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A novel soft tissue thickness measuring method using cone beam computed
tomography

Article  in  Journal of Esthetic and Restorative Dentistry · November 2018

DOI: 10.1111/jerd.12428

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Received: 29 May 2018 Revised: 8 August 2018 Accepted: 16 August 2018
DOI: 10.1111/jerd.12428

CLINICAL ARTICLE

A novel soft tissue thickness measuring method using cone

beam computed tomography
Önder Gürlek1 | Şule Sönmez1 | Pelin Güneri2 | Nejat Nizam1

1
Department of Periodontology, School of
Dentistry, Ege University, Izmir, Turkey Abstract
2
Departmentof Oral Diagnose and Radiology, Objective: The aim of this study was to introduce a novel soft tissue thickness measurement
School of Dentistry, Ege University, Izmir, method using cone beam computed tomography (CBCT) and to compare the new method with
Turkey
ultrasonic device applications and transgingival probing measurements.
Correspondence
Methods: Twenty-five participants (12 female, 13 male, age range, 25-51 years) were included
Nejat Nizam, Department of Periodontology,
Ege University, School of Dentistry, the study. Soft tissue thickness in lateral incisor, canine, premolar, and molar regions were mea-
35100-Bornova, İzmir, Turkey. sured using transgingival probing (group T), ultrasonic device (group U), and CBCT scan mea-
Email: nejat.nizam@ege.edu.tr surements (group C). Differences and correlations between groups and agreement between
measurement methods were evaluated.
Results: Soft tissue thickness was significantly lower in group U in premolar region, but was sig-
nificantly higher in molar region compared with group C and group T (P < .05). There were sig-
nificant positive correlations in lateral incisor and canine region, between group U and group C,
in premolar region between group T and group C, and in molar region between group U and
group C, and between group C and group T (P < .05). The highest agreement between measure-
ment methods was evident between group T and group C.
Conclusion: Soft tissue thickness values in maxilla may differ depending on the measurement
method and location of the measurement. Ultrasonic device, transgingival probing, and CBCT
measures may not necessarily correlate in all locations. The high agreement between CBCT
measurements and transgingival probing may suggest the newly introduced method as a promis-
ing technique for soft tissue thickness evaluation.

Clinical Significance
This study evaluated the relation between different soft tissue thickness measurement methods
and demonstrated a novel method which can be used in any part of the mouth. The outcome
also suggested that the measurement method and the location might affect the soft tissue thick-
ness value obtained, and therefore might be important in clinical decision making.

KEYWORDS

cosmetic periodontal plastic surgery, gingival thickness, periodontal surgery

1 | I N T RO D UC T I O N of the soft tissue to inflammation, trauma, and surgical interventions

might differ depending on the tissue biotype. As the connective tissue
Proper evaluation of the soft tissue biotype is a crucial step in the suc- loss and epithelial damage is more prevalent in thin biotype, atrau-
cess of periodontal plastic and dental implant surgery, as adequate matic treatment procedures are recommended in such cases.6
soft tissue thickness can avoid unpleasant outcomes after surgical Hwang and Wang1 examined the effect of gingival thickness on
procedures, prosthodontic, and orthodontic treatments.1–3 the success rates of root coverage procedures and demonstrated that
Soft tissues biotype was introduced as thick-flat, thin-scalloped, the critical threshold thickness for complete root coverage was
and thick-scalloped based on the volume and contour characteristics >1.1 mm. Peri-implant mucosa biotype is also a key factor in implant
3,4 5
of the gingiva. Kao and Pasquinelil demonstrated that the response therapy. Patients with thin soft tissue biotype are prone to mucosal

J Esthet Restor Dent. 2018;1–7. wileyonlinelibrary.com/journal/jerd © 2018 Wiley Periodicals, Inc. 1

2 GÜRLEK ET AL.

recessions following immediate implantation,7 but the risk of reces- explained to each individual before the initiation of the study, and
8
sion seems to be less in patients with thick soft tissue. Increasing the written informed consent was received as well.
soft tissue thickness using connective tissue grafts also enhanced the
esthetic results after implant loading.2 Therefore, the accurate mea- 2.2 | Clinical procedures
surement of soft tissue thickness is critical for proper treatment plan-
The patients were scheduled for clinical procedures 1 hour before the
ning and estimating the final outcome of various treatment modalities.
CBCT appointment. Keratinized mucosa of lateral incisor, canine, first
Previous studies demonstrated that the final results could be
premolar, and molar tooth in the quadrant requiring CBCT scan were
directly related to papilla height and gingival line measures, therefore,
selected for evaluation. Holes (3 mm) were prepared on mylar trans-
most of the studies focus on these dimensional changes.3–5 Various
parent matrix strips to demarcate the measurement points by punch-
methods including transgingival probing,2,9,10 ultrasonic device
ing. The sites were air-dried and the strips were gently fixed on the
measurements,11–13 and cone-beam computed tomography (CBCT) keratinized tissue using transparent 4-META/MMA-TBB (Super Bond
scans14–16 were used to evaluate the gingival thickness. Transgingival C & B, Sun-medical Co., Moriyama, Shiga, Japan) cement and the holes
probing, as an effective method, is generally rounded up to the near- were positioned 3 mm above the gingival margin (Figure 1A).
est 0.5 mm therefore can cause high measurement errors. The tech- The first measurement was performed with the ultrasonic device
nique is performed under local anesthesia, which can increase the (K&M Instruments Ltd., Hong Kong.), which uses the pulse echo prin-
local soft tissue volume,3,9,10 and further complicate the measure- ciple. The mucosa is sound permeable and the ultrasonic pulses are
ments. Ultrasonic evaluation is a painless and noninvasive method but transmitted at intervals of 1 millisecond through the soft tissue and
the access to the maxillary posterior region is limited.10–14 Also, the reflected at the alveolar bone or root surface. Soft tissue thickness is
pressure applied during the measurement can affect the final out- digitally displayed with a sensitivity of 0.01 mm when the acoustic
come. On the other hand, CBCT provides high quality three- signal is transmitted within 2-3 seconds intervals. A thin layer of gel
dimensional diagnostic images of hard tissues, but it is not useful in was applied to the transducer probe, which was then placed over the
soft tissue imaging due to the low resolution and contrast.15,17–19 To measurement site with minimum pressure to produce acoustic cou-
evaluate the soft tissue thickness in CBCT scans, radiopaque materials pling as described previously.21 The measurement was repeated in tri-
20
were placed over the soft tissue. Since an accurate measurement ple and the mean value for each site was recorded. The
requires a precise contact between the radioopaque material and soft measurements using the ultrasonic device formed the group U.
tissue surface, and it is difficult to achieve it with previously used The ultrasonic gel was gently washed out, the mucosa and the
materials such as, gutta percha and aluminum foil, the sensitivity of transparent strip was air-dried. Radioopaque 4-META/MMA-TBB
the measurements can be impaired. adhesive cement was applied as a thin layer over the hole using a den-
There is no method, so far, as the gold standard for soft tissue tal adhesive brush (Figure 1B,C). The sticker was then removed and
thickness measurements and precise, reproducible, and straightfor- after the polymerization, a radiopaque white colored circle remained
ward measuring methods are emerging in the field. Therefore, the aim over the soft tissue (Figure 1D). CBCT scans (Kodak 9000, New York),
of the present study is to introduce a novel soft tissue thickness mea- (120 kV, 75 mA, 2 seconds scan time, 100-120 field view) were

suring method using CBCT, and to compare the results obtained with obtained to include the data in group C. The CBCT scans were imme-

bone sounding and ultrasonic evaluation. diately followed by transgingival probing.

Transgingival probing was performed with a periodontal probe
(UNC 15, Hu-Friedy, Chicago, Illinois) as described previously.10,22
2 | MATERIAL AND METHODS Briefly, after local anesthesia, the periodontal probe with a rubber
stopper is pierced perpendicularly through the center of the radi-
opaque adhesive cement until the resistance of the alveolar bone is
2.1 | Study population
felt. The probe was then removed and the thickness of soft tissue was
Twenty-five participants (12 female, 13 male, age range: 25-51 years) measured as the distance from the tip of the probe to the rubber stop-
referred to Department of Periodontology, School of Dentistry, Ege per using a digital caliper sensitive to 0.1 mm. The radio opaque
University for implant surgery enrolled in the study. The inclusion cri- cement was gently removed and the clinical procedure is finalized.
teria were as follows; having healthy soft tissues with no sign of The data obtained from transgingival probing formed the group
inflammation, being systemically healthy, nonsmoker and >18 years of T. All the clinical procedures and clinical measurements were per-
age, taking no medication, and requiring CBCT evaluation for implant formed by the same precalibrated examiner (ÖG) who demonstrated
surgery at least in one quadrant of the maxilla. Patients having dental/ 0.86 and 0.92 intraclass correlation coefficient to ultrasonic measure-
endodontic or periodontal diseases, individuals received radiotherapy ments and transgingival probing, respectively.
in the head and neck area in the past 6 months, pregnant and nursing The CBCT images were analyzed independently using a digital
patients and those with teeth numbers <20 were excluded. software (CS Image, Kodak Dental Imaging Software, New York). The
The study was conducted in full accordance with ethical princi- focal planes of the CBCT scans were adjusted to the center of the
ples, including the World Medical Association's Declaration of adhesive cement according to apico-coronal and mesiodistal aspects.
Helsinki, as revised in 2008, and was approved by the Ethics Commit- Then, the thickness of the keratinized mucosa was measured as the
tee of Ege University (Protocol no: 12-4.1/4). The study protocol was distance between the hard tissue, either root surface or alveolar bone,
GÜRLEK ET AL. 3

FIGURE 1 A, Fixation of the mylar transparent matrix strip with predefined hole on the soft tissue, (B and C) application of adhesive cement over
the hole, and (D) final appearance of the adhesive after the removal of mylar transparent matrix

and radiopaque material (Figure 2). After the three measurements in Correlations between groups were evaluated using Pearson cor-
three consecutive days, the mean value for each tooth was noted by relation test and the agreement between measurement methods was
the same radiology specialist (PG). Digital measurements revealed high assessed using Bland-Altman plot with 95% confidence limits. P < .05
intra-examiner liability, as shown by an intraclass correlation coeffi- was considered statistically significant in the analyses.
cient of 0.96 for the CBCT measurements.

3 | RE SU LT S
2.3 | Statistical analyses
The values for soft tissue thicknesses measured with ultrasonic
A commercially available statistical software (GraphPad Prism version
device, transgingival probing, and CBCT are shown in Table 1. The
6.00c for Mac OS X, GraphPad Software, La Jolla, California) was used
thickness in premolar area was significantly lower in group U com-
to evaluate all the data obtained in the study. The distribution of the
pared with group T (P < .01) and group C (P < .05), however, it was
parameters was evaluated using D'Agostino-Pearson omnibus normal-
higher in molar regions compared with group T (P < .05) and group C
ity test. The differences between groups were evaluated using
(P < .05). There was no significant difference between the measure-
repeated measures one-way ANOVA and when a difference was evident
ments in group T and group C in any of the regions (P > .05). The soft
Tukey's multiple comparisons test was used for pairwise comparisons.
tissue thickness was similar for all the measurement methods in other
parts of the maxilla (P > .05). When all the measurements are pooled
and compared irrespective of the location no significant difference
was evident between any of the methods (P < .05).
The correlations between the measurement methods are shown
in Table 2. In lateral and canine region, there was significant positive
correlation between group U and group C (P = .024, r = .450, and
P = .020, r = .463, respectively) and in premolar region between
group T and group C measurements (P = .001, r = .618). In molar
region, there were significant positive correlations between group U
and group C (P = .048, r = .400) and between group C and group T
(P = .006, r = .538). When all the measurements are pooled and evalu-
ated irrespective of the measurement location, there were significant
positive correlations between group U and group C (P < .001,
r = .352) and between group C and group T (P < .001, r = .473).
Bias, SD of Bias, and 95% limits of agreements between the mea-

FIGURE 2 CBCT image of the measurement location. The soft tissue surements methods are demonstrated in Table 3 and the Bland-
thickness measurement direction perpendicular to long axis of the Altman plot was shown in Figure 3. The bias in different measurement
tooth locations were lowest between group T and group C (range between
4 GÜRLEK ET AL.

TABLE 1 Soft tissue thickness in different location measured using between measurements methods was highest between group T and
different methods group C for all the measurements (Figure 3, Table 3).
Measurement
Location Group U Group T Group C
Lateral 1.59  1.93 1.76  2.05 1.74  2.07 4 | DI SCU SSION
Canine 1.79  0.42 1.92  0.34 1.90  0.41
Premolar 1.68  0.31a,b 1.96  0.33 1.91  0.41 Previous data demonstrated that the soft tissue thickness was a cru-
Molar 2.17  0.38c 1.95  0.32 1.93  0.37 cial factor in the success of certain surgical procedures and dental
All sites (mean) 1.85  0.42 1.93  0.33 1.91  0.39 treatments.1–3 Gingival thickness correlated with residual bone height
and sinus membrane thickness in posterior maxilla.23 The tissue bio-
All values are demonstrated as Mean  SD mm.
a
Significant difference compared with group T (P < .01). type also affected the response of the soft tissue to inflammation,
b
Significant difference compared with group C (P < .05).
c trauma, and surgical interventions.5 Therefore, appropriate soft tissue
Significant difference compared with both group T and group C (P < .05).
measurement may be important to evaluate the prognosis and the
treatment plan of certain cases. From a scientific point of view, a pre-
−0.004 and 0.053) and higher bias were evident between group U cise, technically insensitive and reproducible soft tissue measuring
and group T and between group U and group C (range between method may also facilitate a proper comparison of the published data,
−0.287 and 0.229, and −0.233 and 0.241, respectively; Table 3). Simi- however, the agreement between previously described methods are
larly, pooled data demonstrated lower bias between group T and still questioned. Therefore, we introduced a novel soft tissue measur-
group C (0.019) compared to bias between group U and group T ing method using CBCT in the current study and compared the results
(−0.082), and between group U and group C (−0.063). The agreement with previously described methods.
Visual evaluation, transgingival probing, ultrasonic, and radiologic
measurement may be used to evaluate gingival biotype. Even though
TABLE 2 Correlations between different measurement methods
visual inspection may be possible, the method is based on subjective
Group U Group T Group C measures and it is not considered a valid method especially for the
Lateral Group U r 0.065 0.450 patients with high esthetic risk. One of the simplest methods for gingi-
p 0.757 0.024 val biotype assessment is transgingival probing, which is time-
Group T r 0.065 0.388 effective and no specific tool is required. However, it must be per-
p 0.757 0.055 formed under local anesthesia, which could increase the local volume
Group C r 0.450 0.388 and patient inconvenience as well.3,10,22 The measurement value is
p 0.024 0.055 generally rounded to nearest 0.5 mm and may overestimate the soft
Canine Group U r 0.024 0.463 tissue thickness. The rubber stopper on the probe may slip and further
p 0.910 0.020 complicate the measurement. Transgingival probing therefore remains
Group T r 0.024 0.364 as an invasive method and cannot be carried out in routine daily
p 0.910 0.074 practice.
Group C r 0.463 0.364 An ultrasonic device was then introduced to avoid the negative
p 0.020 0.074 effects of transgingival probing. Eger et al. 13
measured the gingival
Premolar Group U r 0.237 0.174 thickness with a resolution of 0.1 mm, and stated that the validity and
p 0.254 0.406 reliability of the ultrasonic device was excellent. Müller et al. 11,12

Group T r 0.237 0.618 aimed to assess the thickness of all parts of masticatory mucosa by
p 0.254 0.001 using an ultrasonic measuring device in two consecutive studies. They
Group C r 0.174 0.618 noted that, intra and interindividual measurement error was revealed
p 0.406 0.001 in the second and third molars. Also, the diameter of the transducer
Molar Group U r 0.371 0.400 probe prevented the ease of use is posterior areas. Therefore the
p 0.068 0.048 reproducibility in posterior areas may be affected.
Group T r 0.371 0.538 Besides the imaging of hard tissues in dentistry, CBCT is widely
p 0.068 0.006 used in assessing the gingival thickness, with a high diagnostic accu-
Group C r 0.400 0.538 racy. Januario et al.17 described a soft tissue CBCT (ST-CBCT) method
p 0.048 0.006 to visualize and measure the gingival thickness at various sites in the
All sites Group U r 0.145 0.352 mouth. They suggested using lip and tongue retractors while scanning
p 0.149 <0.001 to prevent the collapse of the soft tissues of lips and cheeks on the
Group T r 0.145 0.473 facial gingiva, as the low resolution of density and contrast of the soft
p 0.149 <0.001 tissues prevent the visualization of buccal mucosa. Some studies indi-
Group C r 0.352 0.473
cate that using retractors or cotton rolls may apply pressure on soft
p <0.001 <0.001
tissues causing dimensional alterations.18–22,24 In a study by Yilmaz
Significant correlations are shown in bold face. et al.,25 the palatal masticatory mucosa thickness was measured using
GÜRLEK ET AL. 5

TABLE 3 Bias, SD of Bias, and 95% limits of agreements between the measurements methods

Group U-T Group U-C Group T-C

Bias SD Limits of agreement Bias SD Limits of agreement Bias SD Limits of agreement
Lateral −0.145 0.520 −1.16 to 0.88 −0.149 0.425 −0.98 to 0.68 −0.004 0.418 −0.82 to 0.82
Canine −0.126 0.536 −1.18 to 0.93 −0.112 0.43 −0.96 to 0.73 0.014 0.424 −0.82 to 0.85
Premolar −0.287 0.395 −1.06 to 0.49 −0.233 0.464 −1.14 to 0.67 0.053 0.329 −0.59 to 0.70
Molar 0.229 0.395 −0.55 to 1.00 0.241 0.412 −0.57 to 1.05 0.012 0.336 −0.65 to 0.67
All sites −0.082 0.497 −1.06 to 0.89 −0.063 0.464 −0.97 to 0.85 0.019 0.374 −0.71 to 0.75

FIGURE 3 Bland-Altman plot of the measurement methods

6 GÜRLEK ET AL.

CBCT images and high contrast and resolution medical lcd displays ACKNOWLEDGMENT
were used to detect the soft tissue structures to make a proper mea- We would like to thank Dr Ceren Gürlek for her kind assistance during
surement. They propose that at the clinical practice the limited con- the photography.
trast and resolution of the CBCT may be a disadvantage to make such
measurements. Cao et al.20 proposed a novel and noninvasive tech-
nique based on CBCT imaging, in which a mixture of opaque agent CONFLIC T OF INT E RE ST
and alginate impression material was used to visualize the dentogingi- The authors have stated explicitly that there are no conflicts of inter-
val profile. They stated that the proposed technique could replace the est in connection with this article.
invasive procedures, however, the pressure applied over the soft tis-
sues in certain areas or inadequate contact between the material and
soft tissue surface may prevent the proper measurement. However, DISC LOSURE
the adhesive material used in the current study is applied without any The authors do not have any financial interest in the companies or
pressure and polymerize chemically in place. The material can also be products used in this study.
applied to larger areas to enable proper visualization of both soft and
hard tissues in the same image. Therefore, the currently described
technique seems to be a simpler method, which eliminate the disad- KEY F INDINGS
vantages of previously described techniques. Measurement method and location may affect the soft tissue thick-
It was interesting to note that the pooled data resulted in similar ness values, and the newly described method may be an alternative to
soft tissue thickness measurements, however, the significant differ- current techniques.
ences between the measurement methods were on specific locations.
The significant differences were between the ultrasonic device and ORCID
other measurement methods in posterior maxilla, but the data was
Nejat Nizam https://orcid.org/0000-0003-2739-3919
similar for CBCT and transgingival probing measurements. Similarly,
Borges et al.26 evaluated the gingival thickness of 29 patients using
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