|Year : 2013 | Volume
| Issue : 2 | Page : 116-121
Prevalence of different gingival biotypes in individuals with varying forms of maxillary central incisors: A survey
Vinaya Bhat, Sonali Shetty
Department of Prosthodontics, Including Crown and Bridge, A.B Shetty Memorial Institute of Dental Sciences, Mangalore, India
|Date of Web Publication||25-Sep-2013|
Prosthodontist, Famdent Clinic, Andheri West, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Gingival Perspective: The gingival perspective in restorative dentistry is important in harmonizing esthetics and biological function. In this regard, the gingival biotypes have been stated to be thick or thin. Patients with thin biotype are more prone to recession, inflammation, and compromised soft tissue response. The correct recognition of gingival biotypes is important for the treatment of planning process in restorative and implant dentistry. The purpose of the survey was to evaluate the prevalence of different biotypes in individuals with varying forms of maxillary central incisors.
Materials and Methods: A total of 200 subjects visiting the outpatient department in the range of 18-50 years participated in the study. Three clinical parameters were recorded by one examiner. This included the crown width/length ratio of the two central incisors, papillary height and gingival thickness. The measurements were tabulated and evaluated.
Results and Conclusion: The thicker biotype was observed to be more prevalent in male population with short, wider forms of maxillary central incisors while the females had thinner biotypes and narrow, long form of maxillary central incisors. Among the different age groups, young group had a thicker biotype (73) compared to older group (40). The mean papillary height was in the range of 4.3-4.7 mm with decreased height in the thicker biotypes.
Keywords: Papillary height, thick biotype, thin biotype, varying forms
|How to cite this article:|
Bhat V, Shetty S. Prevalence of different gingival biotypes in individuals with varying forms of maxillary central incisors: A survey. J Dent Implant 2013;3:116-21
|How to cite this URL:|
Bhat V, Shetty S. Prevalence of different gingival biotypes in individuals with varying forms of maxillary central incisors: A survey. J Dent Implant [serial online] 2013 [cited 2021 Sep 26];3:116-21. Available from: https://www.jdionline.org/text.asp?2013/3/2/116/118888
| Introduction|| |
Recently, in restorative dentistry, more emphasize is being given to gingival perspective for harmonizing esthetics along with function. Mimicking the gingival silhouette as the adjacent teeth in any restorative procedure exhibits an excellent treatment outcome. 
The gingival perspective depends on gingival complex, tooth morphology, contact points, hard and soft tissue considerations, periodontal bioform, and biotype.  The gingival or periodontal biotype in humans have been classified as thin or thick.  Various studies have shown a wide range of clinical difference in form and appearance in tissue biotypes. , The thick biotype consists of flat soft tissue and thick bony architecture and is most often found to be prevalent in the population. This type of tissue form is dense and fibrotic with large zone of attachment, thus making them more resistant to gingival recession. 
On a contrary, ''thin'' gingival biotype is delicate, thin with highly scalloped soft tissue with thin bony architecture characterized by bony dehiscence and fenestrations. Such type is more prone to recession, bleeding, and inflammation. Claffey and Shanley  defined the thickness not more than 1.5 mm as a thin biotype while more than 2 mm as a thick biotype. The importance of the clinical identification helps in better determination of the treatment outcome. The thinner periodontal biotype needs more attention when extraction is carried out owing to their thin alveolar plate.  The hard and soft tissue contouring is more predictable after surgery in the case of thick biotype. The value of thick biotype has been emphasized in increased wound coverage, site protection, stability of implants by creating a seal around implants.  Linkevicius et al.,  studied the influence of soft tissue thickness on crestal bone changes around implant, documented significant peri implant bone loss in sites with thin tissue compared to thick tissues. Nisapakultorn et al.,  in his study on 40 patients documented a thin biotype being significantly associated with increased risk of facial mucosal recession.
Various methodologies have been documented for measurement of the gingival tissue form. This includes visual inspection, ultrasonic devices, trans gingival probing, and Cone beam computerized tomography imaging.
The use of trans gingival probing serves as a simple method but requires local anaesthesia leading to distortion of soft tissues. The ultrasonic devices though are non-invasive fail to determine minor differences in gingival tissues.  The use of Cone beam computerized tomography (CBCT) is gaining popularity in regards to the same but this procedure requires technical expertise and becomes expensive with higher radiographic exposure. 
Hence, the use of simple methods to identify the gingival tissue biotype can help the clinician with the better treatment planning and definitive treatment outcome. Kan et al.,  in his study had stated a simple method to differentiate between the gingival biotype, based on the transparency of the periodontal probe through the gingival margin. Hence, this survey was undertaken to determine the prevalence of gingival biotype in the Southwest coastal population of India, as related to the varying forms of maxillary central incisors.
- To assess the gingival thickness (biotype)
- To study the prevalence of gingival biotypes of upper central incisors in relation to sex and age
- To study the prevalence of gingival biotypes with varying forms of central maxillary incisors
- To determine the prevalence of gingival biotype in relation to papillary height.
| Materials and Methods|| |
A total of 200 subjects visiting the outpatient department of A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka in the age range of 18-50 years, participated in the survey. Based on the age, they were divided into two groups, i.e. group I (18-30 years) and group II (30-50 years). Further selection criteria were fixed as follows:
- Subjects with restorations in the anterior maxillary teeth
- Pregnant or lactating mothers
- Subjects with clinical signs of periodontal disease having pockets more than 3 mm
- Orthodontic treatment, rotations
- Subjects with clinical signs of periodontal disease or clinical attachment loss.
A written informed consent was taken by the subjects to participate in the study. Three clinical parameters were recorded by one examiner to avoid bias. First, Crown width/crown length ratio (CW/CL) of the right and the left central incisor was measured.  The assessment was recorded with the help of digital calipers. The crown length was measured as the distance between the incisal length of the crown and the free gingival margin or Cemento enamel junction (CEJ) on the central incisors, while the crown width was measured as the border between the middle and the cervical portion [Figure 1]a and b].
Secondly, 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  [Figure 2].
Lastly, the gingival thickness (GT) was assessed and categorized into thick and thin on the site level. This evaluation was based on measurement with the help of periodontal probing into the sulcus at the midfacial aspect of both the central maxillary incisors. 
If the outline of the underlying periodontal probe could be seen through the gingival, it was categorized as thin (score 0) [Figure 3]. If it was not visible, it was categorized as thick (score 1).
The measurements were tabulated.
| Results|| |
- Frequency distribution of different biotypes among male and female - Among the male population, thicker gingival biotype was observed to be more prevalent with score 1 (63%) while compared to thin form (37%). Among the female subjects, higher prevalence of thin biotype was found with a score 0 (59%) when compared to males (41%) [Graph 1] [Additional file 1]
- Prevalence of varying central incisors (Crown width/ Length ratio) among different gender: The frequency distribution of male population was 125 while female was 75 among the 200 subjects participating. The male population had a ratio of 0.79 and 0.80 of the right and left central incisors resp. While female population have a ratio of 0.81 and 0.82 of the right and left central incisors, respectively. Males had a short wide form while females had long, narrow form.[Graph 2] [Additional file 2]
- Prevalence of different gingival biotypes in the participants with varying forms of upper central incisors in relation to age: Out of the total participants, 125 were in the younger age group (18-30 years) while 75 were in the older age group (30-50 years). Among the young group, more participants had thick gingival biotype (73) than then thinner biotype (42). In the older age group, more prevalence of thinner biotype (40) was seen compared to thicker biotype (35) [Graph 3] [Additional file 3]
- 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, 56% had a thick gingival biotype while 44% had thin biotype while for the long, narrow tooth form of central incisors, 39% had thick gingival biotype while 62% had thin biotype [Graph 4] [Additional file 4]
- Evaluation of PH in relation to gingival biotype: The mean PH was found to be 4.7 mm in males and 4.3 mm in females. The PH was found to be lesser in participants with thin biotype as compared to thick biotype [Graph 5] [Additional file 5].
| Discussion|| |
Demands for an excellent esthetic outcomes requires the establishment of periodontium and its compatibility with the surrounding hard and soft tissues. Various factors influence the position and form of gingival tissue around the natural tooth or fixed prosthesis. The gingival biotype plays an important role in harmonizing the ideal esthetics for any restorative procedure. 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. The survey was carried on 200 subjects divided into two age groups.
The method of assessment of gingival biotype ranges from assessment with periodontal probe, or visual examination, ultrasonic devices or radiographic methods. The use of the periodontal probe for penetration within the sulcus was carried out in this study. Kan et al.,  in their study concluded that the gingival biotype identification with periodontal probe and direct measurement is not statistically different and is adequately reliable and objective. In contrast, study conducted by Olsson et al.,  demonstrated no significant association between visual and measured gingival tissue forms. Eghbali et al.,  also did a study to compare the assessment of gingival biotype in experienced and in experienced clinician. They concluded that simple visual inspection could not be relied as an effective method irrespective of the clinician's experience.
The frequency distribution of GT states thicker biotype (score 2) in males (63%) as compared to females. Females have more number of thin biotype (59%) while 41% have a thick biotype. The results stated are in agreeable to those with De Rock et al.,  and Muller et al.,  who stated 1/3 rd of the sample to be females with a thinner biotype. De rock et al. in their study presented that male participants had thicker gingiva to conceal the periodontal probe when compared to female. Study by Eghbali et al.,  documented the presence in 1/3 rd of female samples with thin scalloped gingival form while 2/3 rd of the male samples with broad band of keratinized tissue and thick flat biotype. They also mentioned that the thin biotype in females was associated with long slender teeth while males showed quadratic teeth with thicker biotype.
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. Oschbein and Ross  were the first to document the relation of flat thick gingival form with square tooth form and thin gingival biotype with tapered tooth form. Studies by Morris,  Lindhe  documented that individuals with tapered crowns have a thinner biotype, making them more susceptible to gingival recession. Chow and Wang  in their review article stated the presence of long narrow form with thin gingival tissue. Seo et al.,  in their study did not find any statistically significant differences between the longer and shorter teeth in relation to gingival biotypes.
On comparing the prevalence of gingival biotypes between different age groups, the thicker biotype has been more prevalent in younger age groups. Vandana and Savita  in their study on GT on 32 individuals showed thicker gingiva in younger age group and stated that decrease in keratinisation and changes in oral epithelium may be the contributing factors. 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 possible relate to increased amount of recession and also the presence of thin biotype in older age group. Chow et al.,  also evaluated 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. With age, the interdental papilla recedes; this explains the greater frequency of thin biotype seen with older age group. Warasswapati et al.,  explained that racial and genetic factors contributed significantly for the same.
In a recent study by Cook et al.,  they evaluated various gingival parameters in patients having different periodontal biotypes. The results in 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, tooth with rotations and malpositions were excluded. But, on a wider range, most number of people are 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. 
| Conclusions|| |
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 is associated with long, narrow tooth form
- The thicker biotype is more prevalent in male population while the female population consists of thin, scalloped gingival biotype
- The thick flat biotype is seen in younger individuals while older age group shows thin scalloped gingival biotype
- Decrease in PH is observed with thin biotype.
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[Figure 1], [Figure 2], [Figure 3]