CBCT-Based Assessment of Buccal Bone Thickness in the Aesthetic Zone of Menopausal Women

Abstract

Objective

To evaluate cone-beam computed tomography (CBCT) scans and measure buccal bone thickness in the aesthetic zone of menopausal women using the Romexis software, determining the effect of menopause on alveolar bone thickness in the anterior maxilla.

Materials and Methods

This retrospective, analytical cross-sectional (comparative) study was conducted at the Department of Prosthodontics, Islamic International Dental College and Hospital, Islamabad, Pakistan. A total of 147 CBCT scans of female patients aged 45 to 55 years were reviewed. Ninety scans were excluded for poor quality or incomplete data, and 50 scans were selected based on eligibility. Participants were divided into menopausal (≥ 50 years) and nonmenopausal (< 50 years) groups, each with 25 cases. Buccal bone thickness was measured at the crestal and midroot regions of the anterior maxillary teeth using the Planmeca Romexis Viewer 6.4.3 software. Measurements were performed by a calibrated examiner. The Mann–Whitney U and Wilcoxon signed-rank tests were used; a p-value of < 0.05 was considered significant.

Results

The nonmenopausal group demonstrated significantly greater mean buccal bone thickness than the menopausal group (p = 0.002) at both the crestal and midroot regions. Effect sizes indicated moderate to large clinical impact.

Conclusion

Menopausal women exhibited a significant reduction in buccal bone thickness of maxillary anterior teeth, emphasizing the influence of hormonal changes on alveolar bone health.

Keywords

menopause - CBCT - alveolar bone - bone resorption - estrogen

Introduction

Menopause typically occurs in women between 49 and 51 years of age and results in a decline in estrogen levels, influencing bone metabolism.[1] [2] Estrogen deficiency activates cytokines such as interleukin (IL)-1α, IL-6, IL-11, and tumor necrosis factor-α, which promote osteoclastogenesis and bone resorption.[3] The systemic effects of menopause are well established, but its implications for alveolar bone remain under investigation.[4]

In the past several years, more women over the age of 50 have been interested in dental implant therapy, especially in the anterior maxillary area, where aesthetics are very crucial. Studies suggest that women under 55 years who receive cosmetic treatments focus on their skin and nose, whereas women over the age of 55 years focus more on the lower third area of their faces to improve aesthetics.[1] [2] Even if additional bone augmentation procedures are required, dental implant therapy can improve appearance and self-image, increasing quality of life.[1] The increase in dental implant therapy demand among postmenopausal women emphasizes the importance of predictable aesthetic and functional implant outcomes in this demographic.

Dental implants in the anterior maxilla require sufficient buccal bone thickness (≥ 2 mm) for aesthetic and functional success.[5] [6] Insufficient cortical thickness can lead to complications such as dehiscence, gingival recession, and implant failure.[7]

Cone-beam computed tomography (CBCT) provides accurate three-dimensional assessment of alveolar bone thickness at possible implant placement locations and analysis of cortical and trabecular bone morphology, aiding preimplant evaluation.[8] [9] Since slight changes in bone thickness and quality can impact implant treatment aesthetic and functional outcomes, CBCT is an excellent method for examining alveolar bone in postmenopausal women.[9] [10]

However, limited data exist regarding buccal bone thickness variations among menopausal women. This study aims to evaluate these changes in Pakistani women using CBCT and Planmeca Romexis software, offering insight into implant planning for postmenopausal patients. This will aid prosthodontists in placing implants that meet all requirements, including biological, biomechanical, and aesthetic standards.

Materials and Methods

This retrospective, analytical cross-sectional (comparative) study was conducted at the Department of Prosthodontics, Islamic International Dental College and Hospital, Islamabad, Pakistan. The study was approved by the Institutional Ethical and Scientific Review Board on June 30, 2025 (IIDC/IRC/2025/006/005). Patient's CBCTs recorded as part of routine diagnostic procedure between December 2024 and May 2025 (over a period of 6 months) were extracted from the patient's database at the radiology unit of Islamic International Dental College and Hospital, Islamabad, Pakistan. Data collection and analysis were initiated only after Institutional Review Board approval.

The study used consecutive sampling of qualifying CBCT scans taken over a 6-month period after ethical approval, with the goal of minimizing selection bias by including all records that satisfied the inclusion criteria.

A total of 147 CBCT scans were first evaluated of female patients aged 45 to 55 years who visited the Department of Prosthodontics at Islamic International Dental College and Hospital, Islamabad, between December 2024 and May 2025.

Following the study protocol, 90 scans were eliminated due to poor image quality or insufficient data. The final sample comprised 50 CBCT scans from female patients who were prescribed imaging for diagnostic purposes and met the eligibility requirements. Attrition bias was not applicable, as the data was retrospective and drawn from existing records.

On the basis of age-based classification, classifying women over 50 years as menopausal and those under 50 as nonmenopausal, the study's participants were split into two groups: 25 nonmenopausal women and 25 menopausal women.

CBCT radiographs were recorded with CBCT Planmeca ProMax 3D Classic (Planmeca) by Planmeca Romexis 6.4.3 software. The voxel size was 0.08 mm (80 µm) and the field of view was 10 cm × 6 cm. Exposure settings were 16 seconds, 8 mA, and 90 KVP.

Female subjects, age ranging between 45 and 55 years (either near to menopause or menopausal) with all maxillary anterior teeth present, having normal periodontal and endodontic status, were eligible for the study.

Excluded from the study were individuals having missing maxillary anterior teeth, periapical radiolucencies or periodontal ligament widening, diabetes, osteoporosis, a history of smoking or drugs including corticosteroids, bisphosphonates, or hormone therapy, having a history of immunodeficiency disease, or a history of orthodontic treatment. Subjects having dehiscence or fenestration in the anterior maxillary buccal bone were also excluded.

A single, skilled examiner performed CBCT analysis to determine the thickness of the buccal bone using the Planmeca Romexis viewer 6.4.3 software. To reduce the chance of bias, the examiner was properly trained and calibrated before collecting data. To evaluate the CBCT images, the coronal and axial views were altered and adjusted to provide a sagittal view showing the maximum root length measured from the apical point of the root to the cementoenamel junction ([Fig. 1]). Half of the measured root length was used to establish the hypothetical midroot point. Planmeca Romexis viewer 6.4.3 software was used to assess buccal bone thickness, which is defined as the distance between the outer buccal cortex and the tooth surface at two points: bone crest and midroot ([Fig. 2]).[2]

Fig. 1 Maxillary cone-beam computed tomography (CBCT) image of maxillary anterior teeth showing slice orientation in axial, coronal, and sagittal planes through Romexis software.

Fig. 2 Sagittal view evaluation of maxillary anterior teeth in menopausal and nonmenopausal women. (C) The maximum root length was measured from the apical point to the cementoenamel junction (CEJ). (D) The midroot was equal to half of the measured length. (F) Buccal bone thickness was assessed at two points: crestal and midway. (G) These measurements were taken for each maxillary anterior tooth. (H) Planmeca Romexis image with an added calibration marker (scale bar = 1 mm) for dimensional reference.

[Fig. 1] shows slice orientation in axial, coronal, and sagittal planes through Romexis software. [Fig. 2] shows a sagittal (cross-sectional) CBCT slice obtained perpendicular to the dental arch with Planmeca Romexis software. A 1-mm scale bar has been added for calibration purposes. Buccal bone thickness was measured in the sagittal (cross-sectional) plane, which is perpendicular to the tooth's long axis, to reflect the shortest linear distance between the external root surface and the outer buccal cortical plate.

Data were analyzed using IBM SPSS (v27.0). The Shapiro–Wilk test confirmed nonnormal distribution. Wilcoxon signed-rank and Mann–Whitney U tests compared intra- and intergroup data. Effect sizes (r) were calculated; confidence intervals were not computed and are noted as a limitation. A p-value of < 0.05 was considered statistically significant.

Results

In this study, the buccal bone thickness in the crest and middle regions of the front maxillary teeth was measured in 50 women, 25 of whom were in the menopausal group and 25 of them were in the nonmenopausal group. The women's mean ages were 52.32 ± 2.87 and 46.7 ± 2.11, respectively. The mean age of the groups differed significantly (p ≤ 0.001).

Both the nonmenopausal and menopausal groups' descriptive statistics, including the minimum, maximum, mean, standard deviation, range, median, mode, and variances of bone thickness variables in the buccal region are displayed in [Tables 1] and [2].

Table 1 Descriptive statistics for bone thickness in the buccal region for the nonmenopausal group based on side, area, and tooth

	Nonmenopausal group measurements (mm)	Mean  ±  SD	Minimum	Maximum	Range	Median	Mode	Variance
Left CI	Buccal crestal bone thickness	0.97  ± 0.28	0.5	1.5	1	0.9	0.8	0.076
	Buccal midroot bone thickness	0.74  ± 0.18	0.4	1.1	0.7	0.8	0.8	0.032
Left LI	Buccal crestal bone thickness	1.1  ± 0.32	0.6	1.7	1.1	1	0.8	0.11
	Buccal midroot bone thickness	0.84  ± 0.28	0.4	1.3	0.9	0.8	0.8	0.08
Left Canine	Buccal crestal bone thickness	1.88  ± 0.68	0.8	3	2.2	2	1.3	0.47
	Buccal midroot bone thickness	0.98  ± 0.36	0.2	2.1	1.9	1	0.8	0.13
Right Canine	Buccal crestal bone thickness	1.94  ± 0.57	1.1	3.9	2.8	1.8	1.6	0.33
	Buccal midroot bone thickness	0.96  ± 0.28	0.5	1.6	1.1	0.9	1	0.078
Right LI	Buccal crestal bone thickness	1.25  ± 0.297	0.8	2.2	1.4	1.3	1.3	0.089
	Buccal midroot bone thickness	0.83  ± 0.27	0.4	1.4	1	0.8	0.6	0.07
Right CI	Buccal crestal bone thickness	1.024  ± 0.33	0.5	2	1.5	1	1	0.108
	Buccal midroot bone thickness	0.78  ± 0.23	0.3	1.2	0.9	0.8	0.8	0.052

Abbreviations: CI, central incisor; LI, lateral incisor; SD, standard deviation.

Table 2 Descriptive statistics for bone thickness in the buccal region for the menopausal group based on side, area, and tooth

	Menopausal group measurements (mm)	Mean  ±  SD	Minimum	Maximum	Range	Median	Mode	Variance
Left CI	Buccal crestal bone thickness	0.68 ± 0.32	0	1.1	1.1	0.8	0.8	0.105
	Buccal midroot bone thickness	0.596  ± 0.34	0	1.1	1.1	0.6	0.8	0.113
Left LI	Buccal crestal bone thickness	0.94 ± 0.39	0.3	1.8	1.5	0.8	0.8	0.16
	Buccal midroot bone thickness	0.68 ± 0.35	0	1.6	1.6	0.8	0.8	0.12
Left Canine	Buccal crestal bone thickness	1.52  ± 0.75	0.5	3.4	2.9	1.3	1	0.5597
	Buccal midroot bone thickness	0.79  ± 0.57	0	2.5	2.5	0.7	0.6	0.33
Right Canine	Buccal crestal bone thickness	1.38  ± 0.55	0.7	2.9	2.2	1.4	0.8	0.298
	Buccal midroot bone thickness	0.76  ± 0.51	0	2.4	2.4	0.6	0.6	0.26
Right LI	Buccal crestal bone thickness	0.93  ± 0.38	0	1.7	1.7	0.8	0.8	0.14
	Buccal midroot bone thickness	0.70  ± 0.34	0	1.5	1.5	0.7	0.8	0.12
Right CI	Buccal crestal bone thickness	0.72 ± 0.29	0	1.1	1.1	0.8	0.8	0.08
	Buccal midroot bone thickness	0.6  ± 0.40	0	1.4	1.4	0.5	0.8	0.16

Abbreviations: CI, central incisor; LI, lateral incisor; SD, standard deviation.

Comparative Analysis of Buccal Bone Thickness on the Basis of Area, Side, and Tooth Between Menopausal and Nonmenopausal Groups

[Table 3] shows that, in comparison to the menopausal group, the nonmenopausal group's buccal crestal bone was significantly higher in the upper left central incisor, right canine, right lateral incisor, and right central incisor. While, in the buccal mid root region of the upper left and right canines, the nonmenopausal group had significantly higher values than the menopausal group. Moderate-to-large effect sizes (r = 0.33–0.52) in all anterior crestal regions, as well as the crestal and midroot regions of canines, indicate clinically relevant postmenopausal buccal bone loss, which may have an impact on implant functional and aesthetic outcomes.

Table 3 Menopausal and nonmenopausal buccal bone thickness comparison based on area, side, and tooth

	Variable (mm)	Group	Number	p-Values Mann–Whitney U test	Effect size r
Left CI	Buccal crestal bone thickness	Premenopausal	25	0.004	0.41
		Postmenopausal	25
	Buccal midroot bone thickness	Premenopausal	25	0.129	0.22
		Postmenopausal	25
Left LI	Buccal crestal bone thickness	Premenopausal	25	0.086	0.24
		Postmenopausal	25
	Buccal midroot bone thickness	Premenopausal	25	0.092	0.24
		Postmenopausal	25
Left Canine	Buccal crestal bone thickness	Premenopausal	25	0.05	0.28
		Postmenopausal	25
	Buccal midroot bone thickness	Premenopausal	25	0.022	0.33
		Postmenopausal	25
Right Canine	Buccal crestal bone thickness	Premenopausal	25	< 0.001	0.52
		Postmenopausal	25
	Buccal midroot bone thickness	Premenopausal	25	0.048	0.28
		Postmenopausal	25
Right LI	Buccal crestal bone thickness	Premenopausal	25	0.001	0.45
		Postmenopausal	25
	Buccal midroot bone thickness	Premenopausal	25	0.10	0.23
		Postmenopausal	25
Right CI	Buccal crestal bone thickness	Premenopausal	25	0.002	0.43
		Postmenopausal	25
	Buccal midroot bone thickness	Premenopausal	25	0.061	0.27
		Postmenopausal	25

Abbreviations: CI, central incisor; LI, lateral incisor.

Buccal Bone Thickness Comparison in Terms of Left and Right Sides Between Groups

The thickness of the buccal crestal bone between the left and right central incisors differed significantly (p = 0.042). No statistically significant changes were seen between the crestal and midroot bone thicknesses in any of the other left versus right tests (p > 0.05) ([Table 4]). Thus, except for a minor asymmetry in the crestal region of the central incisors, buccal bone thickness exhibited no significant left–right variation. The findings lend support to the clinical premise that bilateral bone symmetry exists in the anterior maxillary region.

Table 4 Comparative analysis of buccal bone thickness in terms of left and right sides between groups

		p-Values Wilcoxon signed rank test	Effect size r
Buccal crestal bone thickness	Left CI vs. right CI	0.042	0.29
	Left LI vs. right LI	0.182	0.19
	Left canine vs. right canine	0.845	0.03
Buccal midroot bone thickness	Left CI vs. right CI	0.224	0.17
	Left LI vs. right LI	0.953	0.01
	Left canine vs. right canine	0.224	0.17

Abbreviations: CI, central incisor; LI, lateral incisor.

Buccal Bone Thickness Comparison in Terms of Crestal and Midroot Area Between Groups

The buccal bone thickness in the midroot and crestal regions of the anterior teeth in the menopausal and nonmenopausal groups is displayed in [Table 5]. The nonmenopausal group's mean buccal bone thickness in both the midroot and crestal regions of the anterior teeth was greater than that of the menopausal group, and the difference was statistically significant. [Figs. 3] and [4] demonstrate a comparison of buccal bone thickness between menopausal and nonmenopausal women in the buccal crestal and midroot regions, respectively. A substantial effect size at the crestal level (r = 0.50) and a moderate effect size at midroot (r = 0.31) show a significant clinical impact—menopause-related bone decrease is not a simple finding but reflects a consistent biological trend.

Table 5 Comparative analysis of buccal bone thickness in terms of area between groups

Area	Group	Thickness (min–max)	Mean ± SD	p-Value Mann–Whitney U test	Effect size r
Crest	Menopause	0.29–0.98	0.617 ± 0.187	< 0.001	0.50
	Nonmenopause	0.50–0.95	0.712 ± 0.113
Midroot	Menopause	0.00–0.94	0.413 ± 0.206	0.027	0.31
	Nonmenopause	0.34–0.73	0.512 ± 0.091

Abbreviations: Max, maximum; Min, minimum; SD, standard deviation.

Fig. 3 Buccal crestal bone thickness comparison between menopausal and nonmenopausal women.

Fig. 4 Buccal midroot bone thickness comparison between menopausal and nonmenopausal women.

Mean Buccal Bone Thickness Comparison Between Groups

Both the menopausal and nonmenopausal group's buccal bone thicknesses are displayed in [Table 6]. The nonmenopausal group's mean buccal bone thickness was greater than the menopausal group's, and the difference was statistically significant (p = 0.002). The moderate to large effect size (r = 0.45) indicates that the observed difference is not due to random variation but represents a clinically relevant impact of menopausal status on buccal bone morphology.

Table 6 Comparative analysis of mean buccal bone thickness between groups

Group	Thickness (min–max)	Mean ± SD	p-Value Mann–Whitney U test	Effect size r
Menopause	0.24–1.6	0.85  ±  0.30	0.002	0.45
Nonmenopause	0.73–1.38	1.10  ±  0.17

Abbreviations: Max, maximum; Min, minimum; SD, standard deviation.

Discussion

Dental implants have recently gained popularity as a treatment option for missing teeth. The success rate of dental implant surgery depends on the quality and amount of bone at the implant site. A stronger host bone state confers more stability for the dental implant, which results in improved osseointegration and a higher survival rate. CBCT has been used in studies to assess bone density and crestal cortical bone thickness at dental implant sites. However, it is yet unclear whether menopause impacts bone density and quality at the implant site.[2] This study employed CBCT to assess the association between menopausal age and cortical bone thickness at the dental implant site in females. In our study, menopausal women showed reduced cortical bone thickness in the anterior maxillary region compared to nonmenopausal women.

This retrospective analysis included 50 female patients with a mean age of approximately 49 years. Our study concluded that menopausal women had significantly decreased buccal bone thickness in the crest and midroot point of their maxillary anterior teeth compared with nonmenopausal women. Another study also found that menopausal women had decreased buccal bone thickness in the crest and midroot of their maxillary anterior teeth compared with nonmenopausal women. However, the difference in their analysis was not statistically significant.[2] [11] Menopause is also linked to mandibular condylar trabecular bone loss, as suggested in another study.[12]

In our investigation, the thickness of the buccal crestal bone between the left and right central incisors varied significantly. Otherwise, there were no statistically significant differences between crestal and midroot bone thicknesses in any of the other left and right region's comparisons. The findings support the clinical notion that in our study, bilateral bone symmetry exists in the anterior maxillary region in both menopausal and nonmenopausal women. Another study conducted in a private radiology center in Mashhad, Iran, also found no significant difference in maxillary bone thickness in menopausal and nonmenopausal women between left and right sides.[2] The thickness of the maxillary canine crestal bone was examined in another investigation. According to their findings, there were no appreciable differences between the right and left sides or between men and women at the evaluated point.[13]

In order to investigate the thickness of the buccal bone in the front maxilla, a meta-analysis was conducted. According to their findings, the average bone thickness in the middle of the anterior maxillary root and crestal bone in women was 1.6 to 1.7 and 0.05 to 1.3 mm, respectively.[14] In a different investigation, the average thickness of the crestal bone (0.59–0.67 mm) and the middle of the root (0.52–0.62 mm) was determined,[2] which were much thinner than the average bone thickness of the middle of the root (4.13–5.12 mm) and crestal bone (6.17–7.12 mm) calculated in our current study.

Another study was conducted on 239 patients, including 60 nonmenopausal women and 59 menopausal women. According to their findings, menopausal women had noticeably reduced bone thickness in the crest and middle buccal region of the front maxillary teeth compared with nonmenopausal women.[1] Furthermore, the study found that buccal bone thickness was greater than 1 mm in the majority of areas, which is consistent with our study findings (the current study's average buccal bone thickness is between 0.85 and 1.10 mm). The averages of buccal bone thickness measured in another study were 0.56 to 0.65 mm (less than 1 mm), which is inconsistent with our study findings being less than 1 mm.[2]

In a particular investigation, the relationship between menopausal age and implant site crestal bone thickness was examined. Of the 85 patients they investigated, 48 were women under 50 and 37 were over 50 years of age. The authors of the retrospective analysis employed age classification similar to our study, classifying women over 50 years as menopausal and those under 50 as nonmenopausal, because they were unable to precisely assess the status of women's menopause due to the retrospective nature of their analysis. In line with the current study, their research found that women over 50 years of age had thinner buccal bone sections than women under 50 years, but they were unable to detect a significant relationship between the two variables.[15] For the menopausal and nonmenopausal groups of women in our study, the mean age was 52.32 ± 2.87 and 46.7 ± 2.11, respectively. Moreover, our study found a statistically significant difference in the mean thickness of buccal bone between the menopausal and nonmenopausal groups.

Different surveys found that osteoporosis was more prevalent in postmenopausal women compared to male individuals. Osteoporosis raises the risk of hip, spine, and wrist fractures. Numerous studies have examined whether osteoporosis causes long-term bone loss in the jaw.[1] [2] [15] Dental implant surgeries have recently gained popularity. Successful dental implant surgery relies heavily on the quality and amount of bone at the implant site. According to research, osteoporosis can reduce the success rate of dental implant surgery.[15] Based on studies, menopausal women are more likely to develop osteoporosis in their jawbone, which can impair chewing performance and can lead to tooth loss.[2] [15]

Based on our study's results, it can be inferred that the average alveolar bone thickness in the buccal region of maxillary anterior teeth was much lower in the menopausal group than in the nonmenopausal group, and the difference was statistically significant. A substantial effect size at the crestal level and midroot reveals a major clinical impact. The bone loss that is associated with menopause is not a straightforward discovery; rather, it reflects a constant biological pattern.

The menopausal group was significantly older than the nonmenopausal group (p < 0.001). Because ageing is known to affect bone density and cortical bone thickness, some of the observed changes in buccal bone thickness could be attributed to age rather than menopause. Bone remodeling with age, reduced blood flow, and decreased osteoblastic activity may all be factors that make the menopausal impact appear stronger than it is. As a result, while menopause is medically related to bone loss owing to estrogen insufficiency, it is difficult to distinguish it from the typical senescent abnormalities in bone that occur with age. Subsequent study should include age-matched controls to further understand the unique impact of menopause.

Limitations

This study was limited to a Pakistani population, which may restrict the generalizability of findings to other ethnic or racial groups. Future multicenter studies with larger, more diverse samples are needed to validate and expand upon these results. As a retrospective, single-center analysis, the study is also subject to potential selection bias, though the hospital caters to a wide and varied regional population, enhancing representativeness to some extent.

Measurements were performed by a single examiner without formal intra- or interexaminer reliability testing, which may have introduced systematic bias. However, the examiner underwent extensive training and calibration prior to data collection to minimize this limitation. Future investigations should incorporate reliability testing to strengthen measurement validity.

The actual menopausal status of participants, which varies individually, was inferred based on age rather than detailed medical or hormonal assessment due to the retrospective study design. Additionally, the absence of multivariate or regression analyses to adjust for confounding variables, particularly age, limits the interpretability of the results. Although nonparametric tests such as the Wilcoxon signed-rank and Mann–Whitney U tests were applied, the significant age difference between groups could have introduced residual confounding. Future studies employing multivariable modeling could better isolate the independent effect of menopause on buccal bone thickness.

The lack of available literature although welcomes avenues to approach this topic in much detail but proved a challenge as well. Since collaborative studies were minimum and support via literature seemed difficult. This scarcity of comparative data restricts comprehensive benchmarking and highlights the need for additional research in this area.

Conclusion

Menopausal women demonstrated a statistically significant reduction in mean buccal bone thickness within the anterior maxillary region compared with nonmenopausal women. These findings highlight the influence of hormonal changes on alveolar bone quality. In clinical practice, preimplant assessments for menopausal women should carefully evaluate buccal bone thickness, and bone grafting procedures should be considered where indicated to optimize implant stability and aesthetic outcomes.

Conflict of Interest

None declared.

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Publication History

Article published online:
29 January 2026