11.
5  Volumetric Measurements for Evaluation of Oral Soft Tissue Changes
11.5 Volumetric Measurements
for Evaluation of Oral Soft
Tissue Changes
David Schneider and
Sven Mühlemann
11.5.1 Introduction
Quantitative volumetric analyses focusing on
alterations of tissue dimensions are of great inter-
est in various fields of preclinical and clinical
research. Different methods have been used for
the measurement of changes of hard and soft tis-
sue dimensions following various therapeutic
interventions. In particular, such analyses have
been performed in connection with bone aug-
mentation and soft tissue grafting procedures
(Friedmann et al., 2011; Proussaefs et al., 2002;
Schneider et al., 2011) for implant site develop-
ment or at pontic areas, comparison of ridge pres-
ervation techniques following tooth extraction
(Covani et al., 2011; Fickl et al., 2008), for the
determination of tooth wear (Kramer et al., 2006;
Mehl et al., 1997; Petersilka et al., 2003), to
measure the effects of orthodontic treatment
(Marini et al., 2007), and for analyses of long-
term tissue stability, e.g., around dental implants
(Cardaropoli et al., 2006; Jemt and Lekholm,
2005; Schneider et al., 2011). In general, the
analysis is based on the comparison of tissue
dimensions within a defined area of interest at
two or more time points. The dimensions of the
tissues are either assessed by the measurement of
the actual tissue volume, which is then compared,
or by comparison of a tissue surface to a reference
surface.
The measurements can be performed either
clinically by obtaining the measured value
intraorally or post-clinically by capturing the clin-
ical situation (photograph, conventional impres-
sion, intraoral optical scan, radiographs, etc.) and
secondary data processing (Fig 11.5-1).
11
11.5.2 Clinical Measurements
Clinical intraoral linear measurements for the
quantification of, e.g., gingival recessions, papilla
height or the width of the alveolar ridge, can be
performed with periodontal probes or calipers
(Covani et al., 2004; Chen et al., 2008; Grunder,
2011; Grunder, 2000). The use of tooth supported
stents guiding these instruments at a defined pos-
ition and direction allows standardized measure-
ments at different time points and by different
examiners (Perez et al., 2005). Stents and probes
can also be used for the mapping of the surface
topography. Endodontic files can be used for soft
tissue thickness measurements and assessment of
the bony contour by ridge mapping (Östlund,
1958); (Studer et al., 1997) (Fig 11.5-2). Soft tis-
sue thickness has also been measured by ultra-
sonic devices (Cardaropoli et al., 2006; Eger et al.,
1996; Tsiolis et al., 2003).
It is of great importance that the measurements
are always performed in a reproducible manner,
i.e., using the same, stable reference points, in the
same direction using the same tools, etc. A cali-
bration of the method and examiner(s) is manda-
tory.
Direct intraoral measurements have several
advantages. They are relatively fast, simple and
inexpensive and the results are available immedi-
ately. No secondary data processing is necessary
and therefore possible errors from additional work
steps are excluded. However, the measurements
can be falsified by reading or rounding errors, lim-
ited accessibility or non-standardized measure-
ment technique. Moreover, more clinical time is
usually needed for data collection than in the case
of post-clinical bench top measurements. In addi-
tion, measurements cannot be verified or repeated
at a later time point. Depending on the invasive-
ness of the method, patient discomfort can arise.
This is particularly true for the evaluation of bone
dimensions that usually require surgical re-open-
ing of the site for direct access to the site. Even
after flap elevation, some of the areas may not be
accessible for measurements and, therefore, may
require radiographic evaluation.
183
Analytical Methods

Clinical chairside Post-clinical

approach labside approach

Clinical chairside Capturing of clinical situation

Clinical
measurement (photograph, impression,
appointment
(probe, caliper,…) optical scan,…)
- Timepoint 1

Value 1 Data Set 1

Processing of data (fabrication/

sectioning of models, digitization,
Laboratory transformation of file format,…)

Data Set 1.1

Clinical chairside Capturing of clinical situation

Clinical
measurement (photograph, impression,
appointment
(probe, caliper,…) optical scan,…)
- Timepoint 2

Value 2 Data Set 2

Processing of data (fabrication/

sectioning of models, digitization,
Laboratory transformation of file format,…)

Data Set 2.1

Matching of data sets;

Measurements in data sets
Laboratory

Values

Comparison and analysis

Analysis of values obtained from
of obtained values from
post-clinical lab side measurement
Data analysis measurement 1 and 2

Results Results

Fig 11.5-1 Workflow of clinical and bench top based volumetric evaluation.

184
 11.5  Volumetric Measurements for Evaluation of Oral Soft Tissue Changes
11.5.3 Lab side Measurements
In the case of post-clinical laboratory analysis, the
clinical situation is recorded in a first step, and
data processing and measurements are performed
in a second step. For this purpose, different tech-
niques have been developed, including analysis of
photographs, cast models, optical scan data and
radiographs (Alpiste-Illueca, 2004; Arasawa et al.,
2012; Ender and Mehl, 2011; Friedmann et al.,
2011; Henriksson and Jemt, 2004; Januario et al.,
2008; Jemt and Lekholm, 2003; 2005; Oberoi et
al., 2009; Oz et al., 2011; Ricci, 2007; Rodrigues
et al., 2012; Schneider et al., 2011; Shirota et al.,
2010; Strebel et al., 2009; van Brakel et al., 2011;
Weinlander et al., 2009; Windisch et al., 2007).
Usually, data obtained at different time points
during treatment are compared. This implies that
adequate reference points for measurements are
defined and can properly be identified in all data
sets. These reference points must be present in all
data sets, identical in their position and dimension
and also remain stable during the follow-up period
to ensure proper matching and superimposition of
the data sets. The data analysis can again be per-
formed using analogue techniques, similar to
direct clinical measurements, such as calipers, rul-
ers, etc. or by digitalization and analysis in a soft-
ware program. For the latter, different file formats
are considered as a standard, which is important
to ensure data compatibility. Current file formats
include JPEG (Joint Photographic Experts Group /
.jpg) and TIFF (Tagged Image File Format / .tiff)
for image files, STL (Surface Tesselation Language
/ .stl) for surface files and DICOM (Digital Imag-
ing and Communications in Medicine /.dcm) for
radiographic files.
With the indirect method, clinical data are col-
lected at a given time point and can be processed
any time after the patient appointment. It can be
analyzed in different ways and several times, if
necessary, and by different examiners. Also, stor-
age over a long period and additional evaluation
at a later time point are possible. The interpreta-
tion of the acquired data can be potentially facil-
itated, e.g., by enhancement of the original
11
Fig 11.5-2  Clinical application of stent-guided soft-tissue
thickness measurement using an endodontic file.
image quality or the use of high magnification. A
larger variety of measuring tools can be applied
than for intraoral application. For digital data
processing, a broad variety of software programs
is available and offers almost unlimited options
for analyses (Figs 11.5-3 to 11.5-7).
Disadvantages of the indirect method arise
from possible errors during data acquisition and
processing (impression taking, cast production,
non-standardized photographs/radiographs,
optical scanning, data digitization, defective dig-
ital data, radiographic artifacts, etc.). The use of
digital techniques is associated with infrastruc-
tural investments and operating expenses and
requires appropriate training. Moreover, many of
the evaluation protocols lack adequate valida-
tion. One major challenge is the identification of
stable reference points for measurements or ref-
erence surfaces for data superimposition of mul-
tiple data sets. This must be considered during
the development of the research protocol and
respected during clinical data collection.
11.5.4 Considerations for Data Collection
and Analysis
Although “volumetric” implies a three-dimen-
sional (3D) analysis, the analyses are primarily
performed in a 2D way. The distance between
two points on two surfaces is measured in a given
185
Analytical Methods
Fig 11.5-3  Digitalized model of preoperative
situation.
Fig 11.5-5  Superimposed models (yellow-semitrans-
parent = preoperative, green = postoperative).
Qualitative and quantitative analysis of volume
changes in the area of interest.
direction (Fickl et al., 2008; Januario et al., 2008;
Kirmeier et al., 2011). Depending on the size of
the area of interest, the absolute volume can be
calculated from the sum of the linear measure-
ments. To simplify the procedure and the data
analysis, the measurements are often limited to a
186
Fig 11.5-4  Digitalized model of postoperative
situation.
Fig 11.5-6  Visualization of volume changes between
models from incisal view (green = postoperative,
turquoise = projection of preoperative surface in area of
interest).
Fig 11.5-7 Cross-sectional
views of surfaces (yellow =
preoperative, green =
postoperative, gray = area
of interest). Lower left: axial
section, lower right:
bucco-oral section, upper
right: tangential section.
few linear measurements in the most relevant area
(e.g., midcrestally).
Another way to calculate the volume in digital
data sets is the addition of voxels or pixels in differ-
ent sections within the area of interest. This analysis
is independent of the axis or direction of vectors

between the two surfaces. However, it may require
a specific software program for calculation of the
volume. By summarizing the number of volume
elements (voxels) of a known volume, the overall
volume can be calculated. In case of area elements
in pictures of images (pixels), only areas can be
compared by addition of the pixels of a known size.
If several sections through the 3D area of interest in
defined intervals are used, an approximate volume
calculation is also possible from the size and num-
ber of pixels and the section interval.
Depending on the outcome variable, different
values can be obtained to measure dimensional
alterations. Besides linear measurements, one
possibility is the measurement of the tissue vol-
ume in a defined area and calculation of the vol-
ume difference between two or more time
points. This implies that the area of measurement
can be identified and defined to be identical in all
data sets, e.g., by segmentation in a software
program.
Although calculation of the absolute volume
within a measured area seems to provide the most
complete information, there are some challenges
in data interpretation when comparing volume
changes at different sites. If the area of interest is
different at each site or subject (e.g., due to a dif-
ferent size of a tooth gap), the comparison of the
absolute volume is inappropriate. Relative values
or calculation of the mean linear change between
the analyzed surfaces can be used to provide ade-
quate data for comparison.
However, the most appropriate method for data
collection and analysis depends on the study
design and outcome parameters. It must be care-
fully evaluated prior to the initiation of any volu-
metric investigation.
Acknowledgments
University funding was used for the completion of
this article. The authors declare no conflict of
interest with any of the products used in the pres-
ent manuscript.
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