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Table of Contents
ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 101-110

Comparative evaluation of three different methods for evaluating alveolar ridge dimension prior to implant placement: An in vivo study


1 Department of Prosthodontics, Demonstrator Department of Prosthosdontics, Rohtak, Haryana, India
2 Department of Radiology, PGIMS, Rohtak, Haryana, India
3 Department of Oral and Maxillofacial Surgery, PGIDS, Rohtak, Haryana, India

Date of Web Publication25-Sep-2013

Correspondence Address:
Anshul Chugh
Department of Prosthodontics, PGIDS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.118872

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   Abstract 

Background: During treatment planning for dental implant placement, there is a need for assessment of alveolar bone. Bone evaluation limited to the use of panoramic and or periapical radiographs may be insufficient, as it provides only two-dimensional information about the implant sites. Computed tomography (CT) provides three-dimensional information. The measurement of alveolar ridge dimensions can be accomplished using ridge-mapping technique. This technique involves penetrating the buccal and lingual mucosa down to the alveolar bone (following the administration of local anesthetic) with calipers and measures the bucco-lingual width of the underlying bone.
Purpose: The aim of the study is to compare the techniques, i.e. ridge mapping, direct surgical exposure, and CT scan, which are used to measure the alveolar ridge bone width, and determine their accuracy in the clinical application.
Materials and Methods: The study was conducted on 20 patients who reported to the Out-patient Department (OPD) of Prosthodontics and Crown and Bridge, PGIDS, Rohtak (Haryana) for replacement of edentulous span with dental implant. Width of alveolar ridge was studied by three techniques, i.e. CT scan procedure, ridge mapping, and direct surgical exposure at two points (3 mm from the crest of ridge and 6 mm from the crest of ridge), and then taking measurements of surgical exposure as the control group, the measurements obtained from the other two techniques were compared and then accuracy of these methods was assessed. The mean, standard deviation, standard error of mean, and degree of freedom were calculated and subjected to statistical analysis using Student's unpaired " t" test.
Results: Results suggested that there is no significant difference in the measurements obtained by direct surgical exposure technique, ridge-mapping technique, and CT technique.
Conclusion: Use of ridge-mapping technique along with panoramic and intraoral radiograph is adequate in cases where the pattern of resorption appears more regular and where mucosa is of more even thickness. It is suggested to use CT scan technique in situations where the alveolar ridges are resorbed, there is presence of maxillary anterior ridge concavities, vestibular depth is inadequate, and ridge mapping is not feasible.

Keywords: Computed tomography scan, direct surgical exposure, implants′ alveolar ridge height and width, ridge mapping


How to cite this article:
Chugh A, Bhisnoi P, Kalra D, Maggu S, Singh V. Comparative evaluation of three different methods for evaluating alveolar ridge dimension prior to implant placement: An in vivo study. J Dent Implant 2013;3:101-10

How to cite this URL:
Chugh A, Bhisnoi P, Kalra D, Maggu S, Singh V. Comparative evaluation of three different methods for evaluating alveolar ridge dimension prior to implant placement: An in vivo study. J Dent Implant [serial online] 2013 [cited 2019 Aug 18];3:101-10. Available from: http://www.jdionline.org/text.asp?2013/3/2/101/118872


   Introduction Top


Throughout history, humans have attempted to replace missing or diseased tissues with natural or synthetic substances. There are two elements in tooth replacement, the materials for the replacement of tooth and some form of attachment mechanism. Various materials have been used for replacement of missing teeth, including carved ivory and bone, and also natural extracted teeth. As a mechanism of attachment, clinicians have long sought an analog for periodontal ligament. An alternative attachment mechanism was discovered by means of an accidental finding by Prof. Per Ingvar Branemark and his colleagues during 1950s-1960s. The metallic structure became incorporated in the living bone in a way formerly believed to be impossible, and Branemark called it osseointegration.

Use of osseointegrated implants is a widely accepted procedure in the rehabilitation of edentulous spaces. [1],[2] Treatment planning for implants includes a radiographic and clinical examination that provides information about the location of anatomical structures, the quality and quantity of available bone, the presence of bone lesions, [1],[2],[3],[4] the occlusal pattern, and the number and size of implants, as well as prosthesis design, all of which are essential for successful implant treatment. [1],[3]

Many types of radiographic imaging are recommended for treatment planning for implants, such as panoramic, intraoral periapical and occlusal radiographs, conventional tomography, and computed tomography (CT). Bone evaluation limited to the use of panoramic and or intraoral periapical radiographs may be insufficient because it only provides two-dimensional information about the implant sites. [5] The two-dimensional information obtained from standard dental radiographs allows the clinician to make an initial assessment of the bone levels available for implant treatment, but they give no indication of bone width. The clinicians need to identify the best method for each clinical situation. [6],[7],[8],[9],[10],[11] Since CT provides three-dimensional information, it is useful in diagnosis prior to dental implant treatment. [12] CT has several advantages over other imaging techniques that produce cross-sectional views of the jaws, and it has been found to most accurately reflect the true osseous morphologic condition of the jaws. [13] In order to optimize the information provided by more advanced radiographic techniques, it is necessary to provide information about the planned final restoration.

A stent that mimics the desired tooth setup is constructed and radiographic markers usually made of Gutta Percha or another radiopaque material are placed within it. Alternatively, if the patient has a suitable acrylic denture, radiographic markers may be placed within occlusal or palatal cavities cut in the acrylic teeth. The denture can also be replicated in clear acrylic to provide the radiographic stent. The radiopaque marker or rod can be placed in the position and angulations of the planned prosthetic setup. Thus, for a screw-retained prosthesis, the marker would indicate the access hole for the screw retaining the restoration. Alternatively, the relation of the bone ridge to the proposed tooth setup can be shown by painting the labial surface of the stent with a radiopaque varnish. The choice of radiographic marker is important in that it should be visible on the radiographic image but not interfere with the scan. When using CT, metal markers should be avoided as they can produce scattering on the image. Stents are also useful in the edentulous patient as they serve to stabilize the position of the jaws while the radiographs are being taken. The stent can also provide the radiographer with a true occlusal plane from which to orientate the axial scans.

The measurement of alveolar ridge dimensions can be accomplished using ridge-mapping calipers. [14],[15],[16],[17] This technique involves penetrating the buccal and lingual mucosa down to the alveolar bone (following the administration of local anesthetic) with calipers designed for this purpose. The pointed tips of the instrument penetrate the buccal and lingual soft tissue layers and measure the bucco-lingual width of the underlying bone. A series of measurements of the proposed implant site can be made prior to reflection of a mucoperiosteal flap. The technique has been advocated by Wilson [18] and Traxler et al., [19] as a convenient and reliable method for assessing suitability of potential implant sites. This procedure is performed chairside and provides instant information.

The direct caliper measurement following surgical exposure of alveolar bone of the ridge gives the most accurate measurement. [16],[17] However, the efficiency and accuracy of these techniques still need to be assessed.

Hence, the aim of this study is to compare the techniques, i.e. ridge mapping, direct surgical exposure, and CT scan, which are used to measure the alveolar ridge bone width, and determine their accuracy in the clinical application.


   Materials and Methods Top


Study sample

Twenty-five patients were selected from the Out-patient Department of Prosthodontics and Crown and Bridge, Post Graduate Institute of Dental Sciences, Rohtak. Out of these, 20 cases were selected for the study and 5 cases were excluded during treatment planning procedure (2 after ridge-mapping procedure and 3 after CT scan procedure). After explanation of the proposed study criteria, including alternate treatment, potential risks and benefits, the participants were asked to sign a consent form prior to the implant surgery.

Inclusion criteria

  1. Partially edentulous ridge
  2. At least one periodontally healthy and stable tooth adjacent to the edentulous ridge to serve as abutment for radiographic stent
  3. Healing period of at least 3 months after tooth extraction
  4. Good oral hygiene
  5. Partially edentulous ridge
  6. At least one periodontally healthy and stable tooth adjacent to the edentulous ridge to serve as abutment for radiographic stent
  7. Healing period of at least 3 months after tooth extraction
  8. Good oral hygiene.


Exclusion criteria

  1. Pregnancy
  2. Smoking habits
  3. Debilitating diseases
  4. Immunocompromised patients
  5. Pregnancy
  6. Smoking habits
  7. Debilitating diseases
  8. Immunocompromised patients.


Study design

Twenty implants were placed in patients requiring replacement of missing teeth. Study participants were divided into following groups based on the method of measurements of alveolar ridge width dimensions.

  1. Based on direct surgical exposure (Group 1)

    1. Measurement of alveolar width dimension at point 1 (3 mm from the crest of ridge)
    2. Measurement of alveolar width dimension at point 2 (6 mm from the crest of ridge)
  2. Based on CT scan procedure (Group 2)

    1. Measurement of alveolar width dimension at point 1 (3 mm from the crest of ridge)
    2. Measurement of alveolar width dimension at point 2 (6 mm from the crest of ridge)
  3. Based on ridge-mapping procedure (Group 3)

    1. Measurement of alveolar width dimension at point 1 (3 mm from the crest of ridge)
    2. Measurement of alveolar width dimension at point 2 (6 mm from the crest of ridge).



   Materials and Methodology Top


Study sample

25 patients were selected from the Out Patient Department of Prosthodontics and Crown and Bridge, Post Graduate Institute of Dental Sciences, Rohtak. Out of these, 20 cases were selected for the study and 5 cases were excluded during treatment planning procedure (2 after ridge mapping procedure and 3 after CT scan procedure). After explanation of proposed study criteria including, alternate treatment, potential risks and benefits, the participants were asked to sign a consent form prior to the implant surgery.

Study design

20 implants were placed in patients requiring replacement of missing teeth. Study was divided into following groups based on the method of measurements of alveolar ridge width dimensions.

  1. Based On Direct Surgical Exposure (Group-1)

    1. Measurement of alveolar width dimension at point 1 (3 mm from crest of ridge)
    2. Measurement of alveolar width dimension at point 2 (6 mm from crest of ridge)
  2. Based On Ct Scan Procedure (Group-2)

    1. Measurement of alveolar width dimension at point 1 (3 mm from crest of ridge)
    2. Measurement of alveolar width dimension at point 2 (6 mm from crest of ridge)


  3. Based On Ridge Mapping Procedure (Group-3)

    1. Measurement of alveolar width dimension at point 1 (3 mm from crest of ridge)
    2. Measurement of alveolar width dimension at point 2 (6 mm from crest of ridge).


Methods

Detailed medical and dental history of each patient was taken. Clinical pre-operative photographs were taken as diagnostic records. Edentulous area selected for implant placement was evaluated clinically for bucco- lingual and mesio-distal width and any undercuts. Complete haemogram, blood sugar test, were done to evaluate the fitness of the patient for implant placement. Complete oral prophylaxis was done before the implant placement. Patients were advised to use 0.2% chlorhexidine gluconate mouthwash, twice daily for a period of 15 days. Adequate instructions were given on oral hygiene maintenance.

The diagnostic impression was made of the maxillary and mandibular ridges with irreversible hydrocolloid. Study models were prepared with these impressions. On the study model (with edentulous span) one point was marked on the crest of ridge (reference point) in reference to the adjacent teeth. Then another point (point 1) was marked at 3 mm distance from the reference point at the crest of ridge. Another point (point 2) was marked at 3mm from point 1 i.e. at 6 mm distance form the reference point at the crest of ridge. Point 1 and 2 were marked on both buccal as well as on lingual/palatal aspect [Figure 1]. A line was drawn on the study model taking these points as reference and further extended on buccal and lingual/palatal aspect to serve as a reference for the sectioning of ridge mapping stent [Figure 2].
Figure 1: Markings of point 1 and point 2 done on cast

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Figure 2: Marking of reference line

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On the study model, a self cure acrylic resin custom tray was fabricated with wax spacer [Figure 3]. After removal of the wax spacer, impression was made of the edentulous ridge portion of the cast, including adjacent teeth using vinyl polysiloxane impression material [Figure 4]. The reference line was marked with marker over special tray to cut along that line. The special tray with putty was cut by using electric saw in reference to the line marked and the points were transferred to the impression for ridge mapping [Figure 5].
Figure 3: Two thickness wax spacer adapted over cast

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Figure 4: Transfer of refernce points from cast onto the ridge mapping stent

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Figure 5: Recordings done on all points transferred to graph paper and width of ridge measured

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The cut half of the impression with the markings was then traced on a graph paper to give the shape of the ridge. The points on the impression were transferred on the graph paper [Figure 6]. The same impression after disinfecting with Nanzidone Povidone-Iodine Solution I.P Microbial solution (5%) was then transferred to the patient's mouth. William's periodontal probe was used to get the thickness of mucosa (under local anesthesia) on point 1 and point 2 on both buccal and lingual/palatal aspect. Recordings done of thickness of mucosa on all the points were then transferred to the graph paper having ridge tracing [Figure 7]. Now the exact contour of the alveolar bone was obtained after probing and the width of ridge was measured from two points on buccal side to the two points on lingual side.
Figure 6: Cut half of the impression with markings transferred onto the graph paper

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Figure 7: Slicing of region of interest done

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For radiographic stent fabrication, a clear acrylic resin stent was fabricated over the study model with reference points. The reference points were visible over the stent through the transparent acrylic resin material; a 1 mm diameter hole was then made over these 5 points. The points were then filled with radiopaque Gutta Percha material [Figure 8]. Due to the radiopaque property of Gutta Percha material, the acrylic stent was converted into radiographic stent.

The radiographic stent after disinfection with Nanzidone Povidone-Iodine Solution I.P Microbial solution (5%) was then inserted in the patient's mouth. The CT machine SEIMEN SOMATOM was set at 120kV, 70mAs and the CT scan was done with the patient in supine position and. The sectioning of the region of interest (ROI) (Edentulous span) was done using Diacom viewer software [Figure 9] and the paraxial section with all GP points was selected [Figure 10]. The width of the alveolar ridge was measured on this section.
Figure 8: Slice no. having all five reference points selected and measurements made

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Figure 9: Measurements made using caliper

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Figure 10: Dental implant placed

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The stent which was used for radiograph was then modified by removing the GP material from the stent [Figure 11]. After reflection of mucoperiosteal flap on the buccal and lingual aspect, the ridge was exposed. The modified stent was now placed on the exposed ridge and the measurements were taken on the same points on which the other recordings were done using a caliper [Figure 12]. Hence, this gave the width of the ridge during the surgical exposure.

All the reading of alveolar ridge width obtained from the three techniques i.e. ridge mapping, CT scan and direct surgical exposure were then assessed and compared.
Figure 11: Radiographic stent Modified by removing GP Points

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Figure 12: Measurements made using caliper

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The results obtained were subjected to statistical analysis. The mean, standard deviation, standard error of mean, degree of freedom were calculated and subjected to statistical analysis using Student's Unpaired 't' test.


   Results Top


According to the results obtained from the above study, [Table 1] shows that mean alveolar ridge dimensions obtained from three methods i.e. direct surgical exposure, CT scan procedure and ridge mapping was 3.9800mm, 4.1250 mm and 3.9600 mm respectively for point 1 and 6.4050 mm, 6.5700 mm and 6.4250 mm respectively for point 2. The graph depiction of table is shown in Graph 1 [Additional file 1]. This data shows that the mean difference between CT Procedure measurements and direct surgical exposure at point 1 is 0.1450 mm and at point 2 is 0.0200 mm and mean difference between ridge mapping and surgical exposure at point 1 is -0.0200 mm and at point 2 is 0.0200 mm. The graph depiction of table is shown in Graph 2 [Additional file 2]. This data suggest that except mean difference of ridge mapping and surgical exposure at point 1, rest all measurements were higher for surgical exposure. At this point the mean difference was found to be (-) 0.0200 mm, but is non significant. This shows that at this point there was underestimation of bone but was not significant. A similar study by Perez et al. [20] suggested that both ridge mapping and Linear tomography significantly underestimated the posterior mandibular ridge width when compared to direct measurements.
Table 1: Mean, standard deviation and degree of freedom of measurements made in all the three groups

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[Table 2] and [Table 3] shows mean values of the recorded alveolar ridge width compared in direct surgical exposure and ridge mapping procedure at point 1 and 2 respectively. The mean alveolar ridge width for direct surgical exposure method was 3.9800 mm and 3.9600 mm for ridge mapping procedure at point 1 and 6.4050 mm for direct surgical exposure and 6.4250 mm for ridge mapping procedure at point 2. The graph depiction of table is shown in Graphs 3 and 4 [Additional file 3] [Additional file 4]. The 'P' value for group 1 and group 3 was found to be non significant (P < 0.05 is highly statistically significant) Thus in this study, the alveolar ridge dimensions measured by direct surgical exposure and ridge mapping procedure were same at point 1. The results of this study are in accordance with the study of Chang et al. [21] who concluded his study by stating that ridge mapping provide measurements of the bucco-lingual ridge width consistent with those obtained by direct caliper measurement following surgical exposure of the bone. A study by Perez et al. [20] found no significant difference between ridge mapping and linear tomography measurements at coronal level, middle level and apical level of mandibular ridge.
Table 2: Comparison of direct surgical exposure and ridge mapping procedure (group 1 verses group 3) at point 1

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Table 3: Comparison of Direct surgical exposure and ridge mapping procedure (Group 1 verses group 3) at point 2

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[Table 4] and [Table 5] shows mean values of the recorded alveolar ridge width compared in direct surgical exposure and CT can procedure at point 1 and point 2. The mean alveolar ridge width calculated with direct surgical exposure and CT Scan procedure was 3.9800 mm and 4.1250 mm respectively for point 1 and 6.4050 mm and 6.5700 mm respectively for point 2. The graph depiction of table is shown in Graphs 5 and 6 [Additional file 5] [Additional file 6]. The 'P' value for group 1 and group 2 was found to be non significant (P < 0.05 is highly statistically significant) Thus in this study, the alveolar ridge dimensions measured by direct surgical exposure and CT Scan procedure were same at point 1 and point 2. This study is in accordance with the study done by Goulet et al. [22]who did a human cadaver study and demonstrated no difference between real measurements and image measurements made from CBCT technique which according to author was inferior to conventional CT Scan.
Table 4: comparison of Direct surgical exposure and ct scan procedure (Group 1 verses group 2) at point 1

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Table 5: Comparison of direct surgical exposure and ct scan procedure (group 1 verses group 2) at point 2

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   Discussion Top


In all phases of clinical dentistry, careful planning and diagnosis result in a more predictable outcome. [3] Fabrication of an implant-supported single tooth restoration, both esthetically and functionally, depends on the ridge morphology and the orientation of implant. The placement of dental implants requires meticulous planning and careful surgical procedures. The contour of the residual bone must be evaluated prior to implant placement in order to assure proper implant positioning. It can be visualized using study models along with diagnostic wax-up. [23] A further important part of the planning process is to determine the nature of surgical procedure required to place the implant. [17]

Preoperative radiographic assessment has assumed an increasingly important role in treatment planning for implant-supported prostheses. [13] A panoramic radiograph gives an overall view; however, it is incomplete due to the distortions and inconsistent magnification that it generates. [8],[24] Periapical radiographs of the edentulous region show the bone height, the inter-radicular mesio-distal space, as well as the position of the anatomical structures in a bucco-lingual plane.

Nevertheless, these diagnostic methods reveal no information on the sagittal bony morphology and on the ideal orientation to give the implant to meet restorative requirements. Bone quantity and quality will influence the choice of implants with respect to their number, diameter, length, and type. [7],[8] It often requires a more extensive radiographic examination than that used for other types of oral rehabilitation. Many imaging modalities have been reported to be useful for dental implant therapy, including periapical, panoramic, cephalometric, and tomographic radiography, CT, interactive CT, and magnetic resonance imaging (MRI). [11]

Only a pre-operative bone evaluation of the arch using a scan [25] (along with a radiopaque indicator) or a technique for probing the surface of the bone will allow one to better visualize the sagittal topography of the bone. [18]

The advantages of CT-based systems are uniform magnification, a high-contrast image with a well-defined image layer free of blurring, easier identification of bone grafts or hydroxyapatite materials used to augment maxillary bone in the sinus region than with conventional tomography, multiplanar views, three-dimensional reconstruction, simultaneous study of multiple implant sites, and the availability of software for image analysis.

The disadvantages of CT include limited availability of reconstructive software, expense, higher doses of radiation compared with conventional tomography, lack of understanding of the dentist's imaging needs by the radiologic technologists and medical radiologists who acquire and interpret the CT images, and lack of usefulness for implant-interface follow-up because of metallic streak artifacts.

Some studies concluded that CT is better than conventional tomography. Linear tomography has been reported to significantly overestimate the distance between the alveolar crest and the top of the canal. [7],[8] Lam et al.[26] (1995) have commended the use of CT imaging for assessing bucco-lingual bone dimensions, but they did, however, indicate problems inherent with the use of this technique. These included the length of time to produce an image (20-25 min), the cumulative radiation dose to the head and neck area, and the possibility of a distorted image with metallic tooth restorations and/ or patient movement. A further consideration with CT imaging is financial cost.

Methods of dose reduction for implant imaging include: (a) lowering the mill amperes, (b) changing the spiral CT pitch from 1:1 to 2:1, and (c) reducing the number of slices to the very minimum needed. [27],[28],[29]

The measuring of ridge width can also be accomplished using ridge-mapping calipers. This technique involves penetrating the buccal and lingual mucosa down to bone (following the administration of local anesthetic) with calipers designed for this purpose. A series of measurements of the proposed implant site can be made prior to reflection of a mucoperiosteal flap. The technique has been advocated by Wilson [18] (1989) and Traxler et al. [19] (1992), who suggest that it is a convenient and reliable method for assessing suitability of potential implant sites. The ridge-mapping method has the advantage of being simple to use, and avoids exposure to radiation for the patient.

In the majority of cases in the study, surgery proceeded uneventfully, with the bony ridge widths predicted prior to surgery proving to be reasonably accurate at surgery. [30] It is suggested that in situations where marked concavity of the labial aspect of the bony ridge is evident, one should consider using CT scanning to supplement clinical assessment. In cases where the pattern of resorption appears more regular, and where mucosa is of a more even thickness, ridge mapping with panoramic and intraoral radiography may prove adequate.

The ridge-mapping procedure has the advantage of being simple to use and avoids exposure of the patient to radiation. According to the results obtained from the study, there is no significant difference in direct surgical exposure and ridge-mapping measurements, which supports the use of ridge-mapping procedure for the evaluation of alveolar ridge width for partially edentulous ridges. Ridge mapping has provided measurements of bucco-lingual width consistent with those obtained by direct caliper measurements following surgical exposure of the bone. The results obtained are in accordance with the study done by Perez et al. [20] and Goulet et al.[22]

According to the results obtained from our study, there is no significant difference in CT and direct surgical exposure measurements, which supports the use of CT method for the evaluation of alveolar ridge width measurements in areas where the ridges are resorbed, there are maxillary anterior ridge concavities, high lingual frenum areas, and vestibular depth is less and ridge mapping is not feasible.

Since the sample size was relatively small, further studies are recommended with data of larger size.


   Conclusion Top


The aim of this study was to assess alveolar ridge width obtained from direct surgical exposure, ridge mapping, and CT, and compare and, hence, evaluate the accuracy of these methods in determining the alveolar ridge width during the treatment planning procedure for implant placement.

Thus, this study measured the alveolar ridge width dimensions for pre-surgical planning of implant placement and compared the ridge mapping technique and the CT scan technique with the direct surgical exposure technique and further analyzed based on three parameters selected.

Within the limitations of the study, the following conclusions were drawn:

  1. There is no significant difference in the measurements obtained by direct surgical exposure technique and ridge mapping technique
  2. There is no significant difference in the measurements obtained by CT technique and direct surgical exposure technique
  3. Thus, the measurements of alveolar ridge width dimensions obtained by all the three techniques, i.e. ridge mapping, CT scan, and direct surgical exposure are found to be the same at point 1 and point 2.


Based on the results obtained from this study, the following measures may be recommended for the measurement of alveolar ridge width dimensions for pre-surgical planning of implant placement.

  1. Use of ridge mapping technique along with panoramic and intraoral radiograph is adequate in cases where the pattern of resorption appears more regular and where mucosa is of more even thickness
  2. It is suggested to use CT scan technique in situations where the alveolar ridges are resorbed, there is presence of maxillary anterior ridge concavities, there are high lingual frenum areas, vestibular depth is inadequate, and ridge mapping is not feasible.


Since the sample size was relatively small, further studies are recommended with data of larger size.

 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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