J Clin Periodontol 2013; 40: 1132–1139 doi: 10.1111/jcpe.

12169

The gingival biotype: € ping1,

Jamal M. Stein1,2, Nils Lintel-Ho
Christian Hammächer2, Adrian
Kasaj3, Miriam Tamm4 and

measurement of soft and hard Oliver Hanisch5

1
Department of Operative Dentistry,
Periodontology and Preventive Dentistry,

tissue dimensions - a University Hospital (RWTH), Aachen,

Germany; 2Private Practice, Aachen,
Germany; 3Department of Operative Dentistry

radiographic morphometric study and Periodontology, University Medical

Center, Mainz, Germany; 4Department of
Medical Statistics, University Hospital
(RWTH), Aachen, Germany; 5Private
Practice, Paris, France
Stein JM, Lintel-Höping N, Hammächer C, Kasaj A, Tamm M, Hanisch O. The
gingival biotype: measurement of soft and hard tissue dimensions - a radiographic
morphometric study. J Clin Periodontol 2013; 40: 1132–1139. doi: 10.1111/
jcpe.12169.

Abstract
Background: Gingival biotypes have been reported to influence the outcome of
restorative therapies. The aim of this study was to evaluate the correlation of
different morphometric parameters with the thickness of the buccal gingiva and
alveolar bone at different apico-coronal levels.
Methods: In 60 periodontally healthy subjects, the central maxillary incisor was
examined. Clinical parameters included the crown width/crown length ratio (CW/
CL), gingival width (GW), gingival scallop (SC) and transparency of the peri-
odontal probe through the gingival sulcus (TRAN). Gingival and alveolar bone
dimensions were assessed on parallel profile radiographs.
Results: Crown width/crown length ratio was positively correlated with the thick-
ness of the gingiva at the cementoenamel junction (G3) (r = 0.47) and to the thick-
ness of the alveolar crest (A1) (r = 0.46); whereas SC had a weak negative and GW
had a moderate positive correlation with all radiographic measurements. TRAN
had a stronger negative relation to the thickness at the free gingiva (r = 0.42) than
to other tissue thicknesses. All gingival thickness values were correlated with A1
value. Multivariate models identified CW/CL and GW as significant predictors for
G3 value, whereas CW/CL was a significant predictor for A1 value.
Conclusion: Crown width/crown length ratio and GW could represent surrogate Key words: alveolar bone; crown form;
parameters to anticipate the gingival thickness at the cementoenamel junction, gingival biotype; gingival thickness
whereas CW/CL might also be an indicator for alveolar bone crest thickness.
Periodontal probing has a limited prognostic value for these tissue dimensions. Accepted for publication 8 September 2013

Different tissue biotypes have been
suggested to influence the outcome of
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interests.
No external funding, apart from the
support of the author’s institution,
was available for this study.
1132
restorative treatments (Pontoriero &
Carnevale 2001, Evans & Chen 2008).
Thereby, gingival thickness seems to
play a decisive role. The so-called
“thick-flat” gingival biotype has been
reported to be a prognostic factor for
aesthetically successful outcomes of
implants (Kois 2004), predictable
results after recession coverage (Baldi
et al. 1999, Hwang & Wang 2006)
and regain of gingiva after resective
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
osseous surgery (Pontoriero &
Carnevale 2001). In contrast, patients
with a “thin-scalloped” gingiva had a
higher risk for periodontal recessions
after placement of immediate im-
plants (Evans & Chen 2008), a smal-
ler number of complete root coverage
after root coverage procedures (Baldi
et al. 1999) and a trend towards soft
tissue loss in case of periodontal
inflammation (Ericsson & Lindhe

1984, Wennstr€ om et al. 1987). One
reason for these observations might
be the correlation between gingival
thickness and the dimensions of the
underlying alveolar bone plate (Sei-
bert & Lindhe 1989). In patients with
a thin gingival biotype, the absence or
deficiency (fenestration, dehiscence)
of the buccal bone may cause a trend
towards periodontal recessions after
periodontal treatments (Larato 1970),
increase the amount of ridge resorp-
tion after tooth extractions (Kao
et al. 2008) and reduce the stability of
the inter-dental papillae after the
insertion of immediate implants
(Romeo et al. 2008). However, the
association between thickness of the
gingiva and thickness of the underly-
ing alveolar bone has only been anal-
ysed in one study and it was
concluded to be moderate (Fu et al.
2010).
To increase the predictability of
reconstructive periodontal and (peri-)
implant therapies, it is important to
develop guiding criteria to differenti-
ate thick and thin periodontal bio-
types. Several methods have been
described to classify the gingival thick-
ness: direct measurement (Greenberg
et al. 1976), ultrasonic device (M€ uller
et al. 2000), cone beam computed
tomography (Barriviera et al. 2009)
and probe transparency through the
free gingiva (Kan et al. 2010). While
direct measurement of gingival thick-
ness is an invasive method with limita-
tions of reproducibility, non-invasive
ultrasonic devices could not be estab-
lished as routine devices probably due
to technical reasons (Vandana & Sav-
itha 2005) and costs. Similarly, exten-
sive radiographic diagnostics such as
cone beam computed tomography
does not appear appropriate as a first
choice method for defining gingival bi-
otypes. Therefore, visual inspection of
the transparency of the periodontal
probe through the sulcus had become
the most frequently used method for
discrimination of thin and thick
biotypes (De Rouck et al. 2009,
Kan et al. 2010). Nevertheless, the
prognostic value of probe transpar-
ency has not been analysed in detail
until now.
Furthermore, surrogate parame-
ters such as the crown form (squared
short versus tapered long) (Olsson &
Lindhe 1991) and the height of the
gingival scallop (low versus high)
(Weisgold 1977, Seibert & Lindhe
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Gingival and alveolar bone dimensions 1133
1989) have also been associated with enrolled at the Department of Opera-
the presence of a thick or thin gin- tive Dentistry, Periodontology and
giva respectively. The findings, how- Preventive Dentistry, University Hos-
ever, were not consistent (Olsson pital Aachen between January and
et al. 1993, De Rouck et al. 2009) August 2012. Of this cohort, subjects
and should be verified. were excluded if they met one of the
Therefore, the objective of this following criteria: (i) intake of medi-
study was to examine how previously caments known to increase gingival
reported surrogate parameters corre- overgrowth, (ii) systemic diseases hav-
late with gingival thickness using a ing gingival manifestations and/or
radiographic morphometric method. influence the bone metabolism, (iii)
In particular, the aim was to: pregnancy, (iv) presence of periodon-
tal probing depths ≥4 mm, (v) peri-
• evaluate the correlation between odontal recessions, (vi) signs of incisal
crown form, height of gingival abrasions and (vii) crown restorations
scallop, width of keratinized gin- or fillings in the upper central incisor
giva and periodontal probe trans- area. All study participants not meet-
parency through the sulcus with ing those exclusion criteria underwent
gingival thickness and thickness a clinical oral and radiographic exam-
of the buccal alveolar bone plate ination. The study protocol was
at different apico-coronal levels; approved by the Ethics Committee of
• assess the relationship between the University of Aachen and written
gingival thickness and buccal consent was obtained from all sub-
alveolar bone thickness; and jects before their examinations. After
• define the diagnostic parameter(s) clinical and radiographic examination,
with the highest correlation with quality control of the radiographs led
gingival thickness at the supracr- to a second exclusion of subjects not
estal attachment and alveolar meeting the quality criteria (see Qual-
bone crest in multivariate models. ity Control). Finally, the final study
cohort consisted of 60 participants.
Figure 1 shows a flow diagram on
selection of all subjects according to
Material and Methods
the described criteria.
Study population
Clinical examination and photographic
The study was designed as descriptive analysis
cross-sectional study. A total of 85
volunteers without known periodontal All clinical oral examinations have
or dental diseases had initially been been performed on the left central
Potentially appropriate subjects without known dental diseases
(N = 85)
Exclusion of subjects because of medical history (N = 2)
(Crohn’s disease: 1, Diabetes mellitus Type I: 1)
Potentially appropriate, systemically healthy subjects
(N = 83)
Exclusion of subjects with dental or periodontal lesions on the upper
front teeth (N = 12)
(periodontitis = 3, periodontal recessions = 4, restorations = 3, abrasions = 2)
Subjects considered for clinical and radiologic examination
(N = 71)
Exclusion of subjects due to quality deficiency of
radiographic images (N = 11)
(superimpositions = 6; not identifiable anatomic landmarks = 5)
Final number of subjects included in the study
(N = 60)
Fig. 1. Flow diagram on the selection of study participants according to the inclusion
and exclusion criteria.
1134 Stein et al.
incisor (index tooth) both with direct
measurements and analyses of a
clinical photograph taken from the
region of the index tooth. Prior to
the photograph, a lead plate
(5.0 9 1.0 9 0.1 mm) was used as
reference for all measurements on
the photograph and the radiograph
(Fig. 2a). It was positioned over the
buccal gingival surface with its most
coronal margin aligned with the edge
of the gingival margin at the mid-
buccal position. It was also well
aligned with the long axis of the
tooth and delimited the profile of
the gingiva from a lateral perspec-
tive. After positioning the lead plate
on the gingival surface, tissue adhe-
sive (Histoacrylâ; B.Braun, Melsun-
gen, Germany) was applied over the
margins of the plate in order to
avoid movement.
The following assessments were
made directly on the patients using
a periodontal probe (CP 15 UNC;
Hu-Friedy, Rotterdam, Nether-
lands):
• Width of the keratinized gingiva
(GW) measured from the mid-
buccal position of the marginal
gingiva to the mucogingival junc-
tion, to the nearest 0.5 mm.
• Transparency of the periodontal
probe through the sulcus (TRAN)
was determined after insertion of
the probe into the sulcus on the
midbuccal position and recorded
as categorical variable (yes =
probe visible; no = probe not
visible).
On the clinical photograph the
following parameters were recorded
using a photo software (Adobeâ
(a)
Fig. 2. Index tooth with fixed transfer lead plate. Clinical view (a), radiographic view (b), radiographic measurement points for
assessment of gingival (G1–G6) and alveolar bone (A1–A3) thickness values (c).
Photoshop CS3; Adobe Systems,
San Jose, CA, USA):
• Crown width/crown length ratio
(CW/CL): This measurement was
performed according to the
method of Olsson & Lindhe
(1991). Crown length was mea-
sured from the incisal edge to the
margin of the buccal gingiva. For
assessment of the width, the
crown length was divided into
three equal portions; the width
was recorded as the distance
between the approximal crown
surfaces at the border between the
middle and the cervical portion.
• Height of the gingival scallop
(SC): widest distance between the
line formed by the connection of
the peaks of the two adjacent
inter-dental papillae and the most
apical position of the buccal
marginal gingiva.
Parallel profile radiographs
To analyse the dimensions of the
soft and hard tissue structures in the
coronal aspect of the periodontium
around the index tooth, parallel pro-
file radiographs were obtained from
a lateral position with the use of the
above-described lead plate according
to the method reported by Alpiste-
Illueca (2004). Regarding the
principles of the traditional long-
cone parallel technique for periapical
radiographs, the film was placed par-
allel to the long axis of the tooth to
minimize distortion of the image. A
long distance between the generator
and the object as well as a minimal
distance between the film and the
(b)
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
object was established to produce a
clear image and minimize the magni-
fication effect. The X-ray beam was
oriented perpendicular to the axis of
the tooth and the film. The parallel-
ing system by Rinn for posterior
quadrants was used for this study.
The bite block was fixed with the
anterior teeth so that the film was
positioned on the lateral vestibule.
Particular care was paid to the par-
allel orientation of the film towards
the long axis of the tooth. This was
achieved by viewing the lead plate
through the aiming ring: only the
profile of the lead plate had to be
seen. From each patient, a digital
radiograph (Heliodent DS; Sirona,
Wals, Austria) using an intra-oral
sensor was obtained (RVG 6100;
Carestream Health, Toronto, ON,
Canada) (Fig. 2b).
Analyses of the radiographs
All images of the digital radiographs
have been analysed using a photo
software (Adobe Photoshop CS3;
Adobe Systems). The following
measurements were made on the
radiographs:
• thickness of the free gingiva: dis-
tance between the enamel surface
to the palatal side of the lead
plate measured at the coronal
margin (G1) and the base (G2)
of the free gingiva
• thickness of the gingiva at the
supracrestal attachment: distance
between the root surface and the
palatal side of the lead plate
measured at the cementoenamel
junction (CEJ) (G3), the middle
third (midpoint between the
(c)

distance CEJ - bone crest) (G4)
and directly above the bone crest
level (G5)
• thickness of the attached gingiva:
distance between the buccal mar-
gin of the bone crest and the pal-
atal side of the lead plate (G6)
• thickness of the buccal alveolar
bone plate: distance between the
buccal surface and the palatal
side (Lamina dura) of the buccal
bone plate measured at the bone
crest level (A1), at the border
between the coronal and middle
third (A2) and between the mid-
dle and apical third (A3) of the
root length
For all measurements, the length
of the lead plate in the X-ray was
used as a reference for the calcula-
tion of all measurements (Fig. 2c).
Quality control
The radiographs had to meet several
criteria to be considered for the
study. First, the lead plate had to be
detectable on all X-rays delimiting
the gingival profile in each subject. It
was important that only the profile
of the plate was visible with a mini-
mal thickness over the entire length
ensuring the correct tangential posi-
tion of the index tooth. Second, it
had to be assured that the following
anatomic landmarks could be clearly
identified on the X-rays without
superimpositions: lead plate, CEJ,
bone crest, buccal surface of the
bone plate, buccal root surface. If
these criteria were not fulfilled, mea-
surements could not be performed
and the subjects were excluded from
the study (Fig. 1). Furthermore, the
residual potential error due to a
non-tangential positioning of the
lead plate was calculated by
measuring the minimal and maximal
deviation of the thickness of the
plate in the radiograph from the
real thickness (0.10 mm) in all
subjects. The mean deviation
was 0.10  0.04 mm, whereas maxi-
mal and minimal deviation was
0.13  0.04 and 0.07  0.05 mm
respectively.
Examiner reliability
All measurements were performed
by one examiner (NL). Intra-exam-
iner reliability was evaluated in a
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Gingival and alveolar bone dimensions
subgroup of 10 study participants.
Therefore, all clinical parameters
and those measured on photographs
and radiographs were re-measured
1 week after the first recording. The
intra-class correlation according to
Gwet (2008) was assessed for all
parameters and ranged from 0.98 to
1.00 indicating an excellent level of
reproducibility. As the visual estima-
tion of probe transparency (TRAN)
may underlie a higher degree of sub-
jectivity, for this parameter a second
calibration was performed. In the
same subgroup, TRAN was esti-
mated by the examiner (NL) and
two other dentists (JMS, CH). Inter-
examiner reliability was calculated
using the method of Light (1971)
and resulted in an average kappa of
0.86 indicating a good reliability for
this assessment.
Statistical analysis
Outcome values of all continuous
parameters were given as mean and
standard deviation (SD). Using the
Pearson correlation coefficient with
the corresponding 95% confidence
interval, correlations of CW/CL, SC
and GW with the thickness of the
gingiva at different apico-coronal
levels (G1–G6) as well as thickness
of the buccal alveolar bone plate at
different apico-coronal levels (A1,
A2, A3) were calculated. The rela-
tionship between TRAN and all
thickness measurements was evalu-
ated with the point biserial correla-
tion. Furthermore, multiple linear
regression analyses were performed
to test the association of CW/CL,
Table 1. Clinical and radiographic measurements
Mean  SD or number (%)
Crown width/crown length ratio (CW/CL)
Height of gingival scallop (SC) (mm)
Gingival width (GW) (mm)
Gingival thickness
G1 (mm)
G2 (mm)
G3 (mm)
G4 (mm)
G5 (mm)
G6 (mm)
Alveolar bone plate thickness
A1 (mm)
A2 (mm)
A3 (mm)
Transparency of the periodontal probe (TRAN)
SD, standard deviation.
1135
SC, GW and TRAN with the thick-
ness of the supracrestal attachment
at the CEJ level (G3) and buccal
alveolar bone crest (A1). The
requirements of normally distributed
residuals, homoscedasticity and line-
arity were checked using normal
probability and residual plots. Fur-
thermore, sensitivity analyses were
made to investigate the robustness of
the findings. In case where relevant
changes were observed, they are sta-
ted in the results section. All analy-
ses were done in an explorative
manner. Thus, p-values <0.05 were
considered statistically significant.
The statistical analyses were carried
out with SAS Version 9.2 (SAS
Institute Inc., Cary, NC, USA).
Results
The study population consisted of 60
Caucasian subjects (24 men, 36
women) with a mean age of
31.53 years (range, 18–61 years).
Thirty-one per cent of the subjects
were light smokers (<5 cigarettes/
day). Table 1 shows the descriptive
data of all clinical and radiographic
measurements. The subjects com-
prised crown forms that ranged from
a tapered long form with a very low
CW/CL of 0.55 to a squared short
shape with a maximum CW/CL of
1.0 and an average of 0.72. The
mean values for SC and GW were
4.24 and 4.92 mm respectively. The
mean thickness of the free gingiva
was 0.59 mm at the coronal margin
(G1) and increased to 0.96 mm at its
base (G2). For the gingival thickness
at the supracrestal attachment, the
Range
0.72  0.09 0.55–1.00
4.24  0.85 1.93–6.12
4.92  1.01 2.50–7.00
0.59  0.17 0.22–1.13
0.96  0.24 0.43–1.42
1.25  0.35 0.52–2.06
1.43  0.35 0.68–2.13
1.46  0.37 0.52–2.39
0.79  0.21 0.47–1.57
0.57  0.23 0.20–1.58
0.77  0.30 0.23–1.78
0.85  0.45 0.23–3.01
28 (46.7%)
1136 Stein et al.

mean values in the middle third (G4;
1.43 mm) and directly coronal to the
bone crest (G5; 1.46 mm) were
minimally higher than at the CEJ
(G3; 1.25 mm), whereas the thick-
ness of the attached gingiva over the
bone crest (G6; 0.79 mm) was smal-
ler than the gingival thickness at the
supracrestal attachment (G3–G5).
The mean thickness of the alveolar
bone plate increased from 0.57 mm
at the crest to 0.85 mm at the apical
third of the root length. The peri-
odontal probe that was inserted at
the midbuccal aspect of the sulcus
was visible in 28 subjects (46.7%),
whereas in the other 32 participants
(53.3%) it could not be detected.
Correlation analyses revealed a
positive relationship between CW/
CL and all thickness parameters
(Table 2). Hereby, G3 (r = 0.47) and
A1 (r = 0.43) showed a stronger cor-
relation than the other parameters
(r < 0.4). On the contrary, for SC a
negative correlation with all thick-
ness measurements was found. How-
ever, all relationships were weak
(r > 0.25). The correlation between
GW and all thickness parameters
was moderately positive for G3, G4,
G5 and A3 (r > 0.25, r < 0.3). More-
over, TRAN was negatively corre-
lated with all thickness values
(Table 2). Hereby, TRAN had the
strongest correlation with G2
(r = 0.42), whereas all other rela-
tionships were weaker (r > 0.4).
Besides, the relation between the
thickness of the gingiva and the
alveolar bone plate was examined
(Table 3). There was a positive cor-
relation between the gingival thick-
ness at all levels (G1–G6) and the
thickness of the alveolar bone plate
(A1–A3). However, the correlations
between A1 and thickness of the gin-
giva at the supracrestal attachment
(G3–G5) were the strongest (r: 0.51–
0.56), whereas the correlations
between the attached gingiva thick-
ness at the bone crest (G6) and all
bone thickness values (A1–A3) were
weak (r ≤ 0.25).
To further analyse the association
of the parameters CW/CL, SC, GW
and TRAN with gingival thickness
at the CEJ (G3) and alveolar bone
crest thickness (A1), these parame-
ters were included in two multiple
regression models. CW/CL and GW
were revealed as significant predic-
tors for G3, whereas only CW/CL
was a significant predictor for A1.
All other parameters had no signifi-
cant impact on G3 and A1
(Tables 4, 5).
Discussion
Soft and hard tissue dimensions are
important parameters that affect the
outcome of periodontal and restor-
ative treatments. Knowledge about
these factors may help to better assess
the need for soft or hard tissue aug-
mentations and to avoid failures or
complications, in particular in the
aesthetically critical area. Therefore,
it would be useful to have reliable
guidelines or surrogate objective
parameters for the identification of
critical cases with thin gingival and/or
alveolar bone thickness, which might
compromise the success of the treat-
ment. Different parameters have been
used to assess the gingival thickness
or the so-called gingival biotype.
However, the results and recommen-
dations are controversial and none of
the described parameters can be
considered as best or most reliable.
Up until now, there is no precise

Table 2. Correlation between CW/CL, gingival scallop, width of keratinized gingiva and probe transparency with gingival and alveolar
bone thickness
G1 G2 G3 G4 G5 G6 A1 A2 A3

CW/CL 0.2373 0.3846 0.4663 0.3855 0.2298 0.1063 0.4260 0.2624 0.1010
( 0.0197, (0.1416, (0.2371, (0.1426, ( 0.0276, 0.4555) ( 0.1526, (0.1894, (0.0068, ( 0.1578,
0.4617) 0.5795) 0.6417) 0.5802) 0.3500) 0.6113) 0.4823) 0.3453)
SC 0.1905 0.2510 0.2004 0.2302 0.1510 0.1549 0.1718 0.1663 0.0666
( 0.4226, ( 0.4730, ( 0.4310, ( 0.4558, ( 0.3889, 0.1082) ( 0.3923, ( 0.4067, ( 0.4021, ( 0.3147,
0.0683) 0.0053) 0.0580) 0.0272) 0.1044) 0.0873) 0.0928) 0.1911)
GW 0.0180 0.1653 0.2607 0.2763 0.2744 (0.0196, 0.20196 0.18372 0.20926 0.28808
( 0.2705, ( 0.0939, (0.0050, (0.0218, 0.4921) ( 0.0565, ( 0.0752, ( 0.0489, (0.0344,
0.2371) 0.4011) 0.4810) 0.4937) 0.4323) 0.4169) 0.4384) 0.5032)
TRAN 0.2406 0.4169 0.2990 0.3465 0.3283 0.3805 0.21329 0.24240 0.17892
( 0.4644, ( 0.6043, ( 0.5123, ( 0.5498, ( 0.5354, 0.0783) ( 0.5764, ( 0.4418, ( 0.4659, ( 0.4128,
0.0163) 0.1788) 0.0465) 0.0986) 0.1370) 0.0448) 0.0143) 0.0801)

Pearson correlation coefficients (CW/CL, SC, GW) and point biserial correlation (TRAN) given with 95% confidence interval.
CW/CL, crown width/crown length ratio; GW, gingival width; SC, gingival scallop.

Table 3. Correlation between thickness of the gingiva and alveolar bone plate
G1 G2 G3 G4 G5 G6

A1 0.4757 0.4315 0.5087 0.5830 0.5644 0.2546

(0.2485, 0.6487) (0.1958, 0.6154) (0.2886, 0.6730) (0.3820, 0.7267) (0.3583, 0.7134) ( 0.0014 0.4760)
A2 0.4212 0.3652 0.3225 0.3603 0.3850 0.1438
(0.1838, 0.6076) (0.1196, 0.5645) (0.0720, 0.5308) (0.1140, 0.5606) (0.1420, 0.5798) ( 0.1155, 0.3826)
A3 0.3880 0.2465 0.2110 0.3118 0.3638 0.1027
(0.1450, 0.5819) ( 0.0100, 0.4693) ( 0.0475, 0.4396) (0.0602, 0.5223) (0.1180, 0.56340) ( 0.1561, 0.3468)

For all parameters Pearson correlation coefficients given with 95% confidence interval.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Gingival and alveolar bone dimensions 1137

Table 4. Multiple regression model for the association between CW/CL, probe transpar- gingival thickness at all levels with
ency, gingival width, gingival scallop and the thickness of the attached gingiva at the CEJ the thickness of the buccal alveolar
level (G3) (R2 = 0.3024) bone. This confirms and extends the
DF Parameter estimate SE t-value p-value results of Fu et al. (2010) who recog-
nized a moderate correlation
Intercept 1 0.65866 0.61178 1.08 0.2863 between gingiva and bone thickness
CW/CL 1 1.79769 0.53585 3.35 0.0014 on cadaver teeth. In this case, this
TRAN 1 0.10522 0.08489 1.24 0.2204
relationship was differentiated so far
GW 1 0.08887 0.04013 2.21 0.0310
SC 1 0.05263 0.05625 0.94 0.3535
that the correlations between the
gingival thickness at the supracrestal
CEJ, cementoenamel junction; CW/CL, crown width/crown length ratio; DF, degree of attachment (G3–G5) and the alveo-
freedom; GW, gingival width; SC, gingival scallop. lar bone crest (A1) were stronger
Values in bold are statistically significant (p< 0.05). than correlations between the thick-
ness of other parts of the gingiva
Table 5. Multiple regression model for the association between CW/CL, probe transpar- (G1, G2, G6) and more apical parts
ency, gingival width, gingival scallop and the thickness of the buccal alveolar bone crest of the alveolar bone plate (A2, A3).
(A1) (R2 = 0.2202)
Furthermore, data from the
DF Parameter estimate SE t-value p-value present investigation demonstrates a
positive correlation of the crown
Intercept 1 0.57709 0.42352 1.36 0.1786
form (CW/CL) and the width of the
CW/CL 1 1.14439 0.37096 3.08 0.0032
TRAN 1 0.03169 0.05877 0.54 0.5919
keratinized gingiva (GW) with all
GW 1 0.04098 0.02778 1.48 0.1459 thickness parameters. Thereby, the
SC 1 0.03137 0.03894 0.81 0.4239 strongest correlation was revealed
between CW/CL and the gingiva
CW/CL, crown width/crown length ratio; DF, degree of freedom; GW, gingival width; SC, over the CEJ (G3) as well as the
gingival scallop. alveolar crest (A1). Contrary, the
Values in bold are statistically significant (p< 0.05).
height of the gingival scallop had
only a weak negative correlation
definition of how thick a thick bio- contrast of anatomic landmarks, (iii) with all parameters. The latter was
type should be compared to a thin reproducibility of the real tissue in accordance with the observations
one. One of the reasons may be seen dimensions using a standardized lead of De Rouck et al. (2009) that thin
in the fact that thickness of the gin- plate allowing the calculation of the or thick gingival biotypes are not
giva has been assessed at different magnification effect and (iv) record- necessarily associated with high or
vertical levels (Olsson et al. 1993, Fu ings of the thickness values to 0.1 mm low scallop. Therefore, gingival scal-
et al. 2010, Kan et al. 2010). The using Photoshop software. lop does not seem to be an appropri-
present data clearly show that gingi- Nevertheless, there are two ate indicator for gingival biotypes.
val thicknesses measured at different potential limitations. First, measure- One of the most frequently used
levels (G1–G6) differ from each other ments at the base of the free gingiva methods for identifying gingival
and notably increase from the level of (G2) comprise the sulcus width, thickness was the transparency of
the margin (G1) towards the level which might be considered as bias. the periodontal probe (De Rouck
directly coronal to the bone crest However, as all participants did not et al. 2009, Kan et al. 2010, Fu et al.
(G5), whereas the attached gingiva have any signs of inflammatory gin- 2010, Cook et al. 2011). However,
over the bone crest (G6) was remark- gival diseases and no pathologic probe transparency has not always
ably smaller. Therefore, the results of attachment loss that could be associ- been correlated with measurements
the cited studies were hardly compa- ated with remarkably increased of the gingival thickness (De Rouck
rable. Another reason might be the gingival sulcus, this bias seems to be et al. 2009, Eghbali et al. 2009,
method of measuring gingival thick- negligible. Second, despite the exact Cook et al. 2011). In those who did,
ness. Manual assessment using a calli- parallel positioning, a strictly tan- visibility of the probe was related to
per after tooth extraction (Fu et al. gential projection over the entire the thickness of the gingiva, either
2010, Kan et al. 2010), a syringe with length of the plate is difficult. None- 2 mm from the gingival margin
endodontic depth marker (Olsson theless, the potential error due to the (Kan et al. 2010) or 2 mm apically
et al. 1993) or cone beam radiographs deviation of the projected thickness to the alveolar crest (Fu et al. 2010).
without reference objects (Fu et al. from the real thickness of the lead Although Kan et al. (2010) proposed
2010) might have limitations of their plate was not more than 0.1 mm in this instrument as appropriate for
accuracy. In contrast to these reports, average. This amount of bias can be the differentiation of thick and thin
in this study, a modified radiographic regarded as minimal and supposed gingival biotypes, Fu et al. (2010)
technique described by Alpiste-Illueca to be no larger than errors occurring and Eghbali et al. (2009) reported it
(2004) was used. To obtain maximally in previously reported techniques not as useful. In this study, the
precise measurements, quality control such as direct measurements with results differed according to the ref-
was established regarding the (i) invasive techniques (Olsson et al. erence point of the gingiva. Due to
exactly parallel orientation of the film 1993, Kan et al. 2010). the mild negative correlation
towards the long axis of the tooth, (ii) One of the main results of this (r < 0.3), the findings suggest that
exclusion of cases with insufficient study was the positive correlation of probe transparency is not the best
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1138 Stein et al.
method for evaluation of the thick-
ness of the gingiva at the supracres-
tal attachment (G3–G5), the
attached gingiva (G6) or alveolar
bone thickness (A1–A3). Only for
the free gingiva (G2), the negative
correlation was stronger (r < 0.4).
As G2 was on average located 0.5–
1 mm apically from the gingival
margin, transparency of the probe
may be a helpful indicator for the
thickness of the free gingiva when
restorations are placed slightly
(0.5 mm) subgingival with the need
to conceal alloy margins. However,
periodontal probing does not appear
to be recommended in evaluating the
thickness of the gingiva located at
the CEJ (G3) or more apically (G4–
G6), which might, for example, be of
interest for coverage of implant
abutments, teeth treated with end-
odontic posts having the risk of
corrosion and, therefore, impairing
gingival colour or planning of
implant insertion.
In addition to the correlation
analyses, the association of CW/CL,
GW, SC and TRAN with G3 and
A1 has been tested in two multiple
regression models. G3 and A1 were
chosen as target parameters because
gingival thickness at the CEJ (G3)
corresponds well to the reference
points used in most other studies
(Olsson et al. 1993, Kan et al. 2010),
whereas the thickness of the alveolar
crest (A1) has a particular meaning
for the maintenance of the gingival
stability and might be of strategic
value before restorative and (imme-
diate) implant therapies. The analy-
ses revealed that CW/CL and GW
were significant predictors for G3
value and only CW/CL was signifi-
cantly associated with A1 value. This
supports the hypothesis that teeth
with squared crown forms are more
likely to have a thicker marginal
gingiva and alveolar bone crest than
teeth with tapered crown forms. This
is in disagreement to the data of Ols-
son et al. (1993) who did not find a
significant association between CW/
CL and gingival thickness. The
above-mentioned differences in the
methods of measuring gingival thick-
ness might possibly explain the dis-
crepancies. Another reason could be
seen in the fact that Olsson et al.
(1993) only compared a small num-
ber of subjects with the highest
(N = 10) and those with the lowest
(N = 10) CW/CL values, whereas in
this study all participants (N = 60)
had been included in the analyses.
Conclusions
The data of the present study show
that a clear distinction between a
“thin” and a “thick” gingival biotype
is very difficult. Differences in the
tissue thickness at different apico-
coronal levels and lack of consensus
as to which anatomic landmark
should be used as reference point
might explain the inconsistency of
previous studies in the definition of
gingiva biotypes. Our findings sug-
gest that crown form (CW/CL) and
width of keratinized gingiva (GW)
are helpful indicators for the thick-
ness of the gingiva over the cemento-
enamel junction (G3), whereas CW/
CL also represents a predictor for
the thickness of the buccal alveolar
crest. All thickness parameters of
the gingiva (G1–G6) were positively
related to alveolar crest thickness.
Transparency of the periodontal
probe was negatively correlated with
thickness of free gingiva (G2), but
had only minimal prognostic value
for the thickness of the attached gin-
giva or alveolar crest. Finally, the
data indicated that the height of the
gingival scallop cannot be recom-
mended as an indicator for tissue
thickness. However, due to the lim-
ited sample size the results should
not be generalized. Therefore, it is
recommended in future studies to
verify the predictive potential of
crown form and gingival width (GW)
on tissue thickness considering the
thickness parameters suggested here.
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Clinical Relevance
Scientific rationale for the study:
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Principal findings: Using multiple
regression models, crown form
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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revealed to be a predictor for the
thickness of the gingiva at the ce-
mentoenamel junction and the alveo-
lar bone crest. Transparency of the
periodontal probe had a limited neg-
ative correlation with free gingiva
thickness, but no significant influ-
ence on other tissue dimensions.
Practical implications: Long tapered
crown forms may indicate the pres-
1139
Address:
Jamal M. Stein
Department of Operative Dentistry,
Periodontology and Preventive Dentistry,
University Hospital Aachen (RWTH),
Pauwelsstrasse 30, D-52074 Aachen,
Germany
E-mail: jstein@ukaachen.de
ence of a thinner gingiva at the
cementoenamel junction and a
thinner buccal alveolar bone at the
crest level. Periodontal probing
cannot be recommended for evalu-
ation of the gingival thickness at
the supracrestal attachment.