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 371

Accuracy of Bone Sounding in Assessing

Facial Osseous-Gingival Tissue Relationship in
Maxillary Anterior Teeth

Joseph Y. K. Kan, DDS, MS1 The facial osseous-gingival tissue re-

Yoon Jeong Kim, DDS, MS2 lationship (FOGTR) of anterior teeth
Kitichai Rungcharassaeng, DDS, MS3 is one of the key prognosticators for
John C. Kois, DMD, MSD4 eventual gingival position follow-
ing periodontal,1,2 restorative,3 and
implant procedures.4–6 While im-
The aim of this study was to evaluate the accuracy of bone sounding (BS) in mediate implant placement (IIP) and
assessing the facial osseous-gingival tissue relationship (FOGTR) of failing immediate implant placement and
maxillary anterior teeth. Dental records of patients who received immediate provisionalization (IIPP) procedures
implant placement (IIP) at the maxillary anterior area were screened. Mid-
have been viable treatment options
FOGTR prior to extraction (BS), and immediately after flapless extraction (direct
bone level [DBL] measurement) were analyzed. A total of 160 patients with 190 for replacing maxillary anterior failing
maxillary anterior teeth were included. The mean FOGTR obtained from BS and teeth,7–10 they require the presence
DBL were 3.19 ± 0.71 mm and 3.47 ± 1.29 mm, respectively (P = .004). The two of an intact facial bone with a normal
measurements were identical 83.2% of the time, within 1-mm discrepancy 4.7% FOGTR (3 mm) of the failing tooth
of the time, and > ± 1 mm discrepancy 12.1% of the time. When discrepancy to achieve optimal facial gingival
was observed, BS underestimated DBL 14.2% of the time and overestimated
esthetics.11,12 Therefore, an accurate
2.6% of the time. Though statistically significant, the correlation was weak
(Pearson correlation coefficient r = .238, P = .0018). BS is an acceptably accurate assessment of FOGTR is essential to
and minimally invasive diagnostic tool for measuring FOGTR. However, while proper planning for IIP and IIPP.
the mean difference between BS and DBL measurement is small (0.28 mm), Several methods13,14 have been
the large range of difference can be alarming. Therefore, clinicians should used for FOGTR assessment with
always prepare alternative treatment options for IIP prior to extraction. Int J varying degrees of accuracy and in-
Periodontics Restorative Dent 2017;37:371–375. doi: 10.11607/prd.2664
vasiveness. Direct bone level (DBL)
measurement, performed under di-
rect vision after flap reflection, is the
most accurate method and is consid-
ered the gold standard.13 Nonethe-
Professor, Department of Restorative Dentistry, Loma Linda University,
1
less, because of its invasive nature
Loma Linda, California, USA. that can potentially cause bone re-
2Associate Professor, Department of Periodontics, Loma Linda University,

Loma Linda, California, USA.

sorption and gingival recession, it is
3Professor, Department of Orthodontics and Dentofacial Orthopedics, not recommended as a presurgical
Loma Linda University, Loma Linda, California, USA. diagnostic procedure. Cone beam
4Associate Professor, Graduate Restorative Dentistry, University of Washington;
computed tomography (CBCT) has
Director of Kois Center, Seattle, Washington, USA.
become a standard tool for diagnosis
Correspondence to: Dr Joseph Y.K. Kan, 11092 Anderson Street, Room 4411, and planning of implant treatments,
Center for Implant Dentistry, School of Dentistry, Loma Linda University, especially due to the significant-
Loma Linda, CA 92350, USA. Fax: 909-558-4803.
ly lower effective radiation dose
Email: jkan@llu.edu
produced when compared to con-
 ©2017 by Quintessence Publishing Co Inc. ventional computed tomography.15

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372
Fig 1  Periapical radiograph of failing
maxillary right central incisor due to
external root resorption.
In addition, CBCT is particularly use-
ful in identifying the sagittal root
position, which is crucial in IIP situ-
ations.16 Although CBCT is noninva-
sive, identifying the thin facial bony
crest is often challenging due to the
low contrast resolution of CBCT.14
Bone sounding (BS), also known
as transgingival probing, was advo-
cated in 1976 by Greenberg et al as
an estimator of alveolar bone level.17
Studies have evaluated the accuracy
of BS by comparing BS measure-
ments to DBL measurements18–20
and unequivocally indicate that BS
measurements accurately reflect the
alveolar bone level.21–23 Due to its
simplicity and minimal invasiveness,
BS recently has become an indis-
pensable method to evaluate FOG-
TR of teeth for various periodontal
and restorative procedures.24–28
Nevertheless, most BS accuracy
studies primarily evaluated inter-
proximal sites and posterior teeth,
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where gingival esthetics may not be
of primary concern.21–23 The aim of
this study was to evaluate the accu-
racy of BS as a diagnostic aid in as-
sessing the FOGTR at the midfacial
aspect of failing maxillary anterior
teeth prior to extraction for IIP.
Materials and Methods
Subject Selection and
Data Collection
This study was approved by the In-
stitutional Review Board of Loma
Linda University. Dental records
of patients who received IIP in the
esthetic zone (maxillary canines
and incisors) from January 1998 to
December 2013 at the Loma Lin-
da University School of Dentistry,
Center for Implant Dentistry, were
reviewed. Figure 1 presents a peri-
apical radiograph of a failing maxi-
lary right central incisor included in
this study. Patients were included if
the information on probing depth
at the midfacial site as well as mid-
FOGTR prior to extraction (as eval-
uated by BS), and immediately after
flapless extraction (as assessed by
DBL measurement) was available.
Probing depth, BS, and DBL mea-
surements were recorded to the
nearest millimeter using the same
type of periodontal probe (PCP126,
Hu-Friedy) for all study participants
(Figs 2 and 3). Age and sex of the
patients were also recorded. Pa-
tients who experienced loss of fa-
cial bony plate, trauma, or tear of
the facial free gingival margin dur-
ing extraction were excluded from
the study.
Statistical Analysis
Descriptive statistics were pre-
sented and the frequency distribu-
tion of BS and DBL measurement
discrepancy was also assessed. BS
and DBL measurements were com-
pared using paired t test and their
correlation was expressed as Pear-
son correlation coefficient (r). The
α level was set to .05 for statistical
significance.
Results
A total of 160 patients (103 women
and 57 men) with a mean age of
48.4 (range = 19 to 80) years were
included in the study. A total of 190
maxillary anterior teeth (120 central
incisors, 56 lateral incisors, and 14
canines) were included. The mean
probing depth recorded at the mid-
facial aspect of studied teeth was
1.77 ± 0.55 mm (range = 1–4 mm).
The mean FOGTR obtained from
BS and DBL were 3.19 ± 0.71 mm
and 3.47 ± 1.29 mm, respectively
(Table 1). The measurement discrep-
ancy (BS−DBL) ranged from −9 to
3 mm. The mean difference of 0.28
± 1.31 mm between BS and DBL
measurements was statistically sig-
nificant (paired t test; P = .004).
BS and DBL measurements
were identical 83.2% of the time
(158/190) and had 1-mm discrep-
ancy 4.7% of the time (9/190),
2-mm discrepancy 4.7% of the time
(9/190), and > ± 2-mm discrep-
ancy 7.4% of the time (14/190) (Fig
4). When the discrepancy (16.8%;
32/190) was observed, BS under-
estimated DBL value 14.2% of the
 373

Fig 2  Clinical example of bone sounding measurement prior to Fig 3  Clinical example of direct bone level measurement immedi-
extraction of the maxillary right central incisor shown in Fig 1. ately after extraction of the maxillary right central incisor.

time (27/190) and overestimated it

Table 1 Comparison of FOGTR as Assessed by BS and DBL (n = 190)
2.6% of the time (5/190). Though
statistically significant, the corre- Measurement method Mean ± SD (range) of FOGTR (mm) P
lation between the two measure- BS 3.19 ± 0.71 (3–7) .004*
ment methods was weak (r = .238; DBL 3.47 ± 1.29 (3–12)
P = .002). BS–DBL −0.28 ± 1.31 (−9–3)
*Statistically significant using paired t test (α = .05).

Discussion
100

The percentage frequency distri- 90

bution of ≤ 1 mm measurement (n = 158)

discrepancy (87.9%) and the mean 80

difference (0.28 mm) between BS
70
Frequency distribution (%)

and DBL measurements in this

study are similar to those reported 60
by other studies (91%–97% and
0.1–0.3 mm).18–20,23 Although these 50
measurements validate BS as an ac-
40
ceptably accurate diagnostic tool,
it should be acknowledged that it 30
is far from 100% accurate. Factors
such as root surface anatomy, cervi- 20
cal crown contour, thickness of the
10
facial bony plate, presence of bony (n = 9)(n = 9)
(n = 1) (n = 1) (n = 2) (n = 2) (n = 3) (n = 2)(n = 3)
dehiscence, presence of calculus, 0
presence of facial infrabony defects, –9 –8 –7 –6 –5 –4 –3 –2 –1 0 1 2 3 4
Discrepancy between BS and DBL (mm)
tip diameter of the periodontal
probe, health of the gingival tissue, Fig 4  The frequency distribution of measurement discrepancy between bone sounding
and clinician experience can result (BS) and direct bone level measurement (DBL).

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374
in an under- or overestimation of the
FOGTR measured by BS. Inaccurate
diagnosis due to errors in BS mea-
surements can affect clinicians’ deci-
sion making on treatment planning
for various surgical and restorative
procedures, including IIP and IIPP.
The clinicians should always be pre-
pared in the event that BS does not
reflect the actual FOGTR after tooth
removal or flap reflection in planned
IIP situations.
In this study, the BS-DBL mea-
surement discrepancy ranged from
−9 to 3 mm. The majority of the
discrepancy (14.2%) was an under-
estimation, where the actual crest of
facial bone was more apical than ex-
pected (BS < DBL). Underestimation
is common when the facial bone
dehiscence is deep and narrow, pre-
venting the probe from reaching the
most apical part of the facial bone.
This kind of defect, more often than
not, does not affect the surround-
ing soft tissue condition, which,
when healthy, may be resistant to
the BS force, making it hard for cli-
nicians to discern the tactile sensa-
tion between tight tissue fibers and
thin bony crests. Therefore, deep
and narrow bone dehiscence with
intact connective attachment can
sometimes affect the accuracy of BS
measurement. The average probing
depth of 1.77 ± 0.55 mm (range =
1–4 mm) recorded in this study indi-
cates shallow pockets at the majority
of the data collection sites. Fortu-
nately, a recent study has shown that
the shape (morphology) rather than
the depth of the facial bone defect
may have a greater influence on
facial gingival esthetics and thus
treatment planning in IIPP situa-
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tions.29 Although underestimation
in V-shape defect situations usually
does not alter the treatment plan
for IIPP, an accurate assessment of
FOGTR before surgery is still impor-
tant to minimize unexpected com-
plications.
An overestimation (actual crest
of facial bone is more coronal than
expected; BS > DBL) occurs when
the probe stops beyond the facial
bone crest during BS and/or there is
a change in facial gingival levels dur-
ing/after extraction. Thin facial bony
plate is more likely to cause probe
slippage beyond the bone crest dur-
ing BS, especially when a probe with
a thicker tip is used. The diameter
of the periodontal probe tip used in
this study was 0.56 mm. This is com-
parable to the recommended size
of 0.6 mm with 0.20 gram force to
obtain a pressure that demonstrates
approximate probing depth.30 How-
ever, for BS, a smaller tip might be
advantageous, as less force is need-
ed to reach the bone level and thus
there is less chance of slippage. The
presence of infrabony defect has
also been associated with overes-
timation.20 During even minimally
traumatic extraction, free gingival
margin is usually displaced apically,
causing FOGTR reduction and thus,
overestimation is introduced in this
study; the frequency distribution of
overestimation was only 2.6%. Com-
pared to underestimation, overesti-
mation is less problematic clinically
as the crest of bone is more coronal
than expected and the treatment is
less extensive.
This study has limitations com-
monly associated with any retro-
spective study. While only one
experienced examiner (J.Y.K.) was
involved in data collection, clinical
measurements were not as well-
standardized as in a prospective
study. The measurement location of
BS and DBL might not be as consis-
tent as when a template is used. Fur-
thermore, an inevitable slight facial
free gingival margin distortion and/
or minimal bony crest change after
extraction was not factored into the
study. Collectively, these likely con-
tribute to the weak correlation be-
tween BS and DBL measurements in
this study (r = .238; P = .002). In pro-
spective studies,18–23 templates were
used as references to minimize the
possible measurement errors men-
tioned above. However, the results
of the present study may be useful
as they represent realistic clinical sit-
uations rather than a well-controlled
study environment.
Conclusions
Within the limitations of this study,
BS was shown to be an acceptably
accurate and minimally invasive di-
agnostic tool for measuring FOGTR.
However, while the mean difference
between BS and DBL measure-
ments was small, the large range in
difference can be alarming. For a
successful IIP/IIPP, the periodontal
condition of the failing tooth should
be as ideal as possible. Regardless,
BS is still the less invasive method
to estimate the gingiva-to-bone re-
lationship in spite of the slight pos-
sibility of measurement discrepancy.
Therefore, clinicians should always
prepare for treatment alternatives in
IIP/IIPP situations.

Acknowledgments
The authors reported no conflicts of interest
related to this study.
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