HEAD AND NECK

Iran J Radiol. 2012;9(2):Inpress. DOI: 10.5812/iranjradiol.89138

Iranian Journal of

RADIOLOGY www.iranjradiol.com

Determination of Vertical Interproximal Bone Loss Topography:

Correlation Between Indirect Digital Radiographic Measurement and
Clinical Measurement
Farzad Esmaeli 1, Adileh Shirmohammadi 2*, Masoumeh Faramarzie 2, Nader Abolfazli 2,
Hossein Rasouli 2, Saied Fallahi 2
1 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Periodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran

A R T IC LE I NFO AB S T RAC T

Article type: Background: Diagnosis and accuracy in determining the exact location, extent and con-
Original Article figuration of bony defects of the jaw are of utmost importance to determine prognosis,
treatment planning and long-term preservation of teeth. If relatively accurate diagnosis
Article history: can be established by radiography, proper treatment planning prior to treatment proce-
Received: 05 Feb 2011 dures will be possible.
Revised: 03 Apr 2012 Objectives: The aim of the present study was to assess the correlation between indirect
Accepted: 20 Jun 2012 digital radiographic measurements and clinical measurements in determining the topog-
raphy of interproximal bony defects.
Keywords: Patients and Methods: Twenty interproximal bony defects, preferably in the mandibular
Radiography and maxillary 5↔5 area were selected and radiographed using the parallel periapical tech-
Dental nique. The radiographs were corrected and digitized on a computer using “Linear Mea-
Bone Diseases surement” software; then the three parameters of the base of defect (BD), alveolar crest
Topography, Medical (AC) and cementoenamel junction (CEJ) were determined using a software. Subsequent
to radiographic measurements, clinical measurements were carried out meticulously
during flap procedures. Then linear measurements were carried out using a periodontal
probe to determine the defect depth and its mesiodistal width. Then the amount of corre-
lation between these two measurements was assessed by Pearson's correlation coefficient.
Results: The correlation between clinical and radiographic measurements in defect depth
determination, in the evaluation of defect angle and in determination of defect width
were 88%, 98% and 90%, respectively.
Conclusions: Indirect digital radiographic technique can be used to diagnose intra-osse-
ous defects, providing a better opportunity to treat bony defects.
Published by Kowsar Corp, 2012. cc 3.0.

Implication for health policy/practice/research/medical education:

[Will be written by author. For more information, please refer to the previous issues.]

Please cite this paper as:

Esmaeli F, Shirmohammadi, A, Faramarzie M., Abolfazli N, Rasouli, H, Fallahi, S. Determination of Vertical Interproximal Bone
Loss Topography: Correlation Between Indirect Digital Radiographic Measurement and Clinical Measurement. 2012. Iran J Radiol.
2012;9(2):In press. DOI: 10.5812/iranjradiol.89138

* Corresponding author: Adileh Shirmohammadi, Department of Periodontics, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran.
Tel: +98-4113355965, Fax: +98-4113346977, E-mail: [email protected]
DOI: 10.5812/iranjradiol.89138
© 2012 Iranian Society of Radiology and Tehran University of Medical Sciences; Published by Kowsar Corp.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Indirect Digital Radiography in Determining Vertical Bone Loss Esmaeli F et al.

1. Background allel technique) in determining the topography of peri-

odontal bony defects and compare the results with real
In periodontal diseases, the bone destruction pattern is
measurements.
divided into horizontal (even) and oblique (vertical/an-
gular) defects. In the vertical pattern, bone destruction
does not proceed in a symmetrical pattern. The severity
3. Patients and Methods
of bone destruction varies in different parts around the In this cross-sectional study, 20 interproximal bony
tooth, which explains why the alveolar crest does not defects were selected in patients who had undergone
correspond to cemento-enamel junction (CEJ) and is not phase one periodontal therapy and were candidates for
parallel to it (1). This bone destruction pattern gives rise periodontal surgery. The inclusion criteria included no
to bony defects in which the base of the defect is located contraindications for periodontal surgery and exposure
more apical to the alveolar crest (2). Diagnosis and accu- to X-rays. Patients with shallow palate or elevated floor of
racy in determining the exact location, extent and con- the mouth were excluded. Defects in the 5↔5 area were
figuration of bony defects are of utmost importance to preferably selected. Pre-operative periapical radiographs
determine prognosis, to plan treatment and to preserve were provided using the parallel technique in an XCP film
the teeth in the long run (3). Because determination of holder (Dentsply, Rinn). One radiograph was provided for
the depth and to some extent, the width of bony defects each interproximal defect. In order to determine the ver-
is an important parameter in the prognosis of treatment, tical and horizontal difference between the central ray
it is important to accurately measure these two parame- and orthoradial projection, two pieces of orthodontic
ters on radiographs to develop a correct and appropriate wire with a specific length were placed at a premeasured
treatment plan (4). Recently, digital radiography has at- distance from each other on the mandibular side of the
tracted a lot of attention in determining the depth, width film holder. Then horizontal magnification was calculat-
and topography of bony defects and progression of the ed by dividing the wire length on the radiograph by its
defect since loss of bone density and height should be real length. Vertical magnification was calculated by di-
evaluated using an automated instrument to diagnose viding the distance between the wires on the radiograph
periodontal lesions and assess the treatment success (4). by their real distance. The radiographic machine Philips
There are only a limited number of studies which have Oralix 655 and Kodak E-speed intra-oral films (Eastmary
evaluated radiographic views of bony periodontal de- Kodak) were used in the radiography procedure (56 kVp,
fects with inconclusive results (5). Pepelassi et al. (2000) 7.5 mA). The radiographs were transferred to a computer
evaluated the potential of conventional radiographic using Mustek P3600 A3 PRO Scanner with a resolution of
techniques in the diagnosis of intra-osseous periodontal 400 pixels. Imag J (ver. 1.34) software (National Institutes
defects in comparison with intra-operative evaluations of Health) was used for measurements on a computer.
and concluded that:
1. Radiographic techniques have limited capacity to de- 3.1. Radiographic Examination
termine and diagnose bony defects. Linear Measurement T software was used to open the ra-
2. The accuracy of PA radiographs depends on the num- diographic images and in a manner similar to Photoshop
ber of wall defects, the depth and bucco-lingual width software the following parameters were determined (Fig-
and the location in the jaws. ure 1). BD is the most coronal point where periodontal
3. It is difficult to characterize small and shallow defects ligament (PDL) continuity is observed. If PDL could not
on radiographs (6). be determined, the point at which the alveolar crest (AC)
Kelin et al. evaluated the depth and width of bony de- projection contacted the root surface was selected as the
fects as a diagnostic factor and changes in defect width landmark. If both landmarks were present, the first one
as a determinant of periodontal healing in intra-osseous was designated as BD and the second was designated as
defects treated with GTR 6 and 24 months after surgery. AC. If multiple bone contours were visible, the most api-
In that study, subjects with intra-osseous defects were se- cal contour contacting the root surface was designated as
lected and treated with ePTFE (expanded polytetrafluoro- BD and the most coronal one was designated as AC. CEJ
ethylene, a non-absorbable membrane). A computer was was the fixed coronal reference for these measurements.
used to determine the depth, width and angulations of After CEJ, AC and BD were determined on the screen, the
the defect. The bonefill had been preserved 24 months af- following measurements were carried out:
ter surgery. They also concluded that the depth of the in- Defect depth = CIJ/BD - CEJ/AC
tra-osseous component is a more appropriate diagnostic Defect width: Defect width is the distance between the
parameter compared to the angulations of the defect (4). mesial and distal borders of the bony defect, which is the
distance between the lateral margin of the defect and the
2. Objectives AC on the root surface.
The aim of the present study was to evaluate the diag- Defect angle: Defect angle is the angle between the lat-
nostic value of indirect digital radiography (with the par- eral defect wall and the root surface, which is drawn in

Iran J Radiol. 2012;9(2) Published by Kowsar, © 2012 BRCGL 81

Esmaeli F et al. Indirect Digital Radiography in Determining Vertical Bone Loss

the following manner: imaginary plane which extended from the alveolar crest
One wall of the angle extends from CEJ to BD and the to the buccal (or lingual) plate of the proximal tooth.
other wall extends from BD to the lateral margin of the Subsequently, the impression was removed from the
defect. Radiographic measurements are made after draw- defect using an explorer; then, the tips of the two forks
ing the above-mentioned lines. Subsequent to radio- of a pair of calipers were placed tangential with the
graphic measurements, clinical measurements are car- two proximal walls of the impression and fixed. Then,
ried out accurately during flap elevation. Measurements the angle between the lateral wall of the defect and the
are made after removal of the granulation tissue and root surface was determined. In both digital and clinical
before only resective or regenerative surgical treatment. measurements, a periodontist carried out the measure-
Bony defects not located on proximal surfaces were ex- ment procedures three times and the mean of the three
cluded from the study. At first, vertical defect type (the measurements was reported as the final value. This tech-
number of remaining walls) was determined and the fol- nique minimized intrarater error. After clinical and ra-
lowing measurements were carried out: diographic measurements were completed, the results
Liner measurement: Linear measurement was carried were compared to evaluate similarities and differences
out using a calibrated periodontal probe (PCPUNC-15, Hu- between the methods. These were tested with Pearson’s
friedy) to the nearest 0.5 mm: correlation coefficient. All the statistical analyses were
1. Depth of the osseous defect: the distance between the performed using SPSS version 15. A P-value under 0.05 was
alveolar crest and the base of the osseous defect. considered statistically significant.
2. Mesiodistal width of the osseous defect: the distance
between the root surface and the osseous border of the 4. Results
defect in a mesiodistal direction at the level of the bony
crest or the distance between the mesial and distal bor-
4.1. Correlation Between Clinical and Radiographic
ders of the osseous defect. Accordingly, the minimum
dimensions for a defect are: width = 0.5 mm; depth = 0.5 Measurements in Determining the Defect Depth
mm. According to Graph 1 and Pearson’s correlation coeffi-
3. Defect angle: A hydrosol (elastomeric polyvinylsilox- cient, the correlation between radiographic and clini-
ane impression material) impression was taken from the cal measurements in determining the defect depth was
defect. strong (r = 0.88, P < 0.001).
This impression material was injected into the defect
after mixing. Caution was exercised not to introduce 4.2. Correlation Between Clinical and Radiographic
bubbles into the material. The material was set after 6-7 Measurements in Determining the Defect Angle
minutes and then a sharp blade was used to draw an
According to Graph 2 and Pearson’s correlation coeffi-
cient, the correlation between radiographic and clinical
measurements in determining defect angle was strong (r

Figure 2. Correlation and regression between clinical and radiographic

Figure 1. Radiographic measurements measurements in determining the defect depth

82 Published by Kowsar, © 2012 BRCGL Iran J Radiol. 2012;9(2)

Indirect Digital Radiography in Determining Vertical Bone Loss Esmaeli F et al.

= 0.98, P < 0.001), demonstrating a strong correlation ac- and Angle

cording to regression equation.
According to Graph 4, the mean differences between
clinical and radiographic measurements of defect angle,
4.3. Correlation Between Clinical and Radiographic depth and width were 1.41, 0.24 and 0.42, respectively.
Measurements in Determining the Defect Width
According to Graph 3 and Pearson’s correlation coeffi- 5. Discussion
cient, agreement between clinical and radiographic mea- The results of the present study showed that digitized
surements in determining defect width was strong (r = parallel periapical radiographs have a high level of cor-
0.90, P < 0.001). relation with clinical measurements. Therefore, the tech-
nique can be used to determine prognosis and also for
4.4. Correlation Between Clinical and Radiographic treatment planning in osseous defects of the jaw. In the
Measurements in Determining the Defect Depth, Width present study, the differences between radiographic and
clinical measurements in relation to defect width and
depth were 0.42 and 0.24, respectively, with no statistical-
ly significant differences; i.e. radiographic measurement
was similar to clinical measurement. The results of the
present study regarding width and depth measurements
were respectively, consistent and inconsistent with the
results of a study carried out by Pepelassi et al. (6) which
compared the potential of conventional periapical and
panoramic radiographic techniques in the determina-
tion and imaging accuracy of intra-osseous lesions com-
pared to evaluations during surgical procedures. They
evaluated the presence and measured the dimensions
of osseous lesions during flap surgery, measured the
distance between the alveolar crest and the lowermost
part of the lesion (BD) on radiographs and measured the
mesiodistal width of the lesion clinically using a peri-
odontal probe. The results of their study showed that
periapical radiographs were three times more efficient
than panoramic views in determining the presence of
osseous lesions. The results also revealed that the depth
Figure 3. Correlation and regression between clinical and radiographic of the lesion by the two mentioned radiographic tech-
measurements in determining the defect angle niques is depicted bigger than the actual lesion size. This
controversy might be attributed to the location, the types
of teeth and jaw and the greater depth of the defects in
the study carried out by Pepelassi et al. The results of the
present study in this respect are consistent with those of
Kelin et al. (4). They evaluated the depth and width of the
lesion as a factor involved in determining prognosis and
changes in the width of the lesions as a factor involved
in demonstrating repair of osseous lesions treated with

Figure 4. Correlation and regression between clinical and radiographic Figure 5. Mean differences between clinical and radiographic measure-
measurements in determining the defect width ments of the defect angle, depth and width

Iran J Radiol. 2012;9(2) Published by Kowsar, © 2012 BRCGL 83

Esmaeli F et al. Indirect Digital Radiography in Determining Vertical Bone Loss

GTR, 6 and 24 months after surgery. Periapical radio- the present study, linear evaluation during surgery and
graphs were provided and CEJ-AC and CEJ-BD distances also on conventional periapical radiographs were car-
were measured at baseline and 6 and 24 months after ried out on 0.5-mm intervals; however, linear evaluations
surgery using digitized CCD camera and a computer. on digitized radiographs were carried out by manipula-
The results of the study demonstrated statistically sig- tion on a computer at 0.01-mm intervals, which might
nificant differences in bone filling and bridging of wall be the main reason for the higher value of digitized ra-
defects, 6 and 24 months after surgery compared to con- diographs compared to conventional periapical radio-
ventional treatment modalities. The authors concluded graphs. One of the limitations of the present study was
that the radiographic analysis used in the study is a pre- the number of samples and the absence of evaluation of
cise method for the evaluation of intra-osseous lesions the above-mentioned method in determining the topog-
and treatment results and measurements are close to raphy of various interproximal osseous lesions (one-wall,
actual dimensions. In a study carried out by Wolf et al. (7), two-wall and three-wall defects). Therefore, it is suggest-
selected digital modifications (filters, scatter, structure) ed that further studies should be carried out with larger
in radiographic images did not result in more reproduc- sample sizes for evaluating various types of periodontal
ible or more valid results for measuring bone resorption osseous defects.
in interproximal lesions compared with un-modified The results indicate that digital enhancement can result
digital radiographs. Although the radiographic values in an increased ability to diagnose intra-osseous defects,
were lower than the clinical values in the present study, paving the way for a more appropriate decision-making
the differences were not statistically significant, with a process to treat intra-osseous lesions more properly.
strong correlation between radiographic and clinical val-
ues. Periodontal diseases result in endosteal resorption, Acknowledgements
which produces radiolucencies; however, bone resorp-
None declared.
tion does not produce a uniformly recognizable view.
Extra- and intra-oral radiographic techniques are used to
Authors’ Contribution
record changes. Radiographs are two-dimensional repre-
sentations of a three-dimensional structure. Therefore, [Should be written by author]
the image is not an accurate one and bone resorption
on the radiograph is depicted smaller than the actual le- Financial Disclosure
sion size. Therefore, measurements of bone resorption None declared.
on radiographs are not accurate to diagnose osseous le-
sions. In 1980, Goodson et al. used a computer as an aid Funding/Support
in the linear evaluation of bone resorption (8). Given the
technological advances and introduction of digital radio- None declared.
graphic technique, it has extensively been used in medi-
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