Gingivomorphometry esthetic

evaluation of the crownmucogingival

complex: a new method for collection
and measurement of standardized and
reproducible data in oral photography
Michael Weinlander
Vojislav Lekovic
Sanja Spadijer-Gostovic
Bilijana Milicic
Gerald Krennmair
Hanns Plenk Jr
Authors afliations:
Michael Weinlander, Private Practice, Vienna,
Austria
Vojislav Lekovic, Periodontal Clinic, University of
Belgrade, Belgrade, Serbia
Sanja Spadijer-Gostovic, Department of
Prosthodontics, University of Belgrade, Belgrade,
Serbia
Bilijana Milicic, Periodontal Clinic, University of
Belgrade, Belgrade, Serbia
Gerald Krennmair, Department of Fixed and
Removable Prosthodontics, Dental School
University of Vienna, Vienna, Austria
Hanns Plenk Jr, Michael Weinlander, Bone and
Biomaterials Research, Institute for Histology and
Embryology, Medical University of Vienna, Vienna,
Austria
Correspondence to:
Michael Weinlander
Research Associate
Bone and Biomaterials Research
Institute for Histology and Embryology
Medical University of Vienna
Austria
Tel.: 00431/4277-61336
Fax: 00431/4277-61350
e-mail: implant@drweinlaender.at
Key words: computerized measurements, esthetic evaluation, standardized photography
Abstract
Objectives: A new method is introduced for the esthetic evaluation of the periimplant
mucogingival complex through collection of standardized oral photographs and computer-
assisted measurement of reproducible data. Using this method, different soft tissue and
crown parameters in the dentogingival complex can be measured and the esthetic outcome
monitored.
Material and methods: A photographic device for standardized oral photography and a
standard protocol for the esthetic evaluation of the crownmucogingival complex is
presented, comprising six soft tissue parameters: (1) mesial and (2) distal papilla areas,
(3) mesial and (4) distal papilla heights, (5) soft tissuecrown perimeter, and (6) gingival
recession. In order to demonstrate the reproducibility of standardized oral photographs
and the accuracy of the measurement of the six parameters, the data obtained in each of
two such standardized clinical photographs, taken at 1014 days intervals, of the anterior
maxillary region from 10 patients with no apparent dental disease were compared. For the
statistical analysis of the reproducibility of these dependent data the 95% condence
interval and the coefcients of variation were calculated from measurement means and
ranges of each of the above parameters, pooled from all 10 patients.
Results: Statistical analysis revealed high reproducibility with no signicant differences
between the range of mean values of all six parameter measurements on the rst and
second standardized oral photograph of the same patient, respectively.
Conclusion: Gingivomorphometry on standardized oral photographs can be considered to
be an accurate and reproducible method for the evaluation and measurement of different
dentogingival and periimplant parameters.
The goal of esthetic dentistry is the most
inconspicuous reconstruction or replace-
ment of missing teeth, as well as of peri-
implant hard and soft tissue components.
Color and form may be the two most
important esthetic aspects. Satisfactory es-
thetics as an imitation of nature may be
estimated by subjective impressions and
estimations (Fu rhauser et al. 2005; Meijer
et al. 2005), but can also be supported by
more objectively evaluated parameters(Kan
et al. 2003). Soft tissue margins around
natural teeth or dentogingival implant re-
storations can be subject to changes during
different surgical and restorative treatment
steps or at the time following treatment.
The aims of the present concept were rst
to introduce a device for standardized in-
traoral photographs, for example of the
esthetically critical anterior maxillary
region, then to apply computer-assisted
measurements to the evaluation of the
Date:
Accepted 16 October 2008
To cite this article:
Weinlander M, Lekovic V, Spadijer-Gostovic S, Milicic
B, Krennmair G, Plenk Jr H. Gingivomorphometry
esthetic evaluation of the crownmucogingival complex.
A new method for collection and measurement of
standardized and reproducible data in oral photography.
Clin. Oral Impl. Res. 20, 2009; 526530.
doi: 10.1111/j.1600-0501.2008.01685.x
526 c 2009 John Wiley & Sons A/S
dentogingival complex, and nally to test
the reproducibility of this new gingivomor-
phometrical method which could comple-
ment the esthetic criteria judged by
subjective impressions.
Material and methods
Standardized oral photography and com-
puter-assisted morphometrical measure-
ments
The gingivomorphometry method is a new
concept for evaluating certain intraoral soft
tissue and crown parameters by standar-
dized and reproducible data collection and
standardized and reproducible parameter
measurements.
In order to acquire standardized and re-
producible data in oral photography three
basic criteria have to be fullled:
1. Standardized and reproducible patient
positioning;
2. Standardized and reproducible camera
positioning;
3. Standardized and reproducible mirror
positioning for data collection in the
premolar and molar regions.
A device was developed (Fig. 1), allowing
for the following standardizations:
(1) The patient is in sitting position and
puts his head in a head holder. The
chin is placed on a chin rest and the
forehead rests against a transversal
forehead holder. The chin rest height
may be adjusted to the patient facial
height, and its position is recorded on
a scale mounted at the left side of the
head holder as seen from the patients
position.
(2) The camera is xed to a stand with a
quick mount attachment and can be
moved along a circumferential guide
rail at a range of 1801 around a virtual
center in the patients mouth. For
photographs of the anterior teeth a
xed central camera position is avail-
able. For eccentric and lateral photo-
graphs with a mirror the camera
position can be changed and recorded
at a scale underneath the camera
stand. In addition, height and rotation
of the camera position as well as the
camera object distance can be chan-
ged. Each positional change of the
camera can be recorded separately.
(3) For photographs in the premolar and
molar areas a mirror can be placed in a
ve-step protocol in the mouth of the
patient. The construction allows for a
cheek holding function of the mirror.
All three-dimensional movements of
the mirror can be recorded and repro-
duced at any time. The mirror posi-
tioning basically duplicates a rotating
gallows construction with a lateral,
height and transversal xation of the
mirror. Once in place, the mirror posi-
tion itself can be varied rotationally.
Again, each positional change of the
mirror can be recorded.
Standardized oral photography: In the
manner described above, photographs can
be acquired with standard enlargement,
exposure and aperture. Visual distortions
such as enlargement or reduction resulting
from different cameraobject distances and
changes of angulations can be excluded by
this technique.
Standardized computer-assisted mea-
surements: standardized measurements of
the acquired data the morphometrical
part of this concept are based on the
import of the acquired photographs into
an open source medical image processing
software (OSIRIX
s
). In our concept, the
acquired data les are saved as JPEG les
and are rst imported into an image
processing software (e.g., PHOTOSHOP
s
).
With the help of this software, two refer-
ence lines (RL1, 2) connecting the midfa-
cial gingival levels (FGL) of the adjacent
teeth next to the crown(s) of interest and a
grid are added. The gingival zeniths of the
adjacent teeth can then be marked as re-
ference points and together with the RL
they serve as standard orientation markers
for the intended gingivomorphometrical
measurements (Fig. 2). This modied
JPEG le is then imported into OSIRIX
s
and processed in the 2D mode. A standar-
dized measurement protocol of the follow-
ing six different soft tissue parameters
around crowns is used: (1) Mesial, (2) distal
papilla height, (3) mesial, (4) distal papilla
area, (5) soft tissuecrown perimeter, and
(6) soft tissue height at the gingival zenith
( recession) (Fig. 3). Values for recession
above the RL2 are expressed as positive
values, whereas values underneath RL2
are expressed as negative values. The out-
put of all measurements is immediately
displayed by the program in pixel values.
Clinical application of the method and
statistical analysis of reproducibility
Two standardized clinical photographs of
the anterior maxillary region were taken
from 10 patients at 1014 days time inter-
vals. The patient group consisted of six
female and four male patients with an
average age of 41 years. All patients were
unaffected of dental or periodontal disease
in the evaluated region, but two patients
had full-porcelain crowns and veneers. In
order to evaluate accuracy and reproduci-
bility of this method, the above described
six soft tissue parameters were measured
by one trained observer. At one session,
each parameter was measured three times
to determine intraobserver group variation.
The data obtained in pixels were classied
into minimum, maximum and median
values. For the statistical analysis of each
of the above-mentioned six parameters
Fig. 1. Custom-made device for standardized
intraoral photography (patent pending).
Fig. 2. Standardized oral photograph of the anterior
maxillary region with standard orientation markers
(FGL 1, 2, 3; RL 1,2, see text) for the gingivomor-
phometrical measurements.
Weinlander et al . Gingivomorphometry esthetic evaluation of the crownmucogingival complex
c 2009 John Wiley & Sons A/S 527 | Clin. Oral Impl. Res. 20, 2009 / 526530
these three values were pooled from all 10
patients, and then these mean values were
compared between the two photographs
from each patient. Besides calculating the
signicance of differences between the
mean values of three measurements, using
the paired t-test, the 95% condence inter-
vals and coefcients of variation for these
dependent mean values and their ranges
were calculated using the pooled data of
six measurements of both photographs for
each patient and parameter.
Results
The mean values of the six measured para-
meters obtained from these two standar-
dized clinical photographs, as well as the
comparisons between the three measure-
ments for each patient on the rst and
second oral photograph did not show any
statistically signicant difference (P40.05)
(Table 1). Means ranges, and 95% con-
dence interval calculations of corres-
ponding measurements from the same
photograph and for the six measurements
pooled from all 10 patients show equiva-
lence of the measurements (Table 2). The
variations between maximum and mini-
mum mean values for each parameter,
measured in the rst and second photo-
graph of each patient, as well as the varia-
tions of the six measurements for each
parameter and the respective coefcients
of variation, as assessed from these six
measurements per parameter and patient,
were low (Table 3).
Discussion
Implant supported restorations in the ante-
rior maxilla have become the standard of
care in reconstructing the dentogingival
complex in this esthetically sensible re-
gion. The use of implants in these areas is
supported by high success and survival
rates (Aviva-Arber & Zarb 1996; Scheller
et al. 1998; Haas et al. 2002). Creughers
et al. (2000) report survival rates of single
tooth restorations on implants of up to
98.9% after up to 7.5 years in function.
Fig. 3. The same oral photograph as Fig. 2, highlighting the six measured gingivomorphometrical parameters:
mesial/distal papilla areas and heights, gingival recession and soft tissue perimeter.
Table1. Mean minimum, maximum and median values of measurements of identical parameters, on rst and second photographs from
each patient
First photograph Second photograph Statistical test Signicance
Mesial papilla area (pixel)
Min 119,667.59 34,411.55 126,400.94 27,886.11 Paired t-test: between same parameter
evaluated on two different photographs
P0.191
n
Max 124,526.23 33,330.06 131,101.97 25,113.06 P0.253
n
Median 121,805.41 34,173.13 128,928.8 26,334.13 P0.206
n
Distal papilla area (pixel)
Min 86,988.01 33,618.95 92,899.71 33,578.52 Paired t-test: between same parameter
evaluated on two different photographs
P0.283
n
Max 91,688.67 31,232.19 97,898.53 34,572.17 P0.318
n
Median 89,330.15 32,344.19 95,730.36 33,985.3 P0.265
n
Mesial papilla height (pixel)
Min 417.11 40.35 439.64 29.94 Paired t-test: between same parameter
evaluated on two different photographs
P0.163
n
Max 420.42 38.19 443.22 28.2 P0.138
n
Median 418.68 39.27 441.32 28.4 P0.152
n
Distal papilla height (pixel)
Min 377.63 85.22 395.42 90.4 Paired t-test: between same parameter
evaluated on two different photographs
P0.378
n
Max 385.17 83.42 401.79 88.02 P0.268
n
Median 381.07 84.32 398.68 88.96 P0.324
n
Soft tissue perimeter (pixel)
Min 226,715.67 46,350.92 243,122.95 39,439.37 Paired t-test: between same parameter
evaluated on two different photographs
P0.145
n
Max 235,205.12 45,572.43 252,057.47 33,995.1 P0.214
n
Median 230,931.95 46,205.76 248,015.12 35,416.97 P0.172
n
Gingival recession (pixel)
Min 62.48 27.81 64.22 25.23 Paired t-test: between same parameter
evaluated on two different photographs
P0.514
n
Max 64.38 25.45 64.45 25.35 P0.5
n
Median 63.71 26.18 64.3 25.27 P0.526
n
Signicances of differences (P-values).
n
No statistically signicant difference (P40.05)
Weinlander et al . Gingivomorphometry esthetic evaluation of the crownmucogingival complex
528 | Clin. Oral Impl. Res. 20, 2009 / 526530 c 2009 John Wiley & Sons A/S
Various treatment concepts and recom-
mendations for achieving optimal esthetic
results with implants in esthetic zones
have been reported, including tooth extrac-
tion, extraction socket treatment, three
dimensional and immediate implant place-
ment and implant site development with
different hard and soft tissue augmentation
methods (Landsberg & Bichacho 1994).
Evaluation of the esthetic outcome of im-
plant-supported restorations in the anterior
maxillary region is performed mainly by
various assessments of periimplant soft
tissue and implant crown parameters. Fu r-
hauser et al. (2005) developed the Pink
Esthetic Score. This evaluation is based on
seven variables related to periimplant soft
tissues, assessing the mesial and the distal
papilla, the soft tissue level, the soft tissue
contour, the alveolar process deciency
and the soft tissue color and texture. Meijer
et al. (2005) added ve implant crown-
related parameters in their Implant Crown
Aesthetic Index to expand the evaluation
of the esthetic outcome. These parameters
consist of anatomical form, color and sur-
face characteristics of the crown. Both of
the above ratings are based on the evalua-
tion of oral photographs by different exam-
iners. Even though Fu rhauser et al. (2005)
and Meijer et al. (2005) made important
steps toward a more comprehensive evalua-
tion of the periimplant soft tissue and
crown parameters, their evaluations are
based on non-standardized photographs
and only subjective estimations of the dif-
ferent assessment criteria. In a prospective
study by Kan et al. (2003) a so-called RL
connecting the FGL of the two adjacent
teeth was implemented for evaluating im-
plant success rates, periimplant tissue and
esthetic outcome of immediately placed
and provisionalized maxillary anterior single
implants. In this manner, mesial and distal
papilla height as well as facial gingiva reces-
sion of pre- and post-implantological situa-
tions could be measured and compared. Kan
et al. (2003) were the rst attempting to
eventually measure certain soft tissue para-
meters in the implantogingival complex.
However, the data collection for these mea-
surements again were not standardized and
thus the comparison of the acquired data
only of limited signicance.
With the method proposed in this paper
the evaluation of for example the estheti-
cally sensible anterior maxillary region is
not anymore dependent on subjective esti-
mations of different assessment criteria,
but uses a more evidence-based method.
Hard and soft tissue criteria are governed
mostly by color and form. Forms are very
important for the symmetrical and natural
appearance of reconstructed dentogingival
aspects. Because forms are strictly depend-
Table2. Minimummaximum and range variations of measurements on rst and second
photographs from all patients, and of all six measurements per patient, as compared with
the 95% condence intervals (CI)
First photograph Second
photograph
Six measurements
for each patient
Mesial papilla area (pixel)
Min 83,863.2 104,170.3 83,863.2
Max 179,035.6 174,845.2 179,035.6
Range 95,172.41 70,674.88 95,172.41
95% CI 104,215.74
n
139,395.08w 115,328.83142,528.76 114,863135,871.21
Distal papilla area (pixel)
Min 441,63.1 46,996.2 44163
Max 134,257.9 134,930.5 134,930.5
Range 90,094.84 87,934.31 90,767.41
95% CI 72,693.39105,966.9 78,244.53113,216.2 81,157.56103,902.95
Mesial papilla height (pixel)
Min 381.8 392.4 381.8
Max 471 474.8 474.8
Range 89.19 82.45 93.03
95% CI 398.52438.85 426.71455.92 417.57442.43
Distal papilla height (pixel)
Min 274.8 278.3 274.8
Max 478.2 478.2 478.2
Range 203.33 199.93 203.4
95% CI 337.75424.39 353.04444.33 360.21419.55
Soft tissue perimeter (pixel)
Min 174685 192099.6 174685
Max 303060.9 304336 304336
Range 128375.9 112236.4 129651
95% CI 207101.18254762.73 229621.76266408.48 225001.82253945.26
Gingival recession (pixel)
Min 42.8 46.4 42.8
Max 82.4 82.4 82.4
Range 39.56 35.99 39.56
95% CI 42.3885.03 43.7684.84 51.9176.09
n
Lower bound of 95% CI for means
wUpper bound of 95% CI for means
Table3. Percent variation of the measurements in the two oral photographs from each
patient, total percentages of variation, and coefcients of variation (CV %)
Parameters First photograph
(maxmin)
maximum 100 (%)
n
Second Photograph:
(maxmin)
maximum 100 (%)w
(maximumminimum)
maximum
100 (%)z
C Vy
MP area 2.59 2 2.29 5.07
DP area 11.85 6.56 9.21 5.72
MP height 0.88 1.36 1.1 3.06
DP height 1.73 2.95 2.34 3.01
STC 7.06 6.74 6.9 5.25
GR 3.99 0.33 2.16 1.69
n
% of value changes between maximum and minimum value for each parameter and patient,
rst picture.
w% of value changes between maximum and minimum value for each parameter and patient,
second picture.
z% of value changes between maximum and minimum value for each parameter and six
measurements for each patient.
ycoefcient of variation (%) (SD/average) 100, assessed from six measurements for each
patient.
Weinlander et al . Gingivomorphometry esthetic evaluation of the crownmucogingival complex
c 2009 John Wiley & Sons A/S 529 | Clin. Oral Impl. Res. 20, 2009 / 526530
ing on perspective, distortions resulting
from different angles of photographic view
must be avoided. The exact measurement
of forms as areas or distances can contri-
bute to a more evidence-based evaluation
of esthetic reconstructions. Changes occur-
ring at soft tissue or dental level through
any kind of dental treatment, or for exam-
ple parafunctions, can so be measured and
monitored. To help with a precise reprodu-
cibility of all reference points and prevent
falsied measurements through soft tissue
changes over time, a grid can be added to
the photographs. Although the measure-
ments performed in the present small pro-
spective study were apparently accurate
and reliable, linear measurements (me-
sial/distal papilla height) showed a lower
coefcient of variation than area measure-
ments (mesial and distal papilla area, soft
tissue contour). Because all patients parti-
cipating in this study were unaffected of
dental disease in the area of interest, only
positive values for recession were obtained
for statistical comparison. Increased mea-
surement accuracy by gaining experience of
the present observer suggests that this is
denitely a very sensitive technical
method. It seems to be no shortcoming
that the output of all measurements is
expressed in pixels by the used program.
Because all measurements usually are
needed only for detection of relative
changes over time, a calibration of pixel
numbers to millimeters usually seems not
needed.
Conclusions
The proposed Gingivomorphometry on
standardized oral photographs can be con-
sidered an accurate and reproducible
method for the evaluation and measure-
ment of different dentogingival parameters.
Advantages of this non-invasive method
are reliability, objectiveness and standardi-
zation of the necessary parameters,
particularly for the evaluation of the dento-
gingival complex in the esthetic region of
the anterior maxilla. Further prospective
evaluations with this evidence-based and
computer-assisted method will be neces-
sary to show the efcacy for monitoring
long-term changes in the periimplant mu-
cogingival complex.
References
Aviva-Arber, L. & Zarb, GA. (1996) Clinical
effectiveness of implant supported single tooth
replacement: the Toronto Study. International
Journal of Oral & Maxillofacial Implants 11:
311321.
Creughers, N.H.J., Kreulen, C.M., Snoek, P.A. &
De Kanter, R.J.A.M. (2000) A systematic review
of single tooth restorations supported by implants.
Journal of Dentistry 28: 209217.
Fu rhauser, R., Florescu, D., Benesch, T., Haas, R.,
Mailath, G. & Watzek, G. (2005) Evaluation of
soft tissue around single-tooth implant crowns:
the pink esthetic score. Clinical Oral Implants
Research 16: 639644.
Haas, R., Pollak, C., Fu rhauser, R., Mailath- Pokorny,
G., Do rtbudak, O. & Watzek, G. (2002) A long-
term follow up of 76 Branemark single tooth im-
plants. Clinical Oral Implants Research 13: 3843.
Kan, J.Y.K., Rungcharassaeng, K. & Lozada, J.
(2003) Immediate placement and provisionaliza-
tion of maxillary anterior single implants: 1-year
prospective study. International Journal of Oral
& Maxillofacial Implants 18: 3139.
Landsberg, C.J. & Bichacho, N. (1994) A modied
surgical/prosthetic approach for optimal single
implant supported crown: the socket seal surgery.
Practical Periodontics and Aesthetic Dentistry 6:
1114.
Meijer, H., Stellingsma, K., Meijndert, L. & Ra-
ghoebar, GM. (2005) A new index for rating
aesthetics of implant-supported single crowns and
adjacent soft tissues the implant Crown Aesthetic
index. A pilot study on validation of a new index.
Clinical Oral Implants Research 16: 645649.
Scheller, H., Urgell, J.P., Kultje, C., Klineberg, I.,
Goldberg, P.V., Stevenson- Moore, P.V., Alonso,
J.M., Schaller, M., Corria, R.M., Enquist, B.,
Toreskog, S., Kastenbaum, F. & Smith, C.R.
(1998) A 5-year multicenter study on implant
supported single crown restorations. International
Journal of Oral & Maxillofacial Implants 2: 212
218.
Weinlander et al . Gingivomorphometry esthetic evaluation of the crownmucogingival complex
530 | Clin. Oral Impl. Res. 20, 2009 / 526530 c 2009 John Wiley & Sons A/S