Received: 3 March 2023 Revised: 27 April 2023 Accepted: 29 April 2023

DOI: 10.1111/jerd.13064

RESEARCH ARTICLE

Compatibility of digital and analog methods in assessment

of gingival zeniths

Burcu Karaduman PhD 1 | Semih Sarp DDS 2 | Mustafa Yilmaz PhD 1

1
Faculty of Dentistry, Department of
Periodontology, Biruni University,
Istanbul, Turkey
2
Biruni University, Istanbul, Turkey
Correspondence
Burcu Karaduman, Biruni University, Faculty of
Dentistry, Department of Periodontology, 10.
Yil Caddesi Protokol Yolu No:45 34010
Topkapi, Istanbul, Turkey.
Email: bkaraduman@biruni.edu.tr
Abstract
Objective: The compatibility of digital and analog methods assessing the positions of
gingival zenith (GZ) points has not been evaluated before. Therefore, the aim of this
study was to investigate the accuracy of a digital scanner and a three-dimensional
(3D) measuring tool in specifying positions of GZs by comparing it to the conven-
tional method, an analog plaster cast and a caliper.
Materials and Methods: Both analog and digital impressions were obtained from
32 individuals. Following measurements were conducted in the anterior maxillary
region from canine to canine on both the plaster casts and 3D images: (1) The dis-
tance from GZ to the corresponding vertical midline in each tooth (GZVM), (2) The
distance from GZ of lateral incisor to the corresponding tangent that connects GZs
of central incisor and canine (GZLI).
Results: The intraclass correlation coefficients (ICC) of GZVM in each tooth varied
between 0.366 and 0.755, demonstrating moderate to good compatibility between
the two methods. The ICC of analog and digital GZLI for the right and left lateral inci-
sors was 0.788 and 0.395, respectively.
Conclusion: The digital and analog methods used in this study are compatible in
determining the positions of GZs. Therefore, within the limitations of the present
study, the choice of method can be based on the available equipment, time, comfort,
and personal preference of the researcher.
Clinical Significance: Both digital and analog methods have the capability of deter-
mining the positions of GZs in compatible way.

KEYWORDS
digital technology, esthetics, gingiva, methods

1 | I N T RO DU CT I O N points were previously proposed by different researchers.2–4 Indeed,

The gingival zenith (GZ) refers to the most apical position of the
gingival margin. Knowing ideal positions of GZ points is critical for
successful management of periodontal and restorative procedures in
the esthetic zone.1 However, various relative displacements for GZ
approximate positions of GZ points can differ depending on several
factors, such as tooth position, sex, characteristics of the studied
population, and the used method and data interpretation.1,5–7
In prior studies, GZ positions have been assessed with digital models
obtained by scanning analog casts, analog plaster casts or standardized

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provided the original work is properly cited.
© 2023 The Authors. Journal of Esthetic and Restorative Dentistry published by Wiley Periodicals LLC.

1162 wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2023;35:1162–1166.


KARADUMAN ET AL.
digital photographs.5,6,8–17 However, the compatibility of these
techniques has not been evaluated previously. While dental applications
are increasingly becoming digitalized, establishing scientifically reliable
and precise digital methods is fundamental.18–21 The hypothesis of the
present study was that analog and digital measurements for determining
zenith points would be correlative. Therefore, the aim of this study was
to investigate the accuracy of a digital scanner and a three-dimensional
(3D) measuring tool in determining the positions of GZ points by compar-
ing it to the conventional method using an analog plaster cast and a cali-
per. The null hypothesis was that analog and digital measurements for
determining the GZ points would demonstrate no correlations.
2 | MATERIALS AND METHODS
The Ethics Committee of Biruni University endorsed this study (approval
number: 2019/2514). All participants were informed about the study and
their written consent was obtained prior to enrolment. For sample size
determination, a pilot study, including eight participants, was conducted.
Based on the difference between two dependent means of analog and
digital methods measuring distal displacement of GZ points of central inci-
sors, a minimum required sample size of 25 was calculated (large effect
size, dz = 0.76, ɑ = 0.05) to achieve a power of 95%.
Thirty-two systemically healthy (self-reported) non-smokers aged
18 years and older were enrolled. At the first visit, a full-mouth dental,
periodontal and radiographic screening was performed to assess their
eligibility. The inclusion criteria were as follows: being periodontally
healthy (<10% bleeding on probing, maximum probing pocket depth
at any site ≤3 mm),22 Class I occlusion with full dentition, no previous
orthodontic treatment. Individuals who had signs of gingival inflamma-
tion, dental anomalies, restorations, attrition, abrasion, erosion, clinical
attachment or radiographic bone loss, crowding or spacing, rotation,
gingival recession, gingival overgrowth or altered passive eruption at
the maxillary anterior teeth were excluded.
Both analog and digital impressions were obtained from all indi-
viduals. The measurements were conducted in the anterior maxillary
region from canine to canine on both the plaster casts and 3D images.
All measurements were performed by a single previously calibrated
investigator (S.S.). Intra-examiner reliability was measured by calculat-
ing the distance between the long axis and GZ point of ten central
incisors, which were not part of the present study. The measurements
were repeated on two consecutive days. The intraclass correlation
coefficient (95% CI) for analog and digital measurements ranged
between 0.996 and 1, and 0.998 and 1, respectively.
2.1 | Analog and digital morphometric analyses
An analog impression was taken with a silicone dental impression material
(Zetaplus, Zhermack, Spa, Italy), which was immediately poured with stone
(Cerestone, Pera Alci Dokum San. ve Ticaret, Turkey). Between 24 and 32 h
after pouring, measurements were made with a digital caliper (Hogetex, Gel-
derland, Netherlands) on the plaster casts, as described below.
17088240, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.13064 by Cochrane Peru, Wiley Online Library on [12/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1163
I. On both interproximal sides of each tooth, apical and incisal contact,
area positions were visually identified and marked. Horizontal lines
were drawn to connect the corresponding contact positions. The
midpoint of each line was measured, and a vertical line was drawn
through the midpoints to determine the tooth's long axis. Following,
the GZ was examined visually, and the shortest distance between
the GZ and the vertical line (GZVM) was measured and recorded. A
distal dislocation of the GZ was recorded as a positive value, while a
mesial dislocation was recorded as a negative (Figure 1).
II. A tangent connecting the GZ points of the ipsilateral central inci-
sor and canine was drawn and the shortest distance between the
lateral incisor zenith point and the tangent (GZLI) was measured.
If the GZ of the lateral incisor was located coronally to the tan-
gent, it was marked as a positive value, while an apical dislocation
was recorded as a negative (Figure 2).
The digital impression was taken using an intraoral scanner
(CEREC Omnicam SW 4.5, Dentsply Sirona, Bensheim, Germany).
Standard tessellation language (STL) files were generated from these
scans and imported into a commercial 3D graphics and computer-
aided design software (Rhinoceros 3D: Version 5 Software, Robert
McNeel & Associates, Seattle, USA). The measurements were con-
ducted with an algorithmic modeling plug-in (Grasshopper, Robert
McNeel & Associates, Seattle, USA) that was integrated with the soft-
ware. Interproximal contact area positions and GZs were marked by
the outcome assessor. The above-mentioned lines (GZVM and GZLI)
were drawn, and the calculations were made by the software auto-
matically on 3D images (Figures 1 and 2).
2.2 | Statistical analysis
NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA)
was used for statistical analysis. Descriptive statistical methods (mean,
standard deviation, frequency, percentage, minimum, maximum) were
used while evaluating the study data. The conformity of the quantitative
data to the normal distribution was tested with the Shapiro-Wilk test,
skewness, and kurtosis. Paired t-test was used to compare the values
obtained by analog and digital methods. The difference of the positions of
the GZ points between sexes or between symmetrical teeth was evalu-
ated with the Student's t-test. Intraclass Correlation Coefficient (ICC) was
used to evaluate the measurements' consistency between analog and digi-
tal methods. p < 0.05 was considered statistically significant.
3 | RE SU LT S
The study included a total of 32 individuals (21 females). The age of
the participants varied between 19 and 33 years, with a mean age of
24.09 ± 3.33. A total of 192 teeth were evaluated.
The comparison of the GZVM obtained by the analog method
and that obtained by the digital method is presented in Table 1. The
distance measured with the analog method for the right upper central
 17088240, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.13064 by Cochrane Peru, Wiley Online Library on [12/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1164 KARADUMAN ET AL.

F I G U R E 1 Determining the
distance between the gingival
zenith and the vertical midline
(GZVM) in analog and digital
techniques. (a) Apical contact
positions, (b) Incisal contact
positions, GZ: Gingival zenith,
VM: Vertical midline.

F I G U R E 2 Determining the
distance between gingival zenith
of the lateral incisor and tangent
connecting zeniths of the central
incisor and canine (GZLI) in both
analog and digital techniques.
(A) Gingival zenith of canine,
(B) Gingival zenith of central
incisor, GZ: Gingival zenith.

T A B L E 1 The gingival zenith-long

Digital Analog ICC (95% CI) p
axis distance (GZVM).
RC 0.10 ± 0.09 0.10 ± 0.13 0.649 (0.390, 0.812) <0.001
LC 0.15 ± 0.13 0.12 ± 0.14 0.755 (0.545, 0.874) <0.001
Student's t-test p 0.060 0.488
RLI 0.20 ± 0.12 0.24 ± 0.13 0.613 (0.346, 0.790) <0.001
LLI 0.24 ± 0.11 0.28 ± 0.13 0.366 (0.039, 0.627) 0.016
Student's t-test p 0.082 0.108
RCI 0.40 ± 0.23 0.49 ± 0.21 0.701 (0.384, 0.856) <0.001
LCI 0.42 ± 0.21 0.48 ± 0.18 0.480 (0.174, 0.705) 0.002
Student's t-test p 0.543 0.748

Note: The values are given as mean ± standard deviation. p-values in bold represent significant
difference. Abbreviations: CI: Confidence interval, ICC: Intraclass correlation coefficient, LC: Left canine,
LCI: Left central incisor, LLI: Left lateral incisor, RC: Right canine, RCI: Right central incisor, RLI: Right
lateral incisor.

T A B L E 2 Apicocoronal displacement
Digital Analog ICC (95% CI) p
of lateral incisors' gingival zeniths (GZLI).
RLI 0.37 ± 0.16 0.35 ± 0.14 0.788 (0.604, 0.892) <0.001
LLI 0.40 ± 0.27 0.37 ± 0.20 0.395 (0.057, 0.653) 0.013
Student's t-test p 0.553 0.349

Note: The values are given as mean ± standard deviation. p-values in bold represent significant
difference. Abbreviations: CI: Confidence interval, ICC: Intraclass correlation coefficient, LLI: Left lateral
incisor, RLI: Right lateral incisor.

and left upper canine teeth was found to be significantly higher than
the distance measured with the digital method ( p = 0.002, p = 0.040;
respectively). The degree of concordance between analog and digital
methods is shown in Table 1. The ICC (95% CI) from right canine to
left canine obtained by the analog and digital methods was 0.649,
0.613, 0.701, 0.480, 0.366, and 0.755, respectively. There was no sta-
tistically significant difference between the analog and digital methods
in terms of apicocoronal displacement of lateral incisors' GZ points
( p > 0.05) (Table 2). The ICCs (95% CI) of analog and digital GZLI for
the right and left lateral incisors were 0.788 and 0.395, respectively. A
more detailed breakdown of the concordance between both applica-
tions is shown in Table 2.
The harmony between the GZ points of contralateral teeth with
both digital and analog methods was also evaluated. The GZVMs of
contralateral teeth were compared with each other; no statistically
significant differences were found in analog or digital evaluations
(p > 0.05) (Table 1). Likewise, when the apicocoronal placement of the
GZ points of lateral incisors was compared with each other, no
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KARADUMAN ET AL. 1165

T A B L E 3 Comparisons of gingival zenith-long axis distance between plaster and digital models for linear measurements such as
(GZVM) and apicocoronal displacement of lateral incisors' gingival overjet, overbite, arch width and so forth. have been previously dem-
zeniths (GZLI) between sexes.
onstrated.19 The distinction of the present study, on the other hand,
Female Male P is that soft tissues were comparably evaluated with analog and digital
GZVM RC Digital 0.11 ± 0.09 0.09 ± 0.11 0.598 methods. Indeed, although the accuracy of several digital scanning
Analog 0.09 ± 0.13 0.11 ± 0.14 0.809 systems has been found to be comparable with conventional impres-

RLI Digital 0.18 ± 0.13 0.24 ± 0.11 0.210 sions, soft tissue interference can reduce the accuracy of digital scan-
ners.20 Therefore, the main outcomes suggest that analog and digital
Analog 0.25 ± 0.14 0.22 ± 0.08 0.506
methods are reliable in developing protocols for GZ assessment for
RCI Digital 0.32 ± 0.17 0.54 ± 0.26 0.007
scientific purposes or treatment planning in the esthetic zone.
Analog 0.41 ± 0.18 0.64 ± 0.15 0.001
The digital method in the present study confined entirely digital
LCI Digital 0.41 ± 0.22 0.44 ± 0.21 0.717
impressions and computerized measurements, limiting human error as
Analog 0.45 ± 0.19 0.52 ± 0.15 0.301
much as possible. However, the GZs and interproximal contact posi-
LLI Digital 0.21 ± 0.11 0.30 ± 0.10 0.029
tions were determined by a single researcher with both methods,
Analog 0.27 ± 0.15 0.29 ± 0.10 0.717 which is a limitation of this study. Therefore, digital measurements
LC Digital 0.14 ± 0.12 0.18 ± 0.16 0.432 can be considered not completely free from human error. To over-
Analog 0.11 ± 0.13 0.14 ± 0.15 0.623 come any potential effects of this limitation on the findings, the out-
GZLI RLI Digital 0.35 ± 0.16 0.40 ± 0.15 0.376 come assessor was previously calibrated for both methods. Fully
Analog 0.34 ± 0.15 0.37 ± 0.14 0.686 digitized assessment methods with the use of artificial intelligence can
LLI Digital 0.41 ± 0.33 0.37 ± 0.13 0.675 be beneficial in future studies. To note, the strict exclusion criteria,

Analog 0.38 ± 0.24 0.36 ± 0.11 0.760
Note: The values are given as mean ± standard deviation. p-values in bold
represent significant difference. Abbreviations: LC: Left canine, LCI: Left
central incisor, LLI: Left lateral incisor, RC: Right canine, RCI: Right central
incisor, RLI: Right lateral incisor.
statistically significant differences were found ( p > 0.05) (Table 2). All
GZs of the lateral incisors were located coronal to the tangent except
for a right lateral incisor in a female participant. There were only three
cases, all female, where GZ was mesially located: right canine (digital),
left canine (digital) and right lateral incisor (analog).
When the measurements were compared between males and
females, the digital and analog measurements of the right upper central
were found to be significantly higher in males (p < 0.05). GZVM of the
left lateral in males was significantly higher than that in females, according
to the digital method (p < 0.05). No significant differences were found
between females and males in the apicocoronal placement of the zenith
points according to both assessment methods (p > 0.05) (Table 3).
4 | DISCUSSION
The present study is a first to reveal that two methods, digital and
analog, are compatible in determining the positions of GZ points.
There are prior studies on analyzing zenith positions with only digital
impressions or photographs or assessing the reproducibility of digital
5,8,15
measurement tools. However, to the best of the authors' knowl-
edge, the concordance of digital and analog techniques in determining
zenith points has not been assessed previously.
The results of the present study suggest moderate to good com-
patibility between the two methods. Therefore, the null hypothesis
was rejected. This finding was not unexpected, since compatibility
such as altered passive eruption or history of orthodontic treatment
limit the generalizability of the present study's findings. However,
these criteria were decided on to minimize the potential confounding
effects of varying gingival anatomy and thus to obtain a more homog-
enous data set. Further research can be beneficial in this regard.
Another drawback of this study is that, despite being a widely used,
the intraoral scanner used is not the latest or the most advanced scan-
ner available, although it is a commonly used one, which may have
impacted the outcomes. On the other hand, a recent study demon-
strated a high precision of this intraoral scanner, even though its true-
ness was lower than various other scanners.21
In this study, GZVM, regardless of the measurement method, was
the highest in central incisors, followed by lateral incisors and canines,
respectively. This finding was in agreement with several other recent
studies.1,4,8–12 Apicocoronal relationship of anterior maxillary GZs is
quite consistent across the literature.9–11 GZs of lateral incisors were
located coronally to GZ of central incisors and canines, which was also
in agreement with previous studies.9–11 However, both the GZVM and
GZLI values in the present study seem to be lower when compared to
other studies.9–11 The difference between investigated sample popula-
tions and the sensitivity can be the explanations for this result.
The differences in positions of GZ between different sexes were also
studied. Prior research reported no significant differences in GZLI between
females and males, which are in accordance with the findings of this
study.5,9–11,16 On the other hand, GZ are located significantly more distally
in the right upper central incisor in males than in females, which is consis-
tent with only one prior study.9 Conversely, various researchers empha-
sized that there are no differences in the GZVM between females and
males.6,10,11 The inconsistency among studies can be attributed to two
main factors, unbalanced sex ratio and the pooled data from left and right
teeth in the final analysis. Other possible confounding factors, including gin-
gival phenotype, gingival line angle and tooth shape, may also influence the
difference between females and males and need to be assessed further.

1166
The age of the participants in the present study ranged from 19 to
33 years, with a mean age 24.09 to avoid possible age-related varia-
tions. The majority of the previous research has been performed in
younger adults,5,10 whereas it was previously suggested that there are
inevitable differences in gingival characteristics due to the mesial migra-
tion and active and passive eruption process of teeth with aging.11
However, researchers did not report any difference in terms of GZ posi-
tions and their level between two different age groups. Thus, age does
not seem to be a confounding factor according to available literature.
Even in varying proportions, asymmetry exists in everything in nature.
Although it is a natural phenomenon, smiles with symmetrical morphologi-
cal features are considered more attractive.17 GZ symmetry is another
important parameter in smile design. Therefore, the symmetry between
GZVLs of right and left contralateral teeth and GZLIs of contralateral LIs
were also evaluated in the present study, demonstrating no statistically
significant difference, which is compatible with previous research.17
5 | C O N CL U S I O N
Within the limitations of the present study, digital and analog impres-
sions as measurement methods are compatible in determining the
positions of GZs. However, it is important to note that the accuracy
of these methods can depend on factors, such as the type of scanner
or tool used, the experience of the operator, human error, and the
complexity of the case. Future studies on fully digitalized methods
might assist in eliminating human error in studies on gingival anatomy
and clinical applications concerning smile design.
DIS CLOSURE
The authors do not have any financial interest in the companies
whose materials are included in this article.
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.
ORCID
Burcu Karaduman https://orcid.org/0000-0002-8162-3896
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How to cite this article: Karaduman B, Sarp S, Yilmaz M.
Compatibility of digital and analog methods in assessment of
gingival zeniths. J Esthet Restor Dent. 2023;35(7):1162‐1166.
doi:10.1111/jerd.13064