The International Journal of Periodontics & Restorative Dentistry

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 623

CBCT Compared to Transgingival Probing as a Tool for

Estimating Alveolar Bone Crest Level in Patients with
Altered Passive Eruption

Reem Sami Abdelhafez, BDS, DClinDent (perio)1 Altered passive eruption (APE) is
Raghad Naif Rawabdeh, BDS, MClinDent (perio)1 a situation in which “the gingival
Rola Abdelrahim Alhabashneh, BDS, MPH, MSc1 margin in the adult is located inci-
sal to the cervical convexity of the
crown and away from the cemen-
toenamel junction of the tooth.”1
Crown lengthening surgery is the
The alveolar bone crest level is essential in determining the need for bone removal treatment of choice for APE, includ-
in subjects with altered passive eruption (APE). This study assessed the validity ing gingivectomy or an apically
of CBCT and transgingival probing in determining the alveolar bone crest level. positioned flap with or without os-
Patients presenting with APE were assessed. Transgingival probing was performed
seous resection. The need for os-
to clinically assess the distance between the cementoenamel junction (CEJ) and
the bone crest at the midpoint of the maxillary anterior teeth. CBCT was used to seous resection is determined by
assess this distance at the same point. Upon reflection of a full mucoperiosteal identifying the distance between
flap, the actual distance was measured. Similar actual and CBCT measurements the cementoenamel junc tion
of the distance between the CEJ and bone crest at teeth 13, 22, and 23 (FDI (CEJ) and the alveolar bone crest
numbering system) were recorded (P > .05). However, in teeth 11, 12, and 21, (subtypes A and B). Transgingival
the distance was significantly greater on CBCT scans (P < .05). No significant
probing, under anesthesia, is the
difference was detected between transgingival probing and the actual distance at
all teeth assessed. Careful transgingival probing provides an accurate measure of traditional technique used to dis-
the distance between the CEJ and bone crest. CBCT gives an accurate estimate, tinguish between APE subtypes
though it may not be justified for each patient in the presence of safer methods. A and B. The ability to assess the
Int J Periodontics Restorative Dent 2023;43:623–629. doi: 10.11607/prd.6223 level of the labial bone crest using
transgingival probing is challenging
due to the lack of visibility and the
difficulty in identifying the CEJ and
the bone crest.2 In some cases, the
distinction between the CEJ and
the buccal bone crest is not clear
on a periapical radiograph.2 In ad-
dition, it is sometimes difficult to
determine whether the most apical
line on the radiograph corresponds
Department of Preventive Dentistry, Jordan University of Science and Technology,
1 to the buccal or palatal bone crest.
Ar Ramtha, Jordan. Batista et al3 suggested using CBCT
to diagnose and characterize the
Correspondence to: Dr Reem S. Abdelhafez, Department of Preventive Dentistry, Jordan
University of Science and Technology, P. O. Box 3030, Irbid 22110, Jordan. hard tissue anatomical features of
Fax: +962(0) 2 7095123. Email: rsabdelhafez@just.edu.jo the teeth affected by APE.
CBCT is a computerized tomog-
Submitted February 8, 2022; accepted June 27, 2022.
©2023 by Quintessence Publishing Co Inc. raphy technology that emits conic

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624
x-ray beams and limited radiation, al-
lowing a 3D assessment of the tooth
and bone.3–6 Its clinical applications
lead to advances in planning and
diagnosing alterations in the max-
illofacial region.3,7 In a study per-
formed by Schertel Cassiano et al,8
it was shown that soft tissue CBCT
(ST-CBCT) is a useful tool to assess
the actual length of the anatomical
crown and the amount of gingival
tissue that needs to be surgically re-
moved in an esthetic crown length-
ening procedure to prevent unde-
sired root exposure. Thus, ST-CBCT
is a helpful noninvasive procedure
for planning esthetic crown length-
ening surgeries, making it possible
to better predict their final outcome.
This study assesses the ac-
curacy of CBCT and transgingival
probing in measuring the distance
from the CEJ to the bone crest
compared to the actual distance
measured upon reflecting a full
mucoperiosteal flap.
Materials and Methods
Among 40 patients attending the
periodontics clinic (Jordan Univer-
sity of Science and Technology) who
were screened for inclusion, 22 pa-
tients were selected for this study.
All patients presented with esthetic
concerns regarding excessive gingi-
val display due to APE in at least six
maxillary teeth (central incisors, lat-
eral incisors, canines, and/or premo-
lars). This study was approved by the
university’s institutional review board
and was conducted in accordance
with the 1975 Declaration of Helsinki,
as revised in 2013.
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The inclusion criteria were as
follows: need for surgical crown
lengthening due to APE; aged 18
to 55 years; and presence of an ad-
equate attached gingiva width and
sound maxillary anterior teeth. Sub-
jects were excluded if their teeth
displayed periodontal pockets
≥ 4 mm, grade II/III mobility, or
bone loss. Any restorative work
involving the incisal edges of the
maxillary anterior teeth and/or lo-
cal or systemic contraindications to
surgery resulted in exclusion.
Selected subjects were included
in the study after having been in-
formed on the objectives and de-
tails of the investigation and after
agreeing to participate by signing
a written informed consent. Full-
mouth scaling and polishing was
performed to control inflammation
prior to the recording of baseline
measurements.
Baseline periodontal examina-
tion for the maxillary anterior teeth
(132 teeth) from canine to canine
included probing depth, relative
clinical attachment level, visible
plaque, bleeding on probing, and
keratinized gingiva width. Mea-
surements were performed using a
Michigan O periodontal probe with
William’s grading. Clinical param-
eters recorded to aid in diagnosis
and treatment planning were: crown
width/length and the distance from
the zenith level of the gingival mar-
gin to a fixed point at the midpoint
of the incisal edge (GM–IE), the
CEJ (GM–CEJ), and the bone crest
(GM–BC).
Transgingival probing was uti-
lized to determine the GM–CEJ and
the GM–BC at the midfacial aspect
of each of the six anterior teeth. The
distance between the CEJ and the
BC was determined by subtract-
ing the GM–CEJ distance from the
GM–BC distance. The midfacial
aspect was determined by divid-
ing the mesiodistal width of each
tooth from contact to contact into
halves and locating the correspond-
ing midpoint at the gingival margin
(Fig 1).
CBCT scans were taken for each
subject, and 1-mm sections for each
tooth in the maxillary anterior seg-
ment were viewed and examined.
The number of 1-mm sections was
counted, starting from the first ap-
pearance of the distal aspect to
the last appearance of the mesial
aspect, and the middle section was
determined. The distance between
the CEJ and the BC at this middle
section was measured to the near-
est millimeter for each anterior tooth
to determine the need for bone re-
moval (Fig 2).
Patients were given randomly
allocated computer-generated
numbers. Even numbers received a
laser evaluation on the right quad-
rant, and odd numbers received a
conventional surgical procedure on
the right quadrant. The contralateral
quadrant was thus allocated to the
other treatment modality. The re-
sults of this part are described in a
different paper.9
At the time of the surgical in-
tervention and upon reflection of
a full mucoperiosteal flap, the ac-
tual distance between the CEJ and
the BC was measured to the near-
est millimeter at the same clinically
determined fixed point at the mid-
labial aspect of each tooth using a
 625

1.0 mm

Fig 1 Demonstration of transgingival probing. Fig 2 CBCT measurement of the

CEJ–BC distance.

Fig 3 Actual measurement of

the CEJ–BC distance.

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626

Table 1 Mean Actual CEJ-BC Distance and Distance on CBCT Scans

Actual CBCT
Tooth no. a Mean SD Mean SD P
Right maxilla
13 1.2 0.51 1.3 0.32 .062
12 1.4 0.50 1.6 0.41 .041*
11 0.9 0.68 1.2 0.57 .028*
Left maxilla
21 1.0 0.49 1.2 0.45 .025*
22 1.4 0.50 1.5 0.41 .244
23 1.2 0.55 1.3 0.56 .324
a
FDI tooth numbering system.
*Statistically significant (Wilcoxon signed-rank test).

Results
1.8

1.6 Eighteen patients consented to par-

1.4 ticipate and were included in this
study. Women comprised a majority
CEJ–BC distance (mm)

1.2
of the sample (16 women, 2 men).
1

0.8
Assessing the Distance
0.6
Between the CEJ and Bone
0.4 Crest
0.2
Actual vs CBCT
0
Tooth 13 Tooth 12 Tooth 11 Tooth 21 Tooth 22 Tooth 23 The data shown in Table 1 and Fig 4
Actual CBCT show no statistically significant dif-
ferences (P > .05) between the ac-
Fig 4 Bar graph showing the differences between mean actual and CBCT CEJ–BC dis- tual and CBCT measurements of the
tances for each tooth.
CEJ–BC distance at tooth sites 13,
22, and 23 (FDI numbering system).
Michigan O probe with Williams Statistical Analysis However, at sites 11, 12, and 21, a
grading (Fig 3). greater distance was measured on
The same periodontist (R.R.) Statistical analysis of the results was the CBCT scan compared to the ac-
performed all measurements. Clini- done using SPSS statistics for Win- tual distance, and this difference was
cal, CBCT, and surgical measure- dows (version 25, IBM). Wilcoxon statistically significant (P < .05).
ments were performed at different signed-rank test was used to com-
sessions, and the operator was not pare the CEJ–BC upon flap opening Actual vs transgingival probing
allowed to see the previously docu- to that of CBCT and upon transgin- Data shown in Table 2 and Fig 5
mented measurements. gival probing. show the comparison between

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 627

Table 2 Mean Actual CEJ–BC Distance and Distance on Transgingival Probing

Actual Transgingival probing
Tooth no. a Mean SD Mean SD P
Right maxilla
13 1.2 0.51 1.2 0.88 .763
12 1.4 0.50 1.3 0.77 .763
11 .9 0.68 .9 0.73 .739
Left maxilla
21 1.0 0.49 .9 0.64 .655
22 1.4 0.50 1.4 0.86 .763
23 1.2 0.55 1.2 0.79 .763
a
FDI tooth numbering system.

the CEJ–BC distance as mea-

1.8
sured on transgingival probing and
the distance measured after open- 1.6
ing a flap. No statistically sig- 1.4
nificant difference was found be-
CEJ–BC distance (mm)

1.2
tween both readings on each tooth
(P > .05). 1

0.8

Discussion 0.6

Management of APE requires care-
ful planning. Lack of accurate as-
sessment may result in excessive
or inadequate resection of soft and
hard tissues.10 Technical aspects re-
lated to the hard and soft tissues
play an integral role in the future
stability of crown lengthening pro-
cedures.11 These tissues can be as-
sessed clinically and radiographi-
cally,2,12–14 with inherent limitations
in both techniques.
The present study used several
methods to assess the CEJ–BC dis-
tance: CBCT, clinical transgingival
probing, and actual measurements
upon flap elevation were compared
0.4
0.2
0
Tooth 13 Tooth 12 Tooth 11 Tooth 21 Tooth 22 Tooth 23
Actual Transgingival probing
Fig 5 Bar graph showing the differences between mean actual and transgingival probing
CEJ–BC distances for each tooth.
to assess the accuracy of these mea- comparable measurement indicates
surements. the accuracy of transgingival probing
On all teeth, the present results to diagnose APE and to aid in treat-
showed no statistically significant dif- ment planning. This is in agreement
ference (P > .05) between the actual with previous studies wherein trans-
CEJ–BC distance upon flap elevation gingival bone probing was found to
and the CEJ–BC distance as mea- be consistent with the histometric
sured by transgingival probing. This level.15,16

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628
The validity of transgingival
probing was demonstrated long ago
by Greenberg et al,17 who compared
the distance measured from the oc-
clusal surfaces of teeth to the buccal
bone crest using transgingival prob-
ing. This was also verified in a similar
study by Ursell.18
CBCT is currently a valuable di-
agnostic tool in dentistry. It provides
3D representation of the hard tis-
sues and provides precise informa-
tion regarding the anatomical crown
length, bone thickness, and the CEJ
level. However, CBCT root and tooth
length measurements are accurate
within limits.19–21
The results of the present study
showed no statistically significant
difference between the actual and
CBCT measurements of the CEJ–BC
distance at tooth sites 13, 22, and
23 (P > .05). However, at sites 11, 12,
and 21, the data showed a greater
distance on CBCT scans compared
to the actual distance, and this dif-
ference was statistically significant
(P < .05). Differences in the measure-
ments of these three teeth might be
a consequence of the limitations of
CBCT scans, such as the scan mag-
nification and quality. However, all
measurements were within 2 mm
of the actual distance, and thus the
surgical plan was not affected by this
difference, and it was not clinically
significant.
To the best of the present au-
thors’ knowledge, no previous study
has assessed the accuracy of CBCT
measurements of the CEJ–BC dis-
tance used for the assessment and
planning of APE compared to the
actual distance.
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Conclusions
According to the present results,
CBCT is less accurate than transgin-
gival probing as a tool to aid in the
diagnosis and treatment planning of
APE cases, it is associated with un-
necessary exposure to radiation and
additional patient costs, and it may
not be justified for each patient in the
presence of safer methods.
Acknowledgments
All authors made substantial contributions to
the conception and design of the study. R.S.A.
developed the research question and worked
on the study design. R.N.R. was responsible
for data collection and analysis. R.S.A., R.N.R.,
and R.A.A. were involved in data interpre-
tation and manuscript drafting and revising,
and all gave final approval of the version to
be published.
This research was funded by a grant (no.
20190074) from the Deanship of Scientific
Research at Jordan University of Science and
Technology. This study was approved by the
Institutional Review Board (IRB approval no.
1/120/2019). The authors do not have any fi-
nancial interest in the companies whose ma-
terials are included in this article.
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