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The International Journal of Periodontics & Restorative Dentistry

155

The Dimensions of the iHuman


Dentogingivai Junction

Jomes S. Vacek, DOS' The dentogingivai junction has


Mariin E. Gher, DDS. MEd' been described as a functional
Daniel A. Assad. DDS'
unit composed oi the connec-
A. Charles Richardson, DDS'
tive tissue attachment of the
Leo i. Giambarresi, Pt¡D'
gingiva and the epifheliai
attachment.' Gargiuio et ai^
This study examined the naturally occurring dimensions of the denfoglngi- reported that the connective
vai ¡unction In 10 adult human cadaver jaws. The connective tissue tissue attachment varied in
attachment, epitheliai attachment, ioss of attachment, and sulcus depth iength from 0,0 to 6,84 mm with
were measured tiistomorphometricaliy for 171 tooth surfaces. iVIean mea- a mean of 1,07 mm; this mea-
surements were 1.34 ± 0.84 mm for sutcus depth: hl4 ±0.49 mm for epithe-
surement combined with the
liai attachment: 0.77 ± 0.32 mm for connective tissue atfachment; and
mean length ot the epitheiial
2 92 + 1 69 mm tor lass Of attachment. These dimensions, os measured in
attachment (0.97 mm) has
this study, support the concept that the connective tissue attachment is a
variabie widtf^ within a more narrow distribution and ronge than the
been called the physiologic
epitheiioi attachment, sulcus depth, or toss of attachment. The ievei ot the dentogingivai junction,^ or bio-
ioss ot attachment was not predictive ot the connecfive tissue attachment logic width.3" Aithough these
iength (IntJ Periodont Rest Dent 1994;14:155-ló5.) individuai measurements were
found fo vary greatly from
tooth to tooth, the combined
*Penodantics DeporTmenf. Navol Dental School, Nofionol mean dimension has been
Naval Dental Center, Bethesda. Mary [ond used as a guideiine for reestab-
iishing the ideai attachment
Correspondence fa: CAPT iviorlin E. Gner, DC, USN. 2014
Subida Terrace, Carlsbod. Calitornio 92009.
dimensions when performing
clinicoi crown iengthening
Reprinf requesfs to: Lbrorion, Naval Dental School, Nafionol surgery.^"" The need to con-
Noval Denfol Center, Befnesda. Maryland 20889-5077.
sider a variable supracrestal
Ttiis article is a work ot the US government and may be repiinteö with- attachment area to aliow for
out peimissioh The opinions or assertions contained tierein are the pri- the range of epitheiiai and
vate views of the authors ond ore not to be construed as official ar as
reflecting the views ot the Department of the r^Iavy or any ottier
connective tissue attachments
department or agency ot the US government has also been discussed.'^''^

Volume 14, Number 2, 1994


156

The importance of the bio- osseaus crest a bioiogic width process. The preserved cadov-
logic width in relation to gingi- was reestablished at 1 year, er tissues yieided sections with
vai health and as a guide for and that its dimension was 0,90 reodily identifiable structures
placing dentai restorations has mm, compared to 4,47 mm on when stained histaiogically.
been studied.'''-" Clinicaiiy, surgically operated control Measurements from these sec-
Newcomb''' found that the teeth without restorations. This tions were used to estimate the
greatest degree of gingivai finding suggests that the bio- study sample size.
inflammation was seen when logic width, if violated, may be in the principal study, each
subgingival crown margins reestabiished at a minimai of 10 jaws, from cadavers rang-
were placed near the base of a c c e p t a b i e dimension for ing in age from 54 to 78 years,
the gingivai crevice, while health. In humans the minimum were used fa prepare seven
Richter and Ueno'^ noted no dimension ot biologic width for biock segmenfs of two or three
ditferenoe in gingivai health the maintenance ot gingivai teeth each (Fig 1). These noh-
when crown margins were health has not been estab- decalcified segments were
placed subgingivally. From his- iished. sectioned first in a mesiodistai
tologie observations on dog The purpose of this study is direction along the long axis
and human autopsy moteriai, to provide additional informa- and contacts of the teeth (Fig
Waerhaug'* concluded that tion on the dimensions of the 2), The remaining faoiai and lin-
pocket deepening in response dentogingivai junction and gual portions were fhen sec-
to artificial crowns did not reiafed structures using nonde- tioned buccoiinguaily along
occur when the margin did not calcified human block sec- the iang axis of the feeth (Fig
come cioser than 0.4 mm to fions. 3), All secfioning was done wifh
the bottom of the pocket and an EXAKT i cutting/grinding
attached fibers were nof sev- device (Exakt) according to
ered. Than et ai'^ found, how- Method and materials the manufacturer's instructions.
ever, that when the bioiogic The cutting/grinding device is
width was vioiated by dental A piiot study wos conducted to capabie of making 10- to 30-
restorations there was a estabiish appropriate process- pm-thick serial sections of non-
greater mean ioss of connec- ing methods and sample size decalcified tissue approxi-
tive tissue attachment adja- for the study, Biock sections of mately every 0,75 mm. The
cent ta surfaces with a dental dentulous mandibles were resulting thin nondecaicified
restoration than adjacent to obtained from human cadav- secfions confained structures,
those without. ers preserved wifh phenoi- such as the enamel and dental
In a clinical investigation, formaldehyde, glycerin, and restorotions. for observation
Tarnow et al'^ concluded that aicohol; one denfulous man- and reference. Figures 4a to
subgingival crown margin dibie was aiso obfained from a 4d. a ciinicai series, demon-
placement combined with human fresh frozen cadaver, strate the sectioning of the
injury to the gingivai attach- Resuits of the piiot study indi- specimens in preparation for
ment resulted in rapid gingival c a t e d that tissues from fhe histoiogic measurements.
repair in the form of recession fresh frozen cadavers were nof The mesial (M), distal (D),
with limited gingivai inflamma- suitable for histologie exomino- facial (F), and lingual (L) sur-
tion, in a study in dogs. Tal et tion, because of the destruc- faces of every tooth were
al'^ faund that when amaigam tion of the epithelial layer each considered as individual
restorations were piaced at the resulting from the freezing surfaces for measurement of

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157

Fig 1 Schematic representation of a


human mandible Dashed lines repre-
sent the approximate initial sectioning
planes. A = typical twa- to three-tooth
segment.

• Nandecalcified segment A was first sectioned in a mesiodistal direction Fig 3 The tacial and lingual partions
g the lang axis and contacts of the teeth to produce black 8. Block B ' was then (A and C from Fig 2) were sectioned
logically prepored to visualize the mesial and distal surfaces ot the teeth far buccotingually alang the lang axis of
surements. C = lingual partían that remained after sectioning. the teeth (dashed lines). Portion A ' was
histalogically prepared to visualize the
buccal and lingual surfaces.

Volume 14, Number 2,1994


158

Fig 4a Nondecolcitied sections are prepared for histologie Fig 4b Mesial-to-distol block seotions were removed ond
anolysis: posterior mondibular blook segment is shown after used to prepare thin histologie seotiohs, Residuol buocol ond
initiol sectioning. lingual sections were then sectioned to permit meosure-
ments trom those surfaces.

fig dc Mesiol-to-distol seotions were then ground to o 10- Fig 4d Thin section stoined to enhonce identification of
to 30-ijm thickness in preparoticn for stoining. anatomic structures for meosurement.

The Internotionai Journol of Periodontics & Restorative Dentistry


159

Fig Sa (left) Stained thin sectian per-


mits exominotion ot dental restorations,
enamel, and hard tissues in relation to
soft tissues without distortion. Nofe the
presence of calculus, which bridges
the interproximal space immediately
coronal to the gingivai soft tissues.

Fig Sb (right) Photomicragrabh of


interproximai space demonstrates
fransepfal collagen fibers, epithelial
attachment, which extends to the level
of the transepfai fibers, ond bacterial
plaque ond debris on the enamel sur-
face of the teeth coronal ta the inter-
proximaisaft tissues Vacuoles noted
within the gingivai tissues ore process-
ing artifacts.

the dentogingival junction. a drawing tube. iVleosure- ment to the most coronal ex-
Each surface yielded two to ments of the foiiowing struc- tent of the periodontal liga-
four secfions for hisfomorpho- tures were recorded: ment (The coronoi extent of
metric measurement, depend- O) Suicus depth (SUL): the fhe periodonfai iigoment was
ing on the width of the tooth distónos from the crest of the defined os the levei at which
and its location within the arch. free gingiva to the most coro- the PDL was first found to be of
Sections were stained with nal extent of fhe epifheliai uniform thickness when com-
Masson's triohrome or hema- attachment pared with other areas of the
toxylin and eosin stain and (2) Epitheliai ottachment PDL on the tooth being exam-
measured histomorphometri- (EA): the distonce from the ined.)
caliy by the same examiner most coronal extent of fhe epi- (4) Loss of affachment
with a Zeiss Interactive Digital fheliai aftachment to the most (LOA): the distance from the
Analysis System (ZIDAS; Zeiss) coronai extent of fhe connec- cementoenomel junction (CEJ)
(Figs 5a and 5b). Each fissue five fissue attachment to the most coronol extent of
section was viewed and mea- (3) Connective tissue at- the connective tissue attach-
sured through o Zeiss light tachment (CTA): the distance ment
microscope (Zeiss) at x 40 mag- from the most coronai extent of Also recorded were the
nification, which was fitted with the connective tissue attach- subject's identification number.

Volume 14, Number 2, 1994


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age, sex, tooth number, tooth The mean, standard devia- {Tabie 2), When the dimensions
surtace (M = mesial; D = distai; tion, range, and frequency dis- of the EA and the correspond-
B - buccoi; L = iingual), the tribution of the measurements ing CTA for that surface were
type of restoration present, it of the EA, CTA, LOA, and SUL combined (bioiogic width) the
any, and the distance from the were determined. A one-way posterior teeth showed a sig-
apicai margin of the restoration analysis of varionce was used nificantiy greater (P < .004) bio-
to the coronai extent af the to compare measurements logic widfh than the anterior
connective tissue attachment. between surface locations (B, teeth. When moiars and pre-
Only teeth with subgingival L, M, D), orch position (anterior, moiars were analyzed sepa-
restoration margins and a posterior), and surfaces with or rateiy, the bioiogic width of the
microscopicaliy visibie CEJ without a subgingivai dentai moiars was significantiy greater
were inciuded in the measure- restoration. Scheffe's method (P < ,02) than that of the anteri-
ments for subgingival restoro- for muitipie comparisons was or teeth, whiie the bioiogic
tions. The mean dimensions ot used tor discrimination, width of the premoiars was not
the dentogingivai junction for i?egression analysis was used to significantiy different from that
each tooth surface were deter- correlate the CTA dimension to of the moiars or the anterior
mined on 171 surtaces. Mea- the corresponding LOA. teeth (Tabie 3).
surement error wos calculated Tooth surfaces wifh subgin-
by making 124 replicate mea- givai restorations were found to
surements on a total ot 31 ran- Results have a significantly longer EA
domly selected sites. A period (P < .04) than nonrestored
of ot ieast 24 hours eiapsed Medn dentogingivai dimen- teeth, but no significant differ-
between repiicate measure- sions for ail surfaces are shown ences were found for the CTA,
ments. The two measurements in Tabie 1. There were no signifi- SUL, or LOA (Tabie 4), When the
were compared to determine cant differences between the mean measurements for the
the precision of the measure- meosurements for fhe foofh combined dimensions of the
ment technique. surfaces (B, L, M, or D) for SUL, EA and OTA (bioiogic width) for
Every eftort was made fo LOA, EA, or CTA (Fig 6). teeth that had restorations
section the teeth parallel to the Regression analysis showed were compared to the bioiogic
long axis ot the tooth. How- there was no significant corre- width for teeth without restora-
ever, due to variations in root iation between the LOA and tions there was a significantiy
contours, sectioning aiong the the CTA, EA-i-CTA (biologic greater (P < .02) bioiogic width
iong axis resuited in tangential width), or SUL-^EA-hCTA. in restored teeth. There was no
cuts across some isolated areas, When tissue dimensions for significant difference in any of
such as furcation entrances, the anterior and posterior teeth fhese dimensions when com-
because of curvature of the were compared, both the CTA paring fypes of restoration.
root at fhe entrance into the and EA were significantiy Analysis of the precision of
furcation.2'^"^^ This precluded greater in fhe posterior sex- repiicate measurements dem-
accurate dimensional measure- tants. When moiars and premo- onstrated 95% confidence
ments in these areas. These few iars were analyzed separately, intervais of ± 0,08 mm for the
areas were excluded from the only fhe CTA was signiticantiy OTA, ± 0.12 mm for the ËA and
data set. greater in the posterior teeth LOA, and ± 0.14 mm for the sui-
cus depth.

The internotionol Journoi of Periodontics & Restorative Dentistry


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Table 1 Dentogingivai dimensions (mm) for the epithelial attactiment


(EA), connective tissue attachment (CTA). loss ot attachment (LOA), ond
sulcus depth (SUL) tar all surfaces

Measurement
(mean ± SD) Range

EA 1 Id ±0,49 0,32 - 3.27


CTA 0,77 ± 0,29 0.29-1.84
LOA 2,95 ± 1.70 0.60-8,73
SUL 1 32 - 0,BO 0,20 - 6,03

Fia 6 Graph disploys mean fissue dimensions for the epitheliol ottachment (EA).
connective tissue attochment (CTA). loss of ottachment (LOA), and sulcus depth
(SUL). for distal (0). mesiol (MX llnguaift),and buccal (B) surfaces.

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162

Table 2 Tissue d i m e n s i o n (mm) for the epittielial a t t a c t i m e n t (EA), c o n -


nective tissue a t t a c h m e n t (CTA). loss of ottachiment (LOA), a n d sulous
d e p t t i (SUL) for teeth g r o u p e d by arcti position

Meo sûrement
(meon ± SD) Range

EA
Anterior 1.03 + 0 45 0.38-2.4B
Premolar 1.20 ± 0.53 0.32 - 3.27
Moiar 1.22 ± 0.46 0.44 - 2 30
CTA
Anterior 0.71 ±0.24" 0.35 - 1.34
Premolar 0.77 ±0.31 0.29 - 1.84
Mclor 0.89 ±0.31" 0.40-1.77
LOA
Anterior 3.33 ± 1.99 0.76-8.73
Pfemolor 2.73 ± 1.37 0.S7-6.58
Molor 2.76 ± 1.65 0 60-6.50
SUL
Anterior 1.19 ±0.89 G.d3 - 6.03
Premolar 1.30±0.6S 0 26-3.24
Moiar 1.54 + 0.60 0.56-4.04

Table 3 Biologic width (epithelial o t t a o h m e n t plus c o n n e c t i v e tissue


a t t a c h m e n t ) ( m m ) tor teeth g r o u p e d b y a r c h position

Arch Meo sûrement


positron Cm eon ± SD) Range

Anterior 1.75 t 0 56' 0.75-3.29


Premolar 1.97-0 67 0.78-4.33
Molar 2.08 ± 0.55- 0.84 - 3.29

'P<.02.

The International Journal of Periodontics & iiestorative Dentistry


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Tabie 4 Tissue dimensions (mm) for surfaces witti subgingival restora- study. As tound in fhis study, the
tions (restored) and without subgingival restorations (nonrestored) for ttie connective tissue attachment
epittieiial attoctin-ient (EA), connective tissue attachment (CTA), loss ot
attachment (LOA), and suicus deptti (SUL) (CTA) voried in width, but with
a more narrow range ond vari-
Measurement
ance than that for the EA, SUL,
(mean ± SD) Ronge
or LOA. The hisforioal concept
of allowing 1 mm for the CTA
EA would adequotely include the
Restored 1.32 ±0.47' 0.69 - 2.29 CTA dimensions reported here.
Nonrestored 1.11 ±0.49* 0.32-3.27 When the measurements
CTA
for surfaces with subgingival
Restored 0.84 ±0.20 0.42 - 1.47
restorations were compored to
Nonrestored 0.76 ±0.29 0.29-1.84
the dimensions for surfooes
LOA
without restorations, there was
Restored 2 60 ± 1.53 0.60-8.73
a significantly longer EA tor the
Nonrestored 3.01 ±1.73 0 74-8.73
restored teeth thon for the non-
SUL
restored teeth. No signiticont
Restored 1.ÓO + 0 80 0 64 - 4.04
Nan restored 1.27 Í 0 79 0 26 - 6 03
ditterenoe was tound tor the
other dimensions. These results
•P< .04.
Restored (n = 37); norirestored (n = 1<14).
are not in agreement with stud-
ies by Than et oi^' or
KeszthelyF'' that have shown a
greoter loss of attachment
odjocent to restored surfoces:
Discussion ies that use decalcitied and his- however, both ot these studies
toiogicolly prepared tissue. used extrocted teeth without
Nondecalcified secfions were Because human cadaver ottached odjacent structures.
used in this study to minimize material was used in this study, In this sample population
the error introduced by the the duration ot inflommafion no correlation was found be-
dimensionol changes inherent present ot the time of tissue tween the LOA and the corre-
in decoiciticotion ond tissue preparotion couid not be sponding length of fhe CTA or
preparation. The preservation determined, and previous peri- biologic width. This finding sug-
of fissue with stondard histo- odontoi therapy on the sampie gests that ciinicol determina-
iogic methods has been shown population was not known. tion of the LOA wouid not be
to cause a measurabie change Within this somple popuiation usetui in predicting the length
(15% total shrinkage) in the there was a wide ronge ot ioss of the CTA (or concomitant
dimension of the soft tissue; of attochment. The sampie biologic width). Therefore the
therefore, the dimensions of fhe population in the present study clinician couid not use the
suicus would need fo be adjust- may represent a group of attachment levei as a guide-
ed for fhis factor.^'i jhg cieooici- patients that had a iow suscep- line to determine the necessory
fication ot the hard tissue also tibility to the development ot requirements for the reestab-
causes a dimensional change periodontoi diseose,^* beoouse iishment ot the EA ond CTA.
in the tissue.^^ These tactors oniy subjects with few missing The meon dimension of the
must be considered in aii stud- feefh were inciuded in the OTA plus EA (biologic width)

Volume 14, Number 2,1994


164

was 0,33 mm greater on molar iogic width, as currentiy per- Aoknowledgments


teeth thon onterior teeth, ceived, is violated in 8ó% of dis-
Aithough clinicaiiy smoli, this tobuccai root resected maxil- The authors would like to thank ttie
Uniformed Services University of fhe
result suggests that on molar iory first molars.^^ Further
Health Services for its help in providing
teeth a greater iength of bio- research is required to clearly the specimens and Eskinder Dag-
logic width may have to be establish the minimum dimen- nachew for his valuable ossistonce in
allowed when attempting to sions of the dentogingival junc- the preparation ond sectioning of fhe
teeth. We also thank the paftiology
reestabiish naturaily occurring tion compatibie with heolth in deparfment at the Navol Dental
dimensions of the dentogingi- humans. School, National Naval Dental Cerifer,
va[ junction. The range of bio- Bethesda, Maryland for their assistance
logic widfh fhaf was observed and valuable comments This proiect
wos funded by Naval Medical
wos 0,75 mm fo 4.33 mm. The Conclusion Researcn and Development Center.
ideal dimensions to use in a Work Unit # 63706N M0095-06-3014
particular clinical situation can- Within the limitations of this
not be determined by examin- study and the use of individuai
ing the results of this study. teeth as the experimental units
The concept of a bioiogic the foiiowing conclusions ore
width, as currently accepted presenfed:
(0.97 mm for the EA, and 1.07 (1) When comporing fhe
mm for fhe CTA), requires a dentogingival tissue dimensions
minimum of 2,04 mm of sound befween tooth surfaces (B, L,
footh structure above the M, D), fhere were no significant
osseous crest.^"^''° in the pre- differences for any ot the tissue
sent study, 15% of fhe restora- dimensions.
tions vioiated these dimensions, (2) No correlation was
in these sompies the combined found between the LOA and
measurement of fhe EA and the corresponding length of
the CTA wos less than 2.04 mm, the CTA or bioiogic widfh
and the restoration margin was (CTA+EA).
i ess than 2 mm from fhe (3) While significant varia-
osseous crest. These findings tion was noted in the length of
suggest that o minimum dimen- the CTA, it was the least vari-
sion for fhe reestablishment of able ot the tissue dimensions
the biologic width may be less evaluated.
than previously reported.^•^•'•'° (4) The epithelial attooh-
This couid be important when ment wos signiticantly greater
restoring teeth thot hove un- on tooth surfoces odjocenf to
dergone root resective proce- subgingival restorations.
dures that create tooth onato- (5) Both the CTA and EA
my which does not allow for were significantly greater in the
the estoblishment of accept- posterior sextants.
obie dimensions of bioiogic
width. For exampie, a recent
article concluded that the bio-

The Internatianal Journal af Periodontics & Restorative Dentistry


165

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Voiume 14, Number 2. 1994