Quantitative Ultrasound for Periodontal Soft Tissue Characterization.

Periodontal diseases affect 45.9\% of adults aged 30 or older in the United States. Current diagnostic methods for clinical assessment of these diseases are visual examination and bleeding on probing that are subjective, qualitative, and/or invasive. Thus, there is a critical need for research on noninvasive modalities for periodontal tissue characterization. Quantitative Ultrasound (QUS) has shown promising results in noninvasive characterization of various soft tissues; however, it has not been used in periodontics. This study is among initial investigations into the application of QUS for periodontal tissue characterization in the literature. Here, QUS analysis of oral soft tissues (alveolar mucosa and gingiva) is performed in an in vivo animal study including 10 swine. US scanning was performed at the first molar of all four oral quadrants, resulting in a total of 40 scans. We investigated first order speckle statistics of oral tissues by using the two-parameter Burr (power-law b and scale factor l) and Nakagami models (shape factor m and scale factor $\alpha$). Parametric imaging of these parameters was created using a sliding kernel method sweeping regions of interest with a kernel size of 10 wavelengths from a phantom study. Results showed that the difference between gingiva and alveolar mucosa were statistically significant using Burr and Nakagami parameters ($p-value<0.0001$). The Burr b and Nakagami m were higher in gingiva while the Burr l and Nakagami {$\alpha$} were higher in alveolar mucosa. Findings from QUS analyses agreed with observation from histology that showed denser stains for gingiva. Linear classifications of these tissues using 2D parameter spaces of the Burr and Nakagami models resulted in a segmentation accuracy of 93.51\% and 90.91\%, respectively. We propose that QUS holds promising potentials as an augmented tool for disease diagnosis in periodontology.

Ultrasound-based jawbone surface quality evaluation after alveolar ridge preservation.

BACKGROUND: Bone readiness for implant placement is typically evaluated by bone quality/density on 2-dimensional radiographs and cone beam computed tomography at an arbitrary time between 3 and 6 months after tooth extraction and alveolar ridge preservation (ARP). The aim of this study is to investigate if high-frequency ultrasound (US) can classify bone readiness in humans, using micro-CT as a reference standard to obtain bone mineral density (BMD) and bone volume fraction (BVTV) of healed sockets receiving ARP in humans. METHODS: A total of 27 bone cores were harvested during the implant surgery from 24 patients who received prior extraction with ARP. US images were taken immediately before the implant surgery at a site co-registered with the tissue biopsy collection location, made possible with a specially designed guide, and then classified into 3 tiers using B-mode image criteria (1) favorable, (2) questionable, and (3) unfavorable. Bone mineral density (hydroxyapatite) and BVTV were obtained from micro-CT as the gold standard. RESULTS: Hydroxyapatite and BVTV were evaluated within the projected US slice plane and thresholded to favorable (>2200 mg/cm3; >0.45 mm3/mm3), questionable (1500-2200 mg/cm3; 0.4-0.45 mm3/mm3), and unfavorable (<1500 mg/cm3; <0.4 mm3/mm3). The present US B-mode classification inversely scales with BMD. Regression analysis showed a significant relation between US classification and BMD as well as BVTV. T-test analysis demonstrated a significant correlation between US reader scores and the gold standard. When comparing Tier 1 with the combination of Tier 2 and 3, US achieved a significant group differentiation relative to mean BMD (p = 0.004, true positive 66.7%, false positive 0%, true negative 100%, false negative 33.3%, specificity 100%, sensitivity 66.7%, receiver operating characteristics area under the curve 0.86). Similar results were found between US-derived tiers and BVTV. CONCLUSION: Preliminary data suggest US could classify jawbone surface quality that correlates with BMD/BVTV and serve as the basis for future development of US-based socket healing evaluation after ARP.

Ultrasonography-Derived Elasticity Estimation of Live Porcine Oral Mucosa.

OBJECTIVES: To investigate the biomechanical properties of porcine oral tissues with in vivo ultrasonography and to compare the difference between oral alveolar mucosa and gingival tissue concerning compressional and tensile mechanical strain. MATERIALS AND METHODS: Sinclair minipigs (6 females and 4 males, 6 to 18 months of age) were anesthetized for ultrasonography. In vivo high-frequency tissue harmonic ultrasound (12/24 MHz) cine-loops were obtained while inducing mechanical tissue stress (0 to 1 N). Post-processing strain analysis was performed in a cardiac speckle tracking software (EchoInsight®). Region of interest (ROI) was placed for gingival and alveolar mucosa tissues for longitudinal (compressional) and tensile strain analyses. A calibrated gel pad was employed to determine the absolute force (pressure) for the measured tissue strain response function. The resulting elasticity data was statistically analyzed using custom Matlab scripts. RESULTS: In total, 38 sonography cine-loops around the third premolars were included in the investigation. The longitudinal strain of alveolar mucosa ε AM L was found to be significantly (P < .05) larger than that of gingiva ε G L . Across the measured force range, ε AM L ~ 1.7 × Îµ G L . Significant differences between alveolar mucosa and gingiva tissues were found for all forces. The tensile strain of the alveolar mucosa ε AM T was found to be ~2 × Îµ G T (on the epithelial surface of the gingiva). Both were statistically significantly different for forces exceeding ~0.08 N. At depth, that is, 500 and 1000 µm below the epithelial surface, the gingiva was found to have less ability to stretch contrary to the alveolar mucosa. Gingival tissue at 500 µm depth has significantly less tensile strain than at its surface and more than at 1000 µm depth. In contrast, the tensile strain of alveolar mucosa is largely independent of depth. CONCLUSION: Ultrasonography can reveal significant differences in oral alveolar mucosal and gingival elastic properties, such as compressional and tensile strain. Under minute forces equivalent to 10 to 40 g, these differences can be observed. As dental ultrasound is a chairside, and noninvasive modality, obtaining real-time images might soon find clinical utility as a new diagnostic tool for the objective and quantitative assessment of periodontal and peri-implant soft tissues in clinical and research realms. As ultrasound is a safe modality with no known bioeffects, longitudinal monitoring of areas of concern would be particularly attractive.

Overview of Ultrasound in Dentistry for Advancing Research Methodology and Patient Care Quality with Emphasis on Periodontal/Peri-implant Applications.

BACKGROUND: Ultrasound is a non-invasive, cross-sectional imaging technique emerging in dentistry. It is an adjunct tool for diagnosing pathologies in the oral cavity that overcomes some limitations of current methodologies, including direct clinical examination, 2D radiographs, and cone beam computerized tomography. Increasing demand for soft tissue imaging has led to continuous improvements on transducer miniaturization and spatial resolution. The aims of this study are (1) to create a comprehensive overview of the current literature of ultrasonic imaging relating to dentistry, and (2) to provide a view onto investigations with immediate, intermediate, and long-term impact in periodontology and implantology. METHODS: A rapid literature review was performed using two broad searches conducted in the PubMed database, yielding 576 and 757 citations, respectively. A rating was established within a citation software (EndNote) using a 5-star classification. The broad search with 757 citations allowed for high sensitivity whereas the subsequent rating added specificity. RESULTS: A critical review of the clinical applications of ultrasound in dentistry was provided with a focus on applications in periodontology and implantology. The role of ultrasound as a developing dental diagnostic tool was reviewed. Specific uses such as soft and hard tissue imaging, longitudinal monitoring, as well as anatomic and physiological evaluation were discussed. CONCLUSIONS: Future efforts should be directed towards the transition of ultrasonography from a research tool to a clinical tool. Moreover, a dedicated effort is needed to introduce ultrasonic imaging to dental education and the dental community to ultimately improve the quality of patient care.

Interproximal implant thread exposure after initial bone remodeling as a risk indicator for peri-implantitis.

BACKGROUND: Due to the clinical challenges involved in successfully treating peri-implantitis, it is imperative to identify patient- and implant-level risk factors for its prevention. The main goal of this retrospective longitudinal radiographic and clinical study was to investigate whether interproximal radiographic implant thread exposure after physiological bone remodeling may be a risk factor for peri-implantitis. The secondary goal was to evaluate several other potential risk indicators. METHODS: Of 4325 active dental school patients having implants placed, 165 partially edentulous adults (77 men, 88 women) aged 30-91 with ≥2 years of follow-up upon implant restoration were included. Implants with ≥1 interproximal thread exposed (no bone-to-implant contact) (n = 98, 35%) constituted the test group and those without exposed threads (n = 182, 65%) the control group. Descriptive, binary, and multivariate regression analyses were evaluated for goodness of fit. Wald tests were used to evaluate for significance set at 0.05. RESULTS: Of the 280 implants (98 test, 182 control), 8 (2.9%) failed over a mean follow-up period of 7.67 (±2.63) years, and 27 implants (19 test, 8 control) developed peri-implantitis, with the exposed group having eight-fold (7.82 times) adjusted greater odds than the non-exposed. The risk increased four-fold (3.77 times) with each thread exposed. No other patient- or implant-related potentially confounding risk factors were identified. CONCLUSIONS: Exposed interproximal implant threads after physiologic bone remodeling may be an independent risk indicator for incident peri-implantitis. Hence, clinicians should closely monitor patients with implant threads that have no bone-to-implant contact for incident peri-implantitis.

Suggested mesiodistal distance for multiple implant placement based on the natural tooth crown dimension with digital design.

PURPOSE: The purpose of this investigation was to identify a mesiodistal algorithm for multiple posterior implant placement based upon an ideal prosthetically restoration design. METHODS: One hundred one cases of posterior free-end edentulous arches were selected for digital crown designs and measurements. Cone bean computed tomogram and digital fabricated crown were applied. DICOM files were exported to a viewer software (BlueSkyPlan4) to generate digital crown and measurement. The mesiodistal space between roots of adjacent teeth and center of the potential implant horizontally, from both cross-section and coronal plane were measured. Comparisons were performed using t-tests. RESULTS: No significant difference was found in the distances of the maxillary and mandibular posterior implants to adjacent natural teeth (p > 0.05). For interdental/implant distances, premolars are around 4.2 mm and molars are 5.4 mm, correspondently. The second premolar interimplant distance is around 7-7.4 mm. The distance of interimplant of the first molar is about 8-8.5 mm. For the maxillary second molar, the interimplant distance is 9.26 ± 0.29 mm and the mandibular second molar interimplant distance is 9.58 ± 0.19 mm, which is significantly different. No difference was found between the two different measurement methods. CONCLUSION: A mesiodistal algorithm of 4-4.6 (implant to adjacent canine tooth), 7-7.4, 8-8.5, and 9-9.5 mm was recommended for interimplant/tooth distance from first premolar to second molar when placing implants with or without case-specific prosthetic planning prior to surgery.