[Downloaded free from http://www.aihbonline.com on Tuesday, March 19, 2019, IP: 103.255.4.

4]

Original Article

Adaptation of Gingival Biotype in Response to Prosthetic

Rehabilitation
Dipti S Shah, Sareen Duseja, Kalpesh Vaishnav, Rutu Paresh Shah
Department of Prosthodontics and Crown & Bridge, Karnavati School of Dentistry, Gandhinagar, Gujarat, India

Abstract
Background: The gingival biotype is the width of the gingiva in the faciopalatal dimension. It is a feature of the periodontium that is susceptible to
change when exposed to physical, chemical or bacterial injury or as a result of surgical or orthodontic treatment. Aim and Objective: The objective
of the study undertaken was to assess the adaptation of gingival biotype following prosthetic rehabilitation. Materials and Methods: Forty
individuals between 20 and 40 years with healthy periodontium and full complement of teeth with absence of clinical attachment loss or
systemic disease were selected for the study. The individuals were restored with a full‑coverage porcelain fused to metal with a subgingival
margin on root canal‑treated teeth with no gingival recession. The gingival biotype of the tooth with the restoration was evaluated in terms of
thickness with the help of transparency of the probe method. Twenty individuals were selected with thick biotype and rest with thin biotype.
Follow‑up was done after 6 months, and the gingival biotype and gingival recession were re‑evaluated. Results: It was observed that out of
the twenty individuals with thick biotype, eight underwent transformation to thin biotype. Furthermore, thin gingival biotype was more prone
to gingival recession as five individuals were found to have gingival recession. Conclusion: Within the limitations of the current study, it
was observed that gingival biotype may undergo transformation in response to prosthetic rehabilitation from thick to a thin gingival biotype
progressively over a period of time. Hence, supragingival margins should be placed wherever possible. In addition, the thin gingival biotype
has a higher susceptibility towards gingival recession.

Keywords: Gingival biotype, gingival recession, prosthetic rehabilitation

Introduction in biological width. This may also lead to gingival recession

The biotype of the gingiva is a vital factor of concern that
may alter the success of dental treatment. It may particularly
affect the result of periodontal therapy along with procedures
used for root coverage and also implant placement. It is
important to identify the type of gingival biotype as each type
of tissue biotype reacts differently to various conditions such
as inflammation and restorative dental treatment. Special care
must be taken while formulating a treatment plan for cases
with a thin gingival biotype.[1]
The biotype of the thin type typically consists of a fragile veil of
soft tissue covering a scalloped bone which may often exhibit
fenestrations or dehiscence. In such biotypes, the keratinised
mucosa amount is also compromised. The thick biotype,
however, envelopes a thicker plate of buccal bone.[2‑4] Hence,
conversely, it can be assumed that changes in the underlying
bone or exposure to gingival trauma can cause gingival biotype
to undergo transformation. This may occur following violations
Access this article online
Quick Response Code:
Website:
www.aihbonline.com
due to crestal or cortical bone loss. The present study aims
to assess whether fixed prosthetic restoration can have an
irreversible change on the localised gingival biotype turning
a thick fibrotic gingival biotype into a thin and more fragile
one. In addition, an assessment is done herein to evaluate the
role that the gingival biotype plays in the long‑term outcome
of a tooth restored with a full‑coverage restoration.
Materials and Methods
The study was performed in accordance with ethical standards
and with the approval of Ethical Committee of the institute.
Address for correspondence: Dr. Rutu Paresh Shah,
236, M M Jain Society, Opp. Abu Vihar Hall, Ramnagar Sabarmati,
Ahmedabad, Gujarat ‑ 380 005, India.
E‑mail: shahrutu.rs@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Shah DS, Duseja S, Vaishnav K, Shah RP.
10.4103/AIHB.AIHB_30_16 Adaptation of gingival biotype in response to prosthetic rehabilitation. Adv
Hum Biol 2017;7:85-8.

© 2017 Advances in Human Biology | Published by Wolters Kluwer - Medknow 85

[Downloaded free from http://www.aihbonline.com on Tuesday, March 19, 2019, IP: 103.255.4.4]
Shah, et al.: Gingival biotype and prosthetic rehabilitation
Participants
Forty individuals were selected for the study: 20 with a thick
gingival biotype and the other twenty with a thin gingival
biotype.
The patients had to fulfil the following criteria:
• Full complement of teeth
• Presence of single porcelain fused to metal  (PFM)
full‑coverage crown with subgingival margins
• Absence of any periodontal disease, gingival recession
or mobility
• Absence of premature contacts on restored crown.
In the current study, the probe transparency (TRAN) method
was used.[4] With the help of a World Health Organization
periodontal probe, the gingival biotype of the individual was
assessed by gently inserting the probe into the gingival sulcus. If
the outline of the probe was visible, it was categorised as a thin
gingival biotype [Figure 1]. If the outline was not discernible,
it was categorised as a thick gingival biotype [Figure 2]. This
procedure was carried out on the natural unrestored tooth. The
margin locations of the restored teeth were also noted at this
stage. The participants were re‑evaluated for the crown margin
location and the gingival biotype after a 6‑month interval.
Results
Out of the twenty individuals having thick biotype, it was
observed after 6‑month follow‑up that eight of the twenty
individuals had a thin gingival biotype around the tooth with
the full‑coverage crown. It was also noted that, out of the
twenty teeth with thin gingival biotype, five exhibited gingival
recession. This was evident as the previously subgingival
margins of the PFM crowns were clinically visible. Figure 3
shows the position of gingiva with a thin gingival biotype in
the mandibular right first molar restored with a PFM crown of a
participant at the initial evaluation. Figure 4 shows the position
of gingiva at 6‑month follow‑up. It was evident that there
was gingival recession as the previously placed subgingival
margins are clinically visible.
Figure 1: Periodontal probe outline visible through gingiva in individual
with thin biotype.
86
Table 1 shows the number of individuals having thin and thin
gingival biotype after 6‑month interval.
Chart 1 shows the changes in the gingival biotype and gingival
recession after a 6‑month interval. It should be noted that
after 6 months the gingival biotype of individuals with thin
biotype originally did not change but five out of them exhibited
gingival recession.
Statistical analysis was performed using SPSS software version 22
(IBM Analytics, United States), and non‑parametric Wilcoxon
signed‑rank test showed that the change in the gingival biotype of
the group with originally thick gingival biotype was statistically
significant (P = 0.005). The same test on the gingival recession
occurring in the group with thin gingival biotype was not statistically
significant. This may be attributed to the small sample size
considered in the current study. However, it has a clinical value as it
shows that thin gingival biotype is more prone to gingival recession.
Discussion
In 1969, Ochsenbein and Ross indicated that there were two
main types of gingival anatomy – flat and highly scalloped.[5]
The authors reported that flat gingiva was associated with a
square tooth form, while scalloped gingiva was associated with
a tapered tooth form. The authors also proposed that the gingival
contour closely mimics the contour of the underlying alveolar
bone. Seibert and Lindhe used the term ‘periodontal biotype’ later
and categorised gingiva as either thin scalloped or thick flat.[6]
Table  1: Status of individuals’ biotype after 6‑month
interval
After 6 months Total
1 2 3
A 12 8 0 20
B 0 15 5 20
Total 12 23 5 40
1: Thick gingival biotype, 2: Thin gingival biotype, 3: Gingival recession,
A: Group with originally thick biotype, B: Group with originally thin
biotype
Figure 2: Periodontal probe not visible through gingiva in individual with
thick biotype.
Advances in Human Biology  ¦  Volume 7  ¦  Issue 2  ¦  May‑August 2017
[Downloaded free from http://www.aihbonline.com on Tuesday, March 19, 2019, IP: 103.255.4.4]
Shah, et al.: Gingival biotype and prosthetic rehabilitation
Figure 3: At initial evaluation of thin biotype.
Figure 4: At 6‑month follow‑up showing gingival recession in thin biotype.
Chart 1: Status of individual’s biotype after 6‑month interval.
According to De Rouck et  al., the thin type of gingival
biotype was seen in one‑third of the population they studied
and was more commonly seen in women. It was observed
that two‑thirds of the individuals showed a thicker biotype
and the individuals were predominantly males. It has been
Advances in Human Biology  ¦  Volume 7  ¦  Issue 2  ¦  May‑August 2017
confirmed in studies that central incisors with a slender crown
are less resistant to recession as opposed to more bulbous and
squarish crown.
Hence, cases with a thin gingival biotype require judicious
treatment planning.
Three different biotypes were proposed by Becker et  al.
which included a flat, scalloped and a pronounced scalloped
type of gingiva.[7] When height of bone is measured in the
interproximal region to the height at direct midfacial region,
the findings of the above types were flat of 2.1 mm, scalloped
of 2.8 mm and pronounced scalloped of 4.1 mm. Thick
biotypes show greater dimensional stability during remodelling
compared to thin biotypes. It is believed that, in thicker types
of biotypes, there is laminar bone present next to the outer
cortical plate which gives groundwork for metabolic support.
This provides stability and an enhanced prognosis. The thin
biotype, the cortical plate, rapidly undergoes resorption owing
to scarcity or absence of lamina bone. The gingival tissue with
a thick biotype is less susceptible to recession and has greater
ability to fabricate a barrier to hide the margins of restorations.
It was also found in a study conducted by Tao et al.[8] that
central incisors with thin biotypes restored with a PFM crown
were more susceptible to ‘aesthetic failure’ due to gingival
recession. The level of gingival thickness before regenerative
surgery was found to be a predicting factor for further
recession. It was proposed by Kois that the clinical results
seen post‑surgery showed a strong correlation with the form
of gingiva along with that of the alveolar crest. An inferiorly
located alveolar crest has greater risk of gingival recession
which can lead to exposure of subgingivally placed restorative
margins.[9‑12] Patients with thick gingiva were less susceptible
to gingival recession after surgical or restorative therapy.
The margins of the prosthesis should be placed in a way as
to avoid the violation of biological width. The biological
width is defined as the dimension of the soft tissue, which
is attached to the portion of the tooth coronal to the crest of
the alveolar bone.[13] Any impingement of this distance may
cause inflammation, pocket formation, gingival recession and
alveolar bone loss.[14]
For this, the rules for margin placement of a restoration
according to Carranza should be followed diligently for
more predictable results.[15] The rules are as follows: if sulcus
probing depth is 1.5 mm or less, place the restorative margin
0.5 mm below the gingival crest. If sulcus probes are more than
1.5 mm, place the margin half the depth of sulcus below the
gingival crest. However, if a sulcus probing depth is >2 mm,
especially on the facial aspect, evaluate to see whether a
gingivectomy can be performed to lengthen the tooth and
create a 1.5 mm sulcus, then the patient can be treated using
the previous rule.
Various methods were proposed to measure gingival thickness.
The thickness of gingival tissue can be assessed using the
direct method, the TRAN method, by ultrasonic devices and
87
[Downloaded free from http://www.aihbonline.com on Tuesday, March 19, 2019, IP: 103.255.4.4]
Shah, et al.: Gingival biotype and prosthetic rehabilitation
by cone beam computed tomography scans. In the direct
method or transgingival probing method, gingival thickness
is judged using a periodontal probe. A thickness of >1.5 mm
is categorised as thick biotype and <1.5 mm is considered as
thin. This technique has intrinsic limitations, one of them being
that precision of probe is nearest to 0.5 mm. Others include
probe angulation and distortion of tissue while probing.[16]
Alternately, a #15 endodontic K‑file with a silicone disc stop
can be used instead of a periodontal probe.[17]
The TRAN method used in the current study is the simplest
technique to determine the gingival biotype, along with being
least invasive. It causes minimal tissue trauma and requires no
additional instruments.
Significance of the study
It is vital to study the gingival biotype before planning any
prosthodontic treatment. In thin types of tissue biotypes,
it is advisable to place the margins of prepared restoration
supragingivally. If this is not done, in cases where a PFM
restoration is given, the restoration margin may cause a
greyish hue through the thin and translucent gingival tissue.
This ultimately leads to aesthetically inaccurate restoration
and patient dissatisfaction. Moreover, in thin tissue biotype,
restorations that are contoured beyond physiologic limits will
cause mucosal recession. Thicker biotypes more commonly
exhibit pocket formation.[18] However, a study with greater
sample size and a longer follow‑up period is a viable future
research option.
Periodontal surgical techniques can significantly improve
tissue quality and treatment outcome. The best method to
convert a thin soft tissue into a thick biotype is by subepithelial
connective tissue grafting. Other methods of soft tissue
augmentation include modified roll technique and use of
acellular dermal matrix.[19,20]
Providing supragingival margins in thin biotypes will not only
cause minimal tissue trauma while tooth preparation but it is
also easier to maintain oral hygiene. In cases where aesthetics
or caries require subgingival margins, the biologic width must
be maintained to prevent gingival recession.
Conclusion
The current study reflected that the gingival biotype plays
an important role in the outcome of prosthetic rehabilitation.
Non‑judicious tooth preparation and violation of biologic width
can lead to alteration in the thick gingival tissue causing it to
become thinner over time. Furthermore, it was observed that
thin gingival biotype was more commonly associated with
gingival recession than thick biotype. Hence, supragingival
margins should be preferred in such individuals. The thicker
type of gingival biotype has greater resistance towards tissue
recession and can better mask the margins of restorations that
are placed subgingivally. Hence, by understanding the nature of
tissue biotypes, it is possible to employ appropriate periodontal
management while tooth preparation and gingival retraction,
88
to minimize tissue resorption and provide more favourable
results after dental treatment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Esfahrood ZR, Kadkhodazadeh M, Talebi Ardakani MR. Gingival
biotype: A review. Gen Dent 2013;61:14‑7.
2. Müller HP, Eger T. Gingival phenotypes in young male adults. J Clin
Periodontol 1997;24:65‑71.
3. Müller HP, Heinecke A, Schaller N, Eger T. Masticatory mucosa in
subjects with different periodontal phenotypes. J Clin Periodontol
2000;27:621‑6.
4. 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;36:428‑33.
5. Ochsenbein C, Ross S. A reevaluation of osseous surgery. Dent Clin
North Am 1969;13:87‑102.
6. Seibert JL, Lindhe J. Esthetics and periodontal therapy. In: Lindhe J,
editor. Textbook of Clinical Periodontology. 2nd ed. Copenhagen,
Denmark: Munksgaard; 1989. p. 477‑514.
7. Becker  W, Ochsenbein  C, Tibbetts  L, Becker  BE. Alveolar bone
anatomic profiles as measured from dry skulls. Clinical ramifications.
J Clin Periodontol 1997;24:727‑31.
8. Tao J, Wu Y, Chen J, Su J. A follow‑up study of up to 5 years of
metal‑ceramic crowns in maxillary central incisors for different gingival
biotypes. Int J Periodontics Restorative Dent 2014;34:e85‑92.
9. Anderegg CR, Metzler DG, Nicoll BK. Gingiva thickness in guided
tissue regeneration and associated recession at facial furcation defects.
J Periodontol 1995;66:397‑402.
10. Baldi C, Pini‑Prato G, Pagliaro U, Nieri M, Saletta D, Muzzi L, et al.
Coronally advanced flap procedure for root coverage. Is flap thickness
a relevant predictor to achieve root coverage? A 19‑case series.
J Periodontol 1999;70:1077‑84.
11. Pontoriero R, Carnevale G. Surgical crown lengthening: A 12‑month
clinical wound healing study. J Periodontol 2001;72:841‑8.
12. Evans CD, Chen ST. Esthetic outcomes of immediate implant
placements. Clin Oral Implants Res 2008;19:73‑80.
13. Jorgic‑Srdjak K, Plancak D, Maricevic T, Dragoo MR, Bosnjak A.
Periodontal and prosthetic aspect of biological width part I: Violation of
biologic width. Acta Stomatol Croat 2000;34:195‑7.
14. Nugala B, Kumar BS, Sahitya S, Krishna PM. Biologic width and its
importance in periodontal and restorative dentistry. J Conserv Dent
2012;15:12‑7.
15. Newman MG, Takei HH, Klokkevold PR. Carranza’s Clinical
Periodontology. 10th ed. St Louis, Missouri, United States: Elsevier
Saunders Publication; 2010.
16. Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL. Tissue
biotype and its relation to the underlying bone morphology. J Periodontol
2010;81:569‑74.
17. Singh M, Chaubey KK, Madan E, Thakur RK, Agarwal MC, Joshi N.
Correlation between Gingival Biotype and Occurence of Gingival
Recession. Saudi J Oral Dent Res 2016;1:119-23.
18. Nagaraj KR, Savadi RC, Savadi AR, Prashanth Reddy GT, Srilakshmi J,
Dayalan M, et al. Gingival biotype – Prosthodontic perspective. J Indian
Prosthodont Soc 2010;10:27‑30.
19. Tal H, Moses O, Zohar R, Meir H, Nemcovsky C. Root coverage of
advanced gingival recession: A comparative study between acellular
dermal matrix allograft and subepithelial connective tissue grafts.
J Periodontol 2002;73:1405‑11.
20. Scharf DR, Tarnow DP. Modified roll technique for localized alveolar
ridge augmentation. Int J Periodontics Restorative Dent 1992;12:415‑25.
Advances in Human Biology  ¦  Volume 7  ¦  Issue 2  ¦  May‑August 2017