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Classification of Sagittal Root Position in Relation to the Anterior Maxillary

Osseous Housing for Immediate Implant Placement: A Cone Beam Computed
Tomography Study

Article in The International journal of oral & maxillofacial implants · July 2011
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 Classification of Sagittal Root Position in Relation
to the Anterior Maxillary Osseous Housing for
Immediate Implant Placement: A Cone Beam
Computed Tomography Study
Joseph Y. K. Kan, DDS, MS1/Phillip Roe, DDS, MS2/Kitichai Rungcharassaeng, DDS, MS3/
Rishi D. Patel, BDS, MS2/Tomonori Waki, DDS, PhD2/Jaime L. Lozada, DMD4/Grenith Zimmerman, PhD5

Purpose: The purpose of this study was to classify the relationship of the sagittal root positions
of the maxillary anterior teeth to their respective osseous housings using cone beam computed
tomography (CBCT). The frequency of each classification was also reported. Materials and
Methods: A retrospective review of CBCT images was conducted on 100 patients (40 men,
60 women; mean age, 53.1 years) who fulfilled the inclusion criteria. The CBCT images were
evaluated and the relationship of the sagittal root position of the maxillary anterior teeth to
its associated osseous housing was recorded as Class I, II, III, or IV. Results: The frequency
distribution of sagittal root position of maxillary anterior teeth indicated that, of the 600 samples,
81.1%, 6.5%, 0.7%, and 11.7% were classified as Class I, II, III, and IV, respectively. Conclusions:
An understanding of the clinical relevance of sagittal root position will provide adjunct data for the
treatment planning of immediate implant placement and provisionalization in the anterior maxilla.
A classification system may lead to improved interdisciplinary communication in treatment planning
for implant-based therapy in the anterior maxilla. Int J Oral Maxillofac Implants 2011;26:873–876

Key words: anterior maxilla, cone beam computed tomography, esthetics, immediate implant
placement, immediate provisionalization, osseous housing, sagittal root position, single-tooth
replacement, treatment planning

Immediate implant placement and provisionaliza-

tion (IIPP) of a single tooth in the esthetic zone
was first advocated in the mid-1990s and has since
for replacing failing teeth.1–9 In addition to preserv-
ing tissue architecture, reducing treatment time,
and providing the patient with the convenience of
been considered a predictable treatment option an immediate tooth replacement,1,3,7,8 IIPP proce-
dures have also been documented with high suc-
cess rates when established clinical guidelines are
1Professor, Department of Restorative Dentistry, Loma Linda followed.3,6,9 To ensure successful IIPP, in addition
University School of Dentistry, Loma Linda, California. to the presence of an intact bony socket following
2 Assistant Professor, Department of Restorative Dentistry,
extraction and the absence of active infection, pri-
Loma Linda University School of Dentistry, Loma Linda,
California. mary implant stability must be achieved by engag-
3Associate Professor, Department of Orthodontics and ing the implant with the palatal wall and the bone
Dentofacial Orthopedics, Loma Linda University School of approximately 4 to 5 mm beyond the root apex.6–8
Dentistry, Loma Linda, California. Unfortunately, because the available bone around the
4Professor and Director, Advanced Education in Implant
failing tooth may not always be sufficient to achieve
Dentistry, Loma Linda University School of Dentistry, Loma
Linda, California. primary implant stability, alternative treatment op-
5Associate Dean and Professor, School of Allied Health tions should be considered. Factors such as root
Professions, Loma Linda University, Loma Linda, California. length, sagittal root position (SRP), and the morpholo-
gy of the osseous housing are important in determin-
Correspondence to: Dr Joseph Kan, Center for Prosthodontics
and Implant Dentistry, Loma Linda University School of ing the feasibility of IIPP and must be evaluated via
Dentistry, Loma Linda, CA 92350. Fax: +909-558-4803. the use of cone beam computed tomography (CBCT).
Email: jkan@llu.edu While the effect of root length on the IIPP is easily

The International Journal of Oral & Maxillofacial Implants 873

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Kan et al

Fig 1  Class I sagittal root Fig 2  Class II sagittal root Fig 3  Class III sagittal root Fig 4  Class IV sagittal root
position. position. position. position.

understood (the longer the root, the less available was evaluated using images from CBCT scans (i-CAT
bone beyond the root apex and the more limited the Vision, Imaging Sciences International). The arch
selection of implants of appropriate length), the influ- form selector tool was centered through the middle
ence of the relationship between the SRP and its osse- of the arch in the axial plane. The SRP in relationship
ous housing on IIPP has not been documented. to the osseous housing was evaluated by viewing the
The purpose of this CBCT study was to classify the cross-sectional image made at the midpoint of the
SRP with respect to the anterior maxillary osseous tooth parallel to its long axis. A proposed classifica-
housing to aid in treatment planning for immediate im- tion system was used during image assessment. The
plant placement. The frequency of each classification is cross-sectional images were screen-captured and in-
reported and the clinical implications are discussed. dependently evaluated and classified by two exam-
iners. The examiners had been previously calibrated
by simultaneous evaluation of 60 randomly selected
MATERIALS AND METHODS images. If any disagreements occurred regarding the
classification of an image, the image was reevaluated
Patient Selection concurrently by both examiners until agreement was
This retrospective study was approved by the Insti- reached about the most appropriate classification.
tutional Review Board of Loma Linda University and
was conducted in the Center for Implant Dentistry, SRP Classification
Loma Linda University School of Dentistry, California. Each SRP in relationship to its osseous housing was
Pretreatment records and CBCT images (Classic i-CAT, classified as follows:
Imaging Sciences International) were reviewed for pa-
tients who received treatment between May 2006 and • Class I: The root is positioned against the labial cor-
February 2010. Forty male and 60 female patients be- tical plate (Fig 1).
tween the ages of 19 and 84 years (mean, 53.1 years) • Class II: The root is centered in the middle of the al-
were selected according to the following criteria: at veolar housing without engaging either the labial
least 18 years of age at the time of the CBCT scan; or the palatal cortical plates at the apical third of
all maxillary anterior teeth (canine to canine) were the root (Fig 2).
present, with at least two occluding posterior teeth • Class III: The root is positioned against the palatal
(premolar and/or molar) in each quadrant; no radio- cortical plate (Fig 3).
graphic evidence of infection, severe root resorption, • Class IV: At least two thirds of the root is engaging
and/or trauma to the anterior maxillary dentition; and both the labial and palatal cortical plates (Fig 4).
no radiographic evidence of surgical (guided bone/
tissue regeneration) treatment in the anterior maxil- Statistical Analysis
lary dentition. Descriptive statistics were used to report the frequen-
cy (number and percentage) of each classification.
Data Collection The distribution of each SRP classification according
For each study subject, the SRP of each maxillary to tooth position was also recorded.
anterior tooth in relation to the osseous housing

874 Volume 26, Number 4, 2011

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 Kan et al

Table 1   Frequency Distribution of Sagittal Root Position

Classification
Percentage (no.)
SRP Central incisor Lateral incisor Canine Overall
Class I 86.5 (173) 76 (152) 81 (162) 81.1 (487)
Class II 5 (10) 8.5 (17) 6 (12) 6.5 (39)
Class III 0.5 (1) 1.5 (3) 0 (0) 0.7 (4)
Class IV 8 (16) 14 (28) 13 (26) 11.7 (70)
Total 100 (200) 100 (200) 100 (200) 100 (600)

RESULTS SRP of the majority of the teeth in the present study

was favorable for IIPP according to guidelines that
From among the 600 SRP images evaluated in this have been established in the literature.6–8,10
study, there were eight disagreements (1.3%) be- The frequency of Class III SRP in this study was only
tween the examiners. The disagreements were be- 0.7% (range, 0% to 1.5%; Table 1), illustrating the rar-
tween Class I and Class IV (n = 7) and Class I and Class II ity of this root position. In the Class III SRP, the entire
(n = 1). The frequency distribution of SRP classes indi- length of the root engages the palatal cortical plate;
cated that, of the 600 samples, 487 (81.1%) were Class I, therefore, the stability of the implant relies on its en-
39 (6.5%) were Class II, 4 (0.7%) were Class III, and 70 gagement in the available bone on the labial aspect.
(11.7%) were Class IV (Table 1). Because of the increased trabecular nature of the la-
The frequency distribution was categorized ac- bial bone, there is a higher tendency for labial bone
cording to tooth position and SRP (Class I, II, III, and IV) resorption as a result of peri-implant bone remod-
(Table 1). The central incisors presented with 86.5%, eling. Furthermore, labial concavities, occasionally
5%, 0.5%, and 8%, respectively, of Class I, II, III, and IV. observed near the base of the anterior maxilla, can
The lateral incisors presented with 76.5%, 8.5%, 1.5%, potentially lead to fenestration/perforation when la-
and 14%, respectively. The canines presented with bial implant engagement is attempted.
81%, 6%, 0%, and 13%, respectively. Only 6.5% (range, 5% to 8.5%; Table 1) of the study
samples were Class II SRP, in which the root was cen-
tered in the middle of the alveolar housing without en-
DISCUSSION gaging either the labial or palatal cortical plates at the
apical third of the root. Generally, the volume of bone
Anatomically, the palatal aspect of an extraction available surrounding the extraction socket on both
socket in the anterior maxilla is thicker and more cor- the palatal and labial aspects is less than what is en-
tical in nature than its labial counterpart, making the countered in Class I or Class III SRPs, respectively. This
former a more suitable foundation for implant place- amount of bone, while it may be sufficient to prevent
ment and the latter more prone to bone resorption labial/palatal bone fenestration, may not be adequate
and/or collapse. In the Class I SRP, in which the entire to ensure implant stability. Therefore, when a clinician
length of the root is in contact with the labial cortical is considering IIPP procedures in a site with Class II SRP,
plate, a considerable amount of bone is present on the amount of available bone beyond the apex of the
the palatal aspect for implant engagement to attain extraction socket must be critically evaluated, as the
primary stability during IIPP. In general, this palatal stability of the implant relies primarily on it.
implant engagement leaves the labial bone intact In the Class IV SRP, which comprised 11.7% of this
and results in a small gap between the implant and study’s population, the existing tooth root occupies
the labial plate.8 This implant-socket gap is usually the majority of the alveolar volume, and the base of
filled with bone grafting material so that an esthetic the anterior maxilla is often pedunculated. Follow-
hard tissue contour can be maintained both vertically ing extraction, there is a limited amount of bone with
and horizontally.8 In this study, 81.1% (range, 76% to which appropriate implant stability can be obtained. To
86.5%; Table 1) of the 600 samples had a Class I SRP. increase the predictability of the treatment, adjunctive
This suggests that, regardless of tooth position, the bone grafting procedures are often necessary prior to

The International Journal of Oral & Maxillofacial Implants 875

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NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Kan et al

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876 Volume 26, Number 4, 2011

© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
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