Correlation of Gingival Thickness with Gingival Width,
Probing Depth and Papillary Fill in Mandibular Anterior Teeth
Smriti Balaji1, Dr. Priyalochana Gajendran2
1Undergraduate Student, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India
2Senior Lecturer, Department of Periodontics, Saveetha
Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha
University, 162, Poonamalle High Road, Chennai 600077, Tamil Nadu, India
*Corresponding Author
E-mail: 
priyalochana.87@gmail.com
ABSTRACT:
AIM - The aim
of this study is to correlate the gingival width, probing depth and papillary
fill in relation to mandibular anterior region. OBJECTIVE - To
correlate the gingival thickness with gingival width, probing depth and
papillary fill in mandibular anterior region. BACKGROUND -
Gingival biotype is of utmost importance for esthetics and biological functions.
Anatomical characteristic of periodontium such as gingival thickness, width of
keratinized gingiva and alveolar bone morphology will determine the behaviour
of periodontium when subjected to physical, chemical or bacterial insult. It
helps in the assessment before treatment planning for therapeutic modalities
such as orthodontic treatment, periodontal surgeries and implant surgeries. The
different biotypes have diverse effects on clinical outcome of any therapeutic
procedures. REASON
- These parameters are required for treatment planning
and can be used to predict the outcome of therapies.
KEYWORDS: Biotype, gingiva, mandibular
anteriors, papillary, periodontium.
INTRODUCTION:
Gingival biotype plays an important role in
periodontal health1. Knowledge of periodontal biotype or phenotype
is of fundamental importance to an oral clinician as the anatomical
characteristics of the periodontium, such as gingival width, gingival
thickness, alveolar bone morphology will determine the behavior of periodontium
when it is subjected to chemical, physical or bacterial insult during
therapeutic procedures via orthodontic treatment, implant and periodontal
surgery.
Gingival biotype refers to a combination of four
features of the soft tissues that build up a specific picture by Sammut2.
These are:
a) Gingival width- Refers to the width of the
keratinized tissue when measured from the gingival margin to the mucogingival
junction
b) Gingival thickness- Thickness of the tissue
can be measured bucco- palatally
c) Papillary height/proportion- The part of
the gingiva fits in between teeth
d) Crown width/height ratio- Long, narrow
teeth tend to be correlated with contact points further from the alveolar crest
and long papillae that fill the embrasures.
The anatomical and biological characteristics of
gingiva depends on various factors like form of teeth, dimensions of alveolar
process, events that occur during tooth eruption, and the consequent
inclination and position of the fully erupted teeth. Gingival biotype can
either be thick or thin. Thick biotype is dense and fibrotic with a wide zone
of attachment, making it more resistant to recession. Thin gingival biotype is
delicate, highly scalloped soft tissue and is more prone to recession, bleeding
and inflammation. Clinical identification of the biotype helps in better
identification of treatment outcomes, thinner biotype needs more attention3.
The characteristics of gingival thickness, gingival width and consequent
alveolar bone thickness and shape of the dental crown have been used to study
the classification of periodontal phenotype4.
Different biotypes have various diverse effects on
clinical outcome of any therapeutic procedure. Evaluation of biotype can help
in the predicition of treatment outcomes; the stability of osseous crest and
position of free gingival margin are directly proportional to the thickness of
the bone and gingival tissue. There are various methods to evaluate the
thickness of gingiva. These are conventional histology on cadaver jaws,
injection needles, trans gingival probing, histologic sections, cephalometric
radiographs, probe transparency method, ultrasonic radiographs and cone beam
computed tomography5.
Tissue biotypes are interrelated with the outcomes of
a variety of dental clinical procedures. In several dental procedures, gingival
tissue is subjected to various clinical or surgical insults. Both the biotypes
respond differently to various clinical procedures. Patients with thin gingival
biotype are prone to connective tissue damage and epithelial damage, hence,
atraumatic treatment needs to be done and proper oral prophylactic measures
have to be followed by patients with thin biotype. In root coverage procedures,
it was proposed that thick gingiva maintained vascularity, promotes wound
healing before and after surgery. Predictable root coverage was seen in
gingival thickness of more than 1.1 mm, whereas in patients with thin biotype,
connective tissue graft with coronally advanced flap can be done to achieve a
pseudo thick biotype6. Thick bony plates associated with thick
biotypes and thin bony plates with thin biotype respond differently to
extraction. Fracture of labial plates and traumatic ridge resorption in the
apical and lingual direction post extraction is seen in thin biotype when there
is minimal ridge atrophy in thick biotype7. In orthodontic therapy,
there is movement of teeth and tissues to attain an ideal position and
occlusion. Studies showed that there is an increase in incidence of hard tissue
dehiscence and fenestrations and also soft tissue recession in cases of thin
biotypes8,6. Immediate placement of implant can be considered with
predictable results in a thick biotype environment due to less bone loss.
Significant resorption which has a high impact on dental esthetics in seen in
thin biotype8,9. In crown lengthening procedures, significant port
operative tissue rebound has been reported in cases of thick biotype compared
to thin biotype10. Hence there is a need to convert thin biotype to
a thick biotype.
Several studies have tried to sought a better
understanding of anatomical characteristics of periodontium with the purpose of
defining the periodontal biotype of each individual. Not only does the gingival
biotype vary from person to person, but also being a genetically determined
characteristic, it may influence other gingival features. Hence the aim of the
study is to correlate the gingival thickness, gingival width, papillary fill
and probing depth in relation to mandibular lower anteriors.
MATERIALS AND METHODS:
100 subjects with healthy periodontal tissues from
Saveetha Dental College and Hospital were chosen for this study from December
to February. Mandibular anterior teeth were assessed; six teeth per subject
were examined.
Inclusion criteria:
1. Probing depth >3 mm
2. Clinical attachment loss- 0 mm
3. Age: 19 to 35 years
Exclusion criteria:
a) Subjects with crown or restorations
b) Fixed or removable orthodontic treatment
c) Subjects with clinical signs of periodontal
disease
d) Pregnant women
e) Subjects taking medication with any known
effect on the periodontal soft tissues
Gingival thickness (GT) was evaluated based on the
probe transparency method. It was categorized into thin and thick based on the
transparency. Williams probe was inserted into the sulcus in the midfacial
aspect of the mandibular anteriors. If the probe was seen through the gingiva,
it was categorized as thin {score 0). If not, it was concluded as thick gingiva
(score 1).
Gingival width (GW) was measured using Williams
periodontal probe midfacially to the nearest millimeter.
Probing depth (PD) was measured to the nearest millimeter
at the midfacial aspect of mandibular anteriors. It is the distance from the
free gingival margin to the base of the sulcus.
Papillary fill (PF) was evaluated by examining the
embrasure area between two adjacent teeth. Complete fill of the embrasure area
was assigned score 1 and score 0 for incomplete fill of the embrasure area.
Statistical analysis:
For describing patient characteristics standard
deviation, mean and percentage was used. Data were entered using Microsoft
excel and was statistically analysed using SPSS software. Relationship of
biotypes with clinical parameters were assessed using t test and chi square
test.
Figure 1: Mean gingival width and probing depth in thin
and thick gingiva
Thin gingival biotype:
Mean gingival width- 3.48
Mean probing depth- 2.33
Thick gingival biotype:
Mean gingival width- 3.77
Mean probing depth- 2.34
The mean gingival width was found to be more in
subjects with thick gingival biotype when compared to those with thin gingival
biotype (p=0.00). This mean difference was found to be statistically
significant. The difference in the mean probing depth between the thick and
thin gingival biotype was not significant (p=0.00).
Figure 2: Papillary fill
Those with thick gingival biotype had a higher
percentage of study subjects with complete papillary fill when compared to the
thin type of gingival biotype. This difference in the % of complete papillary
fill was found to be statistically significant
Correlation of gingival thickness with gingival width
The mean gingival width in thin gingival biotype was
found to be 3.48 mm, whereas the mean gingival width of thick gingival biotype
was 3.77 mm. The Pearson’s correlation showed a positive correlation between
gingival thickness and gingival width (p=0.00) which was statistically
significant.
Correlation of gingival thickness with probing depth
The probing depth of teeth with thin gingiva was 2.33
mm and probing depth of thick gingiva was 2.34 mm. No correlation was noted
between gingival thickness and probing depth which was not statistically
significant (p=0.907).
Correlation of gingival thickness with papillary fill
83.1% of patients with thick gingival biotype showed
complete papillary fill whereas 68.2% of patients with thin gingival biotype
showed complete papillary fill. A positive correlation was seen between
gingival thickness and papillary fill and was found to be statistically
significant (p=0.00).
DISCUSSION:
The gingival biotype plays an important role in
harmonizing ideal esthetics, function and long term prognosis. Clinical
appearance of healthy periodontium differs from subject to subject and even
among different tooth types. Various components control the form of gingival
tissue around the natural teeth or fixed prosthesis. Many features are
genetically determined; others seem to be influenced by tooth size, shape and
position, and biological phenomena such as ageing. The particular shape,
topographical distribution and width of the gingiva are clearly functions of
the presence and position of erupted teeth. Moreover, tooth shape itself seems
to have an important impact on the clinical features of the surrounding gingiva
and probably also the underlying tooth supporting periodontal tissues2.
A thin and scalloped gingiva is prone to have a thin
and delicate periodontium, highly scalloped gingival tissue which may present
with gingival recession, highly scalloped osseous contour, triangular anatomic
crowns and small incisal contact areas in the teeth. They are almost
translucent in appearance. They have increased incidence of dehiscence and
fenestrations because the soft tissue is highly accentuated due to which there
is minimal or thin bone over the labial root. The prevalence of thin gingiva is
43%. Whereas, the underlying bony architecture in relation to thick gingiva is
thick and surgical exposure in such cases shows thick underlying osseous forms6.
In this study, a non- significant negative correlation
(p=0.907) was found between gingival thickness and probing depth. A study done
by Mulleretal11 in 2000 found higher probing depth
in relation to subjects with thicker gingiva. A significant positive
correlation was seen between gingival thickness and papillary fill
(p<0.005). 83.1% of subjects with thick gingiva had complete papillary fill
whereas only 68.2% of patients with thin gingiva had complete papillary fill.
In a study conducted by Jyotsna et al1 showed non-
significant negative correlation between gingival thickness and papillary fill.
In a review article by Sanaviet al12 described increased
incidence of inter root bone in thinner gingival biotype which in turn caused
more recession12. They also stated that the inter-proximal papilla
does not cover spaces between two teeth in thinner gingiva compared to thicker
biotype. A significant (p<0.005) positive correlation was noted between
gingival width and gingival thickness in our study. Kan et al13 in 2010 stated that the
effect of gingival biotype was limited to facial gingival recession, and was
greater in thin biotypes. The biotype was not found to have any effect on the
interdental papilla.In a study conducted by Savitha B etal15
and Mulleretal11 in which the gingival thickness has been
reported to be thinner in female subjects than male subjects.
Gingival biotype can be enhanced
since it can hamper the ideal esthetic of many procedures. One such procedure
to enhance the biotype of gingival tissue is the use of connective tissue
grafts. It is harvested from the palate or tuberosity and is placed at the site
of thin gingival tissue subepithelially and is sutured. Thin biotype is
converted to thick biotype post healing. This is the most reliable method to
enhance the gingival biotype as it gives a long stability of the results. There
a few limitations of connective tissue grafts, for example, limited
availability, increased operating time and donor site morbidity. An alternative
to connective tissue which can be used to enhance the gingival biotype is the
acellular dermal matrix. Its advantages include decreased patient morbidity and
drawbacks include high cost and limited availability. Another means of
enhancing the biotype is the platelet rich fibrin membrane (PRF). It consists
of fibrin matrix and platelets three dimensionally. It works by the release of
several growth factors like vascular endothelial growth factors and platelet
rich derived growth factor. Recent advances include the use of fetal membranes
such as chorion and amnion membrane which enhances the biotype. These are allografts
derived from human placenta. Main advantages of this membrane is its capability
of excellent revascularization, easy availability and antigenicity. These are
used in conjunction with coronally advanced flap15-18,.
CONCLUSION:
Within the limits of this study, it can be clearly
concluded that there is a positive correlation between gingival thickness with
gingival width and papillary fill and a weak negative correlation between
gingival width and probing depth. These
findings can be utilized as objective guidelines for determining the biotype
and response of gingiva to many dental operative procedures. Clinical
relevance of these parameters have to be tested in longitudinal studies. By
taking into consideration the gingival biotype during treatment planning, more
appropriate strategies for periodontal management may be developed, resulting
in more predictable treatment outcomes.19,20
CONFLICT OF INTEREST:
Nil.
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