Article_6_4_4-Nazari
ORTHODONTICS
EVALUATION OF BONE MINERAL DENSITY USING CONE BEAM COMPUTED
Original Articles
TOMOGRAPHY
Mohammad Sadegh Nazari1a , Ahmad Reza Tallaeipoor2b, Ludovica Nucci3c, Amir Ali Karamifar4d, Abdolreza Jamilian5e* ,
Letizia Perillo3f
1
Department of Orthodontics, School of dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
2
Department of Oral and Maxillofacial Radiology, Cranio Maxillofacial Research Center, Faculty of Dentistry, Tehran Medical Sciences, Islamic Azad
University, Tehran, Iran
3
Multidisciplinary Department of Medical-Surgical and Dental Specialties, Dental School, University of Campania Luigi Vanvitelli, Naples, Italy
4
Department of Orthodontics, School of Dentistry, Semnan University of Medical Sciences, Semnan, Iran
5
Department of Orthodontics, Cranio Maxillofacial Research Center, Faculty of Dentistry, Tehran Medical Sciences, Islamic Azad University, Tehran,
Iran
a
Postgraduate Dental Student
b
DDS, PhD, Professor
c
Undergraduate Dental Student
d
DDS, MSc
e
DDS, PhD, Professor
f
DDS, PhD, Professor
ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(4).art.4
OPEN ACCESS This is an Open Access
Introduction: Bone mineral density (BMD) is an important factor in the use of article under the CC BY-NC 4.0 license.
anchorage device. This study assessed the amount of bone density in the areas
Peer-Reviewed Article
from 2.5 and 8.11 mm from maxillary alveolar to basal bone in Hounsfield units.
Citation: Nazari MS, Tallaeipoor AR, Nucci L,
Methodology: The samples included 30 unilateral cleft palate (15 males and 15 Karamifar AA, Jamilian A, Perillo L. Evaluation of
females) with the mean age of 14.23±2.5 years and 30 non-clefts (15 males and bone mineral density using cone beam computed
tomography. Stoma Edu J. 2019;6(4):241-247
15 females) with the mean age of 14±2.59 years. CBCT was used to estimate the
Received: October 18, 2019
values of bone density in Hounsfield units in the cleft and noncleft patients. BMD Revised December 11, 2019
was measured in 4 heights (2-5-8-11mm) from alveolar bone to basal bone in Accepted: December 12, 2019
Published: December 17, 2019
mesio-distal and bucco-lingual slices in the upper jaw. T-test was used to analyze
*Corresponding author:
the bone density values between the cleft and noncleft. Abdolreza Jamilian
Results: The highest alveolar bone density in the mesio-distal slice was 1004± Department of Orthodontics, Cranio Maxillofacial
Research Center, Faculty of Dentistry, Tehran Medical
6 HU between the right and left centrals in the upper jaw in height of 11 mm in Sciences, Islamic Azad University, Tehran, Iran
Tel/Fax: 0098-22052228, e-mail: info@jamilian.net
non-cleft patients. The least amount of alveolar bone density in the mesio-distal
slice was 259±29 HU in tuberosity in height of 11 mm in cleft patients. In non-cleft Copyright: © 2019
the Editorial Council for the Stomatology Edu Journal.
patients, the most amount of bone density was found 1639± 11 HU between the
centrals in height of 11 mm in the bucco-lingual slice.
Conclusions: Bone density in cleft patients was lower than in non-cleft patients
in all areas and maxillary tuberosity showed the lowest bone density in cleft and
non-cleft patients.
Keywords: Cone Beam Computed Tomography; Bone Mineral Density;
Dental Implants; Single-Tooth; Orthodontics.
1. Introduction has not been broadly used in dentistry because of its
The amount of bone tissue is called bone mineral high cost, presence of artifacts in images, high dose
density (BMD)[1]. Assessment of BMD is necessary in of radiation and complexity of examination.
many clinical conditions such as oral systemic diseas- Recently CT has been replaced by cone-beam com-
es, implant planning and it also has an important role puted tomography (CBCT) to evaluate anatomic struc-
for the stability of mini-implants as anchorage [2,3]. tures and the direct measurement of mineralized tissue
Computed tomography (CT) is a diagnostic method [5,6]. CBCT provides suitable image quality conco-
before performing dental implant. It allows accurate mitant with a lower exposure dose. Fast scanning
three-dimensional evaluation of anatomical struc- time, low cost and a lower number of image artifacts
tures of the bone. It also measures BMD which it are the other advantages of CBCT when compared
expresses in Hounsfield units (HU) [4]. Although CT to CT [7-9]. CBCT has frequently been used to assess
is a diagnostic tool in medical practice, this method the quality of skeletal structures by determination of
Stomatology Edu Journal 241
EVALUATION OF BONE MINERAL DENSITY USING CONE BEAM COMPUTED TOMOGRAPHY
Original Articles
Figure 1. (a) Mesio-distal measurement on the palatal side; (b) Mesio-distal measurement on the buccal side.
Figure 2. (a) Bucco-lingual measurement on the maxilla; (b) Bucco-lingual measurement on the mandible.
mineral density. CBCT has many advantages when measured from the alveolar bone crest to basal bone
compared with conventional CT, including lower in HU obtained by CBCT in unilateral cleft palate and
cost, smaller radiation dose, and the need for less non-cleft patients.
space. CBCT scanning is associated with some draw-
backs, such as poor soft tissue contrast, motion arti- 2. Methodology
facts and image noise. Conventional CT may distin- The participants in this retrospective research were
guish 70% of root fractures, but the higher cost and 30 unilateral cleft palates (15 males and 15 females)
high dose of radiation limit the use of this technique with the mean age of 14.23+2.5 years and 30 non-
[10]. BMD can be recognized by Gray values acquired cleft patients (15 males and 15 females) with the
with CBCT as the HU values [11]. mean age of 14+2.59 years. The criteria to select the
CBCT provides a three-dimensional analysis with patients were as follows: no history of serious disease
the quantification of the mineral density of jaws in affecting oral bones, no periodontal problems, no
Hounsfield units (HU) [3]. CBCT is a valuable method previous fracture, no history of bone grafting, no pre-
for diagnosis and treatment planning especially in vious orthodontic therapy, none of the patients were
cleft lip and palate patients because it offers better on hormone therapy or taking calcium, vitamin D,
data about the size and appearance of the anatomic fluorides, calcitonin, bisphosphonates, no palatal fis-
structures affected by the cleft, the position of miss- tula or infection. CBCT of all the patients were taken
ing teeth, the amount of BMD, as well as the posi- by the same radiologist for orthodontic treatment.
tion of mini screw, dental implants and so on. To our All unilateral cleft palate patients had palatal clo-
knowledge no study compared the BMD of cleft pa- sure before the age of 2. The CBCT (New Tom 5G; QR,
tients with non-cleft samples. Verona, Italy) was performed to assess BMD in the
Therefore, due to the lack of research in this area the cleft and noncleft regions in all patients. The images
aim of this study was to compare the BMD of inter- were obtained at 120 kV and 8 mA. 0.2 mm3 voxel,
radicular distances at heights of 2, 5, 8 and 11 mm 80 mm field of view BMD was calculated using the
242 Stoma Edu J. 2019;6(4): 241-247 www.stomaeduj.com
EVALUATION OF BONE MINERAL DENSITY USING CONE BEAM COMPUTED TOMOGRAPHY
Table 1. BMD in Hounsfield units (HU) from the mesio-distal slice in the maxillary arch between teeth and
Original Articles
tuberosity.
Mesio-distal slice 2 mm 5mm 8 mm 11 mm
Region Group Mean ±SD Mean ±SD Mean ±SD Mean ±SD
1-1 Non-cleft 896±17 ** 935±6 ** 983±4 ** 1004±6 **
Cleft 884±5 923±7 973±5 994±5
2-1 Non-cleft 874±7 ** 916±5 ** 953±6 ** 994±5 **
Cleft 862±9 908±8 941±8 984±6
Non-cleft 851±6 ** 897±25 * 935±7 ** 945±5 **
3-2
Cleft 842±19 882±27 923±9 932±10
4-3 Non-cleft 845±25 * 872±28 896±27 915±34
Cleft 832±26 860±29 885±27 904±34
5-4 Non-cleft 832±34 857±26 886±22 872±24
Cleft 831±27 845±25 875±23 857±25
6-5 Non-cleft 934±61 980±89 954±72 645±50
Palatal side Cleft 913±40 951±37 927±35 634±50
7-6 Non-cleft 899±39 934±47 880±37 542±57
Palatal side Cleft 877±59 919±43 868±39 535±50
6-5 Non-cleft 825±42 846±38 870±41 643±47
Buccal side Cleft 814±43 838±35 855±42 626±46
7-6 Non-cleft 770±82 ** 671±90 773±79 406±81
Buccal side Cleft 721±63 660±88 759±77 397±79
Non-cleft 650±125 566±129 408±98 265±55
Tuber
Cleft 643±107 539±105 407±64 259±29
** P 01/0> * P 05/0>
Xoran Cat software version 3.1.62 (Xoran Techno- molar and first molar (5 and 6); between the first and
logies, Ann Arbor, MI, USA). This software includes second molars (6 and 7). Mean and standard devia-
an application to outline the selected bone within tions of BMD were measured for heights of 2-5-8 and
a defined area and to provide the average BMD in 11 mm in cleft and non-cleft patients. T-test was used
HU. Using the Xoran Cat software, version 3.1.62 the to analyze the bone density values between the cleft
slices were made in the alveolar bone height in the and noncleft. SPSS 18.0 (SPSS, Inc, Chicago, IL, USA)
range of 2-5-8- to 11 mm from the alveolar crest to was used for statistical analysis. The differences were
the basal bone in mesio distal slices and in bucco- considered statistically significant with the p<0.05.
lingual slices on the right and left sides of the max-
illary arch. In other words, BMD was measured in 4 3. Results
heights (2-5-8-11mm) from the alveolar bone to the The highest alveolar BMD in the mesio distal slice was
basal bone in mesio distal and bucco-lingual slices in 1004± 6 HU between the right and left centrals in the
the following areas. Figures 1 and 2 show the mesio- upper jaw in height of 11 mm in non-cleft patients.
distal and bucco-lingual measurement respectively. The least amount of alveolar BMD in the mesio-distal
Between the right and left centrals (1 and 1); be- slice was 259±29 HU in tuberosity in height of 11 mm
tween the central and lateral incisors (1 and 2); be- in cleft patients. The highest amount of BMD in the
tween cuspids and first premolars (3 and 4); between posterior region found was 980± 89 HU which was
the first and second premolars (4 and 5); between the between the second premolar and the first molar in
second premolar and first molar (5 and 6); between a depth of 5 mm from the mesio-distal view in non-
the first and second molars (6 and 7); the region distal cleft patients and it was 927±35 HU in height of 8
to second molars (7D) and tuberosity for both sides mm in the same slice in cleft patients. The highest
of the upper jaw. These heights were also measured amount of BMD in the palatal side was 980±89 HU in
on the palatal and buccal sides in mesio-distal slice 5 mm from alveolar crest in non-clefts patients and
only in the posterior region between the second pre- the lowest one was 626±46 HU in the buccal side in
Stomatology Edu Journal 243
EVALUATION OF BONE MINERAL DENSITY USING CONE BEAM COMPUTED TOMOGRAPHY
Table 2. BMD in Hounsfield units (HU) from the bucco-palatal slice in the maxillary arch between teeth and
Original Articles tuberosity.
Bucco-palatal slice 2 mm 5mm 8mm 11mm
Region Group Mean ±SD Mean ±SD Mean ±SD Mean ±SD
1-1 Non-cleft 615±5 ** 683±4 ** 783±6 ** 1639±11**
Cleft 607±5 671±6 772±6 1582±26
2-1 Non-cleft 684±4 ** 764±6 ** 845±4 ** 1447±10 **
Cleft 673±7 753±9 836±6 1438±10
3-2 Non-cleft 756±6 ** 848±18 ** 903±6 ** 1257±10 **
Cleft 744±7 837±6 894±6 1248±10
Non-cleft 825±5 ** 924±5 ** 963±4 ** 1064±4 **
4-3
Cleft 819±7 917±7 949±8 1051±8
5-4 Non-cleft 934±6 ** 993±4 ** 1008±9 ** 830±20
Cleft 921±7 981±8 1001±9 822±19
6-5 Non-cleft 1078±18 ** 1159±21 ** 1030±9 ** 674±105
Cleft 1064±19 1146±20 1018±9 661±104
7-6 Non-cleft 1332±43 1439±45 1254±24 ** 643±22 *
Cleft 1331±44 1427±45 1209±31 631±19
Tuber Non-cleft 833±34 839±26 365±19 * 262±19 *
Cleft 822±32 750±25 354±17 251±19
** P 01/0> * P 05/0>
11 mm from alveolar crest in clefts samples. Table 1 second premolar and first molar in depth of 5 mm
shows the means, standard deviations between the from the crest of the alveolar bone and also in the
assessed areas on cleft and non-cleft patients in me- bucco-lingual slide, may be between the first and
sio-distal slice. The BMD of the anterior region of the second molars in a depth of 5 mm from the crest of
maxilla in non-cleft patients was statistically higher alveolar bone in cleft and non-cleft patients. The in-
than the cleft samples in the bucco-lingual slices in sertion of mini-implants in this area, considering only
all areas. In non-cleft patients, the highest amount of the highest BMD as a factor for success, would be
BMD found was 1639±11 HU between the centrals more interesting. But one must keep in mind that this
in height of 11 mm in the bucco-lingual slice in non- does not always occur, because other factors may
cleft patients. The highest amount of BMD in the pos- contribute to loosening the mini-implants. For mini
terior region was found between the first and second implant installation there must be adequate cortical
molars in a depth of 5 mm from the bucco-lingual bone thickness and also high BMD. It is considered
view in both cleft and non-cleft patients which was that BMD is a key factor for the stability of mini-im-
1439±45 HU and 1427±45 HU respectively. There was plants as anchorage. BMD should be such so as to
no significant difference between the 2 groups in this favor the mechanical retention of the mini implant in
area. The least amount of BMD found was 251±19 HU a predetermined position. There are many factors for
in tuberosity in height of 11mm in the bucco-lingual losing mini-implants as anchorage and one of these
slice of cleft patients Table 2 shows the values ob- factors is poor density [12-15]. BMD has an important
tained for the means, standard deviation between role in a successful implant. Areas of lesser bone qual-
the assessed areas on cleft and non-cleft patients in ity have exhibited weaker stability and higher failure
bucco-lingual slice. rates of dental implants [16,17]. The data which one
obtained from this study will serve as guidelines
4. Discussion for choosing the best quality of alveolar BMD for
The result of this research can be used as additional the placement of mini implants or dental implants.
information to select the most suitable area for an- There was a progressive increase in BMD from cleft
chorage devices such as mini- implants. These find- to non-cleft patients in all areas. This study showed
ings suggest that the best quality of alveolar bone that the maxillary tuberosity area had a lower BMD
density for mini implant installation from the mesio- and also showed that BMD was greater on the palatal
distal view, may be in the posterior area between the side than the buccal side between second premolars
244 Stoma Edu J. 2019;6(4): 241-247 www.stomaeduj.com
EVALUATION OF BONE MINERAL DENSITY USING CONE BEAM COMPUTED TOMOGRAPHY
and the first & second molars in both groups. Due to tions and limitations of currently used reconstruction
Original Articles
this fact anchorage devices can be applied on the algorithms [25].
palatal side. On the other hand, with respect to the
aesthetic concerns of the device, and for greater me- 5. Conclusions
chanical control, mini implants can be inserted in the BMD in non-cleft patients was higher than in cleft
lingual side[18]. BMD can be measured in HU by CT patients in all area; however, the mean BMD in non-
and CBCT [8]. With CT, BMD values are presented in cleft patients was significantly greater than in cleft
Hounsfield Unit (HU) based on density of air (-1,000 patients from the upper left to the right canines in
HU) and pure water (0 HU).The density of cortical all areas in the medio-distal slice. Significantly higher
bone ranges from±1,000 to ±1,600 HU values [19]. BMD was found in the labial cortical plate between
Turkyilmaz et al [20] determined that BMD ranged the centrals on the mesio distal direction in depth
from 278 to 1,227 HU in the jaws, with a mean of 751 of 11 mm from the alveolar crest in cleft and non-
HU. According to Turkyilmaz et al, the variability of cleft patients; however, the differences between 2
the different amount of DBM in the literature is due groups were significant. The highest amount of BMD
to the effect of variables such as age and sex. BMD was found between the first and second molars on
varies according the regions of the jaws and may be the bucco palatal area 5 mm from the alveolar crest
affected by many factors including osteoporosis, ex- in cleft and non-cleft patients and the differences
istence or absence of cleft [21-22]. between them were not statistically significant. The
Because of the high dosage of CT and lower dose of maxillary tuberosity showed the zBMD.
radiation exposure of CBCT, recently CBCT has been The amount of BMD was higher in the palatal side
widely used for craniofacial imaging [23]. than the buccal side both in cleft and non-cleft pa-
Pripatnanont et al [24] found that the mean BMD tients between the second premolar and the first &
after grafting in the cleft site was 426.1±120.1 HU second molars.
which was statistically lower than that in the noncleft
site with the mean value of 543.9 ±120.2 HU. Regard- Author Contributions
ing the different types of secondary alveolar bone MSN: responsible for study design, administration,
grafting in patients with cleft lip and palate, Scalzone data interpretation, recruitment, statistical analysis,
et al [25] in a systematic review found that the au- literature review. ART: responsible for data interpreta-
tologous bone and rh-BMP2 graft showed a similar tion, critical revision and final approval of the article.
effectiveness in maxillary alveolar reconstruction AJ: responsible for the study concept, study design,
assessing bone graft volume and height, although data interpretation, critical revision, writing and re-
the rh-BMP2 graft showed a relative shorter length vising the report and final approval of the article.
of hospital stay. The use of BMD using CBCT required LN: responsible for the literature review.
high stability and reliability of gray values and a con- AAK: responsible for data gathering, LP: responsible
sistent correlation between quantitative gray values for drafting, data interpretation, critical revision and
and density. Various limitations are associated with final approval of the article.
the use of Hounsfield unit values in CBCT. These is-
sues relate to the limited-field of CBCT geometry, Acknowledgment
basic radiation physics principles and the assump- There is no conflict of interest.
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Mohammad Sadegh NAZARI
Postgraduate Student
Department of Orthodontics
School of Dentistry
Mashhad University of Medical Sciences, Mashhad, Iran
CV
Maohammad Sadegh Nazari graduated from the Tehran Azad University of Dental School in 2017 and as
a resident of orthodontics in 2018 at the Mashhad University of Medical Science. He became a top Iranian
student researcher in 2016 and a national student in 2016. He has published 9 articles. He has participated in
various conferences and congresses and has had several oral presentation and posters. His scientific interests
are focused on orthognathic surgery patients.
246 Stoma Edu J. 2019;6(4): 241-247 www.stomaeduj.com
EVALUATION OF BONE MINERAL DENSITY USING CONE BEAM COMPUTED TOMOGRAPHY
Questions
Original Articles
1. What is the amount of bone tissue?
qa. Hounsfield unit;
qb. Bone mineral density (BMD);
qc. Bone resorption;
qd. Bone remodeling.
2. Which one is used to evaluate anatomic structures and thr direct measurement of
mineralized tissue before dental implant?
qa. CBCT;
qb. HU;
qc. MRI;
qd. CT.
3. What is the highest alveolar bone density in the mesio distal between … in the upper
jaw in height of … mm in … patient?
qa. Right and left centrals, 8, non-cleft;
qb. Central and lateral, 11, non-cleft;
qc. Right and left centrals, 11, non-cleft;
qd. Central and lateral, 8, non-cleft.
4. Which is the highest amount of bone density in the posterior region?
qa. First and second molars;
qb. Second premolar and first molar;
qc. First and second premolars;
qd. Second and third molars.
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