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Gingival biotype — Prosthodontic perspective

Article  in  The Journal of Indian Prosthodontic Society · March 2010

DOI: 10.1007/s13191-010-0011-3 · Source: PubMed

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Journal of Indian Prosthodontic Society (March 2010) 10:27–30
DOI: 10.1007/s13191-010-0011-3
Journal of Indian Prosthodontic Society (March 2010) 10:27–30 27
REVIEW ARTICLE

Gingival Biotype - Prosthodontic Perspective

K. R. Nagaraj, Ravindra C. Savadi, Anupama R. Savadi, G. T. Prashanth Reddy, Srilakshmi J., Malathi Dayalan,
Jins John

© Indian Prosthodontic Society

During treatment planning it is important to recognize different gingival biotypes and forms, because they
can affect the esthetic outcome of the treatment. This review provides an insight into the different gingival
biotypes, their response to inflammation and trauma; significance in different prosthodontic modalities like
esthetic rehabilitation and implant therapy.

Keywords: Thick and thin biotypes, Dentogingival complex, Bioform

Introduction The biologic width is 2.04 mm (calculated by addition

of the linear measurement of the connective tissue and
In our modern competitive society, a pleasing appearance epithelial attachment) [1, 2, 3].
often means the difference between success and failure
in both our personal and professional lives. The gingival
perspective of esthetics is concerned with the soft tissue
envelope surrounding the teeth. To provide excellent
esthetics, evaluation of gingival type and form is very
important from the start of treatment plan to the final
restorative placement.

Anatomy of the Dentogingival Complex

The dentogingival complex is composed of three entities:

The supra-crestal connective tissue attachment - the
connective tissue fibers originate from the osseous
crest to the cemento-enamel junction (CEJ);
Epithelial (or junctional epithelium) attachment - the Fig. 1 Biologic width
epithelial attachment from the CEJ onto the tooth
enamel; and Gingival Biotype and Bioform
The sulcus-coronal to the junctional epithelium is the The gingival biotype is classified as thin or thick.
gingival sulcus. Whereas the prevalence of thick biotype is 85% and thin
K. R. Nagaraj • R. C. Savadi • A. R. Savadi • G. T. P. Reddy • biotype is 15%.
Srilakshmi J. • M. Dayalan • J. John The thin periodontal biotypes: Thin gingival tissue
Department of Prosthodontics,
The Oxford Dental College and Hospital, tends to be delicate and almost translucent in appearance,
Bengaluru - 560068, Karnataka, India the tissue appears friable with a minimal zone of attached
Gingiva. Which escalates the risk of recession following
e-mail: drkrnag@yahoo.co.in crown preparation and periodontal or implant surgery. It
28 Journal of Indian Prosthodontic Society (March 2010) 10:27–30

is particularly significant in full coverage crowns for the Thick periodontal biotype is fibrotic and resilient, making
following reasons. it resistant to surgical procedures with a tendency for pocket
The thin gingival margins allow visibility of a formation (as opposed to recession). Therefore, a thick
metal substructure (either porcelain fused to a metal biotype is more conducive for implant placement, resulting
crown or implant abutment), thereby compromising in favorable esthetic outcomes.
esthetics in the anterior regions of the mouth. In
these circumstances, all-ceramic crowns, or ceramic Characteristics of Thick Gingiva
implant abutments are a prerequisite to avoid esthetic
reproval. Relatively flat soft tissue and bony architecture

Due to the fragility of the thin tissue, delicate Dense fibrotic soft tissue
management is essential for avoiding recession and Relatively large amount of attached gingiva
hence visibility of subgingivally placed crown margins Thick underlying osseous form
at the restoration/tooth interface [1, 4, 5]. Relatively resistant to acute trauma
Reacts to disease with pocket formation and infrabony
Characteristics of Thin Gingiva
defect formation [4, 5, 6].
Highly scalloped soft tissue and bony architecture
Delicate friable soft tissue
Minimal amount of attached gingiva
Thin underlying bone characterized by bony
dehiscence and fenestration
Reacts to insults and disease with gingival recession [6].

Thick biotype

Bony architecture

Gingival Bioforms

Periodontal bioforms are categorized into three basic

gingival scallop morphologies, high, normal and flat.
Whereas the facial and lingual gingival scallop mimics the
Thin gingival biotype underlying bone architecture, but not interproximally.
Journal of Indian Prosthodontic Society (March 2010) 10:27–30 29

Comparison of tissue response to inflammation, surgery and tooth extraction [1, 7]

Thick gingival biotype Thin gingival biotype
Inflammation • Soft tissue: marginal inflammation; • Soft tissue: thin marginal redness gingival
cyanosis; bleeding on probing; edema/ recession
fibrotic changes • Hard tissue: rapid bone loss associated
• Hard tissue: bone loss with pocket with soft tissue recession
formation/infrabony defects
Surgery Predicable soft and hard tissue Difficult to predict where tissue will
contour after healing heal and stabilize

Tooth extraction Minimal ridge atrophy Ridge resorption in the apical and
lingual direction

The normal discrepancy is 4 mm between the Tissue Biotype in Prosthodontic Treatment

interproximal gingival peaks (most coronal) and the mid-
facial free gingival margin peaks (most apical). When this Tooth preparation: Margins of the preparation have to
discrepancy is <4 mm, a flat scallop is evident, while a be placed supragingivally in thin biotypes. If margins are
>4 mm discrepancy results in an exaggerated or high placed subgingivally for porcelain fused to metal restoration
scallop. With a shallow scallop, the interproximal bone grayish discoloration of the margin is seen because of
is thin, and the interproximal gingival contour nearly translucency of thin biotype, which leads to esthetic
parallel to the underlying bone contour. The flat bioform failure. Whereas in thick biotypes margins can be placed
is advantageous for implant therapy since the bone has subgingivally in esthetic zones.
a congruous relationship with the free gingival margin Over contoured restorations will lead to gingival
(FGM) and is less prone to postsurgical recession. With recession in thin biotypes. Pocket formation is seen in
a pronounced or high scallop, the interproximal bone is thick biotype.
wider, but the disparity between the bone contour and the
Gingival retraction: Care to be taken to avoid injury
FGM is problematic for favorable esthetics (due to possible
to the soft tissue in thin biotypes. Thin retraction cord is
recession and creation of ‘black triangles’) following
used for retraction. If cord is retained more than 15 minutes,
implant or restorative procedures [1].
chances of recession are more. Retraction of gingiva can be
accomplished more comfortably in thick biotype.
Tissue biotype in implant treatment planning: The
Tooth Morphology
thick and thin biotypes have different osseous and soft
Tooth morphology determines two aspects of gingival tissue forms and these distinctions would significantly
undulations. influence implant site preparation and treatment planning.
The stability of the osseous crest and soft tissue is directly
The basic tooth forms
proportional to the thickness of the bone and gingival
Convex acuity of a tooth circumference. tissue. Thick biotypes are associated with thick bony plates
The basic tooth forms - circular, square or triangular, and thin biotypes are associated with thin bony plates, with
determine the degree of gingival scallop. Circular (oval) potential for fenestrations and dehiscence and respond
or square teeth produce a shallower gingival scallop, while differently to extraction and have a different pattern of
triangular teeth form the opposite, a pronounced scallop, osseous remodeling following implant placement. Proper
predisposes to the so-called ‘black triangles’; especially care should be taken during extraction in thin biotype
with a thin biotype which has a propensity for recession. cases to prevent labial plate fracture. During postoperative
Furthermore, triangular teeth have divergent roots with healing phase, more dramatic alveolar resorption is seen
thicker interproximal bone, resulting in reduced vertical in apical and lingual direction for the ridge associated
bone loss compared with square teeth, whose root proximity with thin biotype. When these tissue biotypes are carefully
and thinner interdental bone have a higher incidence of considered, various periodontal and surgical strategies can
vertical bone resorption. be employed to improve the treatment outcome either by
 30 Journal of Indian Prosthodontic Society (March 2010) 10:27–30

minimizing alveolar resorption or by providing a better possibility of significant resorption, which may have an
tissue environment for implant placement. impact on esthetics. Furthermore, the loss of peri-implant
structures may result in thin, translucent tissue over the
Ridge Preservation in Thick vs Thin Biotypes implant, which appears grayish, especially if the facial
plate is lost and implant threads are exposed. In these cases,
Prevention of postextraction alveolar bone loss is critical further bone and soft tissue grafting procedures may be
in assuring implant success. Thin periodontal biotype is necessary. However, once an implant is in place, it may be
associated with thin alveolar plate, so it is usual to see more difficult to regain pre-extraction tissue contours. In a thick
ridge remodeling when compared with thick periodontal biotype environment, immediate placement of an implant
biotype which is associated with thick alveolar plate. can be completed with predictable results.
In thin biotypes, it’s not only a traumatic extraction is
critical in ridge preservation, it is important to consider Conclusion
strategies to preserve the alveolar bone such as socket
preservation or ridge preservation procedures [1, 8]. Evaluation of gingival tissue biotypes is important in
This loss can be 1.5–2.0 mm over the first 12 months treatment planning. Since thick and thin gingival biotypes
with most loss occurring during the initial 3 months. A are associated with thick and thin osseous patterns, the
variety of approaches can be employed to address this two tissue types respond differently to the inflammation and
problem, but most involve grafting the extraction socket trauma and have different patterns of osseous remodeling
and using membranes to support missing/perforated bony following the extraction or implant procedure. In
walls. Ridge preservation should be considered for most fixed prosthodontics, care to be taken in finish line
thin biotype cases. placement and retraction and type of restoration selection
Classically, socket or ridge preservation involves the use in esthetic zone.
of a graft material placed in the socket followed by a variety By understanding the nature of the tissue biotype, the
of other substances such as demineralized freeze-dried bone practioner can employ appropriate periodontal and surgical
allograft, mineralized freeze-dried bone allograft, xenograft procedures to minimize alveolar resorption and provide a
(mostly of bovine source), and alloplastic materials more favorable environment for implant placement.
(β-tricalcium phosphate, durapatite, hydroxyapatite).
The ridge preservation strategy is only successful if the
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