|Year : 2017 | Volume
| Issue : 1 | Page : 12-15
Gingival biotype assessment: Variations in gingival thickness with regard to age, gender, and arch location
Vipin Agarwal1, Sunny2, Nidhi Mehrotra2, Vivek Vijay3
1 Department of Periodontics, Private Practice, Rishikesh, Uttarakhand, India
2 Department of Periodontics, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India
3 Senior Lecturer, Faculty of Dentistry, SEGi University, Selangor, Malaysia
|Date of Web Publication||6-Mar-2017|
67, Sona Enclave, Near Food Plaza, Modinagar, Ghaziabad - 201 204, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: An adequate width of the attached gingiva helps in maintaining esthetics and proper plaque control. A thin gingiva may lead to recession after trauma or surgical and inflammatory injuries, thus sufficient thickness of the attached gingiva is desirable. Studies have shown considerable intra- and inter-examiner variation in both width and thickness of attached gingiva, which might be due to the presence of different gingival biotypes present in the adult population. By ascertaining gingival thickness, we can diagnose periodontal diseases and plan a proper treatment which is important for a good prognosis. Aims: The aim of the study is to evaluate the variations in the thickness of gingiva with respect to age, gender, and location in the dental arch. Materials and Methods: A total of 90 (45 males and 45 females) periodontally healthy subjects were divided into three different age groups. These individuals were examined for their gingival thickness in the maxillary and mandibular arches. Results: It was observed that the thickness of gingiva significantly decreased with age in both the arches and was significantly higher in females than males. The maxillary arch had thicker gingiva as compared to mandibular arch. Conclusion: In the present study, we concluded that the thickness of the gingiva varies with age, gender, and arch location.
Keywords: Attached gingiva, biotype, periodontal diseases, transgingival probing
|How to cite this article:|
Agarwal V, Sunny, Mehrotra N, Vijay V. Gingival biotype assessment: Variations in gingival thickness with regard to age, gender, and arch location. Indian J Dent Sci 2017;9:12-5
|How to cite this URL:|
Agarwal V, Sunny, Mehrotra N, Vijay V. Gingival biotype assessment: Variations in gingival thickness with regard to age, gender, and arch location. Indian J Dent Sci [serial online] 2017 [cited 2020 Apr 4];9:12-5. Available from: http://www.ijds.in/text.asp?2017/9/1/12/201639
| Introduction|| |
It has been long known that the clinical appearance of the healthy marginal periodontium differs from subject to subject and even among different tooth types. Many features are genetically determined; other seems to be influenced by tooth size, shape and position, and biological phenomena such as age, gender, and growth. Attached gingiva is one of the most important anatomic and functional landmarks in the periodontium. Restoring an adequate width of attached gingiva is a part of the periodontal plastic and esthetic surgery. According to the literature, the alveolar bone and the gingival margin surrounding a tooth with pronounced cervical convexity are located more apically than they would be in teeth with flat surfaces, suggesting that the gingival margin is affected by the cervical convexity of the crown.,
In 1969, Ochsenbein and Ross  indicated that there were two main types of gingiva morphology, namely, the scalloped and thin or flat and thick gingiva. They also reported that flat gingiva was associated with a square tooth form whereas scalloped gingiva was associated with a tapered tooth form. They also proposed that the contour of the gingiva closely followed the contour of the underlying alveolar bone. The term “periodontal biotype” was later introduced by Seibert and Lindhe  to categorize the gingiva into “thick-flat” and “thin-scalloped” biotypes. Claffey and Shanley  defined the thin tissue biotype as a gingival thickness of <1.5 mm, and the thick tissue biotype was referred to as having a tissue thickness ≥2 mm.
Tissue biotypes were associated with the outcomes of periodontal therapy, root coverage procedures, and implant esthetics. It was suggested that gingival or periodontal diseases were more likely to occur in patients with a thin gingival biotype. Similarly, in implant restorations, the thick flat tissue biotype was an important factor for a successful esthetic treatment outcome. In root-coverage procedures, a flap thickness of 0.8–1.2 mm was associated with a more predictable prognosis.
The identification of gingival biotype may be important in clinical practice since differences in gingival and osseous architecture have been shown to exhibit a significant impact on the outcome of restorative therapy. Sufficient thickness of attached gingiva is desired as a thin and delicate gingival margin may lead to recession after trauma, surgical, or inflammatory injuries. Thick gingival tissue eases manipulation, maintain vascularity, and promote wound healing during and after surgery. In natural teeth, Pontoriero and Carnevale  showed that more soft tissue regained following crown lengthening procedures in patients with a so-called thick flat biotype than in those with a “thin scalloped biotype.” This observation is in line with a higher prevalence of gingival recession in the latter as reported by Olsson and Lindhe.
Many methods were proposed to measure tissue thickness. These include direct measurements, probe transparency, ultrasonic devices, and most recently, cone-beam computed tomography (CBCT). Initial gingival thickness measurements have been reported by Kydd et al., who utilized ultrasonic echo-ranging instrumentation to measure the resting thickness of masticatory mucosa in selected sites and the change in thickness as a result of compressive mechanical stress.
By ascertaining gingival thickness, we can diagnose periodontal disease and optimize treatment as properly planned treatment is extremely important for prognosis. The use of simple and reliable methods to identify the gingival biotype in clinical practice would be advantageous as this could help to tune the treatment for the individual and predict its specific outcome, and noninvasive ultrasonic devices could not be established as routine devices probably due to technical reasons and costs.
Thus, this study aims to evaluate the variations in the thickness of gingiva with respect to age, gender, and dental arch.
| Materials and Methods|| |
A total of ninety systemically healthy controls who visited the outpatient department of Seema Dental College and Hospital, Rishikesh, India, participated in the study. The subjects were explained the study, and written consent was obtained. The study was approved by the Ethical Committee of Seema Dental College and Hospital, Rishikesh, India. The periodontally healthy subjects with no loss of attachment who had all six anterior teeth in both maxillary and mandibular arches were included in the study. Exclusion criteria were patients with periodontitis, pregnant and lactating females, patients with gingival recession in the anterior teeth, extensive restorations/crowns, and those under medication affecting the periodontium such as cyclosporin A, calcium channel blockers, and phenytoin.
The subjects were divided into three different groups based on age. The first group included the subjects with 15–25 years of age, the second group included the subjects with 26–39 years of age, and the third group had subjects with age more than 40 years. Each group comprised 15 males and 15 females.
The facial gingiva was anesthetized using a lidocaine spray (nummit 15%). The gingival thickness was assessed midbuccally using an endodontic spreader (20 number) as shown in [Figure 1] fitted with a rubber stopper and measured on the ruler up to the nearest millimeter. This measurement was made halfway between the mucogingival junction and the free gingival groove in the attached gingiva as shown in [Figure 2]. The thickness of the attached gingiva was recorded for six maxillary and six mandibular anterior teeth. Errors were minimized by allowing only one examiner to perform all the measurements. The final readings each for maxillary and mandibular gingival thickness were obtained by calculating the mean of all six measurements in the respective arches.
|Figure 2: Procedure for assessment of gingival biotype in mandibular anteriors.|
Click here to view
The mean thickness of gingiva was compared across different age groups by performing one-way analysis of variance. The unpaired t-test was used to compare the mean thickness of gingiva between male and female subjects and also to compare between maxillary and mandibular arches. P < 0.05 was considered as statistically significant.
| Results|| |
The mean thickness of attached gingiva in the maxillary and mandibular arch for 15–25 years age group was 1.22 (±0.28) mm and 0.94 (±0.26) mm respectively; for 16–39 years age group was 1.07 (±0.21) mm and 0.92 (±0.14) mm, respectively, and for the age group of ≥40 years, it was 0.96 (±0.13) mm and 0.78 (±0.15) mm, respectively. The thickness of gingiva significantly decreased with age in both the arches [Table 1] and [Figure 3].
|Table 1: Thickness of gingiva in different age groups in both the arches|
Click here to view
The mean thickness of attached gingiva in maxillary and mandibular arch in males was 1.03 (±0.03) mm and 0.88 (±0.31) mm, respectively, whereas in females, it was 1.14 (±0.03) mm and 0.98 (±0.03) mm, respectively. The thickness of gingiva was significantly higher in females than males [Table 2] and [Figure 3].
The mean thickness of attached gingiva in maxillary arch was 1.08 (±0.03) mm and in mandibular arch was 0.88 (±0.02) mm. Thus, thickness of attached gingiva was more in maxillary arch as compared to mandibular arch.
| Discussion|| |
The gingival biotype is gaining considerable attention as one of the key elements influencing esthetic treatment outcome. Patients with a thick gingiva have been shown to be relatively resistant to gingival recession following surgical and/or restorative therapy.,,, According to a study by Müller and Eger, periodontal phenotype had been described as either thick which is associated with a square form of maxillary incisors or thin which is associated with slender tooth form. According to Kydd et al., the average thickness of gingiva between lateral incisors and central incisors are slightly below 3 mm between premolars and molars slightly above 3 mm and at third molar region about 4 mm. In a study by De Rouck et al., the thin gingival biotype occurred in one-third of the study population and was most prominent among women, whereas the thick gingival biotype occurred in two-thirds of the study population and occurred mainly among men.
According to a study by Müller et al. has shown the thinner masticatory mucosa of women compare to men. Muller's study also supports the result that women have the thinner gingiva than men. He also concluded that the facial gingival is thicker in the maxilla than in mandible. The thinnest gingiva of 0.7–0.9 mm is found at canines in the maxilla and at the premolars in the mandible. These are the teeth with relatively high prevalence and incidence of gingival recession. The studies have examined how mucosal thickness and biologic width affect crestal bone loss around implants. A study by Berglundh and Lindhe  concluded that thin gingival tissue can lead to marginal bone loss during formation of the peri-implant biologic width. According to Abrahamsson et al., thick tissues (i.e., ≥2.5 mm) can avoid significant crestal bone recession; however, the authors recommend avoiding supracrestal placement of implants if an implant is surrounded by a thin biotype.
Because the thickness of the gingival and bone tissues affects the treatment outcomes, possibly due to a difference in the amount of blood supply to the underlying bone, and the susceptibility to resorption, it is important to determine the tissue biotype before the start of the restorative treatment. In cases involving root coverage surgeries, a flap thickness of 0.8–1.2 mm  produced more predictable outcomes. An initial gingival thickness was found to be the most predictable factor for predicting the success of complete root coverage procedures.
Ochsenbein and Ross  believed that long-tapered teeth tend to have a thin-scalloped periodontium, whereas wide-square teeth have thick-flat periodontia. In 1991, Olsson and Lindhe  proposed that long-narrow teeth are more susceptible to gingival recession than short–wide teeth because of the difference in periodontal biotype. In 1993, Olsson et al. reported no significant difference between narrow- and wide-crown forms with respect to the thickness of the free gingiva.
Various methods have been employed by research workers and clinicians to measure the thickness of gingiva, which is of immense importance considering their use in many therapeutic modalities for correction of mucogingival problems. Measurements of these parameters have been calculated by noninvasive methods, such as application of ultrasonic devices  and CBCT. Although the former method is more comfortable for the patient, the authors found difficulty in obtaining reliable results on a consistent basis. The latter method using CBCT reveals a high-quality image of hard and soft tissue and allows measurements of the dimensions and relationships of these structures. However, this method is unable to distinguish between normal and inflamed gingiva, which have similar images acquired by CBCT due to which sometimes the measurements are likely to be unreliable and the cost factor involved in both the previous methods also act as a limitation for their use in routine practice. However, clinically, measuring gingival thickness with accuracy and cost-effectiveness can be done using an endodontic spreader under adequate local anesthesia.
| Conclusion|| |
It has been demonstrated that the thickness of the gingiva reduces with increasing age in both maxillary and mandibular dental arches. However, more thickened gingiva was observed in maxillary arch when compared to mandibular arch. With regard to gender, the females had greater thickness of attached gingiva when compared to males.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shekhawat NR, Dodwad V, Kukreja BJ. Determination of gingival thickness with variance component. Pharm Biomed Sci 2012;24:62-4.
Kolte R, Kolte A, Mahajan A. Assessment of gingival thickness with regards to age, gender and arch location. J Indian Soc Periodontol 2014;18:478-81.
Esfahrood ZR, Kadkhodazadeh M, Talebi Ardakani MR. Gingival biotype: A review. Gen Dent 2013;61:14-7.
Hirschfeld L. A study of skulls in the American Museum of Natural History in relation to periodontal disease. J Dent Res 1923;5:241-65.
Ochsenbein C, Ross S. A reevaluation of osseous surgery. Dent Clin North Am 1969;13:87-102.
Huang LH, Neiva RE, Wang HL. Factors affecting the outcomes of coronally advanced flap root coverage procedure. J Periodontol 2005;76:1729-34.
Seibert JL, Lindhe J. Esthetics and periodontal therapy. In: Lindhe J, editor. Textbook of Clinical Periodontology. 2nd
ed. Copenhagen, Denmark: Munksgaard; 1989. p. 477-514.
Claffey N, Shanley D. Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontol 1986;13:654-7.
Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL. Tissue biotype and its relation to the underlying bone morphology. J Periodontol 2010;81:569-74.
Pontoriero R, Carnevale G. Surgical crown lengthening: A 12-month clinical wound healing study. J Periodontol 2001;72:841-8.
Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodontol 1991;18:78-82.
Greenberg J, Laster L, Listgarten MA. Transgingival probing as a potential estimator of alveolar bone level. J Periodontol 1976;47:514-7.
Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: An evaluation of maxillary anterior single implants in humans. J Periodontol 2003;74:557-62.
Müller HP, Heinecke A, Schaller N, Eger T. Masticatory mucosa in subjects with different periodontal phenotypes. J Clin Periodontol 2000;27:621-6.
Kydd WL, Daly CH, Wheeler JB 3rd
. The thickness measurement of masticatory mucosa in vivo
. Int Dent J 1971;21:430-41.
Goaslind GD, Robertson PB, Mahan CJ, Morrison WW, Olson JV. Thickness of facial gingiva. J Periodontol 1977;48:768-71.
De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The gingival biotype revisited: Transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol 2009;36:428-33.
Stein JM, Lintel-Höping N, Hammächer C, Kasaj A, Tamm M, Hanisch O. The gingival biotype: Measurement of soft and hard tissue dimensions – A radiographic morphometric study. J Clin Periodontol 2013;40:1132-9.
Anderegg CR, Metzler DG, Nicoll BK. Gingiva thickness in guided tissue regeneration and associated recession at facial furcation defects. J Periodontol 1995;66:397-402.
Baldi C, Pini-Prato G, Pagliaro U, Nieri M, Saletta D, Muzzi L, et al.
Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol 1999;70:1077-84.
Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008;19:73-80.
Müller HP, Eger T. Masticatory mucosa and periodontal phenotype: A review. Int J Periodontics Restorative Dent 2002;22:172-83.
Müller HP, Schaller N, Eger T, Heinecke A. Thickness of masticatory mucosa. J Clin Periodontol 2000;27:431-6.
Eger T, Müller HP, Heinecke A. Ultrasonic determination of gingival thickness. Subject variation and influence of tooth type and clinical features. J Clin Periodontol 1996;23:839-45.
Serino G, Wennström JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 1994;21:57-63.
Cardaropoli G, Lekholm U, Wennström JL. Tissue alterations at implant-supported single-tooth replacements: A 1-year prospective clinical study. Clin Oral Implants Res 2006;17:165-71.
Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996;23:971-3.
Abrahamsson I, Berglundh T, Wennström J, Lindhe J. The peri-implant hard and soft tissues at different implant systems. A comparative study in the dog. Clin Oral Implants Res 1996;7:212-9.
Olsson M, Lindhe J, Marinello CP. On the relationship between crown form and clinical features of the gingiva in adolescents. J Clin Periodontol 1993;20:570-7.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]