Gingi Vo Morpho Me Try

Gingivomorphometry – estheticevaluation of the crown–mucogingivalcomplex: a new method for collectionand measurement of standardized andreproducible data in oral photography

Michael WeinlanderVojislav LekovicSanja Spadijer-GostovicBilijana MilicicGerald KrennmairHanns Plenk Jr

Authors’ affiliations:Michael Weinlander, Private Practice, Vienna,AustriaVojislav Lekovic, Periodontal Clinic, University ofBelgrade, Belgrade, SerbiaSanja Spadijer-Gostovic, Department ofProsthodontics, University of Belgrade, Belgrade,SerbiaBilijana Milicic, Periodontal Clinic, University ofBelgrade, Belgrade, SerbiaGerald Krennmair, Department of Fixed andRemovable Prosthodontics, Dental SchoolUniversity of Vienna, Vienna, AustriaHanns Plenk Jr, Michael Weinlander, Bone andBiomaterials Research, Institute for Histology andEmbryology, Medical University of Vienna, Vienna,Austria

Correspondence to:Michael WeinlanderResearch AssociateBone and Biomaterials ResearchInstitute for Histology and EmbryologyMedical University of ViennaAustriaTel.: 00431/4277-61336Fax: 00431/4277-61350e-mail: [email protected]

Key words: computerized measurements, esthetic evaluation, standardized photography

Abstract

Objectives: A new method is introduced for the esthetic evaluation of the periimplant

mucogingival complex through collection of standardized oral photographs and computer-

assisted measurement of reproducible data. Using this method, different soft tissue and

crown parameters in the dentogingival complex can be measured and the esthetic outcome

monitored.

Material and methods: A photographic device for standardized oral photography and a

standard protocol for the esthetic evaluation of the crown–mucogingival complex is

presented, comprising six soft tissue parameters: (1) mesial and (2) distal papilla areas,

(3) mesial and (4) distal papilla heights, (5) soft tissue–crown perimeter, and (6) gingival

recession. In order to demonstrate the reproducibility of standardized oral photographs

and the accuracy of the measurement of the six parameters, the data obtained in each of

two such standardized clinical photographs, taken at 10–14 days intervals, of the anterior

maxillary region from 10 patients with no apparent dental disease were compared. For the

statistical analysis of the reproducibility of these dependent data the 95% confidence

interval and the coefficients of variation were calculated from measurement means and

ranges of each of the above parameters, pooled from all 10 patients.

Results: Statistical analysis revealed high reproducibility with no significant differences

between the range of mean values of all six parameter measurements on the first and

second standardized oral photograph of the same patient, respectively.

Conclusion: Gingivomorphometry on standardized oral photographs can be considered to

be an accurate and reproducible method for the evaluation and measurement of different

dentogingival and periimplant parameters.

The goal of esthetic dentistry is the most

inconspicuous reconstruction or replace-

ment of missing teeth, as well as of peri-

implant hard and soft tissue components.

Color and form may be the two most

important esthetic aspects. Satisfactory es-

thetics as an imitation of nature may be

estimated by subjective impressions and

estimations (Furhauser et al. 2005; Meijer

et al. 2005), but can also be supported by

more objectively evaluated parameters(Kan

et al. 2003). Soft tissue margins around

natural teeth or dentogingival implant re-

storations can be subject to changes during

different surgical and restorative treatment

steps or at the time following treatment.

The aims of the present concept were first

to introduce a device for standardized in-

traoral photographs, for example of the

esthetically critical anterior maxillary

region, then to apply computer-assisted

measurements to the evaluation of the

Date:Accepted 16 October 2008

To cite this article:Weinlander M, Lekovic V, Spadijer-Gostovic S, MilicicB, Krennmair G, Plenk Jr H. Gingivomorphometry –esthetic evaluation of the crown–mucogingival complex.A new method for collection and measurement ofstandardized and reproducible data in oral photography.Clin. Oral Impl. Res. 20, 2009; 526–530.doi: 10.1111/j.1600-0501.2008.01685.x

526 c� 2009 John Wiley & Sons A/S

dentogingival complex, and finally to test

the reproducibility of this new gingivomor-

phometrical method which could comple-

ment the esthetic criteria judged by

subjective impressions.

Material and methods

Standardized oral photography and com-puter-assisted morphometrical measure-ments

The gingivomorphometry method is a new

concept for evaluating certain intraoral soft

tissue and crown parameters by standar-

dized and reproducible data collection and

standardized and reproducible parameter

measurements.

In order to acquire standardized and re-

producible data in oral photography three

basic criteria have to be fulfilled:

1. Standardized and reproducible patient

positioning;

2. Standardized and reproducible camera

positioning;

3. Standardized and reproducible mirror

positioning for data collection in the

premolar and molar regions.

A device was developed (Fig. 1), allowing

for the following standardizations:

(1) The patient is in sitting position and

puts his head in a head holder. The

chin is placed on a chin rest and the

forehead rests against a transversal

forehead holder. The chin rest height

may be adjusted to the patient facial

height, and its position is recorded on

a scale mounted at the left side of the

head holder as seen from the patient’s

position.

(2) The camera is fixed to a stand with a

quick mount attachment and can be

moved along a circumferential guide

rail at a range of 1801 around a virtual

center in the patient’s mouth. For

photographs of the anterior teeth a

fixed central camera position is avail-

able. For eccentric and lateral photo-

graphs with a mirror the camera

position can be changed and recorded

at a scale underneath the camera

stand. In addition, height and rotation

of the camera position as well as the

camera object distance can be chan-

ged. Each positional change of the

camera can be recorded separately.

(3) For photographs in the premolar and

molar areas a mirror can be placed in a

five-step protocol in the mouth of the

patient. The construction allows for a

cheek holding function of the mirror.

All three-dimensional movements of

the mirror can be recorded and repro-

duced at any time. The mirror posi-

tioning basically duplicates a rotating

gallows construction with a lateral,

height and transversal fixation of the

mirror. Once in place, the mirror posi-

tion itself can be varied rotationally.

Again, each positional change of the

mirror can be recorded.

Standardized oral photography: In the

manner described above, photographs can

be acquired with standard enlargement,

exposure and aperture. Visual distortions

such as enlargement or reduction resulting

from different camera–object distances and

changes of angulations can be excluded by

this technique.

Standardized computer-assisted mea-

surements: standardized measurements of

the acquired data – the ‘morphometrical’

part of this concept – are based on the

import of the acquired photographs into

an open source medical image processing

software (OSIRIXs

). In our concept, the

acquired data files are saved as JPEG files

and are first imported into an image

processing software (e.g., PHOTOSHOPs

).

With the help of this software, two refer-

ence lines (RL1, 2) connecting the midfa-

cial gingival levels (FGL) of the adjacent

teeth next to the crown(s) of interest and a

grid are added. The gingival zeniths of the

adjacent teeth can then be marked as re-

ference points and together with the RL –

they serve as standard orientation markers

for the intended gingivomorphometrical

measurements (Fig. 2). This modified

JPEG file is then imported into OSIRIXs

and processed in the 2D mode. A standar-

dized measurement protocol of the follow-

ing six different soft tissue parameters

around crowns is used: (1) Mesial, (2) distal

papilla height, (3) mesial, (4) distal papilla

area, (5) soft tissue–crown perimeter, and

(6) soft tissue height at the gingival zenith

(¼ recession) (Fig. 3). Values for recession

above the RL2 are expressed as positive

values, whereas values underneath RL2

are expressed as negative values. The out-

put of all measurements is immediately

displayed by the program in pixel values.

Clinical application of the method andstatistical analysis of reproducibility

Two standardized clinical photographs of

the anterior maxillary region were taken

from 10 patients at 10–14 days time inter-

vals. The patient group consisted of six

female and four male patients with an

average age of 41 years. All patients were

unaffected of dental or periodontal disease

in the evaluated region, but two patients

had full-porcelain crowns and veneers. In

order to evaluate accuracy and reproduci-

bility of this method, the above described

six soft tissue parameters were measured

by one trained observer. At one session,

each parameter was measured three times

to determine intraobserver group variation.

The data obtained in pixels were classified

into minimum, maximum and median

values. For the statistical analysis of each

of the above-mentioned six parametersFig. 1. Custom-made device for standardized

intraoral photography (patent pending).

Fig. 2. Standardized oral photograph of the anterior

maxillary region with standard orientation markers

(FGL 1, 2, 3; RL 1,2, see text) for the gingivomor-

phometrical measurements.

Weinlander et al . Gingivomorphometry – esthetic evaluation of the crown–mucogingival complex

c� 2009 John Wiley & Sons A/S 527 | Clin. Oral Impl. Res. 20, 2009 / 526–530

these three values were pooled from all 10

patients, and then these mean values were

compared between the two photographs

from each patient. Besides calculating the

significance of differences between the

mean values of three measurements, using

the paired t-test, the 95% confidence inter-

vals and coefficients of variation for these

dependent mean values and their ranges

were calculated using the pooled data of

six measurements of both photographs for

each patient and parameter.

Results

The mean values of the six measured para-

meters obtained from these two standar-

dized clinical photographs, as well as the

comparisons between the three measure-

ments for each patient on the first and

second oral photograph did not show any

statistically significant difference (P40.05)

(Table 1). Means� ranges, and 95% con-

fidence interval calculations of corres-

ponding measurements from the same

photograph and for the six measurements

pooled from all 10 patients show equiva-

lence of the measurements (Table 2). The

variations between maximum and mini-

mum mean values for each parameter,

measured in the first and second photo-

graph of each patient, as well as the varia-

tions of the six measurements for each

parameter and the respective coefficients

of variation, as assessed from these six

measurements per parameter and patient,

were low (Table 3).

Discussion

Implant supported restorations in the ante-

rior maxilla have become the standard of

care in reconstructing the dentogingival

complex in this esthetically sensible re-

gion. The use of implants in these areas is

supported by high success and survival

rates (Aviva-Arber & Zarb 1996; Scheller

et al. 1998; Haas et al. 2002). Creughers

et al. (2000) report survival rates of single

tooth restorations on implants of up to

98.9% after up to 7.5 years in function.Fig. 3. The same oral photograph as Fig. 2, highlighting the six measured gingivomorphometrical parameters:

mesial/distal papilla areas and heights, gingival recession and soft tissue perimeter.

Table 1. Mean minimum, maximum and median values of measurements of identical parameters, on first and second photographs fromeach patient

First photograph Second photograph Statistical test Significance

Mesial papilla area (pixel)Min 119,667.59 � 34,411.55 126,400.94 � 27,886.11 Paired t-test: between same parameter

evaluated on two different photographsP¼ 0.191n

Max 124,526.23 � 33,330.06 131,101.97 � 25,113.06 P¼ 0.253n

Median 121,805.41 � 34,173.13 128,928.8 � 26,334.13 P¼ 0.206n

Distal papilla area (pixel)Min 86,988.01 � 33,618.95 92,899.71 � 33,578.52 Paired t-test: between same parameter


Max 91,688.67 � 31,232.19 97,898.53 � 34,572.17 P¼ 0.318n

Median 89,330.15 � 32,344.19 95,730.36 � 33,985.3 P¼ 0.265n

Mesial papilla height (pixel)Min 417.11 � 40.35 439.64 � 29.94 Paired t-test: between same parameter


Max 420.42 � 38.19 443.22 � 28.2 P¼ 0.138n

Median 418.68 � 39.27 441.32 � 28.4 P¼ 0.152n

Distal papilla height (pixel)Min 377.63 � 85.22 395.42 � 90.4 Paired t-test: between same parameter


Max 385.17 � 83.42 401.79 � 88.02 P¼ 0.268n

Median 381.07 � 84.32 398.68 � 88.96 P¼ 0.324n

Soft tissue perimeter (pixel)Min 226,715.67 � 46,350.92 243,122.95 � 39,439.37 Paired t-test: between same parameter


Max 235,205.12 � 45,572.43 252,057.47 � 33,995.1 P¼ 0.214n

Median 230,931.95 � 46,205.76 248,015.12 � 35,416.97 P¼ 0.172n

Gingival recession (pixel)Min 62.48 � 27.81 64.22 � 25.23 Paired t-test: between same parameter


Max 64.38 � 25.45 64.45 � 25.35 P¼ 0.5n

Median 63.71 � 26.18 64.3 � 25.27 P¼ 0.526n

Significances of differences (P-values).nNo statistically significant difference (P40.05)


528 | Clin. Oral Impl. Res. 20, 2009 / 526–530 c� 2009 John Wiley & Sons A/S

Various treatment concepts and recom-

mendations for achieving optimal esthetic

results with implants in esthetic zones

have been reported, including tooth extrac-

tion, extraction socket treatment, three

dimensional and immediate implant place-

ment and implant site development with

different hard and soft tissue augmentation

methods (Landsberg & Bichacho 1994).

Evaluation of the esthetic outcome of im-

plant-supported restorations in the anterior

maxillary region is performed mainly by

various assessments of periimplant soft

tissue and implant crown parameters. Fur-

hauser et al. (2005) developed the ‘Pink

Esthetic Score’. This evaluation is based on

seven variables related to periimplant soft

tissues, assessing the mesial and the distal

papilla, the soft tissue level, the soft tissue

contour, the alveolar process deficiency

and the soft tissue color and texture. Meijer

et al. (2005) added five implant crown-

related parameters in their ‘Implant Crown

Aesthetic Index’ to expand the evaluation

of the esthetic outcome. These parameters

consist of anatomical form, color and sur-

face characteristics of the crown. Both of

the above ratings are based on the evalua-

tion of oral photographs by different exam-

iners. Even though Furhauser et al. (2005)

and Meijer et al. (2005) made important

steps toward a more comprehensive evalua-

tion of the periimplant soft tissue and

crown parameters, their evaluations are

based on non-standardized photographs

and only subjective estimations of the dif-

ferent assessment criteria. In a prospective

study by Kan et al. (2003) a so-called RL

connecting the FGL of the two adjacent

teeth was implemented for evaluating im-

plant success rates, periimplant tissue and

esthetic outcome of immediately placed

and provisionalized maxillary anterior single

implants. In this manner, mesial and distal

papilla height as well as facial gingiva reces-

sion of pre- and post-implantological situa-

tions could be measured and compared. Kan

et al. (2003) were the first attempting to

eventually measure certain soft tissue para-

meters in the implantogingival complex.

However, the data collection for these mea-

surements again were not standardized and

thus the comparison of the acquired data

only of limited significance.

With the method proposed in this paper

the evaluation of for example the estheti-

cally sensible anterior maxillary region is

not anymore dependent on subjective esti-

mations of different assessment criteria,

but uses a more evidence-based method.

Hard and soft tissue criteria are governed

mostly by color and form. Forms are very

important for the symmetrical and natural

appearance of reconstructed dentogingival

aspects. Because forms are strictly depend-

Table 2. Minimum–maximum and range variations of measurements on first and secondphotographs from all patients, and of all six measurements per patient, as compared withthe 95% confidence intervals (CI)

First photograph Secondphotograph

Six measurementsfor each patient

Mesial papilla area (pixel)Min 83,863.2 104,170.3 83,863.2Max 179,035.6 174,845.2 179,035.6Range 95,172.41 70,674.88 95,172.4195% CI 104,215.74n–139,395.08w 115,328.83–142,528.76 114,863–135,871.21

Distal papilla area (pixel)Min 441,63.1 46,996.2 44163Max 134,257.9 134,930.5 134,930.5Range 90,094.84 87,934.31 90,767.4195% CI 72,693.39–105,966.9 78,244.53–113,216.2 81,157.56–103,902.95

Mesial papilla height (pixel)Min 381.8 392.4 381.8Max 471 474.8 474.8Range 89.19 82.45 93.0395% CI 398.52–438.85 426.71–455.92 417.57–442.43

Distal papilla height (pixel)Min 274.8 278.3 274.8Max 478.2 478.2 478.2Range 203.33 199.93 203.495% CI 337.75–424.39 353.04–444.33 360.21–419.55

Soft tissue perimeter (pixel)Min 174685 192099.6 174685Max 303060.9 304336 304336Range 128375.9 112236.4 12965195% CI 207101.18–254762.73 229621.76–266408.48 225001.82–253945.26

Gingival recession (pixel)Min 42.8 46.4 42.8Max 82.4 82.4 82.4Range 39.56 35.99 39.5695% CI 42.38–85.03 43.76–84.84 51.91–76.09

nLower bound of 95% CI for means

wUpper bound of 95% CI for means

Table 3. Percent variation of the measurements in the two oral photographs from eachpatient, total percentages of variation, and coefficients of variation (CV %)

Parameters First photograph(max–min)maximum � 100 (%)n

Second Photograph:(max–min)maximum � 100 (%)w

(maximum–minimum)maximum� 100 (%)z

C Vy

MP area 2.59 2 2.29 5.07DP area 11.85 6.56 9.21 5.72MP height 0.88 1.36 1.1 3.06DP height 1.73 2.95 2.34 3.01STC 7.06 6.74 6.9 5.25GR 3.99 0.33 2.16 1.69

n% of value changes between maximum and minimum value for each parameter and patient,

first picture.

w% of value changes between maximum and minimum value for each parameter and patient,

second picture.

z% of value changes between maximum and minimum value for each parameter and six

measurements for each patient.

ycoefficient of variation (%)¼ (SD/average) � 100, assessed from six measurements for each

patient.


c� 2009 John Wiley & Sons A/S 529 | Clin. Oral Impl. Res. 20, 2009 / 526–530

ing on perspective, distortions resulting

from different angles of photographic view

must be avoided. The exact measurement

of forms as areas or distances can contri-

bute to a more evidence-based evaluation

of esthetic reconstructions. Changes occur-

ring at soft tissue or dental level through

any kind of dental treatment, or for exam-

ple parafunctions, can so be measured and

monitored. To help with a precise reprodu-

cibility of all reference points and prevent

falsified measurements through soft tissue

changes over time, a grid can be added to

the photographs. Although the measure-

ments performed in the present small pro-

spective study were apparently accurate

and reliable, linear measurements (me-

sial/distal papilla height) showed a lower

coefficient of variation than area measure-

ments (mesial and distal papilla area, soft

tissue contour). Because all patients parti-

cipating in this study were unaffected of

dental disease in the area of interest, only

positive values for recession were obtained

for statistical comparison. Increased mea-

surement accuracy by gaining experience of

the present observer suggests that this is

definitely a very sensitive technical

method. It seems to be no shortcoming

that the output of all measurements is

expressed in pixels by the used program.

Because all measurements usually are

needed only for detection of relative

changes over time, a calibration of pixel

numbers to millimeters usually seems not

needed.

Conclusions

The proposed Gingivomorphometry on

standardized oral photographs can be con-

sidered an accurate and reproducible

method for the evaluation and measure-

ment of different dentogingival parameters.

Advantages of this non-invasive method

are reliability, objectiveness and standardi-

zation of the necessary parameters,

particularly for the evaluation of the dento-

gingival complex in the esthetic region of

the anterior maxilla. Further prospective

evaluations with this evidence-based and

computer-assisted method will be neces-

sary to show the efficacy for monitoring

long-term changes in the periimplant mu-

cogingival complex.

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530 | Clin. Oral Impl. Res. 20, 2009 / 526–530 c� 2009 John Wiley & Sons A/S

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