|Year : 2018 | Volume
| Issue : 1 | Page : 35-38
An assessment of different gingival biotypes in individuals with varying forms of maxillary central incisors and canines: A hospital-based study
Dhalkari Chandulal, Wagatkar Jayshri
Department of Periodontology, Government Dental College, Aurangabad, Maharashtra, India
|Date of Web Publication||9-May-2018|
Dr. Wagatkar Jayshri
Room No. 38, Government Dental Hostel, Aam Khaas Maidaan, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: The gingival morphology plays an important role in determining the final esthetic outcome. Different gingival biotypes respond differently to inflammation, restorative, trauma, and parafunctional habits. Some gingival features are influenced by tooth shape, position, and size, as well as gender and age. The thick biotype is more resistant to gingival recession and thin gingival biotype is more prone to recession, bleeding, and inflammation.
Methods: A total of 220 patients of the age group of 20–50 years with well-aligned dentition and healthy gingival tissues, who agreed to be a subject of the study were included. Gingival biotype (GT) was assessed by a single examiner. Crown width/crown length ratio (CW/CL) of both central incisors and canines was determined according to Olsson and Lindhe. Gingival biotype was evaluated and categorized into thick or thin. Papillary Height (PH) was calculated as the distance from the top of the papilla to a line connecting the midfacial soft tissue margin of the two adjacent teeth, and the mean value was calculated.
Results: In this study, 103 males and 117 females had participated. CW/CL ratio of the maxillary central incisors and canines, respectively, was 0.80 and 0.82 in males and 0.82 and 0.79 in females. Males had a short, wide form while females had long, narrow form. Thicker gingival biotype was more common in males. 71.84% of subjects with short, wide tooth form of maxillary central incisors had a thick and 28.16% had thin gingival biotype, whereas 48.72% of long, narrow tooth form of central incisors had thick and 51.28% had thin gingival biotype. Thick gingival biotype (62.20%) was more prevalent in young age group. The mean PH was 4.51 mm in males and 4.04 mm in females.
Discussion: The determination of thickness of the gingival tissue plays an important role in treatment planning process for orthodontics, root coverage, extractions, and implant placement, especially in the maxillary anterior area. GT is assessed by an invasive and a noninvasive method. Many studies have emphasized the findings that the thicker biotype prevents mucosal recession, hides the restorative margins, and camouflages the titanium implant shadows. It also prevents biological seal around implants, thus reducing the crestal bone resorption.
Conclusion: Our study confirmed that the thicker gingival biotype is more prevalent in males and is associated with short, wider form of teeth while thinner scalloped biotype is more common in females and is associated with long, narrow tooth form. Thick flat biotype is seen in younger individuals while thin scalloped gingival biotype in older age. Decrease in PH is observed with thin biotype.
Keywords: Canines, central incisors, gingival biotype, papillary height
|How to cite this article:|
Chandulal D, Jayshri W. An assessment of different gingival biotypes in individuals with varying forms of maxillary central incisors and canines: A hospital-based study. Int J Oral Health Sci 2018;8:35-8
|How to cite this URL:|
Chandulal D, Jayshri W. An assessment of different gingival biotypes in individuals with varying forms of maxillary central incisors and canines: A hospital-based study. Int J Oral Health Sci [serial online] 2018 [cited 2019 Feb 19];8:35-8. Available from: http://www.ijohsjournal.org/text.asp?2018/8/1/35/232173
| Introduction|| |
In recent years, the dimensions of different parts of the masticatory mucosa, especially gingival thickness (GT), have become a subject of considerable interest for dental researchers, both from an epidemiologic and therapeutic point of view. The long-term success of esthetic restorations depends on several factors such as gingival biotype, architecture of the gingival tissue, and shape of the anterior teeth. The gingival morphology plays an important role in determining the final esthetic outcome. Different gingival biotypes respond differently to inflammation, restorative, trauma, and parafunctional habits. Some gingival features are influenced by tooth shape, position, and size, as well as gender and age, i.e., many features of the gingiva are genetically determined.
Seibert and Lindhe coined the term periodontal biotype to elucidate different gingival architecture types based on buccolingual thickness. The thick biotype consists of flat soft tissue and thick bony architecture. This tissue form is more resistant to gingival recession due to its dense and fibrotic nature. However, thin gingival biotype is delicate, highly scalloped soft tissue with thin bony architecture characterized by bony dehiscence and fenestrations, which is more prone to recession, bleeding, and inflammation. Claffey and Shanley defined the thickness <1.5 mm as a thin while >2 mm as a thick biotype.
The aim of this study was to ensure the GT, to study the frequency of gingival biotypes of upper central incisors and canines in relation to sex and age, also with varying forms of maxillary central incisors and canines, and to determine the prevalence of gingival biotype in relation to papillary height (PH).
| Materials and Methods|| |
A total of 220 patients attending the outpatient department in the age group of 20–50 years with well-aligned dentition and healthy gingival tissues were invited to participate in the study. Patients agreed to be a subject of the study were included. All patients provided informed consent for indulging in the present study.
The exclusion criteria of subjects were as follows: (i) Missing of any of the maxillary incisors and canines, (ii) Dental restorations in any maxillary incisor and canines, (iii) Clinical signs of periodontal disease, (iv) Pregnant or lactating females, (v) Taking medication with known effect on the periodontal soft tissue, (vi) Systemic disease that may affect periodontal tissue, (vii) History of previous periodontal surgery in upper anterior region, (viii) Previous or current orthodontic treatment, and (ix) Attrition of the incisal edges of maxillary incisors and canines.
The inclusion criteria were as follows: (1) Individuals presenting all maxillary and mandibular incisors and canines and (2) Individuals having good oral hygiene without any clinical signs of gingival inflammation or attachment loss (periodontal probing does not exceed 3 mm).
GT was assessed in each patient by a single examiner. For assessment of gingival morphology, the following parameters were recorded: Crown width/crown length ratio (CW/CL) of both central incisors and canines was determined according to Olsson and Lindhe. The CL was measured between the incisal edge of the crown and the free gingival margin, or if discernible, the cementoenamel junction. CW is the distance between the approximal tooth surfaces, which was recorded at the border between the middle and the cervical thirds.
GT was evaluated and categorized into thick or thin on site. This evaluation was based on the transparency of the periodontal probe through the gingival margin while probing the sulcus at the midfacial aspect of both central maxillary incisors and canines to the full depth. If the outline of the underlying periodontal probe could be seen at the whole subgingival part, it was categorized as thin (score: 1); if not, it was categorized as thick (score: 2).
PH was calculated as the distance from the top of the papilla to a line connecting the midfacial soft tissue margin of the two adjacent teeth, and the mean value was calculated.
The measurements were calculated.
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 mean thickness of gingiva between males and females. Correlation coefficient was used to assess magnitude and nature of correlation between PH and thickness of gingiva. P < 0.05 was considered as statistically significant. Data were analyzed using statistical software STATA version 10.0 (StataCorp., College Station, TX: USA). Data had normal distribution to use the t-test.
| Results|| |
- Prevalence of varying central incisors (CW/length ratio) among different gender: The frequency distribution of male population was 103 while female was 117 among the 220 subjects participating. In male population, the CW/height ratio was 0.80 and 0.82 of the maxillary central incisors and canines, respectively, while female population has a ratio of 0.82 and 0.79 of the central incisors and canines, respectively. Males had a short, wide form while females had long, narrow form
- Frequency distribution of different biotypes among different gender: Among the male population, thicker gingival biotype was more common with score 2 (71.84%) when compared to females (48.72%)
- Prevalence of different gingival biotypes in participants with varying forms of central maxillary incisors: Among the participants with short, wide tooth form of maxillary central incisors, 71.84% had a thick gingival biotype, while 28.16% had thin biotype, whereas for the long, narrow tooth form of central incisors, 48.72% had thick gingival biotype, while 51.28% had thin biotype
- Prevalence of various gingival biotypes in the participants with varying forms of upper central incisors and canines in relation to age: Out of the total participants, 103 were in the younger age group (20–30 years), 81 were in the middle age group (30–40 years), while 36 were in the old age group (40–50). Among the young group, more participants had thick gingival biotype (62.20%)
- Evaluation of PH in relation to gingival biotype: The mean PH was found to be 4.51 mm in males and 4.04 mm in females. The PH was found to be lesser in participants with thin biotype as compared to thick biotype.
| Discussion|| |
In contemporary society, the esthetic view of the gingiva is an important picture framework for patient's smile and restorative treatment. Various factors influence the position and form of gingival tissue around the natural tooth or fixed prosthesis. Determining the thickness of the gingival tissue plays an important role in treatment planing process for orthodontics, root coverage, extractions, and implant placement, especially in the maxillary anterior area. The objective of the present survey was to evaluate the prevalence of the different gingival tissue biotypes in individuals with varying forms of upper central incisors and canines. The survey was carried on 220 individuals divided into three age groups. Because the thickness of the gingiva 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. Therefore, it is important to take into consideration the differences in gingival tissue during treatment planing.
GT is assessed by an invasive and a noninvasive method. Invasive methods included injection, needle or probe, histologic sections, or cephalometric radiographs, while noninvasive methods included visual examination, the use of ultrasonic devices, probe transparency, and cone-beam computed tomography (CBCT). The ultrasonographic method of assessing GT is a noninvasive method, but it has multiple drawbacks but not limited to the nonreliability of results when the thickness of gingival exceeds 2–2.5 mm and the difficulty to determine the correct position and achieve a reproducible measurements. The CBCT measurements are accurate representation of the clinical thickness of both labial gingiva and bone. However, exposure to radiation and cost make it less desirable. The transparency of a periodontal probe was chosen as it is considered atraumatic, rapid, and with relatively low cost. Furthermore, this method was found to be an easy, reproducible, reliable, and objective method. A decision to study the maxillary central incisors was made because previous studies have found that the difference between biotypes was more observable in these teeth.
The frequency distribution of prevalence of GT in relation to groups of subjects with different combinations of morphometric data related to central maxillary incisors states that short, wider teeth are associated with thick biotype while long, slender teeth are associated with thin biotype. 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 greater 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.
Eger et al. applied an ultrasonic device for measuring GT and defining three gingival phenotypes. Eger et al. found that the characteristics of the maxillary front teeth could be extrapolated to other parts of the masticatory mucosa, in particular the palatal mucosa. In the present study, the frequency distribution of gingival tissue states thicker biotype (score 2) in males (71.84%) as compared to females (48.72). The results stated are in agreeable to those with De Rouck et al. and Müller et al., who stated one-third of the sample to be females with a thinner biotype. De Rouck et al. in their study presented that male participants had thicker gingiva to conceal the periodontal probe as compared to female. A study by Eghbali et al. documented the presence in one-third of female samples with thin scalloped gingival form while two-third of the male samples with broadband of keratinized tissue and thick flat biotype. It is observed that the thin biotype in females was associated with long slender teeth while males showed quadratic teeth with thicker biotype.
On comparing the prevalence of gingival biotypes between different age groups, the thicker biotype has been more prevalent in younger age groups. In 2005, Vandana and Savitha used transgingival probing for demonstrating that the gingiva was thicker in the mandibular arch as compared to the maxillary arch. This is in contrast with the study conducted by Müller et al., in which a thicker gingiva was found in maxilla and the thinnest facial gingiva was found in the maxillary canines and first mandibular premolars. Chow et al. also estimate various factors associated with the appearance of gingival papillae and found significant associations with age and the crown form and GT. Olsson et al. documented that the central incisors with narrow tooth form had greater amount of recession when compared to incisors with square form.
Chang  in his study stated that an inverse relationship has found to be existing between PH and age. In the present study, the decreased PH has been observed in relation with thick biotype. Sanavi et al., in their review article, described that the inter-root bone is more in the thinner biotype. This in turn can cause more recession. They also stated that the interproximal papilla does not cover the spaces between two teeth in thinner biotype as compared to thick biotype. This could possibly relate to increased amount of recession and also the presence of thin biotype in older age group.
In a recent study by Cook et al., they estimated various gingival parameters in patients having different periodontal biotypes. The results of their study documented no significant differences between tissue biotypes and crown height to width ratio, age, sex, and gingival margin position. In the present study, teeth with rotations and malpositions were excluded. However, on a wider range, most number of people is associated with sight malrotations. It should be emphasized that tooth position significantly can alter the gingival parameters.
The relevance of this survey in periodontal surgeries and implant dentistry can be emphasized. The thicker biotype prevents mucosal recession, hides the restorative margins, and camouflages the titanium implant shadows. It also prevents biological seal around implants, thus reducing the crestal bone resorption.
| Conclusion|| |
Within the limitations of the present survey, following conclusions were drawn: The thicker gingival biotype is associated with short, wider form of teeth while thinner scalloped biotype with long, narrow tooth form. The thicker biotype is more prevalent in male population while thin scalloped gingival biotype in females. The thick flat biotype is seen in younger individuals while thin scalloped gingival biotype in older age. Decrease in PH is observed with thin biotype.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Vandana KL, Savitha B. Thickness of gingiva in association with age, gender and dental arch location. J Clin Periodontol 2005;32:828-30.
Ochsenbein C, Ross S. A reevaluation of osseous surgery. Dent Clin North Am 1969;13:87-102.
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.
Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodontol 1991;18:78-82.
Kao RT, Fagan MC, Conte GJ. Thick vs. thin gingival biotypes: A key determinant in treatment planning for dental implants. J Calif Dent Assoc 2008;36:193-8.
Müller HP, Schaller N, Eger T, Heinecke A. Thickness of masticatory mucosa. J Clin Periodontol 2000;27:431-6.
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.
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.
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.
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.
Eghbali A, De Rouck T, De Bruyn H, Cosyn J. The gingival biotype assessed by experienced and inexperienced clinicians. J Clin Periodontol 2009;36:958-63.
Chow YC, Eber RM, Tsao YP, Shotwell JL, Wang HL. Factors associated with the appearance of gingival papillae. J Clin Periodontol 2010;37:719-27.
Chang LC. The association between embrasure morphology and central papilla recession. J Clin Periodontol 2007;34:432-6.
Sanavi F, Weisgold AS, Rose LF. Biologic width and its relation to periodontal biotypes. J Esthet Dent 1998;10:157-63.
Cook DR, Mealey BL, Verrett RG, Mills MP, Noujeim ME, Lasho DJ, et al.
Relationship between clinical periodontal biotype and labial plate thickness: An in vivo
study. Int J Periodontics Restorative Dent 2011;31:345-54.
Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance of keratinized mucosa in maintenance of dental implants with different surfaces. Periodontol 2006;77:1410-20.