J Periodontol March 2008

Comparison of Different Methods of Assessing Alveolar Ridge Dimensions Prior to Dental Implant Placement
Lung-Cheng Chen,* Tord Lundgren, Hadar Hallstrom,* and Fabrice Cherel*
Background: The aim of this study was to compare ridgemapping measurement before surgical ap reection and measurement using images from cone beam computerized tomography (CBCT) to direct caliper measurement following surgical exposure of the bone. Methods: Sixteen subjects with 25 sites for planned implant placement or ridge augmentation were recruited. An acrylic stent was fabricated for each subject. The stent provided three buccal/lingual pairs of consistent measurement points for each implant site located 4, 7, and 10 mm from the summit of the alveolar soft tissue. Two independent examiners participated. Results: Comparisons of bucco-lingual ridge width using ridge-mapping versus direct caliper measurements showed that 94% and 89% of the pairs of measurement deviations were within 1 mm for examiners 1 and 2, respectively. The corresponding comparison of CBCT images versus direct caliper measurements showed 70% and 55% agreement for examiners 1 and 2, respectively. CBCT image measurements provided lower levels of agreement than ridge-mapping measurements because of the more frequent and larger magnitudes of deviations compared to direct caliper measurements. Conclusions: Most often, ridge mapping provides measurements of the bucco-lingual ridge width consistent with those obtained by direct caliper measurement following surgical exposure of the bone. As applied in this study, CBCT was less consistent compared to direct caliper measurements and did not provide any additional, signicant diagnostic information. J Periodontol 2008;79:401-405. KEY WORDS Alveolar ridge; computerized tomography; mapping; measurement.

* Department of Periodontics, School of Dentistry, Loma Linda University, Loma Linda, CA. Department of Periodontology, College of Dentistry, University of Florida, Gainesville, FL.

he use of dental implants to support prosthodontic restorations has a high success rate.1 Careful diagnosis and treatment planning are critical for a favorable outcome. Evaluation of the dimensions of the available alveolar bone is an important prerequisite. Bone evaluation limited to the use of panoramic and/or periapical radiographs may be insufcient because it only provides two-dimensional information about implant sites.2-4 Assessment of the bucco-lingual dimension of the osseous ridge also is needed for proper treatment planning.5 The bucco-lingual ridge width can be evaluated by computerized tomography (CT).6,7 An alternative method is ridge mapping using a caliper device under local anesthesia.8-11 The pointed tips of the instrument penetrate buccal and lingual soft tissue layers and measure the bucco-lingual width of the underlying bone. This procedure is performed chairside and provides instant information. Ridge mapping may obviate tomographic imaging. To determine this, ridge mapping needs to be compared to what would seem to be the most accurate measurement, i.e., direct caliper measurements following surgical exposure of the bone.10,11 Thus, the aim of this case series study was to compare ridgemapping measurement before surgical ap reection and measurement using images from cone beam computerized tomography (CBCT) to direct caliper

doi: 10.1902/jop.2008.070021

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measurement following surgical exposure of the bone. MATERIALS AND METHODS Subjects Sixteen subjects (seven males and nine females; age range: 36 to 69 years) with 25 sites for planned implant placement or ridge augmentation were recruited. One subject provided four sites, six subjects provided two sites, and nine subjects provided one site. The subjects were chosen from individuals referred to the Advanced Periodontics Clinic at the School of Dentistry, Loma Linda University. The Institutional Review Board of Loma Linda University granted approval for the study based upon the principles of the World Medical Association Declaration of Helsinki. The participants signed an informed consent prior to examination. Subjects were enrolled into the study between March 2004 and January 2005. Non-pregnant, healthy subjects were selected using the following inclusion criteria: presence of a partially edentulous ridge in the maxillary anterior region (from left to right second premolar region); presence of at least one periodontally healthy and stable tooth adjacent to the edentulous ridge to serve as an abutment for guidance stents as described below; a healing period 3 months following any extraction in the area of implant placement; and a treatment plan including implant placement or ridge augmentation before implant placement. Stent Fabrication to Prepare for Measurements A study model was made from an alginate impression, and a clear acrylic stent was fabricated. Three pairs of buccal/lingual measurement points were dened at the site for implant placement and marked on the study model. These points, located 4, 7, and 10 mm from the summit of the alveolar soft tissue, were transferred to the stent by drilling 1.0-mm diameter guide holes. In this manner, the stent provided consistent buccal and lingual locations for the assessment of ridge width. The holes in the guidance stent were lled with gutta percha for use during the preoperative tomography to provide radiopaque landmarks indicating the locations for comparative radiographic ridge width measurements. Alveolar Ridge Dimensions Assessed by CBCT CBCT was performed with subjects in a supine position. The device was operated at 110 kV with an exposure time ranging from 5.4 to 9.0 seconds depending on the size of the area to be analyzed (maxilla, mandible, or both). The images were obtained from 2-mm CT axial sections and sagittal or coronal reconstructions processed with the software program provided by the manufacturer. The stent with gutta percha in the guide holes was placed in the mouth before the im402

ages were obtained. The examiner selected an image for measurement that showed the clearest gutta percha imprints for the buccal and lingual aspects at all levels of measurements (4, 7, and 10 mm). The measurements were performed using the softwares built-in measurement tool. The largest distance between the buccal and lingual bone walls was recorded to the nearest 0.1 mm. Ridge-Mapping Measurements Before Surgical Flap Reection Following local anesthesia, the stent was placed in the area to be measured (the gutta percha was removed from the guide holes). The tips of the ridge-mapping instrumenti were inserted into the guide holes, penetrating through the soft tissues until there was contact with bone. The width of the alveolar ridge at the various levels (4, 7, and 10 mm) was recorded to the nearest millimeter. Direct Caliper Measurements Following Surgical Exposure of the Bone Following surgical ap reection, ridge width was measured directly on the exposed bone at the various locations of the guide holes using the same caliper device and stent as described previously. Examination Two examiners (TL and L-CC) obtained independent recordings of all three measurements. Ridge-mapping and direct caliper measurements were obtained during the surgical visits. CBCT measurements were obtained prior to surgery following collection of all clinical data. Unfortunately, because of difculties in the recruitment of subjects, calibration exercises were limited to two subjects. Data Analysis Ridge-mapping and CBCT measurements were compared to direct caliper measurements for each of the two independent examiners. Frequency distributions of differences of various magnitudes between pairs of measurements and the mean SD of these differences were calculated using individual measurement locations as the unit for calculation. RESULTS The 16 subjects with 25 implant sites provided 75 measurement positions. For 11 of these measurement positions located at the 10-mm level, caliper measurements could not be obtained because of interference with a shallow vestibulum, leaving 64 measurement positions for evaluation. Comparisons of bucco-lingual ridge width using ridge-mapping versus direct caliper measurements
NewTom 9000, Aperio Services, Sarasota, FL. NewTom QR-DVT 9000, Aperio Services. i IRMC, G. Hartzell & Son, Concord, CA.

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Chen, Lundgren, Hallstrom, Cherel

Figure 1.
Proportion (%) of differences of various magnitudes (mm) comparing ridge mapping (RM) and direct caliper measurements (DM) (RM - DM). Mean SD of the series of differences. The number of observations is indicated within brackets at the top of each bar. A) Results for examiner 1. B) Results for examiner 2.

Figure 2.
Proportion (%) of differences of various magnitude (mm) comparing CBCT image measurements (CBCT) and direct caliper measurements (DM) (CBCT - DM). The number of observations is indicated within brackets at the top of each bar. Mean SD of the series of differences. The 0-mm bar includes deviations between -0.5 and +0.4 mm, the 1-mm bar includes deviations between +0.5 and +1.4 mm, and so forth. A) Results for examiner 1. B) Results for examiner 2.

for examiners 1 and 2 are presented in Figure 1. Concordant recordings were obtained for 72% and 70% of the comparisons for examiner 1 and 2, respectively. Deviations within 1 mm occurred for 94% and 89% of the comparisons for examiner 1 and 2, respectively. Of the 64 measurement sites compared, deviations of 3 to 4 mm occurred for two sites for each examiner. The standard deviation for the series of differences was 0.86 and 0.81 for examiner 1 and 2, respectively.

Comparisons of bucco-lingual ridge width using the CBCT image versus direct caliper measurements for examiner 1 and 2 are presented in Figure 2. Deviations limited to differences between -0.5 to +0.4 mm were observed for 44% and 42% of the comparisons for examiner 1 and 2, respectively. Deviations within 1 mm were observed for 70% and 55% of
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comparisons for examiner 1 and 2, respectively. Of the 64 measurement sites compared, deviations 3 mm occurred for eight sites for examiner 1 and 16 sites for examiner 2. Positive deviations (= larger values for CBCT images than for direct caliper measurements) were more frequent than negative deviations. The standard deviations for the series of differences were 1.72 and 2.21 for examiner 1 and 2, respectively. DISCUSSION In the present case series study, ridge-mapping and CBCT image measurements were compared to direct caliper measurements for evaluation of the buccolingual width of the alveolar ridge. Direct caliper measurement following surgical exposure of the bone would seem to be the most accurate measurement and could be considered the gold standard.10,11 Therefore, the reliability of the other two methods, ridge mapping and CBCT image measurements, was evaluated by comparison with the direct caliper measurements. A comparison of ridge-mapping to direct caliper measurements showed that 94% and 89% of the deviations were within 1 mm for examiner 1 and 2, respectively. These numbers indicate that ridge mapping often provides an evaluation of the width of the alveolar ridge that is quite accurate. This agreement was obtained despite the fact that the stent was fabricated on study models with the mucosa in place and may have been positioned slightly differently after ap reection. However, for a few measurement sites, both examiners had deviations of 3 to 4 mm. These deviations could be explained by two circumstances: 1) the presence of a dehiscence in the alveolar ridge, which was observed following ap reection; one of the recordings most likely measured to the bony edge of the dehiscence, whereas the other recording measured inside the dehiscence defect; and 2) the location of the measurement site was at the very crest of the alveolar ridge; one of the measurements was made just coronal to the crest and resulted in a 0-mm recording, whereas the other measurement was made slightly more apically, thus recording the width of the crest. A comparison of the CBCT image to direct caliper measurements showed that 70% and 55% of the deviations were within 1 mm for examiner 1 and 2, respectively. Deviations 3 mm occurred for eight sites for examiner 1 and 16 sites for examiner 2, who had less experience. The maximum deviation was 8 mm. Thus, these results demonstrate less favorable agreement compared to those between ridgemapping and direct caliper measurements. As above, some of the deviations 3 mm between the CBCT image and direct caliper measurements could be ex404

plained by the fact that the location of the measurement site was at the very crest of the alveolar ridge, providing a 0 reading with one of the methods. All others, accounting for the majority of deviations 3 mm, were positive (= larger values for the CBCT image than for direct caliper measurements). Thus, the bucco-lingual width was overestimated using the CBCT images. This seemed to be related to difculties in dening the cortical borders of the alveolar process. Another problem related to the CBCT measurements was the difculty in nding single buccallingual cross-sectional images that passed through the center of all six gutta percha points. When interpreting the ndings of the present study, it should be considered that examiner calibration prior to the study was limited to a couple of subjects. However, the high degree of agreement between ridgemapping and direct caliper measurements for both examiners seems to provide indirect evidence that these two recordings were reproducible at a satisfactory level. The more limited agreement observed between the CBCT and direct caliper measurements might be related, at least in part, to an inferior reproducibility of the CBCT measurements. Wilson8 introduced the concept of ridge mapping. Traxler et al.9 compared the use of two different calipers in four subjects and 11 sites marked with a waterinsoluble pen. The maximum deviation between the two calipers for individual pairs of measurements was 0.5 mm. ten Bruggenkate et al.10 used another ridge-mapping instrument in 60 subjects and 176 maxillary implant sites and compared preoperative measurements (ridge mapping) to measurements following mucoperiosteal ap reection (direct caliper measurements) without the use of any device to identify the measurement locations. The mean ridgemapping measurements averaged 0.4 mm less than the direct caliper measurements. However, the frequency of deviations of different magnitudes comparing the two methods was not reported. Allen and Smith11 used still another caliper comparing ridgemapping to direct caliper measurements in 11 subjects and 25 maxillary anterior sites, using stents to identify the measurement locations. Details of the magnitude of the deviations were not provided. However, statistically signicant differences between the two methods were observed. CONCLUSIONS The results of the present study support the use of ridge mapping in the anterior maxillary area. Most often, ridge mapping provides measurements of the bucco-lingual ridge width consistent with those obtained by direct caliper measurements following surgical exposure of the bone. As applied in this study,

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Chen, Lundgren, Hallstrom, Cherel

CBCT was less consistent compared to direct caliper measurements, and it did not provide any additional, signicant diagnostic information. However, it must be kept in mind that ridge mapping may give erroneous readings. ACKNOWLEDGMENTS The authors thank Dr. Jan Egelberg, School of Dentistry, Loma Linda University, for assistance during manuscript preparation; Dr. Matt Riggs, Department of Psychology, California State University, San Bernardino, California, for statistical consultation; and Sam Sadanala, School of Dentistry, Loma Linda University, for graphics support. No funding was received for this study, and the authors report no conicts of interest. REFERENCES
1. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol 2002;29(Suppl. 3):197-212. 2. Danforth RA, Clark DE. Effective dose from radiation absorbed during a panoramic examination with a new generation machine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:236-243. 3. Lecomber AR, Downes SL, Mokhtari M, Faulkner K. Optimisation of patient doses in programmable dental panoramic radiography. Dentomaxillofac Radiol 2000; 29:107-112.

4. Danforth RA, Dus I, Mah J. 3-D volume imaging for dentistry: A new dimension. J Calif Dent Assoc 2003; 31:817-823. 5. Simon BI, Von Hagen S, Deasy MJ, Faldu M, Resnansky D. Changes in alveolar bone height and width following ridge augmentation using bone graft and membranes. J Periodontol 2000;71:1774-1791. 6. Williams MY, Mealey BL, Hallmon WW. The role of computerized tomography in dental implantology. Int J Oral Maxillofac Implants 1992;7:373-380. 7. Ziegler CM, Woertche R, Brief J, Hassfeld S. Clinical indications for digital volume tomography in oral and maxillofacial surgery. Dentomaxillofac Radiol 2002; 31:126-130. 8. Wilson DJ. Ridge mapping for determination of alveolar ridge width. Int J Oral Maxillofac Implants 1989; 4:41-43. 9. Traxler M, Ulm C, Solar P, Lill W. Sonographic measurement versus mapping for determination of residual ridge width. J Prosthet Dent 1992;67:358-361. 10. ten Bruggenkate CM, de Rijcke TB, Kraaijenhagen HA, Oosterbeek HS. Ridge mapping. Implant Dent 1994;3: 179-182. 11. Allen F, Smith DG. An assessment of the accuracy of ridge-mapping in planning implant therapy for the anterior maxilla. Clin Oral Implants Res 2000;11: 34-38. Correspondence: Dr. Tord Lundgren, Department of Periodontology, College of Dentistry, University of Florida, P.O. Box 10034, Gainesville, FL 32610. Fax: 352/3925899; e-mail: tlundgren@dental.u.edu. Submitted January 12, 2007; accepted for publication August 15, 2007.

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