Vestibular thickness in the aesthetic zone: the challenge of anatomical reality

Aesthetic success in anterior implantology depends on a critical parameter: labial alveolar bone thickness (LABT). While the clinical literature recommends a minimum of 2 mm to ensure long-term tissue stability, this standard often conflicts with individual morphological realities. This study specifically documents the anatomical situation of patients in the central province of Saudi Arabia, where ethnic and regional variations directly influence the alveolar structure.

The objective of this work is to accurately map the LABT of the maxillary anterior teeth in order to secure surgical planning protocols. The authors evaluate the impact of sex, age and root level on this available bone volume. The tested hypothesis is based on a heterogeneous bone distribution, suggesting that universal anatomical standards do not apply uniformly to all populations.

The results highlight a challenging clinical finding for the practitioner: average bone thickness consistently remains below the 2 mm required for optimal stability. The study reveals more pronounced bone fragility in women and increased thinness in the middle third of the root compared to the apical zone. These data emphasise the importance of rigorous preoperative CBCT analysis to anticipate the almost systematic use of bone augmentation techniques in this population.

Rigorous analysis of the vestibular wall

To evaluate the anatomical reality of the aesthetic zone, the study involved the analysis of 206 sagittal CBCT scans from a population in the central province of Saudi Arabia. The objective was to measure the labial alveolar bone thickness (LABT) of the six anterior maxillary teeth.

The team defined three standardised measurement points to precisely map the bone topography on each root:

• Point A: coronal level, extending from the alveolar crest to the cervical third.
• Point B: mid-root level.
• Point C: level of the apical third.

Beyond simple morphological measurement, the authors compared the data according to laterality (right versus left side), patient gender and age groups. Statistical analysis was performed using SPSS software (version 26.0), with a significance level set at p < 0.05 to identify clinically relevant anatomical variations.

A vestibular thickness consistently below the critical threshold

The collected data reveal a major anatomical reality for implantology: the mean labial alveolar bone thickness (LABT) in the maxillary anterior region is consistently below the 2 mm threshold, often considered the prerequisite for long-term aesthetic stability. This bone thinness varies significantly according to root height (p < 0.05).

The study shows that the most vulnerable area is located in the middle third of the root, where the thickness drops below one millimetre (0.83 mm to 0.95 mm). Conversely, the apical third offers the greatest volume, without however reaching 2 mm (maximum 1.55 mm).

Influence of patient profile: the impact of gender

The comparative analysis shows no statistically significant difference regarding laterality (right vs left) or age groups. However, gender appears to be a determining factor (p < 0.05):

• Female patients exhibit an overall lower bone thickness than men.
• This difference is particularly marked on the left canine (coronal and apical thirds) as well as on both canines in the middle third.

These observations highlight that, while the thinness of the buccal plate is an anatomical constant in this population, women present an increased risk of peri-implant dehiscence or recession in the absence of surgical compensation.

Analysis of maxillary anatomical constraints

This study highlights a major clinical reality: the labial bone thickness (LABT) in the maxillary aesthetic zone is almost systematically insufficient to meet the standards for long-term implant stability. The results show that the bone is thinnest at the middle third of the root, with values falling below the critical 1 mm mark (0.83 to 0.95 mm). Even at the apical third, the wall never reaches the safety threshold of 2 mm.

The direct implication for the practitioner is the high risk of fenestration during drilling or post-implant periodontal recession. The study demonstrates significant gender-related variability: female patients present a thinner buccal bone than men, a crucial factor for managing aesthetic risk in the anterior zone. Notably: neither age nor location (right or left side) influences this morphology, suggesting a structural anatomical constant in the studied population.

These data confirm that guided bone regeneration or alveolar preservation techniques should not be considered as secondary options, but as frequent therapeutic necessities. The prevalence of a bone wall of less than 2 mm requires a cautious approach, particularly during immediate implantation protocols where implant positioning must imperatively favour the palatal aspect to compensate for this natural vestibular thinness.

Study highlights

This analysis highlights a critical anatomical reality: the thickness of the buccal alveolar bone in the maxillary aesthetic zone is consistently below the 2 mm safety threshold. Measurements reveal a particularly thin bone plate at the mid-root level (often less than 1 mm), emphasising a high risk of dehiscence during implant placement.

In practical terms, for the practitioner:

• Anticipate the buccal defect: Do not rely on natural anatomy to ensure long-term aesthetic stability; bone augmentation or palatal positioning of the implant should be the norm rather than the exception.
• Increased vigilance in women: Data show significantly more pronounced bone thinness in female patients, requiring heightened caution to prevent post-implant periodontal recessions.
• CBCT as a prerequisite: The low average bone thickness makes three-dimensional assessment essential to accurately quantify the available volume prior to any immediate extraction-implantation.

Technical glossary of the study

LABT (Labial Alveolar Bone Thickness): Measurement of the labial alveolar bone thickness, a critical morphological parameter for soft tissue stability and implant positioning in the aesthetic zone.

CBCT (Cone-Beam Computed Tomography): Three-dimensional cone-beam imaging technology enabling precise analysis of bone density and volume on sagittal slices.

Anterior maxillary region: Anatomical area extending from upper canine to canine, defined as a sensitive aesthetic zone where bone support is often limited.

Vestibular wall (Facial plate): Thin bony plate covering the external surface of the dental roots, whose integrity is essential to prevent post-implant gingival recession.

Alveolar bone crest: Most coronal level of the bone surrounding the tooth, serving as a reference point to assess the height and thickness of the available bone.

Apical third: Terminal portion of the dental root; area where, according to the data of this study, the thickness of the vestibular cortical bone is statistically the highest.

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