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Original Article

Analysis of the gingival biotype


based on the measurement of the
dentopapillary complex
Ranjan Malhotra, Vishakha Grover, Arvind Bhardwaj, Kanika Mohindra

Department of
Periodontics and Oral
Implantology, National
Dental College and
Hospital, Gulabgarh,
Derabassi, Mohali,
Punjab, India

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Website:
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Abstract:
Background: The gingival morphology of the maxillary anterior region plays an important role in determining
the final esthetic outcome. Knowledge of the periodontal biotype is of fundamental importance because the
anatomical characteristics of the periodontium, such as gingival thickness, gingival width and alveolar bone
morphology, will determine periodontium behavior when submitted to physical, chemical, or bacterial injury or
during periodontal or implant surgical procedures and orthodontic treatment. Materials and Methods: 50 subjects
with healthy periodontal tissues with no loss of attachment and (b) presence of all anterior teeth in both upper and
lower jaw were selected. On clinical examination gingival thickness was recorded based on the transparency of
periodontal probe. Following parameters are recorded from dental cast, i.e., crown length, crown width, papillary
length (PL) and papillary width. Results: There was highly significant correlation between gingival biotype and
crown length and area of papilla with P value 0.002 and 0.013 respectively. Significant correlation was found
between area of crown and PL with P value 0.013 and 0.016. The results of discriminant function analysis
showed that average crown length was the best single determinant of biotype and area of papilla was the next
best choice. Conclusion: Within the limits of the current investigation, the existence and correlation of different
gingival biotypes and dentopapillary complex dimension has been confirmed. These findings can be utilized as
objective guidelines for determining the biotype and response of gingiva to many dental operative procedures.
Key words:
Crown length, crown width, dentopapillary complex, gingival biotype, papillary length, papillary width

DOI:
10.4103/0972-124X.128199

INTRODUCTION

Quick Response Code:

Address for
correspondence:
Dr. Vishakha Grover,
Department of
periodontology and oral
implantology, National
Dental College and
Hospital, Gulabgarh,
Derabassi District, SAS
Nagar, Mohali, Punjab,
India.
E-mail: vishakha_grover@
rediffmail.com
Submission: 15-04-2013
Accepted: 13-05-2013

nowledge of the periodontal biotype or


phenotype is of fundamental importance
to an oral clinician because the anatomical
characteristics of the periodontium, such as
gingival thickness, gingival width and alveolar
bone morphology, will determine the behavior
of periodontium when submitted to physical,
chemical, or bacterial insult or during therapeutic
procedures viz periodontal surgeries, [1]
implant,[2,3] orthodontic treatment.[4] A direct
correlation exists between gingival biotype and
susceptibility to gingival recession following
surgical and restorative procedures. Specifically,
it was pointed out how thick and thin gingival
biotypes respond differently to inflammation,
restorative trauma and parafunctional habits.
These traumatic events result in various types
of periodontal defects, which respond variably
to different treatments. Therefore, an accurate
diagnosis of gingival tissue biotype is of the
utmost importance in devising an appropriate
treatment plan and achieving a predictable
esthetic outcome.
There is a considerable intra and inter-individual
variation in both width and thickness of the facial
gingiva, giving rise to the assumption that different

Journal of Indian Society of Periodontology - Vol 18, Issue 1, Jan-Feb 2014

gingival phenotypes might exist in any adult


population. The bulky slightly scalloped marginal
gingiva with short and wide teeth[5] on one hand
and thin highly scalloped marginal gingiva with
slender teeth on the other may serve to illustrate
the existence of markedly different periodontal
entities or so-called gingival biotype. The term
gingival or periodontal phenotype was coined
by Muller.[6] Gingival biotype is known to be
dependent upon many factors such as age, gender,
growth, tooth shape, tooth position, tooth size and
genetically determined factors.
The characteristics of gingival thickness, gingival
width and subjacent alveolar bone thickness
have been used as a base for the classification of
periodontal biotypes. However, for some authors,
use of the term periodontal phenotype more
correct to describe features of the periodontium,
which are influenced by both genetic [7] and
environmental factors. In these studies, gingival
thickness, gingival width and the shape of the
dental crown are taken to relate to define the
classification of periodontal phenotype.
Gingival biotype refers to a composite or
aggregate of four features of the soft tissues and
the teeth they surround that build up to a specific
picture by Sammut.[8] These are:
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Malhotra, et al.: Correlating gingival biotype with dentopapillary complex

1. The gingival width (keratinised tissue width): Which


refers to the width of the keratinised tissue when
measured from the gingival margin to the mucogingival
junction
2. Gingival thickness (thick or thin): The thickness of the tissue
in a bucco-palatal dimension. If you insert a probe into the
midbuccal sulcus of the maxillary central incisor and you
can see it through the tissue then it is thin by this definition.
If you cant see it, it is thick
3. Papilla height (PH)/proportion: The part of the gum that
fits in between teeth
4. Crown width/height ratio: Long, slender teeth tend to be
associated with contact points distant from the alveolar
crest and long papillae that fill the embrasures.
Over past few years, several studies have tried to sought
a better understanding of anatomical characteristics of
periodontium with the purpose of defining the periodontal
biotype of each individual. As such there have been no
defined objective criteria for identifying gingival biotype.[9]
So the cross sectional analysis of variants had been planned
to get insight into the association/relation between gingival
biotype and the dentopapillary complex if any significant
determinants can be objectively defined to classify the
biotype.

MATERIALS AND METHODS


50 subjects with healthy periodontal tissues with no loss of
attachment and (b) presence of all anterior teeth in both upper
and lower jaw were selected from those visiting the outpatient
Department of Periodontology and Oral Implantology,
National Dental College and Hospital, Derabassi.
Subjects with crown restorations or fillings involving the
incisal edge on anterior maxillary teeth, pregnant and lactating
females, subjects taking medications with any known effect
on the periodontal soft tissues, volunteers with clinical signs
of periodontal disease defined as having pockets >3 mm were
excluded from the study.

All the eligible subjects were explained about the study and a
written informed consent was obtained.
Selected subjects were greeted and seated for the appointment
on the dental chair in a comfortable position. Alginate
impressions of selected study participants were made and
poured with dental stone.
Gingival thickness on maxillary anterior teeth was clinically
recorded and was categorized into thick or thin on a site
based level. This evaluation was based on the transparency
of the periodontal probe through the gingival margin
while probing the sulcus at the mid-facial aspect of both
central maxillary incisors. If the outline of the underlying
periodontal probe could be seen through the gingiva, it was
categorized as thin and if not, it was categorized as thick
[Figures 1 and 2]
Dental casts were obtained which is the positive replica
of the whole mouth. Following parameters were recorded
from the dental cast
Crown length (CL)[9] was measured between the incisal edge
of the crown and the free gingival margin, or if discernible,
the cemento-enamel junction
Crown width (CW) [9] i.e., the distance between the
approximal tooth surfaces, was recorded at the border
between the middle and the cervical portion
Papillary height (PH) [9] was assessed to the nearest
0.5 mm using the same periodontal probe at the mesial
and distal aspect of both central incisors. This parameter
was defined as the distance from the top of the papilla to
a line connecting the mid-facial soft tissue margin of the
two adjacent teeth. The mean value will calculated for the
three papilla
Papillary width (PW) was calculated at the base of papilla
between two approximated tooth surfaces
From canine to canine, the area of the facial papilla (AP), the
facial surface area of the anterior tooth (AT), the proportion
of the dento-papillary complex (AP/AT).

The study protocol was duly reviewed and approved from the
institutional ethical committee.

Data so collected was put to statistical analysis via SPSS


software. Statistical analysis: Intra-examiner repeatability of the
clinician who performed all clinical examinations was analysed.
For total continuous variables, intra-examiner repeatability
was evaluated using Pearsons correlation coefficient. Mean

Figure 1: Thin gingival biotype

Figure 2: Thick gingival biotype

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Journal of Indian Society of Periodontology - Vol 18, Issue 1, Jan-Feb 2014

Malhotra, et al.: Correlating gingival biotype with dentopapillary complex

Figure 3: Mean crown length for thick and thin gingival biotype

Figure 4: Mean crown width for thick and thin gingival biotype

Figure 5: Mean papillary length for thick and thin gingival biotype
Figure 6: Mean papillary width for thick and thin gingival biotype

Figure 7: Mean area of papilla for thick and thin gingival biotype
Figure 8: Mean area of the crown for thick and thin gingival biotype

Figure 9: The ratio between area of papilla/area of the crown for thick and thin
gingival biotype

values and standard deviations were calculated per subject for


all continuous variables. Significant disparities were assessed
using the independent-samples t-test.

RESULTS
The study population consisted of 50 periodontally healthy
subjects with a mean age of 35 years. Results showed that the
crown length ranged from 7.9 mm to 12 mm for thin biotype
and for 6 mm to 10.5 mm for thick biotype [Figure 3]. The crown
width ranged from 6 mm to 11.5 for thin biotype and 6 mm
Journal of Indian Society of Periodontology - Vol 18, Issue 1, Jan-Feb 2014

to 9.5 for thick biotype [Figure 4]. The papillary length (PL)
ranged from 3.3 mm to 6 mm for thin biotype and is 3 mm to
6 mm for thick biotype [Figure 5]. The Papillary width (PW)
ranged from 4.3 mm to 7 mm for thin biotype and 3.5-6.3 mm for
thick biotype [Figure 6]. Area of papilla ranged from 13.2 mm
to 36 mm sq and for thick biotype is 12-30 mm sq [Figure 7].
Area of crown ranged from 55.2 mm to 95.6 mm sq for thin
biotype and 42-96 mm sq for thick biotype [Figure 8]. Area of
papilla/area of crown ranged from 0.02 to 0.48 for thin biotype
and for thick biotype is 0.022-6.44 [Figure 9].

DISCUSSION
In recent years, the dimensions of different parts of the
masticatory mucosa, especially gingival thickness, has become
the subject of considerable interest in periodontics from both an
epidemiologic and a therapeutic point of view.[10] Since studies
have concluded that the thickness of the gingiva plays a vital role
in development of mucogingival problems and in the success
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Malhotra, et al.: Correlating gingival biotype with dentopapillary complex

of treatment for recession and wound healing, assessment of


gingival thickness is relevant to clinical periodontics.
Clinical appearance of normal gingival tissue reflects the
underlying structure of the epithelium and lamina propria.
It has been long known that clinical appearance of healthy
marginal periodontium differs from subject to subject and
even among different tooth types. Many features are directly
genetically determined, others seem to be influenced by tooth
size, shape and position and biological phenomena such
as growth or ageing. The particular shape, topographical
distribution and width of the gingiva are clearly functions of
the presence and position of erupted teeth. Moreover, tooth
shape itself seems to have an important impact on the clinical
features of the surrounding gingiva and probably also the
underlying tooth supporting periodontal tissues.

thin biotype is 5.13 mm and for thick is 4.44 mm. The mean
papillary width for thin biotype is 4.921 mm and for thick
biotype is 4.622 mm. The mean area of papilla for thin biotype
is 25.1004 mm sq and for thick biotype is 24.500 mm sq. The
mean area of the crown for thin biotype is 76.327 mm sq and
for thick biotype is 66.541 mm sq. The mean value of the area
of papilla/area of the crown for thin biotype is 0.3280 and for
thick biotype is 0.5382 [Table 1]. There was highly significant
correlation between gingival biotype and crown length and
area of papilla with P value 0.002 and 0.013 respectively.
Significant correlation was found between area of crown and
PL with P value 0.013 and 0.016. The results of discriminant
function analysis showed that average crown length was the
best single determinant of biotype and area of papilla was the
next best choice. The cut-off value of average crown length was
calculated to be 8.62 [Table 2].

The thickness of masticatory mucosa is evaluated by


the invasive methods [6,11] and non-invasive methods. [12]
Invasive methods include using injection needle, probe, or
cephalometric radiograph and non-invasive methods such
as ultrasonic devices. Although the ultrasonographic method
of assess in gingival thickness is non-invasive, drawbacks
included the relative unavailability of the instrument,
difficulty in maintaining the directionality of the transducer
and non-reliable results when the thickness of gingiva exceeds
2-2.5 mm. Hence, to overcome these problems, De Rouck
et al. (2009)[3] introduced a method to check for the gingival
thickness based on the transparancy of the periodontal probe
through the gingival margin while probing the sulcus at the
midfacial aspect of incisors. If the outline of the underlying
periodontal probe could be seen through the gingival margin,
it was categorized as thin if not, it was categorized as thick.
This method was employed in the study as it was relatively
easy and non-invasive. Maxillary incisors were selected as
reference teeth because differences between biotypes are most
explicit for these teeth and because their specific features are
easily found in other parts of the dentition.[13,14]

Similar findings have been reported earlier by Anand et al.[6]


who correlated the prevelance of thick and thin biotype with
gender and tooth morphology. Results showed that Cluster A
displayed slender tooth form crown width/crown length (CW/
CL 0.77), gingival width and (GW) 4.80 mm, papillary
height (PH) 4.52 mm and a thin gingiva. Cluster B presented
similar features CW/CL 0.79, GW 4.50 mm and PH 4.29 mm
with no statistical significant differences from Cluster A.
Cluster B showed clear thick gingiva. Cluster C differed from
the other Clusters in many parameters. Subjects showed a
more quadratic tooth form (CW/CL 0.88), a broad zone of
keratinized tissue (GW 5.42 mm) low papillae (PH 2.84 mm)
and thick gingival.

The results of the present study showed that the mean value of
crown length for thin biotype is 9.706 mm and for thick biotype
is 8.478 mm. The mean value of crown width for thin biotype
is 7.844 mm and for thick biotype is 7.87 mm. The mean PL for

Considering the growing attention paid to anterior esthetics


by both patients and clinicians, such findings can help enhance
the knowledge of the morphologic and anatomic form of the
gingiva, which can be utilized as a guide to achieve optimal

Another study by Lee,[9] suggested clinical guidelines for


discriminating the thin biotype, which might be susceptible to
gingival recession and found that the results of discriminant
function analysis showed that AP Sum 5 (area of facial papilla)
was the best single determinant of biotype and PL Sum 5 (PL) was
the second best choice in the study population next best choice.
The cut-off value of PL Sum 5 was calculated to be 23.73 mm.

Table 1: Comparative analysis of mean values of all the parameters in both study groups
Gingival biotype Crown length Crown width Papillary length Papillary width Area of papilla Area of crown Area of papilla/area
(mm)
(mm)
(mm)
(mm)
(mm)
(mm2)
(mm2)
of the crown
Thin
Thick
P value

9.706
8.478
0.002

7.844
7.87
0.923

5.13
4.44
0.016

4.921
4.662
0.326

25.1004
24.5000
0.006

76.327
66.541
0.013

0.3280
0.5382
0.398

Table 2: Correlations between variables using Pearsons correlation analysis


Parameters
(P)
Average crown length
Average crown width
Average papilla length
Average papilla width
Area of crown
Area of papilla
Area of papilla/crown
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Average crown Average crown Average papilla Average papilla Area of crown Area of papilla Area of papilla/
length (mm)
width (mm)
length (mm)
width (mm)
(mm2)
(mm2)
crown
1
0.011
0.689
0.051
0.786
0.540
0.054

0.011
1
0.080
0.573
0.620
0.303
0.036

0.689
0.080
1
0.100
0.480
0.735
0.019

0.051
0.573
0.100
1
0.384
0.583
0.106

0.786
0.620
0.480
0.384
1
0.598
0.067

0.540
0.303
0.735
0.593
0.598
1
0.94

0.054
0.36
0.019
0.106
0.167
0.094
1

Journal of Indian Society of Periodontology - Vol 18, Issue 1, Jan-Feb 2014

Malhotra, et al.: Correlating gingival biotype with dentopapillary complex

soft-tissue esthetics. A thorough understanding of the biotype


form of the gingival tissue is mandatory, for a clinician so as
to predict the tissue response to various pathologies as well
as before treatment planning, to optimize the final outcome of
the periodontal therapy.
Within the limits of the current investigation, the existence and
correlation of different gingival biotypes and dentopapillary
complex dimension has been confirmed. The results of
discriminant function analysis showed that average crown
length was the best single determinant of biotype and area of
papilla was the next best choice. The result of the present study
showed that there was highly significant correlation between
gingival biotype and crown length and area of papilla. These
findings can be utilized as objective guidelines for determining
the biotype and response of gingiva to many dental operative
procedures. But further long-term studies should be carried on
with large sample size to ascertain these findings.

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How to cite this article: Malhotra R, Grover V, Bhardwaj A,


Mohindra K. Analysis of the gingival biotype based on the
measurement of the dentopapillary complex. J Indian Soc
Periodontol 2014;18:43-7.
Source of Support: Nil, Conflict of Interest: None declared.

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