J Clin Periodontol 2015; 42: 458–461 doi: 10.1111/jcpe.

12390

Cone-beam computed Hasan Guney Yilmaz1, Fatma Boke2

and Aysa Ayali3
1
Faculty of Dentistry, Department of

tomography evaluation of the Periodontology, Near East University, Mersin,

Turkey; 2Faculty of Dentistry, Department of
Periodontology, Ankara University, Ankara,

soft tissue thickness and greater Turkey; 3Faculty of Dentistry, Department of

Oral and Maxillofacial Surgery, Near East
University, Mersin, Turkey

palatine foramen location in the

palate
Yilmaz HG, Boke F, Ayali A. Cone-beam computed tomography evaluation of the
soft tissue thickness and greater palatine foramen location in the palate. J Clin
Periodontol 2015; 42: 458–461. doi: 10.1111/jcpe.12390

Abstract
Aim: The aim of this study was to evaluate the palatal mucosa thickness and
greater palatine foramen location using cone-beam computerized tomography
(CBCT).
Materials and Methods: Cone-beam computerized tomography images of 345
patients were measured. The relationship between palate vault depth and angle
between the alveolar bone and palatal plane (PA) was evaluated. Differences in
the palatal mucosal thickness according to age, gender and tooth site were evalu-
ated.
Results: The mean palatal mucosal thickness from the second molar to the canine
teeth were 3.7, 3.3, 3.7, 3 and 3 mm, respectively. The palatal mucosal thickness
at the second molar and second premolar was statistically different from those at
other zones. There was no correlation between the palatal junction angle and the
palatal depth. Greater palatine foramen was observed at the level of third molar
Key words: cone-beam computed
tooth, between third and second molar, second molar 63%, 31% and 6% in men tomography; free gingival graft; subepithelial
and 56%, 36% and 8% in women respectively. connective tissue graft
Conclusions: The second premolar to second molar zone was considered a suit-
able graft site based on the mean palatal mucosal thickness. Accepted for publication 12 March 2015

Periodontal plastic surgery is per- of the most common periodontal con- et al. 2004). Gingival recession is
formed for aesthetic and functional ditions and is defined as the move- associated with several causative fac-
purposes, and plays an important role ment of the gingival margin from tors such as traumatic tooth brushing
in periodontal treatment (Chambrone cemento-enamel junction (CEJ) to the or periodontal disease (Chambrone &
et al. 2008). Gingival recession is one apical (Bouchard et al. 2001, Cetiner Chambrone 2006). Root coverage
procedures are broadly categorized
Conflict of interest and source of funding statement into pedicle graft and free soft tissue
graft techniques (Azzi et al. 2001,
There are no conflicts of interest to disclose in the present study.The study was self-
funded by the authors and their institution.
Chambrone et al. 2010). Pedicle
grafts have a key advantage over free
458 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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The thickness of the palatal mucosa 459

soft tissue grafts in that the blood The junction angle between the tooth was determined on the CBCT
supply to the flap is maintained. alveolar crest and hard palate was images.
Unfortunately, there is little increase used to determine the palatal junc- The differences in palatal muco-
in the tissue thickness and the width tion angle (PA). The depth of the sal thickness according to tooth site
of keratinized gingiva when using a palate was measured using the dis- were analysed using one-way analy-
pedicle graft (Paolantonio et al. tance from the alveolar crest to the sis of variance (ANOVA), and if a sta-
1997). In contrast, free soft tissue mid-palatal suture (Fig. 1). tistically significant relationship was
grafts, such as the free gingival graft Gingival thickness was measured found, then the Tukey multiple com-
and subepithelial connective tissue on a cross sectional images from parison test was performed. The dif-
graft (SCTG), can increase the width the second molar to the canine for ferences in palatal mucosal thickness
of keratinized gingiva and tissue each tooth. Three points were iden- according to gender were analysed
thickness (Zucchelli & De Sanctis tified for beginning at the gingival using the Student’s t-test, and the
2000, Zuhr et al. 2014). margin to the hard palate at equal correlation between the palatal
Palate is main donor site for intervals, and the tissue thickness mucosal thickness and age was eval-
SCTG (Zucchelli & De Sanctis 2000, at each point was measured perpen- uated using Pearson correlation
Chambrone et al. 2008, Zuhr et al. dicular to the palatine bone in the analysis (p = 005). Pearson correla-
2014). Graft thickness and volume safe zone (Fig. 2). The differences tion analysis was also used to evalu-
are important factors to determine in palatal mucosal thickness accord- ate the relationship between the
appropriate treatment and prognosis. ing to age, gender and tooth site palatal depth, and the PA.
The size of SCTG can be related to were evaluated. The relationship Before the study, a calibration
the position of neurovascular bundle between the palatal depth and the session was performed to determine
and palatal mucosa thickness. Direct PA was evaluated. Greater palatine intra-examiner consistency in the
and indirect methods have been foramen location in relation to the CBCT measurements. Forty patients
applied to assess the palatal mucosa
thickness. It can be directly mea-
sured using an endodontic reamer
and periodontal probe after adminis-
tering a local anaesthetic (Studer
et al. 1997, Wara-aswapati et al.
2001). Indirect measurement meth-
ods, such as ultrasonography, com-
puted tomography (CT) and recently
cone-beam computed tomography
(CBCT), have also been described
(Eger et al. 1996, Song et al. 2008,
Barriviera et al. 2009). The aim of
this retrospective study was to evalu-
ate and palatal mucosa thickness
and greater palatine foramen loca-
tion using CBCT images to establish
the ideal zone for SCTG.
Fig. 1. Measurement of the palatal junction angle.
Materials and Methods
This retrospective study evaluated
patients at the Near East University,
Faculty of Dentistry. This retrospec-
tive review of patient’s clinical
records was approved by the New
East University Human Subjects
Review Board. Exclusion criteria
were as follows: periodontitis and
current pathology in the palatal
region, smoking, taking any medica-
tions which affect the gingival tissue
thickness. A total of 345 patients
(181 male and 164 female) aged from
15 to 69 years (mean 40.6 years)
were selected. CBCT images were
obtained and evaluated using a high-
resolution medical screen with the
Newtom NNT program (Nio Colar
3MP, Barco, Kortrijk, Belgium). Fig. 2. Measurement of the palatal mucosa thickness.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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460 Yilmaz et al.

were included for this session, and the direct method transgingival and measuring palatal mucosal thick-
the measurements were repeated sounding by means of a periodontal ness. However, in some cases, distin-
twice at 1-h intervals. The range of probe has been used for this pur- guishing between the different soft
mean errors for palatal mucosal pose; however, this method may be tissues may be impossible on CBCT
thickness, and PA assessments were uncomfortable for the patient images. Thus, when performing
0.11–0.16, and 0.10–0.12, respec- because it must be performed under CBCT, soft tissue retraction (lips and
tively, and indicated consistent reli- local anaesthesia (Studer et al. 1997, cheeks) is required to distinguish the
ability during the evaluation period. Wara-aswapati et al. 2001). Also, palatal or buccal mucosa, and the
depth measured by these techniques cheek or lip. Also CBCT systems have
can be affected by volume of local been reported to demonstrate con-
Results
anaesthetic and inflammation (Stu- trast discernment. When compared
There was no correlation between der et al. 1997, Song et al. 2008). In with CBCT, CT systems demonstrate
the palatal junction angle and the addition, these procedures are per- superior contrast detectability. The
palatal depth (p > 0.05). The mean formed immediately before graft har- limited contrast resolution of CBCT
thickness (standard deviation) of the vesting, and as a result, pre-surgical technology makes it difficult to detect
palatal mucosa is shown in Table 1. planning cannot be done. A non- different soft tissue structures (Ange-
The palatal mucosa was thickest at invasive method that applies an lopoulos et al. 2012). Therefore, to
the second molar and second premo- ultrasonic device has also been eliminate to this disadvantage high
lar regions, and was significantly described (Eger et al. 1996, M€ uller contrast and resolution medical lcd
thicker than at the first molar, first et al. 1999, 2000). Although this displays were used in the current
premolar and canine regions method is more comfortable for study. However, at the clinical prac-
(p < 0.05; Table 1). The mean thick- patients, measurement errors can tice the limited contrast resolution of
ness by region was significantly dif- occur depending on the anatomical CBCT may be a disadvantage espe-
ferent between men and women structure of the palatal region; there- cially patients who have anatomical
(p < 0.05). A positive correlation fore, the results may be inconsistent, variations.
was found between the age and the and repeated measurements are It is important to mention that
increased palatal mucosa thickness required (M€ uller et al. 1999, 2000). this is a quantitative and not a quali-
(p = 0.01, r = 0.54). Greater palatine As an alternative to existing meth- tative method, because the differ-
foramen was observed at the level of ods, the tooth, gingiva and other ences between the epithelial, fat and
third molar tooth, between third and periodontal tissues may be imaged connective tissues cannot be seen on
second molar, second molar 63%, by CT and CBCT (Song et al. 2008, the images. The aim of the current
31% and 6% in men and 56%, 36% Barriviera et al. 2009, T€ oz€
um et al. retrospective study is to evaluate the
and 8% in women respectively. 2012, Yilmaz & T€ oz€
um 2012, Ueno palatal mucosal thickness at the
et al. 2014). The aspect ratio of CT large population with relatively non-
and CBCT images is 1:1, and these invasive method. Therefore, CBCT
Discussion
images can be saved and printed, evaluation was chosen, however, cost
The palatal masticatory mucosa is and multiple measurements can be effectiveness and low contrast values
the main donor site of connective tis- performed on the computer screen of this method are the limitations of
sue in periodontal plastic surgery or on hard copies (Barriviera et al. this study.
during soft tissue grafting (Zuhr 2009). Compared to conventional In the present study, the palatal
et al. 2014). The surgical success of tomography, CBCT presents several mucosa thickness varied among the
soft tissue grafts is closely associated advantages including lower radia- tooth sites. The palatal mucosa mea-
with the graft thickness (Zucchelli & tion, better image quality, greater sured a mean of 3 mm at the canine
De Sanctis 2000, Chambrone et al. patient comfort and lower cost region, 3 mm at the first premolar
2008). The thickness of the mastica- (Barriviera et al. 2009). Therefore, in region, 3.7 mm at the second premo-
tory mucosa at the palate has been the current retrospective study, lar region, 3.3 mm at the first molar
evaluated in different studies. Palatal CBCT was used to evaluate the region, and 3.7 mm at the second
mucosal thickness has been mea- palatal mucosal thickness. Consistent molar region. These measurements
sured using direct and indirect meth- with the results of this study are similar to those of previous stud-
ods (Eger et al. 1996, Studer et al. Barriviera et al. (2009) reported that ies (Studer et al. 1997, M€ uller et al.
1997, M€ uller et al. 1999, 2000). At CBCT may be applied for visualizing 1999, 2000, Barriviera et al. 2009).
However, Song et al. (2008) deter-
mined that the palatal mucosa is
Table 1. Mean and standard deviation (SD) values of PMT according to tooth site thicker at the premolar region on
PMT Apical  SD Middle  SD Coronal  SD Mean  SD CT images and it is stated that
canine to premolar region may be
M2 5.5 mm  0.12 3.5 mm  0.51 2.2 mm  0.82 3.7 mm  0.48* the most appropriate donor site that
M1 4.7 mm  0.52 3.0 mm  0.82 2.3 mm  0.87 3.3 mm  0.74 contains a uniformly thick mucosa.
P2 5.1 mm  0.44 3.8 mm  0.55 2.3 mm  0.84 3.7 mm  0.61* This difference may be due to age,
P1 3.8 mm  0.64 3.1 mm  0.68 2.2 mm  0.92 3.0 mm  0.75 ethnicity, varying measurement
C 3.9 mm  0.92 3.2 mm  0.32 2.1 mm  0.66 3.0 mm  0.63
methods, and the placement of the
*Statistically significant (p < 0.05). measurement points. Also smoking
C; canine; M1, first molar; M2, second molar; P1, first premolar; P2, second premolar. affects the palatal mucosal thickness.
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The thickness of the palatal mucosa 461

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Clinical Relevance second molar and second premolar Practical implications: The second
Scientific rationale for study: The regions and a positive correlation premolar to the second molar
size of graft can be related to was found between the age and the zone may the safe zone for graft
the palatal mucosal thickness. The increased palatal mucosa thickness. harvest.
palatal mucosa was thickest at the

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