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 345

Relationship Between Clinical

Periodontal Biotype and Labial Plate
Thickness: An In Vivo Study

D. Ryan Cook, DDS, MS1/Brian L. Mealey, DDS, MS2 Contemporary dental therapy in-
Ronald G. Verrett, DDS, MS3/Michael P. Mills, DMD, MS4 volves the marriage of form and
Marcel E. Noujeim, DDS, MS5/David J. Lasho, DDS, MSD6 function influenced by esthetics,
Robert J. Cronin Jr, DDS, MS7 especially in the maxillary anterior
region. Understanding how the
The primary aim of this study was to evaluate the differences in labial plate thickness periodontium responds to therapy
in patients identified as having thin versus thick/average periodontal biotypes. is critical to achieving a successful
The association between biotype and labial plate thickness was evaluated by esthetic outcome, whether therapy
correlating information obtained from cone beam computed tomographs, diagnostic involves dental implants, surgical
impressions, and clinical examinations of the maxillary anterior teeth (canine to crown lengthening, or convention-
canine) in 60 patients. Compared to a thick/average biotype, a thin biotype was al prosthodontics. Consequently,
associated with thinner labial plate thickness (P < .001), narrower keratinized dental professionals must be aware
tissue width (P < .001), greater distance from the cementoenamel junction to the of the soft tissue morphology and
initial alveolar crest (P = .02), and probe visibility through the sulcus. There was no underlying bony anatomy.
relationship between biotype and tooth height-to-width ratio or facial recession.
There is a general impres-
Periodontal biotype is significantly related to labial plate thickness, alveolar crest
sion among clinicians that patients
position, keratinized tissue width, gingival architecture, and probe visibility but
who exhibit a “thin” biotype also
unrelated to facial recession. (Int J Periodontics Restorative Dent 2011;31:345–354.)
have a thin labial plate overlying
1 rivate Practice, Laguna Niguel, California; Formerly, Resident, Department of Periodontics and Depart-
P the roots of the maxillary anterior
ment of Prosthodontics, University of Texas Health Science Center San Antonio, San Antonio, Texas. teeth. Although this topic has been
2Professor, Department of Periodontics, University of Texas Health Science Center San Antonio,

San Antonio, Texas. discussed in the literature, there

3Associate Professor, Department of Prosthodontics, University of Texas Health Science Center currently are no documented hu-
San Antonio, San Antonio, Texas. man studies that confirm a relation-
4Clinical Associate Professor, Department of Periodontics, University of Texas Health Science Center

San Antonio, San Antonio, Texas. ship between periodontal biotype

5Assistant Professor, Department of Dental Diagnostic Sciences, University of Texas Health Science and labial bone thickness.
Center San Antonio, San Antonio, Texas. In 1923, Hirschfeld1 observed a
6Assistant Professor, Department of Periodontics, University of Texas Health Science Center

San Antonio, San Antonio, Texas. thin alveolar contour and made the
7Professor, Department of Prosthodontics, University of Texas Health Science Center San Antonio, assumption that such a thin bony
San Antonio, Texas. contour was probably accompanied
Correspondence to: Dr Brian L. Mealey, Department of Periodontics, UT Health Science Center San by a thin gingival form. Others have
Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; fax: 210-567-3761; email: [email protected]. described interproximal bone in the

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346

posterior region of the maxilla and the bony crest is positioned close a relationship to the thickness of
mandible as being flat, becoming to the CEJ. In a patient with a low the underlying labial alveolar bone
convex in the maxillary anterior re- alveolar crest position, an increased in the maxillary anterior region.
gion.2 Ochsenbein and Ross3 first propensity for gingival recession Secondary outcomes were aimed
classified the gingival anatomy as may result in exposure of restorative at determining whether clinical cat-
either “flat” or “pronounced scal- margins when finish lines are placed egorization of periodontal biotype
loped,” with the suggestion that intracrevicularly. was related to periodontal probe
flat gingiva was related to a square In 2009, De Rouck et al8 illus- visibility through the facial gingival
tooth form and pronounced scal- trated the presence of two distinct sulcus, papilla height, width of kera-
loped gingiva was related to a gingival biotypes. The first, which tinized tissue, ratio of tooth height
tapered tooth form. Weisgold4 occurred in one third of the study to width, distance from the CEJ
demonstrated an increased suscep- population and was most prominent to the height of the alveolar crest,
tibility to recession in individuals among females, was classified as facial gingival recession, and gin-
with a thin, scalloped gingival archi- having a thin gingival biotype, slen- gival architecture/form. In addi-
tecture. This theory was further sup- der tooth form, narrow zone of ke- tion, the percentage of patients in
ported by studies demonstrating ratinized tissue, and a high gingival the study group with an average
that central incisors with a narrow scallop. The second, which occurred CEJ-to–bone crest measurement of
crown form had a greater preva- in two thirds of the study population < 2.5 mm, 2.5 to 3.5 mm, and > 3.5
lence of recession than incisors with and mainly among males, was clas- mm was determined.
a wide, square form.5,6 Kois7 sug- sified as having a thick gingival bio-
gested a classification system relat- type, quadratic tooth form, broad
ed to periodontal biotype involving zone of keratinized tissue, and a flat Method and materials
the relationship between the ce- gingival margin.
mentoenamel junction (CEJ) and Diagnosis of periodontal bio- Sixty subjects (26 thin biotype,
the crest of the bone. The three cat- type and alveolar crest position 34 thick/average biotype) were
egories included: (1) normal crest: relative to the CEJ influences the enrolled, with the tooth used as
alveolar crest is 3 mm apical to the treatment planning of many esthet- the unit of measure (n = 360). Ex-
CEJ (85% of the population), (2) ic procedures. Periodontal biotype clusion criteria included history
high crest: alveolar crest is < 3 mm evaluation can be a valuable tool in of orthodontic therapy, gingival
apical to the CEJ (2% of the popula- establishing patient expectations in flap surgery, dental trauma, drug-
tion), and (3) low crest: alveolar crest many complex esthetic procedures induced gingival enlargement,
is > 3 mm apical to the CEJ (13% by allowing the clinician to predict periodontitis, and severe gingivi-
of the population). Kois described therapeutic outcomes. tis or the presence of grossly mis-
treatment outcomes in each of the This study was undertaken to aligned teeth, restoration involving
three crest positions and suggested assess whether the clinical deter- the cementoenamel junction, and
that clinical outcomes were strongly mination of biotype provides the missing teeth. This study exam-
related to the gingival/alveolar crest clinician with information relevant ined the relationship of periodontal
form. He discussed how alveolar to the underlying bony contours biotype to labial plate thickness by
crest position may affect tooth prep- in the maxillary anterior region, es- correlating information obtained
aration. For example, preparing in- pecially the thickness of the labial by cone beam computed tomog-
tracrevicular finish lines in a patient plate and the position of the bony raphy (CBCT), clinical examination,
with a high alveolar crest position crest relative to the CEJ. The pri- and diagnostic impressions of the
may increase the susceptibility of mary aim was to determine whether maxillary anterior teeth. Patients
biologic width impingement since soft tissue periodontal biotype has enrolled in the study underwent

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 347

Fig 1    Labial plate thickness at 4, 6, 8, and

10 mm from the CEJ and distance from the
CEJ to the alveolar crest were determined
using CBCT.

10
m
8m m
6m m Labial plate
4m m thickness at 4, 6,
m
8, and 10 mm
apical to CEJ

CEJ to alveolar
crest

CBCT imaging for reasons other thickness of the labial plate at the (Figs 2a and 2b). In addition, during
than those of the study, predomi- sagittal midpoint of each tooth was periodontal probing, the examiner
nantly for diagnostic and treatment determined at distances 4, 6, 8, and determined whether the periodon-
planning purposes, such as prior to 10 mm apical to the CEJ (Fig 1). All tal probe was visible through the
dental implant therapy and restor- measurements were made under marginal soft tissue (Figs 3a and
ative care, endodontic treatment, 2.5× magnification by a single ex- 3b). The examination also consist-
or orthodontic work-up. The proto- aminer in triplicate to ensure accu- ed of periodontal charting (probing
col was approved by the Institution- racy. A second examiner repeated depth, recession, clinical attach-
al Review Board of the University of 10% of these measurements to cali- ment level, bleeding on probing),
Texas Health Science Center at San brate the first examiner’s measure- keratinized tissue width (mm), and
Antonio, and all subjects signed an ments. All subjects were scanned clinical assessment of the gingival
informed consent document prior using 3DX Accuitomo (Morita) with architecture (Figs 4a and 4b). Three
to enrollment in the study. a slice thickness of 1.0 mm, and in- examiners, including the primary
formation was presented in three author, a board-certified periodon-
planes (x, y, and z) using iDixal soft- tist, and a board-certified prostho­
CBCT ware (Morita). Labial plate thick- dontist, categorized each subject
ness measurements were rounded as having either a thick/average or
CBCT was used to digitally mea- to the nearest 0.01 mm. thin biotype to evaluate consisten-
sure the thickness of the labial plate cy of clinical biotype determination
in a faciopalatal direction at several across multiple examiners. Each ex-
fixed points relative to the CEJ. Clinical examination aminer was masked to the results
First, the vertical distance from the of the other examiners. To most
CEJ to the initial crest of bone was The clinical examination was used clearly delineate clinical differences
determined at the sagittal (mesio- to categorize the individual maxil- between biotypes, classification
distal) midpoint of each maxillary lary anterior teeth as having either was limited to two categories: thin
anterior tooth (Fig 1). Then, the a thick/average or thin biotype and thick/average.

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348

Figs 2a and 2b    (left) Thick/average and (right) thin periodontal biotypes.

Figs 3a and 3b   Probe (left) visible and

(right) not visible through the gingival
sulcus.

Figs 4a and 4b    (left) Flat and (right) scalloped gingival architecture.

Fig 5    Diagnostic cast illustrating papilla height (in mm, black lines)
and tooth height-to-width ratio (in mm, white lines).

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 349

Diagnostic impressions thickness measurements within

groups, then the sample of 60 sub-
Dental casts made from irrevers- jects is sufficient to detect this differ-
ible hydrocolloid diagnostic im- ence by the Student t test with a
pressions were used to measure significance of P < .05 and power of
the tooth height-to-width ratio and 90%. The power analysis was per-
the distance from the most apical formed using PASS 6.0 software
extent of the free gingival margin (NCSS).
to the maximum height of the in-
terdental papilla for each anterior
tooth (Fig 5). Results

Consensus among the three exam-

Statistical analysis iners classifying biotype for patients
was consistent. All three examiners
Statistical analysis consisted of two- were in complete agreement for
factor analysis of variance to test 87% of patients; the overall kappa
the interaction between biotype statistic for the three examiners was
and the primary and secondary 0.816, indicating consistency of re-
outcomes. Examiner consistency in sults in clinical biotype classification.
determining the clinical biotype was Of the triplicate digital CBCT
evaluated using the kappa statistic. measurements made by the primary
This study was designed primar- examiner, 96.2% varied by less than
ily to compare mean labial plate 0.10 mm and 99.7% varied by less
thickness for healthy subjects de- than 0.20 mm. Relative to the pri-
fined as having a thin biotype versus mary examiner’s measures, the sec-
average/thick biotype. Although a ond examiner was within 0.10 mm
thin biotype is less prevalent than av- for 87.6% of observations and within
erage/thick biotype, the goal of the 0.20 mm for 97.2% of observations.
original sampling was to include an The Pearson correlation coefficient
equal number of subjects for the two between the mean of the triplicate
biotype classifications. Because this primary examiner’s measures and
is the first study to analyze this com- the corresponding measures by the
parison, there are no historic data on second examiner was 0.996, dem-
which to base estimates for paramet- onstrating the validity of the CBCT
ric statistics. Therefore, a sample size measuring technique.
of 60 healthy subjects was recruited
to ensure adequate power to detect
clinically meaningful differences. If,
for the population of healthy sub-
jects, labial plate thickness means for
thin and average/thick biotype
groups differ by at least 85% of the
standard deviation of labial plate

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350

Table 1 Labial plate thickness at 4, 6, 8, and 10 mm from the CEJ between the two biotypes

Thin biotype Thick/average biotype

Distance from CEJ/ Mean SD No. of Mean SD No. of
Tooth type (mm) (mm) teeth (mm) (mm) teeth P
4 mm
Canine 0.281 0.131 45 0.657 0.150 66 < .001
Lateral incisor 0.366 0.150 44 0.794 0.131 67 < .001
Central incisor 0.383 0.123 44 0.811 0.098 68 < .001
6 mm
Canine 0.328 0.122 52 0.753 0.126 68 < .001
Lateral incisor 0.400 0.145 52 0.885 0.128 68 < .001
Central incisor 0.421 0.133 52 0.903 0.107 68 < .001
8 mm
Canine 0.409 0.129 52 0.856 0.158 68 < .001
Lateral incisor 0.463 0.148 52 1.029 0.161 68 < .001
Central incisor 0.508 0.127 52 1.046 0.156 68 < .001
10 mm
Canine 0.485 0.225 50 0.977 0.224 68 < .001
Lateral incisor 0.540 0.275 52 1.215 0.251 68 < .001
Central incisor 0.601 0.261 52 1.218 0.208 68 < .001
SD = standard deviation.

Association between CBCT and average biotype group (Table 1). that of a thick/average biotype at
clinical examination At all four distances apical to the all four distances from the CEJ—
CEJ and for each tooth type, a thin differences of approximately 0.3 to
Data were organized for analysis biotype was associated with a sig- 0.5 mm in thickness between the
into three groups by tooth type: nificantly thinner labial plate than groups (Table 1, Fig 6). A typical
canines, lateral incisors, and cen- a thick/average biotype (P < .001). CBCT of a thick/average biotype is
tral incisors. The CBCT revealed Figure 6 illustrates these data sepa- illustrated in Fig 7a, while Fig 7b il-
statistically significant differences rated into tooth groups at 4, 6, 8, lustrates the CBCT of a thin biotype.
in labial plate thickness at 4, 6, 8, and 10 mm from the CEJ. Gener- A thin periodontal biotype was
and 10 mm from the CEJ in the ally, a thin biotype was associated also associated with a significantly
thin biotype group versus the thick/ with a labial plate thickness half increased distance from the CEJ to

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 351

Fig 6    Biotype relationship to

labial plate thickness at 4, 6, 1.50 Thin
8, and 10 mm from CEJ. Error Thick/average
bars are ± 1 SD. P < .001 for all
comparisons. 1.25

1.00

Distance from CEJ

0.75

0.50

0.25

0
Canine Lateral Central Canine Lateral Central Canine Lateral Central Canine Lateral Central
incisor incisor incisor incisor incisor incisor incisor incisor

4 mm 6 mm 8 mm 10 mm

Figs 7a and 7b    CBCTs of a (left) thick/

average and (right) thin biotype.

the alveolar crest when compared 71.4% of teeth, and > 3.5 mm in
to a thick/average biotype (P < .001, 19.4% of teeth.
Table 2). Subjects with a thin bio- There was also a significant rela-
type had a mean CEJ-to–bone crest tionship between labial plate thick-
measurement ranging from 3.35 ness and the width of keratinized
to 3.39 mm, while subjects with a tissue (Table 2). For all tooth types,
thick/average biotype ranged from a thin biotype had a significantly nar-
3.06 to 3.15 mm. Overall, the dis- rower zone of keratinized tissue com-
tance from the CEJ to the alveo- pared to a thick/average biotype.
lar crest was < 2.5 mm in 9.2% of The difference between the two
teeth, between 2.5 and 3.5 mm in groups was approximately 1 mm.

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352

Table 2 Biotype relationship to alveolar crest position, keratinized tissue width,

and tooth height-to-width ratio

Thin biotype Thick/average biotype

Mean No. of Mean No. of

Parameter/tooth type (mm) SD (mm) teeth (mm) SD (mm) teeth P
Alveolar crest position
Canine 3.37 0.59 52 3.15 0.44 68 < .030
Lateral incisor 3.39 0.68 52 3.06 0.53 68 < .002
  Central incisor 3.35 0.74 52 3.10 0.46 68 < .020
Keratinized tissue width
Canine 4.63 0.63 52 5.65 0.94 68 < .001
Lateral incisor 4.63 0.66 52 5.74 1.00 68 < .001
Central incisor 4.35 0.68 52 5.31 0.89 68 < .001
Tooth height-to-width ratio
Canine 1.22 0.10 52 1.21 0.11 68 .638
  Lateral incisor 1.24 0.15 52 1.20 0.14 68 .086
  Central incisor 1.16 0.11 52 1.13 0.13 68 .130
SD = standard deviation.

Association between clinical ference was statistically significant to visualize the probe through the
examination and diagnostic (P < .001). There was a tendency for gingival sulcus was associated with
impressions a flat gingival architecture to have a clinical classification of thick/aver-
a lower tooth height-to-width ratio, age biotype. Table 3 illustrates the
There was no significant association while a scalloped gingival architec- relationship between periodontal
found between the clinical classifi- ture was associated with a higher biotype classification and probe vis-
cation of periodontal biotype and tooth height-to-width ratio, but the ibility through the gingival sulcus.
tooth height-to-width ratio (Table 2) differences were not statistically sig- Overall, 84% of teeth in subjects
or papilla height measured on the nificant. with a clinical diagnosis of a thin
diagnostic casts. Gingival architec- periodontal biotype demonstrated
ture was significantly associated with probe visibility through the gingi-
papilla height. Clinical classification Association between the val sulcus, compared to only 7% of
of flat gingival architecture was as- different clinical measurements teeth with a thick/average biotype.
sociated with a mean papilla height Central incisors showed the most
distance of 2.85 mm, while the clini- Probe visibility through the gingi- variability in probe visibility with re-
cal classification of scalloped archi- val sulcus was strongly associated spect to biotype classification.
tecture was associated with a mean with a clinical classification of thin There was a significant rela-
papilla height of 4.43 mm. This dif- periodontal biotype, while inability tionship found between the clinical

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 353

Table 3 Biotype relationship to probe visibility based on

tooth type

Probe visible
Tooth type/biotype Yes No
Canine
Thin
No. of teeth 49 3
% biotype 94.2% 5.8%
Thick
No. of teeth 9 59
% biotype 13.2% 86.8%
Lateral incisor
Thin
No. of teeth 49 3
% biotype 94.2% 5.8%
Thick
No. of teeth 4 64
% biotype 5.9% 94.1%
Central incisor
Thin
No. of teeth 33 19
% biotype 63.5% 36.5%
Thick
No. of teeth 2 66
% biotype 2.9% 97.1%

classification of periodontal bio- biotype. There was no significant sion; therefore, the results relative
type and that of gingival architec- association between periodon- to recession should be interpreted
ture (Fisher exact test, P = .009). tal biotype classification and age, with caution. Interestingly, there
Subjects classified as having a thin race, gingival margin position (re- was also no significant relationship
biotype were more likely to have cession), or sex. It should be noted between gingival architecture and
scalloped gingival architecture that only 6.1% of all teeth evalu- width of keratinized gingiva.
than subjects with a thick/average ated demonstrated gingival reces-

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354

Discussion Although these data may aid clinical situations, including esthetic
clinicians in their diagnosis and crown lengthening, crown/veneer
This research provides the first hu- treatment planning, bone sounding preparations, implant placement
man evidence to support the clinical of each individual tooth remains in the esthetic zone, extraction site
impression that a thin biotype is as- the gold standard in the evalua- wound healing, and mucogingival
sociated with a thin underlying labial tion of alveolar crest position be- therapy. This study provides the
plate and a thick or average biotype cause of patient variation. Tooth first human evidence to support the
is associated with a thicker labial rotations or other malpositions may commonly held opinion that pa-
plate. Likewise, a thin biotype was factor into gingival thickness, la- tients with a clinically thick/average
associated with a significantly great- bial plate thickness, distance from biotype have a thicker labial plate
er distance between the CEJ and the the CEJ to alveolar crest, gingival and a smaller distance from the CEJ
bony crest than was a thick/average architecture, and keratinized tis- to the alveolar crest than subjects
biotype. Probe visibility through the sue width. Although patients in this with a thin clinical biotype.
gingival sulcus was a good clinical study were excluded if gross tooth
indicator for a thin periodontal bio- misalignment was present, the few
type, while a lack of probe visibility “outliers” among the data set were References
through the sulcus was an indicator associated with minor tooth malpo-
  1. Hirschfeld I. A study of skulls in the Amer-
for a thick/average periodontal bio- sition. Clinicians should be aware of ican Museum of Natural History in rela-
type. Central incisors had the most both major and minor malpositions tion to periodontal disease. J Dent Res
1923;5:251–265.
variability in probe visibility overall. and how these changes in anatomi-
 2. O’Conner TW, Biggs N. Interproximal
Although a patient with a thin bio- cal structure may affect therapy. craters. J Periodontol 1964;35:46–57.
type is more likely to present with Many clinicians believe that a  3. Ochsenbein C, Ross S. A reevaluation
of osseous surgery. Dent Clin North Am
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restoration. Alpha Omegan 1977;7:77–89.
average periodontal biotypes may tissue, while a scalloped architec-
  5. Olsson M, Lindhe J. Periodontal charac-
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gival architecture depending on their zone. Data gathered from this of the upper central incisors. J Clin Peri-
odontol 1991;18:78–82.
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and clinical features of the gingiva in
Each patient presentation pos- patients with a flat versus scalloped
adolescents. J Clin Periodontol 1993;20:
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that will influence the esthetic out- A clinician’s knowledge of  7. Kois JC. The restorative-periodontal in-
terface: Biological parameters. Periodon-
come of treatment. On average, this anatomy, form, and function of the tol 2000 1996;11:29–38.
study showed that a patient with a maxillary anterior dentition is para-  8. De Rouck TD, Eghbali R, Collys K,
De Bruyn H, Cosyn J. The gingival biotype
thin periodontal biotype displays a mount in achieving optimal treat-
revisited: Transparency of the periodon-
narrower zone of keratinized tissue ment outcomes. The simple act of tal probe through the gingival margin
than a patient with a thick/average placing a periodontal probe into as a method to discriminate thin from
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centage of patients likely have teeth may provide an excellent clue as
in which the distance from the CEJ to the clinical periodontal biotype
to the alveolar crest is between 2.5 and true nature of the underlying
and 3.5 mm (71.4%), with less fre- labial plate thickness. Classifica-
quent measurements of < 2.5 mm tion of periodontal biotype may as-
(9.2%) or > 3.5 mm (19.4%). sist practitioners in a multitude of

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