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ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 245-250

Evaluation of thickness of palatal masticatory mucosa in posterior teeth and its relation with age and gender


1 Department of Periodontics, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India
2 Al Thuraya Dental and Implant Centre, Abu Dhabi, UAE
3 Department of Periodontics, ITS Dental College, Greater Noida, Uttar Pradesh, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Manish Khatri
Department of Periodontics, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_82_17

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  Abstract 

Background: To evaluate the thickness of palatal masticatory mucosa in posterior teeth by transgingival probing and determine its relation with age and gender. Materials and Methods: Forty systemically healthy volunteers with age range 16–38 years were selected based on the inclusion and exclusion criteria. Eighteen measurement points were made on the cast that was transferred onto the palate using clear acrylic stent to measure thickness. Three different lines a, b, and c: 3, 8, and 12 mm, respectively, from the gingival margin were made starting at the mid-palatal aspect of the canine and ending over the palatal root of the second molar. Six points were defined on each of the lines: Ca (mid-palatal aspect of the canine), P1 (mid-palatal aspect of the first premolar), P2 (mid-palatal aspect of the second premolar), M1 (palatal root of the first molar), Mi (interproximal aspect between the first and second molar), and M2 (palatal root of the second molar). Results: Soft-tissue thickness progressively increased in sites further from the gingival margin and was thickest adjacent to mid-palatal aspect of the second premolar 12 mm away from gingival margin. Younger age group patients had thinner posterior palatal mucosa as compared to older age group patients. Males had thicker posterior palatal mucosa as compared to females, but results were statistically insignificant. Conclusion: The thickness of posterior palatal mucosa showed a varied degree of variation at different marked areas in different teeth, and the difference in the mean thickness was also associated with age and gender.

Keywords: Masticatory mucosa, palatal thickness, transgingival probing


How to cite this article:
Khatri M, Gupta G, Puri K, Bansal M, Garg S, Ranga P. Evaluation of thickness of palatal masticatory mucosa in posterior teeth and its relation with age and gender. Indian J Dent Sci 2017;9:245-50

How to cite this URL:
Khatri M, Gupta G, Puri K, Bansal M, Garg S, Ranga P. Evaluation of thickness of palatal masticatory mucosa in posterior teeth and its relation with age and gender. Indian J Dent Sci [serial online] 2017 [cited 2019 Sep 19];9:245-50. Available from: http://www.ijds.in/text.asp?2017/9/4/245/219632


  Introduction Top


Masticatory mucosa is keratinized stratified squamous epithelium lining the dorsum of the tongue, hard palate, and gingiva.[1] The dimension of gingiva and different parts of the masticatory mucosa has become the subject of considerable interest in periodontics from both epidemiological as well as therapeutic point of view.[2] The masticatory epithelium is inextensible and tolerates significant physical stress due to its underlying convoluted lamina propria.[3]

A critical aspect in the treatment planning of the cases requiring palatal graft is the determination of the thickness of the graft donor site. Thickness of palatal mucosa, in particular, has recently attracted considerable attention with regard to a possible donor site for tissue transplants in plastic surgery since the thickness of tissue grafted from the palate to the recipient site directly affects the surgical outcome.[4],[5] The success of these techniques depends on the site and thickness of soft-tissue graft obtained. Revascularization of the graft may be prevented if the donor tissue is too thick, and graft shrinkage may occur if the tissue is too thin.[6] Therefore, the thickness and volume of the tissue to be grafted from the donor site are important factors in determining the appropriate treatment method and for predicting the prognosis.[7]

To prevent the undesirable outcomes, methods have been developed to help the clinician determine the thickness of the palatal masticatory mucosa before harvesting the graft.[8],[9],[10]

The retrieval of donor tissue from the premolar region in the high and average palate offers a greater margin at safety than retrieval from the shallow (flat) palatal vault in reference to the neurovascular structures. The mean height of the palate vault (the shortest distance between the midline of the hard and soft palates and the cementoenamel junctions of the first molars) in an adult male is 14.90 mm, with a standard deviation of 2.93 mm. The mean height in on adult female is 12.70 mm, with a standard deviation of 2.45 mm. Caution must always be exercised not to violate the neurovascular bundle when obtaining the donor tissue, but extreme caution must be exercised when the palate is shallow.[11]

Thus, the present study was carried out with an aim to evaluate the thickness of palatal mucosa in posterior teeth by transgingival probing and determine its relation with age and gender.


  Materials and Methods Top


Forty systemically healthy volunteers with age range 16–38 years were selected from the outpatient department of the Department of Periodontics of the Institute after screening which was based on the following selection criteria. Participants with a history of surgery in palate, participants with a previous history or presence of any stomatological disease in the palate, previous history of any systemic disease or drug intake which could influence the volume of mucosa, pregnant women or lactating mothers, smokers, patients wearing any removable device, such as removable partial dentures or orthodontic plate retainers, presence of any fixed partial denture, and participants with tooth malposition were excluded from the study. Participants with healthy periodontal tissues, with complete dentition in the maxillary arch with or without third molar, were included in the study. All the participants were briefly informed about the study plan and gave prior consent to participate in the study that was approved by the Institutional Review Board.

To standardize the clinical measurements, acrylic stents were fabricated using clear self-cured acrylic resin only on the maxillary cast using the dough method.

A uniform thickness of self-cured acrylic resin was used to cover the palatal gingiva/mucosa of all the maxillary teeth. The acrylic was extended in the embrasure spaces of the palatal aspect of maxillary anterior teeth. Acrylic was also extended to cover the palatal aspect of maxillary posterior teeth (bilaterally) and was extended to cover the occlusal surfaces and cervical two third of the buccal surfaces of maxillary canines, premolars, and molars. The prepared stent provided a consistent location for the assessment of mucosal thickness [Figure 1].
Figure 1: Stent extension on cast

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The right or left side of palate was selected randomly by flipping a coin. Eighteen measurement points on the selected half were made on the cast, keeping mid-palatine raphae and gingival margin as reference points. Three different lines a, b, and c running parallel to the gingival margin were established starting at the mid-palatal aspect of the canine and ending over the palatal root of the second molar. The distances from the gingival margin to lines a, b, and c were 3, 8 and 12 mm, respectively. Six points were defined on each of the lines, constituting six positions, each located at the level of a tooth. Position Ca was determined at the mid-palatal aspect of the canine, position P1 at the mid-palatal aspect of the first premolar, position P2 at the mid-palatal aspect of the second premolar, position M1 over the palatal root of the first molar, position Mi at the interproximal aspect between the first and second molar, and position M2 over the palatal root of the second molar [Figure 2]. These six points contacting the three lines constituted the eighteen points which were designated for assessing the palatal mucosa thickness. Bold markings were made on the casts to represent these eighteen markings which were transferred on the clear acrylic stent. Fissured diamond burs were used to create holes at the marked eighteen measurement points on the stent [Figure 3].
Figure 2: Definition of measurement points

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Figure 3: Eighteen notified points on stent with holes

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The measurement points were marked with a gentian violet pencil on the palate through the holes made on the stent, and the masticatory mucosal thickness was measured in the hard palate on those eighteen markings by bone sounding using a UNC-15 periodontal probe with rubber stopper after 20 min of anesthetizing the palatal mucosa with block anesthesia (greater palatine nerve and incisive nerve) using 2% lignocaine HCL with 1:80,000 adrenalin solution, and the recordings were rounded off to the nearest millimeter [Figure 4] and [Figure 5].
Figure 4: Prepared stent in patient's mouth

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Figure 5: Palatal thickness measurement with UNC-15 probe

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Statistical analysis

The software used for statistical analysis was SPSS (Statistical Package for the Social Sciences) version 16.0 (IBM Company, New York, United States). Statistical analysis was performed by Mann–Whitney U-test and paired t-test.


  Results Top


The present clinical study was aimed to evaluate the thickness of palatal mucosa in posterior teeth by transgingival probing and determine its relation with age and gender.

The study consisted of forty systemically healthy participants (20 males and 20 females) in the age range of 16–38 on the basis of the screening criteria. Demographic details along with thickness of posterior palatal mucosa (total of 18 points) were recorded in all the forty patients.

Teeth-wise comparison of thickness of palatal mucosa in different notified areas is shown in [Table 1]. The mean thickness of posterior palatal mucosa at line b and line c was greater than line a and also mean thickness at line c was greater than line b at all the six notified points and the difference was statistically significant. The mean thickness at all the six notified points was in decreasing order of P2 (second premolar) >M2 (second molar) >Mi (interdental point between first and second molar) >P1 ( first premolar) >Ca (Canine) >M1 ( first molar).
Table 1: Teeth-wise comparison of thickness of palatal mucosa in different notified areas

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The comparison of thickness of posterior palatal mucosa in different notified areas in younger age group patients (n = 24) (age range: 16–24 years) is shown in [Table 2]. The results indicate that the average mean thickness of posterior palatal mucosa in younger population was in the decreasing order of P2>M2>Mi>P1>Ca>M1. Hence, greatest thickness of palatal mucosa was found at P2 (second premolar) and least at M1 ( first molar). The mean thickness of posterior palatal mucosa at line b and line c was greater than line a and also line c was greater than line b at all the six notified points and the difference was statistically significant.
Table 2: Comparison of thickness of posterior palatal mucosa in different notified areas in younger age group patients (16-24 years)

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The comparison of thickness of posterior palatal mucosa in different notified areas in older age group patients (n = 16) (age range: 25–38 years) is shown in [Table 3]. The results indicate that the average mean thickness of posterior palatal mucosa in older population was in the decreasing order of P2>M2>Mi>P1>Ca>M1. Hence, the greatest thickness of palatal mucosa was found at P2 (second molar) and least at M1 ( first molar). The mean thickness of posterior palatal mucosa in older population at line b and line c was greater than line a at all the six notified points and the difference was statistically significant. The mean thickness of posterior palatal mucosa at line c was significantly greater than line b at five notified points (P1, P2, M1, Mi, and M2), whereas at one notified point (Ca), it was statistically not significant (P = 0.333).
Table 3: Comparison of thickness of posterior palatal mucosa in different notified areas in older age group patients (25-38 years)

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Age-wise intergroup comparison of thickness of posterior palatal mucosa in different notified areas is shown in [Table 4]. Age-wise intergroup comparison of thickness of posterior palatal mucosa in six different notified areas (Ca, P1, P2, M1, Mi, and M2) was statistically not significant at line Aa1 (younger) and at line Aa2 (older) and also Ab1 (younger) and Ab2 (older). Age-wise intergroup comparison of thickness of posterior palatal mucosa in four different notified areas (Ca, P1, M1, and Mi) was statistically not significant at line Ac1 and at line Ac2, but at P2 and M2, it was statistically significant. Age-wise intergroup comparison of thickness of posterior palatal mucosa in four different notified points (Ca, P1, M1, and MI) was thicker in older patients but statistically not significant at lines Aa1, Ab1, and Ac1 (average of mean gingival thickness at line at line a1, a2 and a3 in younger age group patients) and Aa2, Ab2, and Ac2 (average of mean gingival thickness at line a2, b2 and c2 in older age group patients), whereas at P2 and M2, it was statistically significant.
Table 4: Age-wise intergroup comparison of thickness of posterior palatal mucosa in different notified areas

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Gender-wise comparison of thickness of posterior palatal mucosa in different areas for males is shown in [Table 5]. The results indicate that the average mean thickness of posterior palatal mucosa in males was in the decreasing order of P2>M2>Mi>P1>Ca>M1. Hence, the greatest thickness was found at P2 (second premolar) and least at M1 ( first molar). The mean thickness at line b and line c was greater than line a at all the six notified points and the difference was statistically significant. At line c, it was greater than line b at five notified points (P1, P2, M1, MI, and M2) and the difference was statistically significant, whereas at Ca point, it was statistically not significant. Similar results were found in females [Table 6] with line c thickness being significantly greater than line b at all six notified points.
Table 5: Gender-wise comparison of thickness of posterior palatal mucosa in different areas for males

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Table 6: Gender-wise comparison of thickness of posterior palatal mucosa in different areas for females

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Gender-wise intergroup comparison of thickness of posterior palatal mucosa at six different notified areas was statistically not significant as shown in [Table 7].
Table 7: Gender-wise intergroup comparison of thickness of palatal mucosa in different areas for different gender groups

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  Discussion Top


In the present study, posterior palatal mucosal thickness was assessed at eighteen points on three different lines a, b, and c running parallel to the gingival margin at 3, 8, and 12 mm, respectively, which were established starting at the mid-palatal aspect of the canine and ending over the palatal root of the second molar. Six points (Ca, P1, P2, M1, Mi, and M2) were defined on each of the lines, constituting six positions, each located at the level of a tooth, designated for assessing the palatal mucosa thickness in the hard palate by bone sounding using a UNC-15 periodontal probe with rubber stopper. The recordings were rounded off to the nearest millimeter. Similar gingival thickness evaluation of posterior palatal mucosa was done in a study conducted by Studer et al.[12]

In the present study, the mean thickness of the posterior palatal mucosa ranged between 2.10 ± 0.92 mm (over the palatal root of the first molar 3 mm away from gingival margin) and 3.6 ± 1.23 mm (mid-palatal aspect of the second premolar 12 mm away from gingival margin). Mucosa in the hard palate 12 mm away from the gingival margin revealed significantly thicker values than in distances of 3 mm or 8 mm. Hence, the palatal root of the first molar represents an anatomic barrier in graft harvesting in the hard palate, but it is not advisable to harvest soft-tissue grafts beyond this structure to avoid an increasing risk for accidental damage to the greater palatine artery or its branches, and thicker palatal grafts may be harvested if obtained several millimeters away from the gingival margin of the teeth. Thus, the area of the palate from the distal line angle of the canine to the mesial line angle of the palatal root of the first molar provides a sufficient donor tissue for grafting procedures and also reduces the risk of violating the associated neurovascular structures.[6],[11],[12],[13],[14],[15]

In the present study, the younger age group had significantly thinner mucosa (3.28 ± 1.17 mm) than the older age group (3.48 ± 1.45 mm) in relation to posterior palatal mucosa. Younger age group had significantly thinner posterior palatal mucosa because the thickness of orthokeratinized epithelial layer of the hard palate mucosa increases with age, resulting in the thicker palatal mucosa in the older participants. In addition, the hard palate possesses a submucosal layer, which contains various amounts of adipose tissue and small mucous glands. There are other factors that influence the mucosal thickness such as racial, genetic factors and body weight.[6],[13],[14],[15]

Furthermore, in the present study, posterior palatal mucosal thickness was found to be more in males (2.68 ± 0.36 mm) as compared to females (2.63 ± 0.61 mm); however, it was not statistically significant. The results were in accordance to the study done by Müller et al.,[6] Song et al.,[7] Studer et al.,[12] Eger et al.,[16] Kuriakose and Raju,[17] Wara-Aswapati et al.,[18] and Kolliyavar [19] and in contrast with the study done by Schacher et al.[20] who stated that females had thicker mucosa than males which basically depends on body mass.


  Conclusion Top


The thickness of posterior palatal mucosa shows a varied degree of variation, and the difference in the mean thickness might be due to age, gender, ethnicity, varying measurement methods, and the placement of measurement points. The area of the palate from the distal line angle of the canine to the mesial line angle of the palatal root of the first molar provides a sufficient donor tissue for grafting procedures and also reduces the risk of violating the associated neurovascular structures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Schacher B, Bürklin T, Horodko M, Raetzke P, Ratka-Krüger P, Eickholz P. Direct thickness measurements of the hard palate mucosa. Quintessence Int 2010;41:e149-56.  Back to cited text no. 20
    


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