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Al-Nawas, B.; Heimes, D. Buccal Bone Thickness in Anterior and Posterior Teeth. Encyclopedia. Available online: https://encyclopedia.pub/entry/19412 (accessed on 16 November 2024).
Al-Nawas B, Heimes D. Buccal Bone Thickness in Anterior and Posterior Teeth. Encyclopedia. Available at: https://encyclopedia.pub/entry/19412. Accessed November 16, 2024.
Al-Nawas, Bilal, Diana Heimes. "Buccal Bone Thickness in Anterior and Posterior Teeth" Encyclopedia, https://encyclopedia.pub/entry/19412 (accessed November 16, 2024).
Al-Nawas, B., & Heimes, D. (2022, February 14). Buccal Bone Thickness in Anterior and Posterior Teeth. In Encyclopedia. https://encyclopedia.pub/entry/19412
Al-Nawas, Bilal and Diana Heimes. "Buccal Bone Thickness in Anterior and Posterior Teeth." Encyclopedia. Web. 14 February, 2022.
Buccal Bone Thickness in Anterior and Posterior Teeth
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This entry is adapted from the peer-reviewed paper 10.3390/healthcare9121663

The Buccal Bone Thickness (BBT) of maxillary premolar teeth was 1.40 ± 0.75 mm in the region of the alveolar crest, 1.28 ± 0.80 mm at the medial area of the radix, and 1.84 ± 1.16 mm at the apex. Maxillary molar teeth showed a BBT of 1.42 ± 0.74 at the alveolar crest, 1.56 ± 1.05 in the middle part, and 2.78 ± 2.04 mm at the apex. In the mandible, the value distributions were: 0.95 ± 0.58 mm between the crestal part of the root and the surface of the buccal bone, 0.92 ± 0.66 mm at 4 to 9 mm apically to the alveolar crest, and 2.90 ± 1.58 mm at the apex of the radix.

dental implant tomography alveolar bone buccal bone thickness

1. Introduction

Intraosseous dental implants are considered a reliable method for replacing missing teeth and restoring a patient’s masticatory function. With different protocols for a variety of indications discussed in the literature, information regarding the anatomy and bone thickness of the jaw prior to dental implant placement is crucial to increase a surgery’s success and a patient’s safety. For each protocol, data concerning survival time, success rates, and peri-implant bone loss are required to allow for a comparison between different options and to be able to assess the success to be expected in each patient.
Especially when immediate implant placement is required, a detailed analysis of the present clinical conditions is needed. Different types of implant placement protocols are defined: Type 1 includes immediate implant placement (with immediate restoration, early loading and conventional loading), Type 2 includes early placement with soft tissue healing (4–8 weeks), Type 3 includes early placement with partial bone healing (12–16 weeks), and Type 4 includes late placement (>6 months) [1][2][3][4]. Immediate implant placement is defined as implant insertion into the socket on the same day as tooth extraction and should be considered in the presence of patient-centered advantages, such as an aesthetic outcome or a reduced morbidity. Survival rates for immediate placement range from 87 to 100% depending on the type of loading protocol [4][5][6][7]. As immediate dental implant placement is a complex surgical procedure, it is recommended to only be performed by clinicians with a high level of experience and in the presence of the following clinical conditions: Intact socket walls, thick soft tissue, no acute infection at the site, bone apical and lingual to the socket, insertion torques of 25 to 40 Ncm or implant stability quotient (ISQ) value >70, patient compliance, and a facial bone wall that is at least 1 mm thick [4]. Immediate implant placement is an attractive technique, since it enables the immediate restoration of aesthetics and at the same time reduces the number of surgical steps, significantly reducing the time needed for dental restauration. However, it is still premature to consider this procedure as a general standard in implantology [8]. Several animal and human studies [9][10][11] have shown that the alveolar ridge undergoes an unavoidable remodeling process after tooth extraction that leads to a reduction of the bone dimension. The resorption probably results from the interruption of the blood supply together with a tendency to a higher osteoclastic activity [12]. In particular, the anterior maxilla consists of a very thin buccal bone that is reported to be made up of bundle bone [13] and considered to be part of the periodontium, which is why it is reabsorbed after tooth extraction [9]. Furthermore, bone resorption is reported to be much greater at the buccal aspect of the alveolar bone [9]. This renders the need for predicting the degree of future bone loss after tooth extraction [14]. Considering that immediate implant placement gained popularity within the last few years, a critical analysis is needed to evaluate the number of cases fulfilling the clinical conditions–especially in consideration of a reported mean bone loss of 7.5 mm in height when the mean buccal bone thickness is <1 mm compared to a loss in height of just 1.1 mm when buccal bone thickness is ≥1 mm [11].

2. Buccal Bone Thickness in Anterior and Posterior Teeth

While the original treatment protocol required fully healed alveolar ridges prior to implant placement, in the 1990s these protocols were modified towards implant insertion in fresh extraction sockets [2]. As immediate dental implant placement has been a subject of great interest over the last few years, the clinical premises for this approach have been controversially discussed. One of those heavily discussed premises is a facial bone wall of at least 1 mm in thickness [4].
It shows that in the analyzed population the BBT of maxillary front-teeth at 1 to 9 mm to the alveolar crest was on average smaller than 1 mm. The same applies to the mandibular anterior teeth. Regarding the high standard deviation, it can be assumed that in more apically located regions of the anterior mandible, too, bone thickness was smaller than 1 mm in a relevant portion of cases. At the apex of frontal teeth, the average bone thickness was >1 mm. More posteriorly-located teeth were shown to have an average bone thickness of more than 1 mm, both in the mandible and maxilla. Premolars and molars in the maxilla nevertheless showed only an average BBT of <2 mm; only bone thickness in the molar apex region had values of 2.8 mm. In contrast, the mean apical BBT was greater than 2 mm already in the anterior region of the mandible; here, the BBT increased significantly from mesial to distal. This corresponds to a study by Schwartz-Arad et al. who reported a 5-year cumulative survival rate of 89% in immediate implantation with a better prognosis in the mandible compared to maxillary placed implants, especially in the posterior part of the jaw (molar region) [15]. Those findings suggest that caution is needed in performing immediate implantation in the front teeth region. Not only can the bone thickness be reduced, but the buccal bone wall can also be damaged during surgery. In a study by Chen et al. of 34 extracted maxillary central incisors, 52% demonstrated defects of the buccal bone wall [16]. Cooper et al. reported of 21% of cases showing significant bone loss after extraction [17]. The absence of the buccal bone wall can result in aesthetic problems, an increase of stress in the coronal portion of the implant subjected to loading, peri-implant pockets, bacterial colonization, or the development of peri-implant disease [18]. Values of less than 1 mm BBT were correlated to a vertical resorption of 0.21–1.85 mm depending on the type of prosthetic connection [3][19][20]. A minimum thickness of 2 mm was advocated in order to avoid resorption and maintain soft tissue [18][21]. Bone resorption might be caused by a lack of blood supply or the surgical trauma of the implant placement, but can also be influenced by other factors, such as peri-implant soft tissue height, implant design, placement level, and the position and timing of the abutment connection [18]. As a result of bone remodeling, bone resorption occurs six months after tooth extraction, and greater loss is observed in the buccal bone plate [22]. Koh et al. reported that 50% of the original BBT undergoes resorption after immediate implant placement [5], whereas some studies suggested that immediate placement can reduce bone resorption [22]. In consideration of anticipated bone resorption, the implant shoulder should be placed just apical to the mid-facial bone crest to compensate for 0.5 to 1.0 mm of crestal bone loss [3].
It is subjected that bone stability is related to the thickness of the bone at the time of implant placement [18]. Sites with facial bone walls >2 mm were shown to have a better bone fill after immediate implant placement than sites with a thin buccal bone wall (<1 mm) [23]. In addition to hard tissue resorption, greater mucosal recession occurred in implant sites with less than 1 mm of BBT [18] with pre-existing defects of the buccal bone, thin soft tissue biotype, and facial malposition of the implant [2].
Immediate implant placement offers some advantages over delayed surgical protocols: Mello et al. reported a reduction of time required for osseointegration, a minimization of bone resorption by maintaining the periodontal architecture, as well as superior aesthetic results, especially in the front teeth region [6][7][22]. In contrast, other studies did not show any beneficial effect of immediate implant placement on dimensional reduction of alveolar bone and buccal bone loss [24][25]. Immediate implant placement is not only supposed to preserve the alveolar ridge, decrease morbidity and rehabilitation time, as well as to increase patient satisfaction [5][6][7][26][22][27][28][29][30][31], but is also supposed to be more cost-efficient [5][6][22] and believed to offer psychological benefits [5][6]. Yet, there are also some disadvantages associated with immediate implantation, such as lower implant survival rates, marginal bone loss, and the affection of peri-implant soft tissue [5][7][32][33]. The unpredictability of hard and soft tissue changes following immediate implant placement is a key factor that needs to be considered when immediate implant placement is taken into account. Generally, implant primary stability is difficult to achieve, as implants usually do not have direct contact with the alveolar bone. Furthermore, bone graft/membrane is often needed [3][5]. Cochrane, Esposito et al. concluded that while immediate placed implants may be at a higher risk of implant failure and complications, the aesthetic outcome might be superior [34]. In accordance with this, Chrcanovic et al. concluded that immediate implant placement affects implant failure rates but does not affect marginal bone loss or the occurrence of postoperative infection [6]. They suggested that the observed difference regarding the failure rates can be attributed to critical primary stability, as implants usually do not have direct contact with the alveolar bone [6].
Since many healthy patients are assumed to have a BBT smaller than 1 mm, cautious clinical and radiographic assessment is mandatory. This especially applies to patients suffering from diseases that cause a reduced amount of bone.
The effect of age-related hormonal changes within the jaw is still largely unexplored. Micro CT scans show changes of bone structure in postmenopausal women. These changes are associated with bone turnover markers related to bone loss. In a retrospective analysis of 239 individuals, Zhang et al. showed significant differences both between pre- and postmenopausal women as well as between postmenopausal women and older men. Whereas in women this effect might be explained by a reduction of estrogen dependent bone remodeling after the menopause, in men it might rather be attributed to a continuous bone loss caused by a lower calcium absorption, as well as a reduced physical and decreased gonadal activity [35]. Other studies analyzing patients of different ages did not show any difference in BBT [36][37]. Neither could BBT be shown to vary by the location of measurement [36][38] or by the patients’ ethnicity or sex [37]. The latter is generally not believed to be associated with the BBT [39][37][38][40][41][42]. On the contrary, some studies show statistically significant associations between the BBT and age or sex, even if in just some sites [43][44]. Zekry et al. report contradictory findings indicating that an increase in age might be correlated with an increase in BBT. [40]. The divergent results regarding age- and sex-related differences in BBT can possibly be attributed to the subpopulation analyses conducted by Zhang et al. who divided older patients with respect to their sex. Other studies analyzed variations between patients of different sex or age but did not stratify the groups. This might have masked the impact of age-related hormonal changes in postmenopausal women.
Another factor found to affect the BBT is the facial type [45][46]. Consisting of 155 individuals, Ozdemir et al. reported significantly lower values in high-angle patients than in normal and low-angle individuals [46]. Furthermore, Yu et al. found a reduced thickness of the buccal bone in skeletal class III patients with facial asymmetry on the deviated side [47]. Gingival thickness was demonstrated to be significantly correlated with the thickness of the underlying bone [48][49]. Consisting of CBCT scans of 144 individuals, Amid et al. reported a greater BBT at 2 to 6 mm apical to the CEJ in patients with thick gingival biotype [50]. Digregorio et al. investigated the effect of rapid maxillary expansion on BBT in mixed and permanent dentitions. They found a reduction of 0.73 to 1.25 mm in thickness when the maxillary permanent first molars were used as anchorage. With regard to an incidence of dehiscence at the maxillary permanent first molars of 2.5% to 55% after rapid maxillary expansion and similar results in mixed dentition to those observed when permanent teeth were used as anchorage, the use of deciduous teeth might serve as an alternative to avoid BBT reduction [51].
Radiographs should be taken prior to implant placement as implant material may lead to a misdiagnosis of peri-implant bone thickness. Vanderstuyft et al. found an artificial increase of implant diameter in CBCT scans of 12 to 15% due to blooming artefacts and an underestimation of peri-implant bone thickness of 0.3 mm. Within the transition zone of additional 0.45 mm around the implant, the buccal bone cannot always be seen [52].
Rédua et al. analyzed the correlation between spiral CT and CBCT with similar voxel sizes and found a significant correlation for direct measurements of the alveolar bone height [53]. More relevant than the image technique seems to be the real bone thickness. Rédua et al. found an absolute error that was smaller than 1 mm in measurement sites thicker than 0.6 mm. When the bone thickness was smaller than 0.6 mm, the measurements showed great variation for both CBCT and CT scan. The mean difference between real thickness and measurements taken by (CB-)CT was 0.03–0.28 mm in bones thicker than 6 mm and around 1.84–1.89 mm in bones thinner than 0.6 mm. They concluded that the BBT tends to be overestimated by (CB-)CT scans irrespective of the modality [53]. These results strengthen the assumption that a relevant proportion of healthy individuals have a BBT of <1 mm. Furthermore, they support the need of a critical selection of indication for immediate dental implant placement.
The number of included patients varied considerably among papers. Unfortunately, just one paper (Temple, Schoolfield et al. 2017) provided with all their measured data. Rather, most of them included information on the BBTs at the respective measurement point only in the form of summary statistics, most importantly the arithmetic mean and standard deviation. Yet, these two values vary substantially among papers, even if they relate to the same measurement point.
Furthermore, even upon request, only two papers (Temple, Schoolfield et al. 2017 and Amid, Mirakhori et al. 2017) disclosed how many BBTs were measured at every single measurement point that was covered in the respective paper. Therefore, the exact number of measured BBTs is unknown. When trying to estimate this number, one needs to take into account two opposing effects. On the one hand, based on Temple, Schoolfield et al. (2017) and Amid, Mirakhori et al. (2017), it seems to be that in the majority of papers the BBTs of all included patients were not measured at every single measurement point that was considered in that paper. Therefore, the number of patients per measurement point is usually significantly smaller than the total number of patients included. For instance, the data Temple, Schoolfield et al. included altogether 171 patients and BBTs at 24 distinct measurement points. However, not a single patient’s BBT was measured at more than eight measurement points. Rather, the 171 patients were distributed over the 24 measurement points, yet not in a uniform way. While the BBTs of the first premolars of the mandible were measured in 66 patients, the BBTs of the first molar of the mandible were measured in merely 22 patients. Amid et al. had even bigger differences among the patient numbers at their included measurement points. While the canines of the maxilla contained BBTs of only 16 patients, the lateral incisors of the maxilla included those of 171 patients. On the other hand, there are also papers that report a higher number of measured teeth than the total number of BBTs one obtains, assuming that all patients had their BBTs measured at every included measurement point. This can only be explained in a way that the measurement points of the right and left side of the jaw were pooled. However, it lacks the necessary information to infer the exact number of patients per measurement point. After all calculations, assuming that the number of patients per measurement point was equal to the number of patients , resulting in a number of 38,840 measured BBTs. Likely, this results in a small overestimation of the actual number of measurement point samples/BBTs. Fortunately, if the proportion of the actually included patients per measurement point to the total number of patients included follows a random mechanism, the obtained results will still be unbiased. Yet, to account for the resulting uncertainty, the standard errors of all subsequent estimates are substantially scaled up.
Moreover, a limitation is, of course, that buccal bone thickness was measured only on tooth-bearing segments of the jaw and not on extraction sockets. Measuring the buccal bone thickness after tooth extraction gives an even better impression of the feasibility of immediate implant placement according to the established limits. Obviously, a further reduction of the bone thickness due to the extraction of the tooth must be taken into account if a prognosis on the feasibility of the procedure is to be made on the basis of (CB)CT data. In this respect, the collection of data on buccal bone thickness after tooth extraction (ideally measured directly and not by radiographic imaging) would be desirable but is not practical due to the considerably smaller number of studies on this topic and their heterogeneity.

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Subjects: Dentistry, Oral Surgery & Medicine; Radiology, Nuclear Medicine & Medical Imaging
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Bilal Al-Nawas
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Diana Heimes
View Times: 654
Revisions: 3 times (View History)
Update Date: 16 Feb 2022
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