Original Article

Soft Tissue Measurement Method Using

Radiopaque Material on Cone-beam Computed
Tomography: An Ex Vivo Validation Study
Hae-Seok Lee1, Jeong-Ho Yun2, Dong-Won Lee1*
1
Department of Periodontology, Gangnam Severance Dental Hospital, College of Dentistry, Yonsei University,
Seoul, Korea
2
Department of Periodontology, School of Dentistry and Institute of Oral Bioscience, Chonbuk National
University, Jeonju, Korea

*Corresponding author: Dong-Won Lee, periodong@[Link]

Abstract
Purpose: The purpose of this study was to investigate the validity and reproducibility of a
method based on cone-beam computed tomography (CBCT) technology for the visualization and
measurement of gingival soft-tissue dimensions.
Material and Methods: A total of 66 selected points in soft-tissue of the ex vivo head of an adult
pig were investigated in this study. For the measurement of radiographic thickness (RT), wet soft-
tissue surfaces were lightly covered with barium sulfate powder using a powder spray. CBCT was
taken and DICOM files were assessed for soft-tissue thickness measurement at reference points.
A periodontal probe and a rubber stop were used for the measurement of trans-gingival probing
thickness (TPT). Af ter flap elevation, actual thickness of sof t-tissue (actual thickness, AT) was
measured. Correlation analysis and intraclass correlation coefficients analysis (ICC) were performed
for AT, TPT, and RT.
Results: All variables were distributed normally. Strong significant correlations of AT with RT
and TPT values were found. The two ICC values between TPT vs. AT and RT vs. AT differed
OPEN ACCESS significantly.
Conclusion: Our results indicated that correlation of RT was stronger than that of TPT with AT. We
pISSN : 1229-5418
Implantology 2018; 22(4): 210-218 concluded that soft tissue measurement with CBCT could be a reliable method, compared to the
[Link] trans-gingival probing measurement method.

Keywords: Cone-beam computed tomography, Dimensional Measurement Accuracy, Imaging

Received: November 27, 2018

Revised: December18, 2018
Accepted: December18, 2018
Ⅰ. Introduction
Copyright © 2018. The Korean Academy of Oral & Previously, a noninvasive method using a radiopaque material and periapical radiography
Maxillofacial Implantology
This is an Open Access article to measure the vertical length of the interdental papilla in natural teeth and implants was
distributed under the terms of the
Creative Commons Attribution proposed1-3. By using radiopaque material, it was possible to demarcate soft tissue, without
Non-Commercial License ([Link]
org/licenses/by-nc/4.0/) which permits unrestricted
non-commercial use, distribution, and reproduction in underexposing radiography. However, such two-dimensional information limits the
any medium, provided the original work is properly
cited. assessment of the whole periodontium.

210 The Korean Academy of Oral & Maxillofacial Implantology Vol. 22, No. 4, 2018
 IMPLANTOLOGY

The metric assessment of soft tissue dimensions around teeth and implants is of great clinical interest
for the quantification and monitoring of gingival changes during therapies. Gingival soft tissue
dimensions play significant roles in the assessment of whole treatment success, and thus should be
monitored all through therapy. A lack of gingival thickness showed a tendency towards loss in attachment
levels after traumatic, inflammatory, or surgical injuries4. Likewise, orthodontic tooth movement may
adversely affect the mucogingival complex, especially at sites in which the keratinized gingiva and
underlying bone appeared thin5. Acceptable methods for the accurate quantification of tissue changes
when assessing new treatment modalities and materials influencing soft tissues are thus needed6.
Cone-beam computed tomography (CBCT) is used routinely for imaging analyses of the maxillofacial
region7. This modality provides clinicians with high-quality diagnostic images and has become an
important tool in dentistry. However, the inability of CBCT to distinguish overlapped soft tissues, such
as mucogingival thickness on the buccal side of alveolar bone, has limited its application exclusively to
the imaging of hard maxillofacial tissues8.
Several studies reported using CBCT9-12 for studying soft tissue thickness. Although validation
process was not reported, these studies showed us a possibility to study delicate mucogingival soft tissue
by retracting overlapped soft tissue. However, one validation study reported that soft tissues less than
0.5mm was not possible to be confirmed in spiral CT, thus making the application of spiral CT in very
thin mucosa questionable13. In this study, we describe a method based on CBCT technology for the
visualization and measurement of soft tissue dimensions, after demarcating the soft tissue with
radiopaque material. The aim of this study was to investigate the validity and reproducibility of this
method.

Ⅱ. Material and Methods

For this study, the ex vivo head of an adult pig was used. The test sites were confined to the soft tissue
around the posterior teeth. Radiographic markers made of radiopaque flowable composite (EsthetXflow
A3; Dentsply, Milford, DE, USA) were applied to the enamel cusps of each tooth and light cured
(EliparFreeLight 2; 3M ESPE, St. Paul, MN, USA). A total of 22 markers were obtained (Fig. 1). To
align CBCT section and actual measurement as close as possible, CBCT cross section contained two
composite markers. Actual measurement and trans gingival probing were performed on the imaginary
line connecting two composite markers. For the measurement of soft tissue thickness, we chose 9, 12,
and 15 mm apical to the flowable composite markers. Thus, a total of 66 selected points in soft tissue
were investigated in this study.

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Original Article

Fig. 1. Radiopaque flowable composite markers were attached to the enamel (yellow arrows). Red line
indicates imaginary line connecting two composite markers. These line will be the CBCT cross section
and AT and TPT will be performed.
Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

1. Testing intra-observer variability

The measurements were done by a single operator. Prior to taking part in the present investigation,
intra-observer variability was tested under the supervision of the director. 3 parameters were tested.
Thus, 40 arbitrary selected sites on pig mandible were measured with 1) DICOM viewer (Simplant®;
Materialise NV, Leuven, Belgium) after CBCT (Voxel size 0.08 mm, Pax-Zenith 3D; Vatech, Seoul,
Korea) taking, 2) trans-gingival probing and measuring with caliper, 3) actual soft tissue thickness
measurement.

2. Comparison of measuring techniques

1) Experimental group 1
For the measurement of radiographic thickness (RT), wet soft tissue surfaces were covered with
barium sulfate powder (SoloTop; Taejoon, Seoul, Korea, Fig. 2), a radiopaque material used as a
gastrointestinal contrast medium, using a powder sprayer (Cerec Propellant; VITA Zahnfabrik, Bad
Säckingen, Germany). Images were acquired with a CBCT scanner. Scanning parameters were 110
kVp, 24 seconds, 5.7 mA, a voxel size of 0.08 mm, and a field of view of 5 cm×5 cm. DICOM files were
then assessed on viewer as follows. First, concentric circles of 9, 12 and 15 mm diameter were drawn
from composite markers. Then, soft tissue thicknesses were measured at the intersection points between
circle and soft tissue surface (Fig. 3). All gingival thicknesses were determined at the 0.01 mm level by
the software.

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Fig. 2. Barium sulfate powder was sprayed on soft tissue surface.

Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

Fig. 3. Actual cross section of pig mandible (A) and CBCT image (B). Measurements were done 9 mm,
12 mm, 15 mm apical from the markers.
Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

2) Experimental group 2
A probes and rubber stop were used for the measurement of transgingival probing thickness (TPT). A
periodontal probe (Williams PW, Hu-Friedy, Chicago, IL.) was inserted vertically into the soft tissue
surface until resistance of the bone was felt. A rubber stop was placed in contact with the surface to
facilitate the measurement of tissue thickness14. TPT was measured with digital calipers (Mitutuyo,
Tokyo, Japan). All measurements were rounded to the nearest 0.01 mm.

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3) Control group
For the measurement of actual thickness (AT), an incision was made onto each marked area. After flap
elevation, actual soft tissue thickness was measured using the same method that was used for TPT. All
measurements were rounded to the nearest 0.01 mm.

3. Statistical analysis

Statistical analysis was consulted to independent statistician. SAS version 9.2 (SAS Institute, Cary,
NC, USA) and MedCalc (MedCalc Software, Ostend, Belgium) version 12.7.0 were used for data
analyses. The Kolmogorov–Smirnov test was used to determine whether variables were distributed
normally. Correlations of RT and TPT values with AT values were examined using Pearson correlation
coefficients. The distributions of variables were examined using dot plots. For reliability analysis, intra-
class correlation coefficients (ICC) were calculated15 for AT, TPT, and RT. ICC values > 0.75 were
considered to have excellent reliability16. To graphically examine the degree of agreement between
radiographic and actual measurements, a Bland–Altman plot was constructed, and limits of agreement
were calculated for the outcome measure17. P-values < 0.05 were considered to be statistically significant.

Ⅲ. Results
1. Intra-observer variability

The paired t-test revealed no significant difference between the first and second readings. Also,
correlation of the two measurements was significant (Pearson correlation coefficient on parameter 1 =
0.99; P < 0.01, parameter 2 = 0.96; P < 0.01, parameter 3 = 0.97; P < 0.01). The intra-observer variability
and correlation coefficient were comparable to previous studies18.

2. Comparison of measuring techniques

All variables were distributed normally. Mean AT was 1.568 ± 0.64 mm, mean TPT was 1.759 ±
0.74 mm, and mean RT was 1.654 ± 0.664 mm (Table 1). Coefficients of correlation between TPT and
AT, and between RT and AT, were 0.810 and 0.892, respectively (Table 2).
The ICC for TPT vs. AT was 0.87 (95% confidence interval [CI], 0.79–0.92; p < 0.0001), and that for
RT vs. AT was 0.939 (95% CI, 0.9–0.963; p < 0.0001). The two ICC values differed significantly (Table 3).
Figure 4 is a Bland–Altman plot illustrating the degree of agreement between AT and RT values. The

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Table 1. Mean value and standard deviation for clinical measurements (mm) (n = 66)

Variables Mean ± SD
Actual Thickness 1.568 ± 0.64
Transgingival probing Thickness 1.759 ± 0.74
Radiographic Thickness 1.654 ± 0.664
SD: standard deviation.
Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

Table 2. Correlation coefficients with actual thickness and correlation comparison

TPT:AT RT:AT Correlation comparison (P-value)

r 0.80951 0.89217 0.0103
TPT: Transgingival probing Thickness; AT: Actual Thickness; RT: Radiographic Thickness; r: Pearson’s correlation
coefficient.
Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

Table 3. The intraclass correlation (ICC) with AT and ICC comparison

TPT RT ICC comparison

Variables
ICC (95% CI) P-value ICC (95% CI) P-value (P-value)
ICC 0.87(0.788-0.92) <.0001 0.939(0.9-0.963) <.0001 0.0249
CI: confidence interval.
TPT: Transgingival probing Thickness; AT: Actual Thickness; RT: Radiographic Thickness; r: Pearson’s correlation
coefficient.
Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

Fig. 4. Bland-Altman plots portraying the agreement between actual and radiographic measurements
for soft tissue thickness. The solid line indicates the mean difference between actual and radiographic
measurements; dashed line shows the 95% limits of agreement.
Hae-Seok Lee et al. : Soft Tissue Measurement Method Using Radiopaque Material on Cone-beam Computed Tomography: An Ex Vivo Validation
Study. Implantology 2018

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mean discrepancy between thicknesses was –0.09 mm. The 95% limit of agreement for thickness was
0.51 to –0.68 mm.

Ⅳ. Discussion
The purpose of the present study was to validate a simple and noninvasive method of assessing the
dimensions of soft tissues by CBCT. Strong significant correlations of AT with RT and TPT values were
found, indicating that both methods are valid for the assessment of mucogingival soft tissue thickness.
However, statistically significant difference was noted comparing coefficient values, indicating that
correlation of RT and AT was stronger than that of TPT and AT. Although mean difference between RT
and TPT might be minimal (mean difference 0.1 mm) significant difference in correlation with AT
suggests that RT might reflect AT better than TPT.
The radiographic measurement method showed good reliability, as indicated by the ICC. This result
indicates that measurement error is small compared with the variability between AT and RT values.
Comparable results were obtained for TPT. However, the significant difference between ICC values
suggests that the radiographic measurements reflect actual gingival thickness than trans gingival probing,
which is known to be the gold standard method. The narrow limit of agreement showed that the
agreement of RT values was good.
Easy measurements performed with a periodontal probe, e.g., measurement of recession of gingiva,
are fast and commonly part of routine diagnostic examination, but they provide limited three-dimensional
information. The same applies to the ultrasonic method of soft tissue thickness measurement, which
does not provide an overview of the periodontal structures or relationship19.
For the measurement of soft tissue dimensions, trans-gingival probing is commonly used method.1
However, this technique must be performed under local anesthesia, which might cause inadvertent
volume change and discomfort to the patients. The use of radiopaque material enables the noninvasive
measurement of soft tissue width and thickness, thereby allowing more accurate determination of the
clinical prognosis. In addition, this method makes it possible to demarcate overlapped tissue area, such
as buccal gingiva and cheek. However, possible drawbacks of using radiopaque material exists, such as
additional cost for using radiopaque material, blurring of the image, and allergic reaction. These
drawbacks should be dealt in depth for the possible routine clinical usage.
A previous study proposed a novel method based on CBCT technology called soft tissue CBCT to
determine the relationship of the structures of the dento-gingival unit9. This method is a more suitable

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tool for the acquisition of an anatomic overview, and a more painless method to obtain images of the
teeth and surrounding periodontal structures, compared with trans-gingival probing. However,
verification of the method was not reported, and soft tissue dimensions can be underestimated
considerably, depending on scan settings and tissue thickness6. Nevertheless, CBCT is part of the
standard protocol for diagnosis and treatment planning in difficult cases with special questions. As
correlation between bone and soft tissue is becoming important topic, this technique could play an
increasingly significant role in dentistry as it is developed further.
In this study, we verified a method that utilizes the advantages of CBCT while overcoming
disadvantages of this modality for the metric assessment of soft tissue dimensions around teeth and
implants. Although additional research is needed to determine the proper concentration of contrast
medium, the findings of this study suggest an opportunity to increase the usefulness for CBCT.

Ⅴ. Conclusion
In conclusion, the results of the present study suggest that soft tissue measurement with CBCT and
radiopaque material could be a reliable method, compared to the trans-gingival probing measurement
method, with good validity and reproducibility.

Acknowledgements
This study was supported by a faculty research grant of Yonsei University College of Dentistry for
2015(6-2015-0121).

References
1. Lee DW, Kim CK, Park KH, et al. Non-invasive method to measure the length of soft tissue from the
top of the papilla to the crestal bone. J Periodontol. 2005; 76: 1311-1314.
2. Lee DW, Park KH, Moon IS. Dimension of interproximal soft tissue between adjacent implants in
two distinctive implant systems. J Periodontol. 2006; 77: 1080-1084.
3. Lee DW, Huh JK, Park KH, et al. Comparison of interproximal soft tissue height for single implants
and contra-lateral natural teeth. Clin Oral Implants Res. 2009; 20: 1320-1325.
4. Claffey N, Shanley D. Relationship of gingival thickness and bleeding to loss of probing attachment
in shallow sites following nonsurgical periodontal therapy. J Clin Periodontol. 1986; 13: 654-657.
5. Foushee DG, Moriarty JD, Simpson DM. Effects of Mandibular Orthognathic Treatment on

The Korean Academy of Oral & Maxillofacial Implantology Vol. 22, No. 4, 2018 217
Original Article

Mucogingival Tissues. J Periodontol. 1985; 56: 727-733.

6. Ronay V, Sahrmann P, Bindl A, et al. Current status and perspectives of mucogingival soft tissue
measurement methods. J Esthet Dent. 2011; 23: 146-156.
7. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone-beam computed tomography in
dental practice. J Can Dent Assoc. 2006; 72: 75-80.
8. Guerrero ME, Jacobs R, Loubele M, et al. State-of-the-art on cone beam CT imaging for preoperative
planning of implant placement. Clin Oral Investig. 2006; 10: 1-7.
9. Januario AL, Barriviera M, Duarte WR. Soft Tissue Cone-Beam Computed Tomography: A Novel
Method for the Measurement of Gingival Tissue and the Dimensions of the Dentogingival Unit. J
Esthet Restor Dent. 2008; 20: 366-373.
10. Barriviera M, Duarte WR, Januário AL, et al. A new method to assess and measure palatal masticatory
mucosa by cone-beam computerized tomography. J Clin Periodontol. 2009; 36: 564-568.
11. Cao J, Hu WJ, Zhang H, et al. A novel technique for measurement of dentogingival tissue by cone
beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015; 119: 82-87.
12. Silva JNN, Andrade PF, Sotto-Maior BS, et al. Influence of lip retraction on the cone beam computed
tomography assessment of bone and gingival tissues of the anterior maxilla. Oral Surg Oral Med
Oral Pathol Oral Radiol. 2017; 123: 714-720.
13. Ueno D, Sato J, Igarashi C, et al. Accuracy of oral mucosal thickness measurements using spiral
computed tomography. J Periodontol. 2011; 82: 829-836.
14. W
 ara-aswapati N, Pitiphat W, Chandrapho N, et al. Thickness of palatal masticatory mucosa
associated with age. J Periodontol. 2001; 72: 1407-1412.
15. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;
86: 420.
16. Fleiss JL. Reliability of measurement. In: Fleiss JL, The Design and Analysis of Clinical Experiments.
1st ed. New York, NY: John Wiley & Sons; 1986. p.1-32.
17. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res
1999; 8: 135-160.
18. W
 ebber RL, Ruttimann UE, Heaven TJ. Calibration errors in digital subtraction radiography. J
Periodontal Res. 1990; 25: 268-275.
19. Eger T, Müller HP, Heinecke A. Ultrasonic determination of gingival thickness. J Clin Periodontol
1996; 23: 839-845.

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