Assessment of Alveolar Bone Thickness Buccal to Maxillary Anterior and Premolar Teeth in a Sample of Egyptian Population Using CBCT: An Observational Cross-Sectional Study
Conditions: Alveolar Bone Thickness
Sponsor: Cairo University

I 
 
Assessment of alveolar bone thickness 
buccal to maxillary anterior and 
premolar teeth in a sample of Egyptian 
population using CBCT: An 
Observational Cross-Sectional Study 
 .
, 2020
th
6 
September,
 
By 
Menna Mosaad El-said Hassan  
B.D.S 2012  
 
 
 
 
 
 
 
 
 
 
 

II 
 
 
Protocol Checklist 
Section and topic 
Item 
No. 
Checked item 
Reported 
on page 
No. 
Reviewer’s 
check 
 
I. Administrative Information 
 
1 
Title: PECOS elements included 
1 
 
2 
Protocol Registration 
1 
 
3 
Protocol Version 
1 
 
4 
Funding 
1 
 
5 
Roles and Responsibilities of the 
Authors 
1,2 
 
 
II. Introduction 
 
6a 
Scientific Background 
2,3 
 
 
6b 
Review of Literature 
6,7,8,9 
 
 
6c 
Statement of the Problem 
10 
 
 
III. Methods 
A) Study Design 
and Settings 
7 
Study Design 
10 
 
8 
Settings 
10 
 
B) Participants 
9a 
Eligibility Criteria 
11 
 
9b 
Methods of selection or case/control 
ascertainment 
- 
 
9c 
Methods of follow up for cohort 
studies and rationale for choosing 
cases and controls for case control 
studies 
- 
 

III 
 
10 
Matched cohort study—matching 
criteria and allocation ratio (exposed: 
non-exposed) 
Matched case-control study— 
matching criteria and allocation ratio 
(case: control) 
 
 
C) Variables 
11 
Clearly define all variables including 
outcomes and exposures 
12 
 
12 
For each variable of interest, give data 
sources/ measurement 
12,13 
 
13 
Addressing potential sources of bias 
13 
 
D) Study Size 
    14       
Study size 
14 
 
E) Quantitative 
Variables 
15 
Handling of quantitative variables in 
the analyses 
14 
 
F) Statistical 
methods 
16 
Statistical methods used to control for 
confounders 
14 
 
 
 
 
 
 
 
 
IV-Ethics and Dissemination 
 
 
 
17a 
Research ethics approval 
15 
 
17b 
Protocol amendments 
15 
 
17c 
Access to Data 
15 
 
17d 
Dissemination Policy 
15 
 
 
V- References 
 
 
References by reference manager 
16,17,18 
 
 
 
 
 
 
 
 
 
Evidence Based Committee (Reviewers) 

IV 
 
Name 
Signature 
Date 
1. 
 
 
2. 
 
 
 
Research Plan Committee 
Name 
Signature 
Date 
1.  
 
 
2.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1 
 
 
I-Administrative Information 
1-Title: Assessment of alveolar bone thickness buccal to maxillary anterior and premolar 
teeth using CBCT in a sample of Egyptian population using CBCT: An Observational Cross-
Sectional Study 
 
 
2-Protocol Registration: 
Registered at www.clinicaltrials.gov 
ID: ………………… 
 
3-Protocol Version: 1st version 
 
4-Funding: self-funding 
 
5-Roles and responsibilities of the authors: 
Principal Investigator: Menna Mosaad EL-said Hassan 
          Masters degree in Oral and Maxillofacial radiology 
          Department of Oral and Maxillofacial Radiology 
          Faculty of Dentistry, Cairo University 
Roles of the investigator: 
 Preparing the technical proposal. 
 Assuring that the design is appropriate to the proposed question. 
 Identifying the need for sub-recipient agreements. 
 Ensuring that the used procedures are consistent with sound research design and do not 
unnecessarily expose subjects to risk/harm. 
 Being responsible for all required actions to manage and complete the scientific and 
programmatic aspects of the project (including data collection and assessment). 
 Ensuring the integrity and safeguarding of notebooks and scientific data. Ensuring the 
completion, accuracy and timeliness of programmatic (technical) reports. 
Chief Supervisor: Dr. Farid Medhat 
Assistant Professor 
Department of Oral and Maxillofacial Radiology 
Faculty of Dentistry, Cairo University 
 

2 
 
 
Roles of Chief Supervisor: 
 Assisting the candidate -in association with the co-supervisor -to prepare a full research plan 
that can be completed and written up within the prescribed period of study, and to seek approval 
for that proposal. 
 Establishing a research plan with the investigator, in which the work is completed. 
 Discussing the work done through meetings or exchanging email messages if the candidate is 
in a remote location, at least once per month. Assisting the candidate by regularly checking the 
records of data and observations and suggesting improvements where appropriate. 
 Providing constructive criticism and advice on submitted written drafts within agreed time 
frames. 
 Supporting the candidate in the preparation for thesis defense. 
 Facilitating timely completion of the candidate's study and ultimate completion of the thesis. 
 
Assistant Supervisor:  Dr. Arwa Mousa 
                      Lecturer  
                       Department of Oral and Maxillofacial Radiology  
                       Faculty of Dentistry, Cairo University 
Roles of Assistant Supervisor: 
 Monitoring the progress of the student’s research through regular formal supervisory meetings 
and ensuring that the research student keeps an agreed record of these meetings. 
 Being accessible at mutually convenient times when the research student may need advice. 
 Performing the blind assessment during the data collection stage. 
 Giving detailed advice on the necessary completion dates of successive stages of the work so 
that the thesis can be submitted within the relevant maximum registration period. 
 Reading and commenting on the whole of the final draft of the thesis, provided that this is 
presented within a reasonable and agreed time frame, and ensuring that the research student is 
aware that the thesis must comply with all relevant regulations, including those on word length, 
format, and binding.

3 
 
 
II-Introduction  
6. a. Scientific Background: Tooth loss in an esthetic area is often undesired experience for the 
patient. Dental implant offers the most long term solution for missing teeth replacement, 
replicating the root and crown of the natural tooth. This procedure reserves both the gingival 
mucosa and the remaining alveolar bone without damage to adjacent teeth (Singh et al., 2015).  
According to the conventional protocol of dental implant, a period of 3-4 months is required for 
socket healing, followed by implants insertion, then additional 3-4 months are needed for implant 
integration with surrounding bone. Moreover, one additional step is required to load the prosthetic 
abutment (Singh et al., 2012). This conventional protocol consumes extended period of time 
leaving the patient with missing tooth. Many attempts to shorten the overall length of treatment 
had focused on approaches of immediate or early implant placement especially in the esthetic zone 
(Bhola et al., 2008).  
The advantages of the immediate implant placement include, less surgical intervention procedures, 
so reduction in therapy time, preservation of the bone and gingival tissues, and psychological 
confidence for the patient. In spite of the advantage of the immediate implant placement, it is still 
a challenging treatment option for the clinician and presents a higher incidence of complications. 
Gluckman et al., 2018 reported that the anatomic factors which influence the outcomes of 
immediate implant placement at the anterior region are the gingival biotype, the thickness and 
height of the existing alveolar bone, the amount of bone beyond the apex, and the buccal gap. 
 Following tooth extraction, high degree of resorption is expected, which is more severe in the 
buccal alveolar wall thickness (Wang et al., 2014 and Fuentes et al., 2015). In other words, the 
bone change is more suspected in the buccal alveolar bone and the palatal alveolar bone is less 
affected area. Also it was reported by Ten Heggeler et al., 2011 that the resorption of the buccal 
alveolar bone in the anterior are more affected than posterior areas, since the bone resorption is 
more siginficant where the walls are initially thinner. The vertical and horizontal reduction of bone 
dimensions is unavoidable (Lindhe 2014).  In the first 3 months after dental extraction, this 
resorption is more noticeable. However, bone remodeling may last for 12 months but less intense, 
resulting in dimensional change (Dos Santos et al., 2019). In some opinions, the buccal alveolar 

4 
 
bone thickness should be at least 2 mm to prevent labial gingival recession and to achieve an 
optimal biologic and esthetic outcome (Grunder et al., 2005 and Miyamoto et al., 2011).  
Hence in most situations, bone augmentation procedure has been recommended with immediate 
implant placement in the aesthetic zone (Wang et al., 2014). 
Recently, several studies have been published discussing if there is enough thickness in the labial 
alveolar bone for immediate implant placement in an anterior maxillary region. Nevertheless, the 
existing studies only include anterior teeth. There is not enough research regarding the premolars 
although they play a role in the aesthetic region.Therefore, this study is designed to investigate the 
thickness of the buccal alveolar bone of maxillary anterior and premolar teeth in a sample of 
Egyptian population using Cone beam computed tomography (CBCT) at different levels that are 
clinically relevant. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

5 
 
PO question    
P: Maxillary anterior and premolar teeth of the adult Egyptians. 
O: Alveolar bone thickness buccal to the maxillary anterior teeth and premolars of adult 
Egyptian population. 
  
 
Outcome Measured 
Measuring Device 
Measuring Unit 
 
Primary Outcome 
Thickness of the buccal 
alveolar bone of the 
maxillary centrals. 
 
Linear measurement of 
Ondemand Software 
 
Millimeters  
 
Thickness of the buccal 
alveolar bone of the 
maxillary laterals, 
canines and premolar 
teeth 
Linear measurement of 
Ondemand Software 
 
Millimeters 
Secondary Outcomes 
 
Mean difference of the 
alveolar bone thickness 
between genders  
 
Linear measurement of 
Ondemand Software 
 
Millimeters 
 
Mean difference of the 
alveolar bone thickness 
between different age 
groups 
 
Linear measurement of 
Ondemand Software 
 
Millimeters 

6 
 
 
Research question: 
What is the average thickness of the alveolar bone buccal to the maxillary anterior and 
Premolar teeth in the Adult Egyptian population? 
 
6b. Review of literature 
List of main databases used in search: 
 Pubmed  
 Google Scholar 
Keywords: 
Alveolar bone thickness, maxillary anterior teeth, maxillary premolars, CBCT, immediate implant. 
Kim et al., 2012 has reported that the restoration of the maxillary anterior region with 
implant-supported prostheses has been a difficult procedure because of the high aesthetic demand 
of patients. The aesthetic satisfaction and implant placement can be affected by the soft tissue 
defect associated with volumetric changes of the alveolar ridge (Rodriguez et al., 2012). 
It was conducted by Blanes et al. 2007 that the proper alveolar bone thickness is essential for the 
long-term stability of the mucosa around the dental implants. According to the naturally biological 
events, the maxillary alveolar bone of the anterior teeth is thin bony wall that is more liable for 
resorption of the bone than other regions. The thickness of the labial bony wall is of utmost 
importance to determine the most suitable treatment approach (Braut et al. 2011).  
Mandelaris et al., 2013 categorized the alveolar bone thickness into the crestal and radicular zones 
to be used in the implant planning. The crestal zone is the region from the cementoenamel junction 
extending to a point 4 mm apical. The radicular zone extends from the base of the crestal zone to 
Secondary Outcomes 
 
Prevalence of 
dehiscence and 
fenestration in the 
maxillary anterior and 
premolar teeth 
CBCT images on Ondemand 
software 
Categorical nominal 
data 
Percentage (%) 

7 
 
the root apex of each tooth (figure 1). Although both crestal and radicular categorized as either 
thick or thin. Thin is described as < 1mm of bone thickness while thick is >1 mm. 
 Figure 1: Schematic representation of crestal 
and radicular dentoalveolar zones 
 
 
 
 
He also assessed each zone separately, then classified as crestal thick-radicular thick, crestal thick- 
radicular thin, crestal thin-radicular thick, or crestal thin-radicular thin. Results have shown that 
limited buccal bone loss following extraction when there is thick bone in radicular zone. While in 
crestal thick-radicular thin, there is increase in the risk of bone resorption. Post extraction ridge 
augmentation is recommended in the bone defect. Also in crestal thin-radicular thin, a large amount 
of post extraction buccal bone resorption is expected and need for excessive bone graft procedure. 
In Gluckman et al., 2018 classified radial tooth root positions and inclinations when immediate 
implant placement is planned (figure 2): 
Class I: Tooth centrally positioned within ridge  
      Class IA: thick facial bone wall (>1 mm)  
      Class IB: thin facial bone wall (<1 mm) 
 Class II: when Tooth retroclined 
       Class IIA: thick crestal bone  
       Class IIB: thin crestal bone.  
 Class III: Tooth proclined: typically, thick palatal bone, thin facial crest, thick facial wall apically 
Class IV: Tooth facially positioned outside of bone envelope. 
Class V: Thin facial and palatal bone walls. 

8 
 
 
Figure 2. Radial plane tooth root positions for maxillary anterior teeth. A, Tooth centrally positioned within 
ridge. B, Tooth retroclined and thick crestal bone. C, Tooth retroclined and thin crestal bone. D, Tooth 
proclined. E, Tooth facially outside bone envelope. F, Thin facial and palatal walls (Gluckman et al., 2018). 
 
 
Huynh-Ba et al., 2010 evaluated the dimension of the alveolar bone at extraction sites at the 
anterior and premolar maxillary regions. They reported that the mean width of the buccal alveolar 
bone was 0.8 mm from canines to canines, while the mean for premolars sites was 1.1 mm. 
Januário et al., 2011 assessed the thickness of the facial alveolar bone in the anterior dentition of 
the maxilla. They found that, alveolar bone wall thickness was < 1 mm in most of the examined 
locations and was < 0.5 mm in half of assessed sites. 

9 
 
Wang et al., 2014 investigated the thickness of the alveolar bone and the sagittal angulation 
between the long axis of the teeth and the long axis of the associated alveolar bone in the anterior 
and premolars maxillary teeth. He concluded that almost 80% of anterior teeth and 40% of 
premolars exhibited a thin facial alveolar bone (<1 mm) and nearly 30% of sites had a bone wall 
thickness thinner than 0.5 mm. 
Another study was conducted by Demircan and Demircan 2015 on 60 patients to evaluate the 
thickness of the alveolar bone wall at maxillary incisors. Their results revealed that the bone 
thickness in the anterior maxillary area is very thin. Accordingly, they recommended adjunctive 
augmentation procedure for immediate implant treatment to be considered in such cases. 
El Nahass and Naiem 2015 investigated the dimension of the facial buccal plate of alveolar bone 
in the anterior esthetic zone. Their results revealed that only 1% of the incisors showed a thick 
labial bone (1–2 mm) and 73% showed a thin bony wall (0.5–1 mm) and 25% showed very thin 
wall <0.5 mm at the crest of alveolar bone. While at 1 mm from alveolar crest, 7%showed very 
thin bony wall and 86% showed a thin bony wall while only 6% exhibited a thick bony wall. They 
showed at 2 mm apical to alveolar crest that only 1% of very thin bony wall, and about 85% 
showed a thin bony wall and 14% exhibited a thick bony level. They also demonstrated very thin 
bony wall and about 75% thin bony wall and 23% showed thick bony wall at 4 mm apical to 
alveolar crest. 
Gluckman et al., 2018 evaluated the labial and palatal alveolar bone height and thickness at the 
anterior maxilla. They reported that labial alveolar bone thickness of the maxillary anterior teeth 
was predominantly thin at the crest by 83 %and the mid of the root by 92%. 
Regarding the imaging modalities used to examine the thickness of buccal alveolar bone, Deguchi 
et al., 2006 and Lim et al., 2007 used CT to assess the thickness of the buccal and lingual cortical 
bone on the posterior region for the implantation of mini-screws. Others used micro CT for 
measuring the bone structures of the anterior region (Kim et al., 2011). Recently, Cone beam 
computed tomography (CBCT) is preferred as it provides 3-dimensional (3D) images with a great 
accuracy for linear measurements and improve image quality. Moreover, CBCT offers a lower 
radiation exposure for the patients when compared to the conventional CT (Huynh et al., 2010 
and Patel et al., 2014). The CBCT considered as an appropriate diagnostic tool for 3D preoperative 

10 
 
planning (Fokas et al., 2018). Therefore, it will be used to accurately measure the alveolar bone 
thickness. 
6c. Statement of the Problem 
Alveolar bone thickness in aesthetic regions of the maxilla are critical factors in the selection of 
treatment approaches, especially when planning for immediate implant placement. Due to biologic 
events, alveolar bone resorption and remodeling tend to occur after tooth extraction, especially in 
the area of the facial bone. Hence, it is an important factor to consider, which aid in selection of 
implant protocol to be followed by the clinician. It also affects the success of implant placement, 
which in sequence affects aesthetic outcomes. 
Specific Objectives: 
To assess the average thickness of the alveolar bone buccal to the maxillary anterior and premolar 
teeth at different location using CBCT in sample of Egyptian population. 
Hypothesis: null                                                                                                                           
III -Methods   
A) Study design and setting 
7- Study Design: An observational Cross-sectional Study 
8- Setting and Location:  
The CBCT data of this study will be obtained from the CBCT data base available at a private 
radiographic center “Dokki Radiology Center” located in Cairo, Egypt. Being a retrospective 
study, CBCT images of Egyptian patients who have already been subjected to CBCT examination 
as part of their dental diagnosis and/or treatment planning during the years 2018-till present will 
be included according to the proposed eligibility criteria. 
 
 
 
 

11 
 
B) Participants: 
Based on sample size calculation, a sample of 138 CBCT images of maxillary anterior and 
premolar teeth belonging to Egyptian individuals will be examined. The selection of the scans to 
be included will be based on the following eligibility criteria. 
9- Eligibility criteria and selection method: 
 Inclusion criteria: 
 CBCT scans of adult Egyptian patients, males and females with ages starting from 18. 
 CBCT scans with all maxillary anterior teeth and premolars were present in the assessed 
quadrant. 
 CBCT images of good quality without artifacts that could interfere with the assessment of 
the alveolar bone thickness. 
 
 Exclusion criteria: 
 Patients with improper tooth alignment. 
 Patients with bone loss  more than 3 mm from cement-enamel junction (CEJ), as the normal 
bone level is at 1.5-2 mm from CEJ. 
  Patients with any pathological conditions or lesions affecting the normal bony architecture. 
 Patients with history of chemotherapy or radiotherapy. 
 Patients with dental implant, or endodontic, or prosthetic restoration, or current orthodontic 
treatment in the maxillary anterior and premolar region. 
 Patients with labial and palatal cleft. 
. 
10- Matching criteria and allocation ratio: 
 Not applicable in the study 
 
 
 

12 
 
C) Variables:  
11- Details about variable 
1. The thickness of the alveolar bone buccal to the maxillary anterior and premolar teeth at 
1 mm, 3 mm and 5 mm apical to alveolar crest. 
2. Mean difference of the alveolar bone thickness between genders  
3. Mean difference of the alveolar bone thickness between different age groups. 
12- Data Sources / Measurements: 
 Retrospective Data Analysis will be performed after the CBCT images are pooled from 
the computer database of “Dokki radiology center” 
 Scans scanned using PaX-i3D Green VATECH with 0.2 voxel resolution will be examined. 
 Exposure parameters of the scans was varied depending on the individual patient’s sizes. 
 CBCT images will be analysed using OnDemand3D ® DENTAL (Cybermed, Seoul, 
Korea) using the 3D module. In the axial plane, the reference line will be oriented to pass 
through the center of the examined tooth perpendicular to the long axis of the tooth and 
buccal alveolar bone. The long axis of the tooth will dictate the orientation of the vertical 
slice. Bone thickness will be measured from the sagittal cross sectional cut where the CEJ 
will be identified and followed by the measurements in 3 different locations (figure 3): A, 
1 mm apical to alveolar crest ; B,  3 mm from the alveolar crest; and C, 5 mm away from 
alveolar crest. 

13 
 
 
Figure 3: A. A cone-beam computed 
tomographic (CBCT) image in the axial 
plane sliced perpendicular to the labial or 
buccal contour of the alveolar bone of the 
left central incisor. B. A CBCT image in 
the coronal plane sliced parallel to the root 
axis of the left central incisor. C. A CBCT 
image in the sagittal plane sliced parallel to 
the root axis of the left central incisor. D. 
illustrating the positions (1, 3, and 5mm 
from the bone crest) of the measurements 
of the thickness of the facial bone wall 
(Januário et al., 2011 and Bulyalert et al., 
2018). 
 
 
 CBCT images will be interpreted by two oral radiologists; blinded from demographic 
data of the patients and from the results of each other. 
 The first radiologist will evaluate the scans for detection the thickness of the alveolar bone 
buccal to the maxillary anterior and premolars. Then one of them will re-evaluate the 
images with two weeks interval between the two reading sessions. Then the second one 
will evaluate a sample of the scans. 
 . Intra-observer and inter- observer variability between the results will be evaluated. 
13- Addressing potential sources of bias:  
No source of bias. CBCT images will be interpreted by two oral and maxillofacial radiologists 
independently blinded from demographic data of the patients and results of each other.                      
 
 

14 
 
                 
D) Study Size: 
14- Study Size: 
The aim of this study is to assess the thickness of the alveolar bone buccal to maxillary anterior 
and premolar teeth among a sample of Egyptian population. Based upon the results of Gluckman 
et al., 2017, the mean ±SD facial alveolar bone thickness of the central incisors were 0.6 ±0.3mm. 
Acceptable margin of error = 5%, the minimum estimated sample size was 138 patients. Sample 
size calculation was performed using Benchmark six sigma. 
E) Quantitative variables 
15- Handling of quantitative variables in analyses: 
CBCT scans with maxillary anterior and premolar teeth will be examined to assess the average 
thickness of the alveolar bone in the Egyptian population. 
The thickness of the alveolar bone of the maxillary anterior and premolar teeth will be handled as 
mean and standard deviation. 
F) Statistical methods: 
16- Statistical methods: 
Data will be analysed using IBM SPSS advanced statistics (Statistical Package for Social 
Sciences), version 21 (SPSS Inc., Chicago, IL). Numerical data will be described as mean and 
standard deviation or median and range. Categorical data will be described as numbers and 
percentages. Comparisons between male and females for normally distributed numeric variables 
will be done using the Student’s t-test while for non-normally distributed numeric variables will 
be done by Mann-Whitney test. Comparisons between categorical variables will be performed 
using the chi square test. A p-value less than or equal to 0.05 will be considered statistically 
significant. All tests will be two tailed. 
 
 
 
IV. Ethics and dissemination  

15 
 
17a. Research ethics approval: The Study protocol will be submitted to the Ethics committee in 
Faculty of Dentistry- Cairo University for approval  . 
17b. Protocol amendments: Any amendments in the protocol will be reported to the main and 
co-supervisor. 
17c. Access to Data: Investigator, Co-supervisor and main supervisor will have access to the 
final trial data set . 
17d.Dissemination Policy: The Investigator will communicate her results with other participants 
and healthcare providers through publication of the protocol and the research final results and 
recommendations. This will be done through publication websites and journals concerned Oral 
and Maxillofacial Radiology specialty, For Sharing the recommended clinical application obtained 
from the final results of the research. 
 
 
 
 
 
 
 
 
 
 
 
V) References: 
 

16 
 
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17 
 
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postoperative labial bone thickness in maxillary anterior implants: comparing immediate 

18 
 
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of 
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fresh 
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