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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 258-265

Radiographic evaluation of bone density in dentulous and edentulous patients in Riyadh, KSA


1 Dental Implants and Maxillofacial Prosthodontics, King Saud Medical City, Riyadh, KSA
2 Department of Preventive Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, KSA
3 Ministry of Health, King Saud Medical City, Riyadh, KSA
4 Dr. Abdulaziz Alajaji Dental Ployclinic, King Saud Medical City, Riyadh, KSA
5 Department of Biostatistics, King Saud Medical City, Riyadh, KSA
6 Department of Surgical and Diagnostic Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, KSA
7 Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, KSA
8 Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

Date of Submission17-Mar-2019
Date of Acceptance13-Dec-2019
Date of Web Publication7-Feb-2020

Correspondence Address:
Dr. S A Alanazi
Ministry of Health, Riyadh
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_154_19

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   Abstract 


Background: The Cone Beam Computed Tomography (CBCT) is currently being used as the most common diagnostic method to evaluate the bone density of the maxilla and the mandible for planning dental implant. Aim: The aim of the study is to check the quantitative alveolar bone density in complete or partial edentulous and dentulous male and female patients among Riyadh sample population in Saudi Arabia. Materials and Methods: The study involved a cross-sectional analysis of 231 consecutive CBCT images of 231 different patients (115 males and 116 females). The scans were of Saudi National patients who were partially or completely edentulous without any bone infections in the maxilla and the mandible. The findings are presented as descriptive statistics and inferential statistics: student -t-test for two group means, ANOVA for three groups, Post-hoc LSD test for multiple comparisons, Levene statistics for testing the homogeneity of variances and a statistical significance at 5% level. Results: Comparison of mean alveolar bone density in maxillae of dentulous male smokers showed a statistically significant difference for bucco-cortical plate and cancellous bone among different regions. In dentulous male nonsmokers, no significant difference was observed for maxillary regions, while in mandibular areas, a statistically significant difference was seen for buccal cortex, palatal cortex, and cancellous bone among different regions. While studying the scans of female dentulous patients, a statistically significant difference was observed in alveolar bone density for all the areas. Conclusion: Evaluation of bone density is an important step in treatment planning and this study was aimed to provide insight into bone density patterns of population in Riyadh, Saudi Arabia. Further similar studies in different populations can help in planning for more efficient treatment outcomes.

Keywords: Bone density, cone beam computed tomography, mandible, maxilla


How to cite this article:
Al-Attas M A, Koppolu P, Alanazi S A, Alduaji K T, Parameaswari P J, Swapna L A, Almoallim H, Krishnan P. Radiographic evaluation of bone density in dentulous and edentulous patients in Riyadh, KSA. Niger J Clin Pract 2020;23:258-65

How to cite this URL:
Al-Attas M A, Koppolu P, Alanazi S A, Alduaji K T, Parameaswari P J, Swapna L A, Almoallim H, Krishnan P. Radiographic evaluation of bone density in dentulous and edentulous patients in Riyadh, KSA. Niger J Clin Pract [serial online] 2020 [cited 2020 Oct 1];23:258-65. Available from: http://www.njcponline.com/text.asp?2020/23/2/258/277854




   Introduction Top


Research on bone biology in contemporary years has transformed our judgment about many concepts associated with the clinical practice in implants. Awareness of bone density in various areas of the alveolar bone of maxilla and mandible helps the clinician to comprehend and associate various observed clinical events as well as allows the clinician to plan the placement of implants with necessary precautions consequently.[1]

Various studies have been done to estimate the bone density in assorted regions of the maxilla and mandible prior to implant placement, with the observation of low success in low-density areas.[2],[3]

Previously, Bi-dimensional radiographic techniques were used widely in the dental field to visualize and image the jawbone. Currently, the three-dimensional radiographic technique, cone beam computed tomography (CBCT), is being used more commonly for quantitative and qualitative precise evaluation of bone density of dent-maxillofacial structures.[4] Bone density is determined by the total amount of bone mass present in definite volume of bone structure, measured in unit mass/area (in bi-dimensional images) and mass/volume (in three-dimensional images). A better understanding of bone density in the maxilla and mandible aids in numerous scientific results as well as permits the dentist to plan the placement of implants with essential precautions subsequently.[5]

The aim of this study is to check the quantitative alveolar bone density in complete or partial edentulous and dentulous male and female patients among the sample population in Riyadh Saudi Arabia.


   Materials and Methods Top


This study was approved by the Ethical Committee of the King Saud Medical City and it followed the principles of Declaration of Helsinki. The study involved a cross-sectional analysis of 231 consecutive CBCT images of different patients (115 males and 116 females) who visited the King Saud Medical City, Riyadh, Saudi Arabia from December 2017 to June 2018.

The scans were of Saudi National patients who were partially or completely edentulous without any bone infections in the maxilla and the mandible. The age range of patients in the study was 23–60 years.

All the CBCT images were taken by Kodak 9500 cone beam 3D system, the adjusted scan parameters were 90 kVp and 10 mA, depending on the size of patients. The exposure time was 10.8 s, the effective exposure time was 2–5 s and the voxel size was 0.2 mm × 0.2 mm × 0.2 mm; all the CBCTs were taken by the single operator using the same protocol.

The sample size calculation was determined by power analysis with P≤ 0.05 and 95% confidence level and was estimated as 231 valid CBCT images (according to the inclusion criteria).

Patients were selected on the basis of following inclusion and exclusion criteria:

Inclusion criteria: Male or female Saudi nationals above 18 years of age. Males included both smoking and nonsmoking patients. Men who have never smoked and who quit the smoking habit 10 years before were categorized as nonsmokers, and light smokers (≤10 cigarettes/day) and heavy smokers (>10 cigarettes/day) were categorized as smokers in an attempt to make clear discrimination between the smoking categories.

Exclusion criteria were subjects who had any oral pathological disease, or with history of orthodontic treatment, or with history of pathologic lesions in the jaw, or with history of treatments that could have altered bone density.[5]

The CBCT scans were originally taken from all recruited patients as a part of screening prior to implant placement. Region of interest was selected coronally at 3–4 mm to the root apex. Each region was viewed in axial sections. The densities of the buccal bone and cancellous bone were measured by selecting points at interradicular areas between the teeth. For measuring the density of the cortical bone, its center point was chosen. The density of the cancellous bone was measured at two points buccolingually between the buccal and palatal or lingual cortical plates.[6] The alveolar bone density was measured and the male patients were divided as smokers (edentulous and dentulous) and nonsmokers (edentulous and dentulous) simultaneously the female patients were also divided as smokers (Edentulous and dentulous) and nonsmokers (edentulous and dentulous).

The data was manually entered into the database by Principal Investigator. Data was observed and the results were recorded and if errors were identified, they were corrected. After applying the above-mentioned procedure, any inaccurate/incomplete data or invalid data in terms of readings/percentages or in any other form which could not be clarified after verification was excluded from the data set.

Each medical record was assigned a unique identifier, which was associated with the data demographics in a relational database to be accessed only by selected personnel to ensure patient confidentiality for study and data. A hard copy of the Code and Identification variable was maintained in a locked file cabinet in the research coordinator office. Only those involved in the study can access the data.

Descriptive results (including graphical displays) were presented as mean ± standard deviation (in case the data was normally distributed), or median with inter-quartile range (in case data was not normally distributed) for all quantitative variables (e.g. Age). Number (percentage) was to be reported for all qualitative variables (e.g. Gender). The CBCT images were analyzed and the findings were described in terms of frequency, percentage, range, mean, median, and standard error. This data was further subjected to inferential statistics: student's t-test for two group means, ANOVA for three groups, and Post-hoc LSD test for multiple comparisons, using Statistical Package for Social Sciences software version 21 (IBM Corp., Armonk, NY, USA), and Levene statistics for testing the homogeneity of variances; the variable was continuous with an α-error of 5%, power of 80%, and a statistical significance at 5% level.


   Results Top


In this cross-sectional study, scans of 231 patients were evaluated for alveolar bone density in completely and partially edentulous arches. Overall, among females, 28 dentulous maxillae and 23 dentulous mandibles were studied. Among male nonsmokers, 24 edentulous maxillae, 21 edentulous mandibles, 25 dentulous maxillae, and 21 dentulous mandibles were assessed. With regard to male smokers, 19 edentulous maxillae, 25 edentulous mandibles, 18 dentulous maxillae, and 27 dentulous mandibles were evaluated for comparison.

Intergroup comparison in maxillary dentulous male patients showed statistical significant difference in cancellous bone in premolar region and in buccal cortical plate in molar area, whereas, in mandibular dentulous patients, there was no significant difference observed in any area [Table 1] and [Table 2]. Comparison of mean alveolar bone density in maxillae of dentulous male smokers showed statistically significant difference for bucco-cortical plate and cancellous bone among different regions, namely, incisor, canine, premolar, and molar areas. However, no significant difference was seen in the density of palatal cortical plate in different regions of the dentition. On the other hand, in mandible of male smokers, a significant difference in density was seen for buccal and palatal cortices as well as cancellous bone between different regions [Table 3].
Table 1: Mean density (HU) in maxillary dentulous male [intergroup]

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Table 2: Mean density (HU) in mandibular dentulous males [intergroup]

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Table 3: Mean density (HU) in maxillary dentulous (1) and mandibular dentulous (2) of male smoking patients

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On consideration of scans of dentulous male nonsmokers, no significant difference was observed for maxillary regions, while in mandibular areas, a statistically significant difference was seen for buccal cortex, palatal cortex as well as cancellous bone among different regions [Table 4], [Figure 1] and [Figure 2].
Table 4: Mean density (HU) in maxillary dentulous (1) and mandibular dentulous (2) of male nonsmoking patients

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Figure 1: Mean density in maxillary dentulous male patients [intergroup]

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Figure 2: Mean density in mandibular dentulous male patients [intergroup]

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While observing the differences in bone density of completely edentulous males, nonsmokers displayed no significant change among different regions, but for smokers, the only difference found to be statistically significant was for buccal cortex and cancellous bone in different areas [Table 5] and [Table 6] [Figure 3] and [Figure 4].
Table 5: Mean density (HU) in maxillary edentulous (1) and mandibular edentulous (2) of male smoking patients

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Figure 3: Mean density in maxillary dentulous and mandibular dentulous male smoking patients

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Figure 4: Mean density in maxillary dentulous and mandibular dentulous male nonsmoking patients

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Table 6: Mean density (HU) in maxillary edentulous (1) and mandibular edentulous (2) of male nonsmoking patients

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While studying the scans of female dentulous patients, a statistically significant difference was observed in alveolar bone density for all the areas measured between incisor, canine, premolar, and molar regions with both the jaws. In contrast, with edentulous females, no significant difference was observed for any area in both jaws [Table 7] and [Table 8] [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Table 7: Mean density (HU) in maxillary dentulous (1) and mandibular edentulous (2) of female patients

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Table 8: Mean density (HU) in maxillary edentulous (1) and mandibular edentulous (2) of female patients

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Figure 5: Mean density in maxillary edentulous and mandibular edentulous of male smoking patients

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Figure 6: Mean density in maxillary edentulous and mandibular edentulous male nonsmoking patients

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Figure 7: Mean density in maxillary dentulous and mandibular edentulous female patients

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Figure 8: Mean density in maxillary edentulous and mandibular edentulous female patients

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   Discussion Top


The present study was a cross-sectional study evaluating CBCT images of 231 patients to quantitatively assess the alveolar bone density in completely and partially edentulous patients. Various methods have been used to study bone density, among which three-dimensional CBCT scan continues to be widely used owing to its benefits of superior image quality, reproducibility, and validity with reduced time for collection of data. Moreover, CBCT can generate a voxel as small as 0.125 mm in dimension contributing to better resolution of images.[6] In addition, the three-dimensional nature of these scans allows far better orientation of these images to the patient's anatomic features for more reliable real-time measurements. These benefits have led to extensive use of CBCT scans for bone density measurements, especially for implant site assessment as well as for application in clinical orthodontics and this forms the basis of utilizing this approach in our study as well.

The current study involved scans of 115 males and 116 females, who were further categorized as smokers and nonsmokers. Site-specific differences in density were seen with both partial and completely edentulous maxillae as well mandible.

The density of the cortical plates displayed a pattern of being higher in incisor region and decreasing posteriorly, being lowest in premolar area and increasing slightly in molar areas. With respect to buccal cortical plate, significant differences among different regions were seen in partially edentulous males and females, in completely edentulous males (smokers only) but no significant difference was seen in edentulous female jaws. In general, the cortical bone density at different regions in maxillae was lower than in the same areas of mandible. These findings are in concurrence with variations in bone mass in cortices as studied by von Wowern[7] and Devlin et al.[8] Differences in buccal cortical density in different areas of mandible can be attributed to differences in muscle attachment as well as to differing functions in each region. Devlin et al. in their study, had also concluded posterior maxillary bone mineral densities to be lower than that of anterior maxilla. The density of lingual cortical plate at different regions had significant differences only in dentulous mandible of males (smokers and nonsmokers). This indicates that the density may lie at approximately the same level over the lingual cortex. This finding is consistent with the findings of Attili et al.[9] and can be explained by the fact that most of the muscles attached on the lingual side do not produce force but are related more to complicated movements of tongue and mandible.[10]

The palatal cortex did not demonstrate any significant difference in density between different regions except with maxilla and mandible of dentulous females. In dentulous patients, the highest palatocortical thickness was seen in canine region. But similar findings were not observed with edentulous subjects.

With regard to the density of cancellous bone, significant variations were seen in the four measured regions of dentulous maxillae and mandible in males as well as females, except for edentulous maxilla of nonsmoker males. However, in edentulous patients, no similar significance was observed with cancellous bone density. Overall, in the region of cancellous bone, the density was more in incisor and canine regions compared to premolar and molar regions. This is in accordance with von Wowern's analysis that trabecular bone to be denser and coarsely woven in incisor region and most delicately woven in molar region.[11]

While comparing smokers and nonsmokers, no significant difference was seen in bone density in dentulous male subjects except for cancellous bone in maxillary premolar area. Smoking has been associated with increased risk of edentulism and cessation of smoking has been associated with increased likelihood of tooth retention.[12] Saldanha et al. in their study observed that smoking can significantly affect the alveolar process dimensions and bone density in maxillary extraction sites.[13] Rosa et al. too concluded that smoking can have an adverse effect on alveolar bone height and density, acting as a potential risk factor for alveolar bone loss.[14] In females, especially post menopause, smoking has a negative effect on bone density adding to other systemic influences. This vast body of evidence prompted us to include categorization of patients depending upon their smoking habits and assessment of bone density in smokers as well as nonsmokers. It also follows that proper recording of habit like smoking is crucial when planning for prosthetic rehabilitation of edentulous patients with implants.


   Conclusion Top


In conclusion, edentulism is a largely prevalent phenomenon with increasing age and can prove to be a social disability, results in functional limitations, and can adversely affect the overall quality of life.[15] Rehabilitation of these patients with dental implants has emerged as a popular therapeutic option requiring meticulous planning. Evaluation of bone density is an important step in this planning and this study was aimed to provide insight into bone density patterns in the population of Riyadh, Saudi Arabia. Further similar studies in different populations can help in planning for more efficient treatment outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Santiago RC, de Paula FO, Fraga MR, Assis NMSP, Vitral RWF. Correlation between miniscrew stability and bone mineral density in orthodontic patients. Am J Orthod Dentofacial Orthop 2009;136:243-50.  Back to cited text no. 1
    
2.
Chugh T, Ganeshkar SV, Revankar AV, Jain AK. Quantitative assessment of interradicular bone density in the maxilla and mandible: Implications in clinical orthodontics. Prog Orthod 2013;14:38.  Back to cited text no. 2
    
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Jaffin RA, Berman CL. The excessive loss of Branemark fixtures in type IV bone: A 5-year analysis. J Periodontol 1991;62:2-4.  Back to cited text no. 3
    
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Isoda K, Ayukawa Y, Tsukiyama Y, Sogo M, Matsushita Y, Koyano K. Relationship between the bone densities estimated by cone-beam computed tomography and the primary stability of dental implants. Clin Oral Implants Res 2012;23:832-36.  Back to cited text no. 4
    
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Reeves TE, Mah P, McDavid WD. Deriving Hounsfield units using grey levels in cone beam CT: A clinical application. Dentomaxillofac Radiol 2012;41:500-8.  Back to cited text no. 5
    
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Adibi S, Zhang W, Servos T, O'Neill PN. Cone bean computed tomography in dentistry: What dental educators and learners should know. J Dent Educ 2012;76:1437-42.  Back to cited text no. 6
    
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Von Wowern N. Variations in bone mass within cortices of the mandible. Scand J Dent Res 1977;85:444-55.  Back to cited text no. 7
    
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Devlin H, Horner K, Ledgerton D. A comparison of maxillary and mandibular bone densities. J Prosthet Dent 1998;79:323-7.  Back to cited text no. 8
    
9.
Attili S, Surapaneni H, Kasina SP, Kumar VH, Balusu S, Barla SC. To evaluate the bone mineral density in mandible of edentulous patients using computed tomography: An in vivo study. J Int Oral Health 2015;7:22-6.  Back to cited text no. 9
    
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Roberts WE, Gonsalves M. Aging of bone tissue. In: Holm Pedersen P, Loe H, editors. Geriatric Dentistry: A Textbook of Oral Gerentology. 1st ed. Copenhagen: Munksgaard; 1986. p. 83-93.  Back to cited text no. 10
    
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Von Wowern N. Variations in structure within the trabecular bone of the mandible. Scand J Dent Res 1977;85:613-22.  Back to cited text no. 11
    
12.
Dietrich T, Walter C, Oluwagbemigun K, Bergmann M, Pischon T, Pischon N, et al. Smoking, smoking cessation and tooth loss: The EPIC – Postdam study. J Dent Res 2015;94:1369-75.  Back to cited text no. 12
    
13.
Saldanha JB, Casati MZ, Neto FH, Sallum EA, Nociti FH Jr. Smoking may affect the alveolar process dimensions and radiographic bone density in maxillary extraction sites: A prospective study in humans. J Oral Maxillofac Surg 2006;64:1359-65.  Back to cited text no. 13
    
14.
Rosa GM, Lucas GQ, Lucas ON. Cigarette smoking and alveolar bone in young adults: A study using digitized radiographs. J Periodontol 2008;79:232-44.  Back to cited text no. 14
    
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Emami E, de Souza RF, Kabawat M, Feine JS. The impact of edentulism on oral and general health. Int J Dent 2013;2013:498305. doi: 10.1155/2013/498305.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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