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A simple method for measuring thickness of gingiva and labial bone of

mandibular incisors

Article  in  Quintessence international (Berlin, Germany: 1985) · October 2014

DOI: 10.3290/j.qi.a32919 · Source: PubMed

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A simple method for measuring thickness of gingiva
and labial bone of mandibular incisors
Juan Rossell, DDS, MS 1/Andreu Puigdollers, MD, DDS, MS, PhD2/Montserrat Girabent-Farrés, MS, PhD3
Objective: Thin supporting tissues may cause gingival reces-
sions and esthetic problems in the anterior area. The objectives
of this study were to present a simple and reliable radiographic
technique to measure thickness of alveolar bone labial to man-
dibular incisors, and to establish a possible correlation of bone
thickness with its tissue biotype. Method and Materials: A
metal strip was placed over the gingiva of the mandibular inci-
sor axis, and a perpendicular occlusal radiograph was taken of
51 patients. Patients in routine orthodontic practice before any
orthodontic treatment was started were distributed into three
groups according to their periodontal biotype (A1, thin with
< 2 mm keratinized gingiva; A2, thin with > 2 mm; and B, thick
with wide zone of keratinized gingiva), as described by Müller
and Eger.1 Radiographs were scanned and thickness of gingival
tissue and of bone at two levels (at the bone crest and at 3 mm
below the bone crest) was measured to the nearest 0.1 mm.
Measurements of soft tissue and bone thickness were com-
pared and correlated. Results: Groups A2 and B showed a
Key words: diagnosis, gingival recession, gingival thickness, oral hygiene
Thickness of tissues is important for the clinician as it
plays a key role when placing implants, in conventional
periodontal therapy, in restorative and esthetic den-
1 Assistant Professor, Department of Orthodontics and Dentofacial Orthopedics,
Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.
2
Associate Professor and Department Chair, Department of Orthodontics, School
of Dentistry, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Bar-
celona, Spain.
3 Lecturer in Statistics, Department of Physical Therapy (Statistics Unit), Universi-
tat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain.
Correspondence: Dr Andreu Puigdollers, Departament d´Ortodòncia i
Ortopedia Dentofacial, Universitat Internacional de Catalunya, c/ Josep Tru-
eta s/n (Hospital General de Catalunya), 08195 Sant Cugat del Vallès, Spain.
VOLUME 46 • NUMBER 3 • MARCH 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
GENERAL DENTISTRY
Juan Rossell
significant difference in bone thickness at the bone crest.
Correlation of bone and gingival thickness was only found in
gingival biotype B at 3 mm below the bone crest level only
(R = 0.290; P < .001). No other correlation between bone and
gingival thickness was observed in any group. Conclusions:
The radiographic technique proposed in this study is a simple
and reliable method for calibrating the amount of buccal bone
in the mandibular anterior area. It is a cheap and fast diagnos-
tic tool that may help determine the amount of buccal bone
and gingival thickness, and therefore avoid excessive radiation
to patients. Groups A2 and B showed a significant difference in
bone thickness at the bone crest. Although not significant,
group A1 showed the lowest values of bone and gingival thick-
ness, whereas group B showed the highest bone and gingival
thickness. A clear correlation between thickness of bone and
gingiva 3 mm below the cementoenamel junction was found
in group B. (Quintessence Int 2015;46:265–271; doi: 10.3290/j.
qi.a32919)
tistry, and also in orthodontic movements as it may
harm the capacity of the periosteum to induce bone
apposition,2 causing fenestrations, dehiscences, and
predisposing the appearance of gingival recession. This
may be particularly true for labial movements and cor-
recting rotations in thin tissues.3,4 According to recent
studies,3-17 optimal oral hygiene and adequate thick-
ness of the gingiva are supposed to represent indica-
tors for reducing the risk of bone loss and gingival
recession. The presence of a thin alveolar bone has
been underlined as a possible cause of gingival reces-
265
Q U I N T E S S E N C E I N T E R N AT I O N A L
Rossell et al
Fig 1 Mandibular incisors and their gingival complex.
sion,18 but it is sometimes difficult to decide which
patients have this type of bone.
Little attention has been given to thickness of the
underlying bone in establishing diagnostic criteria for
development of gingival recession. It seems plausible
that bone thinness could be an important variable for
predicting recession. The amount of buccal bone seems
to be influenced directly by different genetic factors.18,19
Tissue biotypes have been described and linked to the
outcomes of orthodontic treatment,18,20 but there exist
no clear-cut definitions for different periodontal bio-
types. Visual inspection and palpation seems to reveal
a correlation between gingival thickness and bone
thickness. A good correlation between thickness of
gingival tissue and thickness of bone21,22 has been
described for maxillary incisors, but no correlation
between bone and gingiva has been found in the man-
dibular incisor area.
This study aimed to present a simple and reliable
method for measuring thicknesses of bone and gingiva
labial to mandibular incisors, and to find a possible cor-
relation between the gingival biotype and its underly-
ing bone morphology.
METHOD AND MATERIALS
Subjects
A total of 51 patients (37 women [mean age 28 ± 5.5]
and 14 men [mean age 32.7 ± 9.3]) from a private prac-
266
Fig 2 Radiographic paralleling technique with lip expander in
place, and metal strip placed over the gingiva along the long axis
of the most protruded mandibular incisor.
tice (JR) were included in this investigation before any
orthodontic treatment was started. The study was con-
ducted during a 2-month period from April 2014 to
May 2014. Patients selected for this study met the fol-
lowing requirements:
• aged 18 years or older
• presence of all mandibular incisors
• good periodontal health without bone loss or gingi-
val inflammation
• no dental compensations of skeletal malocclusion
• crowding of less than 4 mm
• no history of dental or traumatic lesions in man-
dibular incisors.
The age difference between the men and women was
not statistically significant (P = .315). This study was car-
ried out after approval by the Ethics and Research Com-
mittee at Universitat Internacional de Catalunya in
March 2014.
Patient records
The examination of the patients included one color
photograph of the mandibular incisors and their gingi-
val complex (Fig 1) and a tangential radiograph
exposed on an occlusal film. The radiograph was taken
of each patient perpendicular to the axis of the crown
of the central mandibular incisors, using the paralleling
technique with a periapical film holding system (Fig 2),
with a metal strip (5.0 × 1.0 × 0.1 mm) placed labial to
VOLUME 46 • NUMBER 3 • MARCH 2015

Fig 3 Determination of gingival thickness category using a
periodontal probe (see text for details).
the keratinized gingiva. A lip expander was used to
keep the lip from touching the metal strip. Air was
blown over the attached gingiva before placing the
metal strip, as the saliva might displace it before taking
the exposure. The metal strip was placed along the long
axis of the most protruded mandibular incisor crown.
Classification
All patients were evaluated and categorized into one of
three possible categories according to the classification
of Müller and Eger:1,20,23 A1 (9 patients, 17.6%), A2 (23
patients, 45.1%), and B (19 patients, 37.3%). The
patients were assigned to each category by two exam-
iners, according to the visual and clinical aspect of the
keratinized gingiva in the mandibular incisors (Fig 3).
Groups A1 and A2 both had thin keratinized gingiva
and differed in width (group A1 comprised val-
ues ≤ 2 mm, and group A2 had width values > 2 mm of
keratinized gingiva). Group B comprised thick and wide
keratinized gingiva. Width of gingiva was measured
with a periodontal probe. Thickness of gingiva was
assessed by two methods, visual aspect (VA) and probe
transparency (PT),24 where the examiner determined
whether the periodontal probe was visible through the
marginal soft tissue (Fig 3).
Radiographs were scanned at a 1:1 scale. Scanned
images were saved in JPEG format. Millimetric measure-
ments were made using Adobe Photoshop software to
0.1 mm precision.
VOLUME 46 • NUMBER 3 • MARCH 2015
Q U I N T E S S E N C E I N T E R N AT I O N A L
Rossell et al
A B
C
3 mm
D
E
a b
Figs 4a and 4b Image obtained with the occlusal radiograph
(a), and drawing representing the five measurements for gingival
and bone thickness at and 3 mm below the bone crest (b). Dis-
tance A (CEJ–BC) represents the distance from the cemento-
enamel junction to the bone crest. Thickness measurement for
gingiva (GT–BC) and bone (BT–BC) at the crest level are repre-
sented as C and B, respectively. Measurements taken 3 mm below
the bone crest are represented as D (BT) and E (GT), respectively.
Radiographic measurements
Five measurements were taken on each radiograph
(Fig 4):
• gingival thickness at bone crest (GT–BC), distance C
• gingival thickness 3 mm below bone crest (GT), dis-
tance E
• bone thickness at the bone crest (BT–BC), distance B
• bone thickness 3 mm below bone crest (BT), dis-
tance D
• distance from the cementoenamel junction to the
bone crest (CEJ–BC), distance A.
The metal strip was used to register the distance
between the most prominent band of gingiva and its
underlying bone, therefore the gingival thickness was
measured from the internal side of the metal strip to the
alveolar bone. The distance from the CEJ (CEJ–BC) was
taken into account in order to ascertain the existence of
significant alveolar bone loss. A single examiner mea-
sured all radiographs, and the same process was
repeated at least 3 weeks after the first measurement was
taken. Reliability was determined using Cohen κ statistics.
267
Q U I N T E S S E N C E I N T E R N AT I O N A L
Rossell et al
A master file was created and the data were statisti-
cally analyzed using a statistical software package.
Intraexaminer reliability was determined using intraclass
correlation coefficient (ICC) with a positive confidence
interval at 95% (CI 95%). McNemar test25 was used to
compare a valid method for group classification
between visual and probe transparency methods.
Finally, the correlation between bone thickness and gin-
gival thickness at bone crest level and 3 mm from the
CEJ, and the distance from CEJ and the bone crest, were
evaluated using a Spearman correlation test. Measure-
ment differences of thickness between three possible
groups were compared with Kruskall-Wallis H test.26 The
data were subjected to CI 95% for the mean of all vari-
ables. The strength of correlation was determined by a P
value < .05, which was considered statistically significant.
RESULTS
Intra-examiner reliability
The intra-examiner reliability for the radiographic mea-
surements was determined using intraclass correlation
coefficient (ICC), and had a κ value of 0.9. These results
demonstrated good intra-examiner reliability for all
measurements. The CI was positive at 95%.
Gender differences
As shown in Table 1, there were no statistically signifi-
cant differences in thickness of bone or gingiva
between men and women at the measured locations at
the bone crest and 3 mm below the bone crest.
Thickness of gingiva and alveolar bone
radiographic measurements
Table 2 shows the mean measurements in gingival and
bone thickness at, and at 3 mm below, the bone crest in
all 51 patients.
Measurement association within each
gingival biotype
Gingival biotype categories and their respective radio-
graphic mean values are shown in Table 3. At the bone
crest, bone thickness (mean ± standard deviation [SD])
268
in group B (0.8 ± 0.4 mm) and group A2 (0.7 ± 0.2 mm)
were statistically significantly correlated. Group A1
(0.4 ± 0.1 mm) had the least bone thickness. All other
measurements of bone and gingival thickness showed
similar values between the different biotypes, and no
further statistically significant differences between
groups were found (P > .05).
Correlation between gingival biotype and
bone thickness
The measurement values that were examined statisti-
cally in order to evaluate a possible correlation
between thickness of gingiva and of bone within each
biotype group produced the following results: At the
bone crest level, no correlation to varying periodontal
biotype was found (Table 4). P values were: group B,
.245; group A1, .355, and group A2, .265. At 3 mm
below the bone crest, a moderate correlation in gingi-
val and bone thickness was found in group B (P = .626),
with a significance level at 99%. No correlation of gingi-
val and bone thickness was observed at this level in
group A1 (-.027) and group A2 (-.342) (Table 4).
DISCUSSION
The present study provides evidence that this radio-
graphic technique is valid for measuring thickness in
the mandibular incisors area. The proposed radio-
graphic technique (Fig 2) is experience sensitive; there-
fore, mistakes during the procedure might alter the
final image. It is very important to pay attention to
every step of the process so the metal strip is in the cor-
rect position and the projection is purely perpendicular,
otherwise a good image of the thickness of the buccal
alveolar bone cannot be obtained. Ultrasonic devices,20
probe transparency,24 and cone-beam computed
tomography (CBCT)21,22,30 have been described in differ-
ent studies as adequate methods for measuring thick-
ness and width of bone and/or keratinized gingiva, but
most of these studies have been performed on maxil-
lary incisors. The previously used ultrasonic devices
have been withdrawn from the market and are no lon-
ger available, and probe transparency can provide only
VOLUME 46 • NUMBER 3 • MARCH 2015
 Q U I N T E S S E N C E I N T E R N AT I O N A L
Rossell et al

Table 1 Measurements (mm) of gingival and bone thickness at and 3 mm below the bone
crest in 51 male and female patients

Male (mean ± SD) Female (mean ± SD) P value (U Mann-Whitney)

GT–BC 0.5 ± 0.2 0.5 ± 0.2 .512
GT 0.9 ± 0.4 0.7 ± 0.4 .318
BT–BC 0.8 ± 0.4 0.7 ± 0.2 .669
BT 0.7 ± 0.3 0.6 ± 0.2 .815
CEJ–BC 2.2 ± 0.7 2.0 ± 0.6 .329

Table 2 Mean measurements (mm) for gingival and bone thickness at and 3 mm below the
bone crest in 51 patients

Mean ± SD Min–max
GT–BC 0.52 ± 0.19 0.2–1.2
GT 0.77 ± 0.38 0.3–1.7
BT–BC 0.71 ± 0.29 0.3–2.0
BT 0.66 ± 0.27 0.3–1.5
CEJ–BC 2.04 ± 0.65 1.0–3.5

Table 3 Measurements (mm) for gingival and bone thickness at and 3 mm below the bone
crest in different periodontal biotypes

A1 (mean ± SD) A2 (mean ± SD) B (mean ± SD) P value (H de Kruskall-Wallis)

GT–GC 0.5 ± 0.1 0.5 ± 0.2 0.5 ± 0.2 .432
GT 0.6 ± 0.2 0.8 ± 0.4 0.8 ± 0.4 .336
BT–BC 0.4 ± 0.1 0.7 ± 0.2 0.8 ± 0.4 .000*
BT 0.5 ± 0.3 0.7 ± 0.2 0.7 ± 0.3 .069
CEJ–BC 1.9 ± 0.5 2.0 ± 0.7 2.1 ± 0.7 .817
*P < .001

Table 4 Correlation of measurements (mm) for gingival and bone thickness at and 3 mm
below the bone crest in different periodontal biotypes

Groups
GT–BC (mean ± SD) BT–BC (mean ± SD) Spearman correlation coefficient
A1 0.5 ± 0.1 0.4 ± 0.1 .355
A2 0.5 ± 0.2 0.7 ± 0.2 .265
B 0.5 ± 0.2 0.8 ± 0.4 .245
GT BT
A1 0.6 ± 0.2 0.5 ± 0.3 -.027
A2 0.8 ± 0.4 0.7 ± 0.2 -.342
B 0.8 ± 0.4 0.7 ± 0.3 .626*
*P < .001

VOLUME 46 • NUMBER 3 • MARCH 2015 269

Q U I N T E S S E N C E I N T E R N AT I O N A L
Rossell et al
visual information. Although CBCT may be a more reli-
able and accurate technique than the radiographic
technique used in the present study, it is more expen-
sive, exposes patients to a higher dose of radiation, and
is not readily available. These are the main reasons that
led to the design of the present study, as this technique
may be used in the dental office every day, as required.
The image obtained provides a clear indication of the
height of the alveolar bone, and the presence of a thick
or thin bone buccal plate. This in turn indicates whether
extensive orthodontic movement can be performed or
if thick tissue is present when considering tissue trans-
parency for prosthesis design.
Other aims of the present study were to determine
thickness of the alveolar bone labial to the mandibular
incisors, and possibly to find a correlation between this
thickness and the thickness of the overlying gingiva at
two different locations. The results show that no accu-
rate predictions of bone thickness of the entire buccal
plate can be made when the gingiva of the mandibular
incisors area are visually inspected. A wide band of
keratinized gingiva was correlated with thick alveolar
bone at the crest level. Although bone thickness could
be related to the visual aspect, no correlation was
found between gingival thickness 3 mm below the
bone crest level and thin periodontal biotype.
The measurements of bone thickness labial to the
mandibular central incisors ranged from 0.3 mm to
2 mm. The gingival thickness measurements at the
same locations ranged from 0.2 mm to 1.7 mm. These
values are in agreement with observations by Müller
and coworkers.23,27 As expected, the highest values for
bone thickness were found in patients with a thick bio-
type (group B) and a thin biotype with > 2 mm of kera-
tinized gingiva (group A2).
Orthodontic labial movement of already proclined
mandibular incisors in patients with thin biotype and
< 2 mm of keratinized gingiva (group A1) should be
considered with caution. Such movements may cause
further thinning of the crestal bone, or even dehis-
cences, and there is a risk of further thinning of the labial
gingiva with resultant gingival recession.4 This should
be considered in orthodontic treatment planning when
270
deciding the final position of the mandibular incisors,
and periodontal grafting should be taken into account.
Melsen and Allais28 demonstrated that the risk for
development of gingival recessions in the anterior
region could be reduced if light forces are applied and
the patient’s oral hygiene is controlled. On the other
hand, Wennström et al3 and Maynard18 stated that the
thickness of the periodontium has a more significant
influence on mucogingival problems. Seibert and
Lindhe29 described thick, flat periodontal biotypes,
which supposedly would better withstand pressure
forces on the periodontium. Marginal thicknesses equal
to or over 2 mm are classified as thick biotypes. The
prevalent view is that normal gingiva with a thick band
of keratinized tissue better resist attrition and disease.
Some weaknesses of the present study, from a tech-
nical point of view, are that the measurements were
performed in areas which for anatomical reasons were
limited, and there was difficulty in differentiating
between patients belonging to group A2 and B when
using palpation and visual inspection. Similar problems
were experienced by Eghbali et al.31 Color photographs
of all patients’ incisors were taken to facilitate the clas-
sification according to the established categories. In the
future, a more in-depth analysis may be required for
studies of the interrelationship between thickness of
the labial bone plate and gingival thickness in different
biotypes, and their correlation to the risk for develop-
ment of gingival recessions associated with orthodon-
tic treatment. This could result in more predictable
treatment outcomes. Since visual inspection and palpa-
tion are not valid methods for identification of peri-
odontal biotypes, more elaborate methods including
CBCT may be required.
Finding new key variables that can lead to the
appearance of gingival recession should help prevent
this condition. Dental clinicians must be aware of the soft
tissue morphology and its underlying bony anatomy.
CONCLUSIONS
The radiographic technique proposed in this study is a
simple and reliable method for calibrating the amount
VOLUME 46 • NUMBER 3 • MARCH 2015

of buccal bone in the mandibular anterior area. It is a
cheap and fast diagnostic tool that may help to deter-
mine the amount of buccal bone and gingiva thickness,
and avoids excessive radiation to patients. Groups A2
and B showed a significant difference in bone thickness
at bone crest. Although it was not significant, group A1
showed the lowest values of bone and of gingival thick-
ness, whereas Group B showed the highest bone and
gingival thickness. A clear correlation between thick-
ness of bone and gingiva 3 mm below the CEJ was
found in group B.
ACKNOWLEDGMENT
The authors are grateful to Dr Bjorn U. Zachrisson for linguistic assis-
tance and advice.
REFERENCES
1. Müller HP, Eger T. Masticatory mucosa and periodontal phenotype: a review.
Int J Periodontics Restorative Dent 2002;22:172–183.
2. Aubin J. Mesenchymal stem cells and osteoblast differentiation. In: Bilezkian
JP, Raisz LG, Martin TJ (eds). Principles of Bone Biology. Vol 1. San Diego:
Academic Press, 2008:85–107.
3. Wennström JL, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reac-
tions to orthodontic tooth movement in monkeys. J Clin Perio 1987;14:
121–129.
4. Yared KFG, Zenobio EG, Pacheco W. Periodontal status of mandibular central
incisors after orthodontic proclination in adults. Am J Orthod Dentofacial
Orthop 2006;130:6.e1–e8.
5. Allais D, Melsen B. Does labial movement of lower incisors influence the level
of the gingival margin? A case-control study of adult orthodontic patients. Eur
J Orthod 2003;25:343–352.
6. Alpiste-Illueca A. Dimensions of the dentogingival unit in maxillary anterior
teeth: a new exploration technique (parallel profile radiograph). Int J Peri-
odontics Restorative Dent 2004;24:386–396.
7. Artun J, Grobéty D. Periodontal status of mandibular incisors after pro-
nounced orthodontic advancement during adolescence: A follow-up evalua-
tion. Am J Orthod Dentofac Orthop 2001;119:2–10.
8. Coatoam GW, Beherents Rg, Bissada NF. The width of keratinized gingiva
during orthodontic treatment: its significance and impact on periodontal
status. J Periodontol 1981;52:307–313.
9. Diedrich P. Probleme und riskien bei der bewegung von unterkieferfrontzäh-
nen. Fortsch Kieferorthop 1995;56:148–156.
10. Djeu G, Hayes C, Zawaideh S. Correlation between mandibular central incisor
proclination and gingival recession during fixed appliance therapy. Angle
Orthod 2002;72:238–245.
11. Dorfman H. Mucogingival changes resulting from mandibular incisor tooth
movement. Am J Orthod 1978;74:286–297.
VOLUME 46 • NUMBER 3 • MARCH 2015
View publication stats
Q U I N T E S S E N C E I N T E R N AT I O N A L
Rossell et al
12. Holmes H, Tennant M, Goonewardene M. Augmentation of faciolingual gin-
gival dimensions with free connective tissue grafts before labial orthodontic
tooth movement: An experimental study with a canine model. Am J Orthod
Dentofac Orthop 2005;127:562–572.
13. Janson G, Bombonatti R, Brandâo AG, Henriques JF, Freitas MR. Comparative
radiographic evaluation of the alveolar bone crest after orthodontic treat-
ment. Am J Orthod Dentofac Orthop 2003;124:157–164.
14. Klohen J, Pfeifer J. The effect of orthodontic treatment on the periodontum.
Angle Orthod 1974;44:127–134.
15. Steiner G, Pearson J, Ainamo J. Changes of the marginal periodontium as a
result of labial tooth movement in monkeys. J Periodontol 1981;52:314–320.
16. Wainwright WM. Faciolingual tooth movement: its influence on the root and
cortical plate. Am J Orthod 1973;64:278–302.
17. Wehrbein H, Bauer W, Diedrich P. Mandibular incisors, alveolar bone, and
symphysis after orthodontic treatment. A retrospective study. Am J Orthod
Dentofac Orthop 1996;110:239–246.
18. Maynard JG. Mucogingival considerations for the adolescent patient. In:
Nevins M, Mellonig JT (eds). Periodontal Therapy. Clinical approaches and
evidence of success. Volume 1. Illinois: Quintessence Publising, 1988:
291–303.
19. Björk A, Skieller V. Normal and abnormal growth of the mandible: a synthesis
of longitudinal cephalometric implant studies over a period of 25 years. Eur J
Orthod 1983;5:1–46.
20. Eger T, Müller H-P, Heinecke A. Ultrasonic determination of gingival thickness.
Subject variation and influence of tooth type and clinical features. J Clin Peri-
odontol 1996;23:839–845.
21. Fu J-H, Yeh C-Y, Chan H-L, Tatarakis T, Leong D, Wang H-L. Tissue biotype and
its relation to the underlying bone morphology. J Periodontol 2010;81:
569–574.
22. Cook R, Mealey B, Verrett R, et al. Relationship between clinical periodontal
biotype and labial plate thickness: An in vivo study. Int J Periodontics Restora-
tive Dent 2011;31:345–354.
23. Müller HP, Heinecke A, Schaller N, Eger T. Masticatory mucosa in subjects with
different periodontal phenotypes. J Clin Periodontol 2000;27:621–626.
24. 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;36:428–433.
25. Quinn M. Note on the sampling error of the difference between correlated
proportions or percentages. Psychometrika 1947;12:153–157.
26. Kruskal W, Wallis W. Use of ranks in one-criterion variance analysis. J Am Stat
Assoc 1952;47:583–621.
27. Müller HP, Eger T. Gingival phenotypes in young male adults. J Clin Periodon-
tol 1997;24:65–71.
28. Melsen B, Allais D. Factors of importance for the development of dehiscences
during labial movement of mandibular incisors: A retrospective study of adult
orthodontic patients. Am J Orthod Dentofac Orthop 2005;127:552–561.
29. Seibert JL, Lindhe J. Esthetics and periodontal therapy. In: Lindhe J (ed). Text-
book of Clinical Periodontology, 2nd ed. Copenhagen: Munksgaard,
1989:477–514.
30. Barriviera M, Duarte W, Januário A, Faber J, Bezerra AC. A new method to
assess and measure palatal masticatory mucosa by cone-beam computerized
tomography. J Clin Periodontol 2009;36:564–568.
31. Eghbali A, De Rouck T, De Bruyn H, Jan C. The gingival biotype assessed by
experienced and inexperienced clinicians. J Clin Periodontol 2009;36:
958–963.
271