JOURNAI OF ESTHETIC DENTISTRY

Biologic Width and its Relation to Periodontal

Biotypes
FARSHID SANAVI, D M D , PHD" (PERIODONTICS, 1 9 8 5 )
A R N O L D S . WEISGOLD, DDS, FACDt (PERIO-PROSTHODONTICS, 1 9 6 5 )
L O U I S F. R O S E , D D S , M D * ( P E R I O D O N T I C S , 1 9 7 0 )

ABSTRACT Although average measurements of the biologic zone do not necessarily reflect any one
clinical situation, they do establish a basis upon which clinical decisions can be made. Clinical
impressions, human autopsy material, and animal studies support the concept of a biologic width.
Impingement on the attachment in a susceptible host has shown adverse reactions, including
gingival inflammation and alveolar bone loss. The concept is clinically important in determining
the extent of osseous surgery necessary in the exposure of sound tooth structure. If the implant-
abutment interface is considered to be similar to a subgingival crown margin, its importance in
relation to peri-implant inflammatory disease is readily apparent. In the presence of inflammation,
it is likely that epithelial migration would occur to a level apical to that source. Clinical observa-
tions indicate that, once the biologic attachment is invaded around the implant, the gingival reac-
tions are similar to those found around natural teeth, whether the tissue is of the thick flat or
thin scalloped type.

I n the past, much effort in den-
tistry has been focused on devel-
oping a restoration that reestablishes
lost function and attempts to mimic
the form, size, color, and appearance
of natural dentition. Recent enhance-
ments of these techniques and the
advent of new restorative materials
have enabled the clinician to repro-
duce the ultimate natural-appearing
prosthesis that maintains the bal-
ance between the restoration and
the health of the supporting tissues.'l2
The success of such a restoration
depends on many factors, among
them soft tissue integrity and appear-
ance. Indeed, the most challenging
procedure in clinical dentistry is the
restoration of gingival harmony
and dental esthetics in the anterior
area, where the dentogingival inter-
face is clearly visible. Therefore, an
understanding of the structure and
physiology of the gingival tissues in
relation to teeth, osseointegrated
implants, and restoration margins is
necessary to achieve a healthy, har-
monious, and maintainable interface
between the restoration and the
surrounding soft tissue.
The gingiva is masticatory mucosa
that covers the tooth and underly-
ing attachment apparatus. It encir-
cles the necks of erupted teeth and
firmly attaches to tooth and alveo-
lar bone. The coronal part of the
gingiva rests on tooth and forms a
scalloped configuration. It also
occupies the entire space between
the teeth apical to the contact area.
The shape of the gingival papilla is
determined by the shape and posi-
tion of the anatomic crown, as well
as contact area and embrasure form.
The gingival sulcus is the space
between the marginal gingiva and
the tooth. It is bordered on one side
by the tooth surface and on the
other by the epithelium lining the
sulcus and covering the gingiva. A

*Clinical Assistant Professor of Periodontics. School of Dental Medicine. Universitv o f Pennsvlvania .

, I

Philadelphia, Pennsylvhnia
tClinical Professor of Periodontics. and Director o f Postdoctoral Periodontal Prosthesis. School of Dental
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
*Professor of Surgery and Medicine, Allegheny University of the Health Sciences, Chief of Division of Dental
Medicine and Surgery, Director of Implant Dentistry, Allegheny University Hospital, Philadelphia, Pennsylvania.
and Clinical Professor in Periodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania.
V O L U M E 10. NUMBER 3 157
J O U R N A L OF E S T H E T I C D E N T I S T R Y
healthy gingiva appears light pink
with a stippled surface and free
from any sign of inflammati~n.~
Clinical observations have led clini-
cians to identify two basic human
periodontal forms."'l The more
prevalent, the thick flat type, occurs
in over 85% of the patient popula-
tion; the other, the thin scalloped
type, occurs in less than 15% of
cases. Becker et a1 expanded on this
categorization after examining over
100 human skulls.ll Their classifi-
cation was more detailed in that the
types were separated into thick flat,
thin scalloped, and pronounced scal-
loped, with the mean distance from
the height of the interdental bone to
Biologic Width and its Relation to Periodontal Biotypes
Figure 1 . Tooth forms of maxillary central incisors. A, square;
B, somewhat more triangular; C, very triangular. Compare
the degree of scalloping of periodontium among the three
types: A, thick flat; B, thin scalloped; and C, pronounced
scalloped.
the alveolar crest being 2.1 mm for
the flat, 2.8 mm for the scalloped,
and 4.1 mm for the pronounced
scalloped classification (Figure 1).
A normal, healthy periodontiurn is
characterized by a rise and fall of
the gingival margin and underlying
bony crest. This undulating appear-
ance places the gingiva more api-
cally on the direct facial and more
incisally at the interproximal. This
is called normal architectural form.
In the healthy periodontium, the
underlying bony crest lies approxi-
mately 2 mm apical to the cemento-
enamel junctions (CEJ) and follows
the configuration of the CEJ on all
four surfaces of the tooth.
Figure 2. Typical maxillary central incisor
from thick flat type of periodontium.

In the thick flat type there is this
normal rise and fall of the gingiva
and bone, but there is not a great
disparity between the direct facial
and that found interproximally.
The gingiva is thick or dense and is
fibrotic in nature. Usually this type
of periodontiurn has, quantitatively
and qualitatively, adequate amounts
of attached masticatory mucosa.
When irritated by tooth prepara-
tion, impression procedures, extrac-
tion, or other clinical techniques,
this periodontium usually reacts
with inflammation, followed by
migration of the junctional epithe-
lium apically, with resultant peri-
odontal pocket formation or redun-
dant tissue (Figure 1, A).
The thin scalloped type of perio-
dontium, on the other hand, is dis-
tinguished by a pronounced dispar-
ity between the height on the direct
facial and that found interproximally
(Figure 1, B and C). The underlying
bone is usually thin on the facial
with dehiscences and fenestrations
commonly found. Usually there is
less attached masticatory mucosa,
from both quantitative and qualita-
tive perspectives. Excessive irritation
of this type of periodontium usually
leads to recession both facially and
interproximally. Although the bony
crest lies about 2 mm apical to the
CEJ and follows its configuration,
the interproximal soft tissue usually
does not completely fill the space
between the adjacent teeth. This is
S A N A V I ET AL
especially true of the interproximal abrupt tapers. In fact, in some
papillae between maxillary central instances, the mesiodistal width of
incisors. It should be noted that it is the root is similar in dimension to
usually in this type of periodontium the widest part of the crown.
where there is recession on the
direct facial of artificial crowns, In the thin scalloped periodontium,
where a blue-grey shadow is often the tooth form is usually more sub-
seen at the gingival margin, and tle and somewhat triangular. Con-
where the interproximal papillae tact areas are located more incisally
recede, revealing “black triangles.” and are small incisogingivally and
faciolingually. The cervical convex-
Teleologic reasoning has led ity is less prominent. Since the con-
researchers to believe that tooth tact areas are located more incisally,
form dictates periodontal form. the interproximal papilla is also
Although an attractive and com- positioned more incisally, hence, the
pelling line of thought, to date, this scalloped form. The roots of these
has not been proven. However, teeth are usually more tapered than
based primarily on clinical observa- those found in the thick flat type
tion, there appears to be direct cor- (Figure 3 ) .
relation between tooth form and
periodontal form.
The teeth found in the thick flat
periodontium are usually character-
ized by being more bulbous and
square in form (Figure 2). Contact
areas are located more apically and
usually are broad incisogingivally
and faciolingually. The cervical con-
vexity on the facial surface is rea-
sonably prominent. Since the con-
tact areas begin more apically, a
central incisor viewed from the
facial surface appears to be square.
The interproximal papillae filling
the space between the teeth termi-
nate at the contact areas, hence, a
flat periodontium. Characteristi-
cally, the roots of these teeth are
broad mesiodistally, compared to
Figure 3. Typical maxillary central incisor
from thin, scalloped type periodontium.
V O L U M E LO. N U M B E R 3 159
 JOURNAL OF ESTHETIC DENTISTRY
Figure 4 . Common gingival reaction to preparations in the biologic zone. A, thick flat periodontium. Note gingival inflamma-
tion hypertrophy around the four maxillary incisor ceramometal crowns; B, thin scalloped periodontium. Note gingival reces-
sion around the two maxilla y central incisor ceramometal crowns.
In comparing the crown and root
forms of each type, it becomes
obvious that the inter-root bone
width (i.e., the amount of bone pre-
sent between two adjacent roots) is
greater in the thin scalloped type
than in the thick flat type of perio-
dontium. As recession occurs and
inter-root bone resorbs apically, the
space between the roots of the thin
scalloped type becomes wider. A
comparison of the soft tissue inter-
proximal papillae in each type is
revealing. The CEJ-bone crest
dimensions appear to be the same
(i.e., bone crest about 2 mm apical
to the CEJ). What is different is
that in most instances, the inter-
proximal papillae do not totally fill
the spaces between the teeth in the
thin scalloped type; almost always,
the space is filled in the thick flat
type (Figure 4).
Histologically, gingiva attaches to
the tooth by means of junctional
epithelium and connective tissue.12
The junctional epithelium shapes
the floor of the gingival sulcus and
160 1998
Biologic Width and its Relation to Periodontal Biotypes
extends apically on the tooth sur-
face to form the attachment seal
around the t ~ o t h . The
~ J ~attached
gingiva is firmly connected to the
cementum and bone by a dense net-
work of collagenous fibers.I3J4This
collagen-rich, cellular-poor layer of
connective tissue appears like a bar-
rier separating the crestal bone from
junctional epithelium (Figure 5).
The combined dimension of the
connective tissue attachment and
the epithelial attachment averages
2.04 mm and has been described as
the biologic width, a term coined
by Dr. D. Walter Cohen.15 This
dimension may become critical when
one considers restoration of a tooth
that has been fractured or destroyed
by caries near the level of the alveolar
crest.I6 The preparation and restora-
tion of a tooth that violates the
epithelial and connective tissue
attachment usually results in a poor
gingival Gargiulo et a1
measured the dimension of attach-
ment apparatus in autopsy mater-
ia1.22Their findings were extensively
used by others to develop a blue-
print for clinical application of the
biologic width.16Js~23 It is important
to emphasize that the measurements
presented in Gargiulo's study are
averages, and close examination of
these data shows a significant range
of values for junctional epithelium
and connective tissue attachment.
From a therapeutic standpoint, the
biologic width becomes of great sig-
nificance in the performance of a
crown lengthening procedure, such
as in cases involving subgingival
caries, fractured teeth, or esthetic
consideration^.'^,^^*^^ Failure to
comprehend the amount of osseous
tissue required to be resected will
often result in violation of the newly
established biologic width during
tooth preparation. Two aspects of
the resective procedure must be
considered: (1) the amount of bone
that must be removed and (2)the
periodontal biotype of the patient.
Endosseous implants require the
integration of three different tissues:
bone, connective tissue, and epithe-

lium. The structure of the soft tissues
surrounding the endosseous implants
is, in many ways, analogous to the
natural dentition. The stratified,
squamous, keratinized oral epithe-
lium is continguous, with a non-
keratinized sulcular epithelium. The
junctional epithelium initiated from
the apical aspect of the sulcular
epithelium adheres to the implant
surface and provides a union
between implant and the surround-
ing gingiva.25
A comparison of the interface
between the connective tissue and
natural teeth or implants reveals a
significant difference between the
two.The orientation of the fibers
appears to be parallel to the implant
surface. Berglundh et a1 and Ruggeri
et a1 demonstrated the presence of a
circular ligament of densely packed
collagen fibers free from inflamma-
tory cells coronal to the osseointe-
grated bone tiss~e.2~*~’Cochran et a1
and Berglundh and Lindhe examined
the dimension of the implantogingi-
val junction in relation to clinically
healthy unloaded and loaded
implants in dogs.28,29Histometric
analysis included the evaluation of
the junctional epithelium and the
connective tissue. The junctional
epithelium measured about 2 mm
in an apicocoronal direction, and
the connective tissue attachment
was more than 1mm. The com-
bined measurement of junctional
epithelium and connective tissue
attachment was 3 mm. The sum of
these measurements was similar to
measurements found around teeth.
Thus, the data confirm what
appears to be an existing biologic
width around titanium. It is physio-
logically formed and appears to be
as stable as that found around nat-
ural teeth.
The preservation of a healthy perio-
dontal attachment is the most sig-
nificant factor in the long-term
prognosis of a restored tooth.30The
fact that an improper restoration
margin, inadequate embrasures, and
poor contour may accumulate plaque
and initiate inflammation and sub-
sequently alveolar bone resorption
and loss of attachment is well docu-
mented.30-32The placement of mar-
gins of a restoration in the sulcular
area is especially important in an-
terior areas, to satisfy the esthetic
demands of patients. The restorative
Figure 5. fnterdental space between first and second molar in a non-ligature-
treated rat. Note the presence of a collagen rich layer above the crestal bone.
S A N A V I ET AL
margin, be it metal or porcelain,
placed in the vulnerable crevicular
area leaves little room for error.33
Recent studies have shown that
violation of the biologic width
results in inflammation and loss of
attachment.18J9The injury caused by
placement of a restorative margin
at the supracrestal connective tissue
attachment leads to bone resorp-
tion, loss of attachment apparatus,
and reestablishment of a biologic
width at a level more apical to the
original position. Such a response is
depicted in Figure 6 . The mechani-
cal violation of the supracrestal
connective tissue attachment was
caused by placement of silk ligature
around the maxillary second molar
of rats. Seven days after ligature
placement, a new biologic width
was established, despite the pres-
ence of bacteria and inflammatory
V O L U M E 10. N U M B E R 3 161
 J O U R N A L OF ESTHETIC DENTISTRY
Figure 6. Interdental space between first
and second molar in a ligature-treated
rat (8 days). Note the establishment of
biotogic width in a new apical position.
Despite the presence of bacteria and
inflammatory cells below the ligature,
the supracresta 1 bone exhibits a collagen-
rich layer of tissue without apparent
inflammatory cells.
infiltrate around the ligature and
the underlying epithelium and con-
nective tissue. The supracrestal con-
nective tissue consisted of layers of
collagen-rich fibers without any
sign of inflammatory cells.
Disturbance and violation of the
biologic width around titanium
implants also has been studied.34
162 1998
Biologic Width and its Relation to Periodontal Biotypes
Abrahamsson et a1 demonstrated
that repeated removal and recon-
nection of an implant abutment
potentially disturbed the established
mucosal attachment and subse-
quently resulted in a more apically
positioned connective tissue attach-
ment.34It was concluded that a
certain width of the peri-implant
mucosa is required to enable a
proper epithelial connective tissue
attachment, and if this soft tissue
dimension is not satisfied, bone
resorption will occur, to ensure the
establishment of attachment with
an appropriate biologic width.
CONCLUSION
It appears that there is a minimal
dimension of peri-implant mucosa
(i.e., biologic width) that is neces-
sary around endosseous implants
and natural teeth. Bone resorption
may take years to afford a stable
soft tissue complex in the osseointe-
grated implant.29Once the fixture
is exposed and the healing abutment
placed, the biologic attachment will
eventually form. From a practical
clinical perspective, if one uses pre-
fabricated abutment heads, there is
little chance for the biologic attach-
ment to be invaded. However, when
using certain abutments to correct
positional problems or to place the
restorative margin into the crevice,
there is the strong possibility that
the biologic attachment will be
compromised. This may be likened
to a natural tooth being prepared
too far apically (i.e., into the bio-
logic attachment). In this situation,
the artificial crown is cement-
retained instead of screw-retained,
with the possibility that remnants
of cement will be left in the sulcus.
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