et al. and Nojima et al. Nevertheless, in the present study, simplest predictable method to determine the arch from was used. In same CBCT scan, which were used for CBT measurements, the arch from was determined, no separate procedure was carried out for this, compared to previous studies where separate cast, photocopying plaster models, occlusal view intraoral photographs, 3D scanning of intraoral tissues or dental casts, digitizing natural, normal occlusion models, and applying mathematic formulas to establish dental AF, were used.
In current study, out of total 90 samples 46% leptoprosopic, 31% and 23% were euryprosopic and mesoprosopic FFs participants [Table 2]a and [Table 2]b. Although preeminent closeness was found between various combinations of FF and AF, such as in euryprosopic FF participants predominant AF was square (54%), in mesoprosopic - oval (48%) and leptoprosopic - tapered AF (41%) but based on the statistical analysis of data, no significant association was found between FF and AF (P > 0.05). These results are in association with the Berksun et al., where they verified a subjective correlation between facial morphology and dental arches without any expressive correlation, through digital photographs and Sellen et al. study in which sophisticated methods of overlapping images were used to verify the correlation between four aesthetic factors: facial morphology, dental morphology, dental AF, and palatal contour. Conversely, the study of Nayar et al. contradict these findings where they found that, 63.63% of leptoprosopic individuals had squarish AF, while 54.6% of mesoprosopic faces had ovoid AF. These differences may be due to the environmental and genetic factor related to this population. Consequently based on our study, the use of the facial type as a method of diagnosis to determine the morphology of the dental arch is not appropriate [Table 2]a and [Table 2]b. Further studies are required to assess mandibular AF using evidence-based research.
In each FF, when the cortical plates were compared both in anterior and posterior region, the buccal and lingual cortical plates of the square AF were significantly thicker compared to the other AFs, both at 4 and 7 mm. [Table 2]a and [Table 2]b. The maximum mean difference was found between square and tapered for buccal side (diff = 0.32) and between square and oval for lingual side (diff = 0.28). Minimum mean difference was found between tapered and oval side (buccal = 0.10, lingual = 0.04). Similar results were derived in the previous studies, where square AF had greater buccal and lingual CBT compared to oval and tapered AF.
In our study, maximum thickness of cortical bone was found in euryprosopic FF and minimum thickness of cortical plate was found in leptoprosopic FF both in anterior and posterior region [Table 2]a and [Table 2]b, Statistically, significant differences in CBT were detected with euryprosopic and leptoprosopic FFs, square and oval; square and tapered AF. Masumoto et al. stated that the morphological features that relate to masticatory function and facial types are also associated with the CBT of the mandibular body. The findings of the present study aided with Masumoto statement, as in euryprosopic FF, square AF was highest in number and in both of them the CBT was maximum in their own category. Furthermore, the outcome of this study can be correlated with the results of former studies,, in which a significant relationship was found between facial type and alveolar thickness.
Based on the results of the present study the reference normal range of CBT could be provided for participants of various types of FFs and AFs [Table 3]. These ranges would be helpful to the clinicians during the selection of endosseous dental implants and mini implants for anchorage. The results of this study re-establishes the fact that the CBT in the posterior region is more compared to anterior region,, and on the buccal side compared to lingual side. This may be due to the fact that the cortical bone is influenced by the masticatory muscle functions. On posterior aspects especially on buccal side strong masticatory muscles are attached which provide continuous pull on every movement and also the mandibular body in the posterior region is resistant to torsional forces. This is in association with the Schwartz-Dabney and Dechow they found significant differences in thickness among the mandibular facial and lingual cortices (sides) (F = 16.3, P < 0.003), with thicker facial side cortices. It was also reported that mean cortical thickness decreases from posterior to anterior. Katranji et al. found that the thickest area of the mandibular buccal cortical bone was in the molar region, followed by the premolar region, with the incisor region being the thinnest. This trend might also be explained by the higher functional demands of the posterior teeth. Van Eijden reported an increase in the longitudinal elastic modulus (increase in stress per unit strain) from molar region to the symphysis. This finding illustrates that there are stress and strain differences that could possibly give rise to the differences in cortical thickness reported for this region.
Perhaps most importantly, the outcomes of the study gave clinicians reference data for CBT in participants with different FF and AF and also related them with the amount of CBT in various region. It showed that there is a definitive correlation between the FF and CBT also between AF and CBT. This will help during the selection process of the dental implants. The more the CBT, the smaller the implant length required for support and the lesser the amount of cortical bonne availability, the longer the implant length required. As, initial implant stability immediately after surgery is mostly attributed to corticalization of the surrounding bone.
| Limitations|| |
A number of limitations of the study must be taken into consideration. The difference between male and female participants was not determined in the study. Small sample size and cross-sectional design. However, in a study by Farnsworth et al. no sex differences in cortical thickness in either the maxilla or the mandible was found between males and females. Inherent limitations of CBCT imaging should also be considered. The spatial resolution may be influenced by partial volume averaging especially in thin bone sections. Also, density of cortical bone was not taken into consideration which may affect the net outcome of implant treatment. So, it is recommended to evaluate bone mineral density of cortical bone, in future research, along with bone quantity (bone thickness) and bone quality (mineralization).
| Conclusion|| |
The results of the present study demonstrate that FF was not associated with AF, significant effects of FF and AF on CBT were seen both on buccal and lingual side and the effect of AF was more compared to FF. Euryprosopic FF and square AF had highest CBT. Hence, patients having euryprosopic FF and square AF may require implants with a shorter length than patients having another FF and AF. Since availability of the cortical bone in euryprosopic FF and square arch patients is greater, there is more stability for the implants in these cases; therefore, implants with a shorter length may be used in these cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We authors are very thankful to Dentaly dental clinic and research center, Abha, KSA for CBCT scans.
Financial support and sponsorship
The authors extend their appreciation to the Deanship of Scientific Research at King Khalid University for funding this work through General Research Project under grant number (G.R.P.23/1439).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]