Original Article

An evaluation of gingival phenotype and thickness as determined by

indirect and direct methods
Jessica Konga; Johan Apsb; Steven Naoumc; Richard Leec; Leticia Algarves Mirandad;

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Kevin Murraye; James K. Hartsfield Jr.f; Mithran S. Goonewardeneg

ABSTRACT
Objectives: To evaluate gingival phenotype (GP) and thickness (GT) using visual, probing, and ultra-
sound (US) methods and to assess the accuracy and consistency of clinicians to visually identify GP.
Materials and Methods: The GP and GT of maxillary and mandibular anterior teeth in 29 orthodon-
tic patients (mean age 25 6 7.5 years) were assessed using probing and US by a single examiner.
General dentist and dental specialist assessors (n ¼ 104) were shown intraoral photographs of the
patients, including six repeated images, and asked to identify the GP via a questionnaire.
Results: An increasing trend in GT values of thin, medium, and thick biotype probe categories
was found, though this was not statistically significant (P ¼ .188). Comparison of probing method
to determinations of GT made by US yielded slight agreement (j ¼ 0.12). Using the visual meth-
od, assessors’ identification of the second GP determination ranged from poor to moderate
agreement (j ¼ 0.29 to j ¼ 0.53).
Conclusions: The probe method is sufficient in differentiating between different categories of GP.
However, further research is required to assess the sensitivity of the probe method in recognizing
phenotypes in the most marginal of cases. Assessors using the visual method lack the ability to
identify GP accurately and consistently among themselves. (Angle Orthod. 0000;00:000–000.)
KEY WORDS: Gingival phenotype; Gingival biotype; Gingival thickness; Visual; Probe; Ultrasound

INTRODUCTION the likelihood of achieving favorable esthetic and func-

tional outcomes.2,3
Maintaining the integrity of the gingival tissues is es- Periodontal phenotype is composed of distinctive
sential for all facets of dentistry to ensure ideal, long- anatomic characteristics. It includes in its definition,
term clinical outcomes.1 Gingival thickness (GT) and GT, GP, keratinized tissue width, thickness of buccal
phenotype (GP) are considered useful predictors for bone, and tooth dimension.4,5 Phenotype is most

a
Graduate Student, Orthodontics, Dental School, The University of Western Australia, Nedlands, Western Australia, Australia.
b
Former Associate Professor and Discipline Lead, Dentomaxillofacial Radiology, Dental School, The University of Western
Australia, Nedlands, Western Australia, Australia.
c
Senior Lecturer, Orthodontics, Dental School, The University of Western Australia, Nedlands, Western Australia, Australia.
d
Associate Professor and Discipline Lead, Periodontics, Dental School, The University of Western Australia, Nedlands, Western
Australia, Australia.
e
Professor and Head, Division of Health and Medical Sciences, School of Population and Global Health, The University of Western
Australia. Nedlands, Western Australia, Australia.
f
E. Preston Hicks Endowed Professor of Orthodontics and Oral Health Research, College of Dentistry, University of Kentucky, KY,
USA; and Professor of Microbiology and Molecular Genetics, College of Medicine; and Clinical Professor, Director of the Craniofacial
Genetics Program, Division of Oral Development and Behavioural Sciences, School of Dentistry, The University of Western Australia,
Nedlands, Western Australia, Australia.
g
Discipline Lead, Orthodontics, Dental School, The University of Western Australia, Nedlands, Western Australia, Australia.
Corresponding author: Dr Mithran S. Goonewardene, Orthodontics, Dental School, The University of Western Australia, 17 Monash
Avenue, Nedlands 6009, Western Australia, Australia
(e-mail: [email protected])
Accepted: May 2023. Submitted: August 2022.
Published online: July 6, 2023
Ó 0000 by the EH Angle Education and Research Foundation, Inc.

DOI: 10.2319/081622-573.1 1 Angle Orthodontist, Vol 00, No 00, 0000

2 KONG, APS, NAOUM, LEE, MIRANDA, MURRAY, HARTSFIELD, GOONEWARDENE

commonly defined using a binary classification MATERIALS AND METHODS

that considers GT 1 mm as thin and .1 mm as
The Human Ethics Committee of the University of
thick. 1,3,6–9 However, the values defining different
Western Australia approved this study with relevant
phenotype classifications exist only as a matter of
patient information and consent documents (reference
discourse.1,2,10,11
number: RA/4/20/5449).
It has been suggested that thin and thick pheno-
Twenty-nine pre-orthodontic patients from the De-
types respond differently to orthodontic, periodontal,
partment of Orthodontics at the Oral Health Centre of
surgical, and restorative treatments.1,3,10,12–18 Individ-
Western Australia (OHCWA) were recruited on a vol-

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uals with thin phenotypes may respond poorly and be
unteer basis from February to July 2019. Patients
prone to the development of gingival recession after
were included if they were 18 years or over with good
excessive orthodontic movements,7,19–21 implant sur-
oral hygiene. The exclusion criteria were:
gery,6,13,22 crown lengthening and root coverage pro-
cedures,23,24 nonsurgical periodontal therapy,25 and • Decay, crowns, or fillings of the maxillary and man-
prosthodontic treatment.22 This is in contrast to thick dibular anterior teeth;
phenotypes that have shown greater soft tissue resil- • Gingivitis or periodontitis;
ience and an increased likelihood to have presence of • Pregnant or lactating;
a papilla between an implant and adjacent tooth.12 • Smoker; or
Therefore, the need for precise determination of GP • Currently or history of taking any medications
and GT prior to commencing treatment is crucial in known to cause enlargement of the gums (calcium
maintaining the long-term health and stability of gingi- antagonists, cyclosporin A, phenytoin).
val tissues.
There continues to be no favored or recognized Visual Assessment
method for determining GP, especially one that can Standardized intraoral photographs of the patients’
repeatedly and reliably be used to make appropriate anterior teeth and surrounding tissues in optimal oc-
classifications. Two methods that are highly practiced clusion were taken by the same examiner (JK), then
among clinicians are: visual assessment (where dif- cropped and prepared to a standardized format. Any
ferent morphological characteristics such as tooth identifiable characteristics were removed to ensure
shape and size, contour of the gingiva, width of kera- anonymity. The photographs were collated in a web-
tinized tissue, and papilla height are evaluated); and based questionnaire using Qualtrics Survey Software
probing (where the transparency of the probe through (Qualtrics, Provo, UT, USA) and distributed via email
the gingival tissues is assessed).9,12,26 However, both as a direct web-linked survey. Assessors were recruited
methods are subjective and offer no empirical mea- on a volunteer basis and comprised general and
surement.1–3,10,11,23,27 Still, they are highly practiced specialist dentists. Information on how to determine
during routine clinical examinations.3,12,23 GP using only visual information in the photographs
Alternatively, direct methods of measuring true GT was provided before starting the questionnaire. The
provide actual numerical information and are the assessors submitted an overall GP determination as
most objective methods.1,14,27 However, techniques either thin, medium, or thick. Six duplicate photographs
such as bone sounding and calipers are invasive and were also inserted randomly to measure intrarater reli-
require local anesthetic.1,3,7,8,13,14,27–34 In recent ability. None of the assessors had been informed of this
years, there has been increasing interest in the use double scoring.
of direct, but noninvasive, methods such as comput-
ed tomography and ultrasound (US). Muller and col- Probe Transparency
leagues conducted numerous studies using US to
assess GT, which they deemed to have remarkable GP was assessed using a Colorvue Biotype Probe
validity and repeatability.8,9,15–18,35 (CBP) (Hu-Friedy Mfg. Co., LLC Chicago, IL, USA). It
This study evaluated these common indirect meth- features three colors: white, green, and blue, each
ods and assessed two hypotheses: representing thin, medium, and thick GP, respectively.
The CBP was inserted into the gingival sulcus at the
1. There would be no difference in the GP classifica- midlabial aspect of each maxillary and mandibular an-
tion afforded by the probing method compared to a terior tooth with minimal pressure. Depending on visi-
direct measurement of GT; bility of the colors through the labial gingiva, a GP
2. Clinicians could accurately identify GP using the vi- classification for each tooth was made. All measure-
sual assessment method with no difference in the ments were performed by a single examiner (JK), who
first and second instances of classification. had been calibrated against a periodontist (LAM).

Angle Orthodontist, Vol 00, No 00, 0000

GINGIVAL THICKNESS MEASURED DIRECTLY AND INDIRECTLY 3

0.01 mm. All measurements were performed by a sin-

gle examiner (JK), calibrated against the radiologist.

Intraexaminer Repeatability
Intraexaminer reproducibility was analyzed by se-
Figure 1. Buccolingual cross-section of the alveolar bone, gingiva, lecting 10 random patients who were re-examined 1
and enamel produced by US from which GT was measured. GT in- week apart using the probing method and remeasur-
dicates gingival thickness; US, ultrasound. ing US images.

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Measuring GT Statistical Analysis

US (Philips Affiniti 70G) was carried out by a dento- Sample size calculation was based on intraclass cor-
maxillofacial radiologist (JA) using a hockey-stick shaped relation coefficient (ICC) in which each tooth was con-
transducer (10 mm 3 30 mm) Koninklijke Philips, NV, sidered as a replicate unit. Therefore, considering an
USA with a frequency of 7–15 MHz to measure the GT alpha level of 0.05, a power of 0.80, and 0.50 as the
of the maxillary and mandibular anterior teeth of each minimal acceptable level of ICC, a sample size of ap-
patient. A tasteless gel pad (Aquaflex) Parker Laborato- proximately 233 teeth (19 subjects) was necessary.36
ries Inc, Fairfield, NJ, USA was used as the medium, Data were analyzed using the R environment (R
covering the labial surface of the teeth and gingiva. Foundation for Statistical Computing). GT for each pa-
Prior to this study, validation of this machine against tient was compared with the probe classifications us-
another direct method (transgingival probing) was ing analysis of variance (ANOVA). A weighted kappa
performed. coefficient (j) assessed the agreement of the probe
US images captured at each tooth showed a bucco- method as well as the intra- and inter-rater reliability. It
lingual cross section of the enamel, gingiva, and alve- was also calculated for each assessor and used as
olar bone (Figure 1). A total of 348 images were used the response value in a multivariate linear regression
to measure GT using a perpendicular line drawn from to investigate if there was any relationship with as-
the mucogingival surface to the summit of the alveolar sessor accuracy and their demographic information.
bone crest. Measurements were performed three Additionally, j was calculated to assess intrarater re-
times, averaged per tooth, and taken to the nearest liability of the assessors using the visual method.

Figure 2. GP determinations grouped into maxillary and mandibular anterior teeth, incisors, and canines. GP indicates gingival phenotype.

Angle Orthodontist, Vol 00, No 00, 0000

4 KONG, APS, NAOUM, LEE, MIRANDA, MURRAY, HARTSFIELD, GOONEWARDENE

Table 1. Frequency and Percentages of Gingival Phenotype

Determinations by Ultrasound, Probing, and Visual Methods
Thin Medium Thick
Ultrasound 5 (17.24%) 5 (17.24%) 19 (65.52%)
Probe 12 (41.38%) 11 (37.93%) 6 (20.69%)
Visual 9 (31.03%) 15 (51.72%) 5 (17.24%)

For continuous variables, ICC was used to validate

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the US machine with transgingival probing as the ref-
erence standard and to assess intra- and inter-rater
reliability for the US method.

RESULTS
Of the 29 preorthodontic patients, there were 19 fe-
males and 10 males. The mean age was 25 6 7.9
years with a range of 18–45 years. The majority of pa- Figure 3. An increasing trend was observed between the mean GT
tients were Asian (62%) followed by Caucasian (38%). and the ordered probe classification groups; however, this relation-
A total of 55% of patients were Class I, 27% were ship was not significant (P ¼ .188).
Class III, and 17% were Class II.
The US machine used in this study showed good 0.85–0.9 mm, 50% of probing determinations were re-
agreement (ICC ¼ 0.85) with transgingival probing. corded as thin.
The intrarater reliability of the examiner using US and
probing methods was excellent (ICC ¼ 0.9, ICC ¼ 0.97). Visual Assessment
The interrater reliability for US and probing method was
also excellent (ICC ¼ 0.98, k ¼ 0.95). A summary of the A total of 104 assessors participated in the web-
GP determinations is shown in Figure 2. based questionnaire. From each demographic, the
greatest proportion were general dentists (62%), and
Probing Method males (61%) aged between 30 and 39 years (39%).
A higher proportion of orthodontists (14%) over other
The counts and percentages of the number of thin, specialists (9%) and general dentists (8%) made
medium, and thick phenotypes classified by US and more correct phenotype identification using the visual
probing are summarized in Table 1. method. No demographic variables were statistically
Table 2 shows counts of GP determinations made significant.
by both methods. The ANOVA analysis to compare Table 3 details the counts and percentages of the
probing and US methods found an insignificant rela- overall GP determination made by assessors using vi-
tionship (P ¼ .188) (Figure 3). When GT were catego- sual assessment. The agreement of each assessor to
rized into groups of thin, medium, and thick phenotype identify GP correctly ranged from disagreement (j ¼
and then compared to the same probe classification 0.23) to fair agreement (j ¼ 0.35). Table 4 shows
groups, there was slight agreement between the US
and probing methods (j ¼ 0.12).
Figure 4 details the proportion of each phenotype
Mean gingival thickness and % probe
recorded by probing arranged in GT of 0.05-mm incre- determinations
ments. For mean thicknesses of 0.7–0.75 mm and

Table 2. Correlation of Probing Classification and Ultrasound

Phenotype Classifications. More Thin (60%) and Medium (60%)
Phenotypes Were Correctly Identified by the Probe Compared to
Thick (26%) Phenotypes
Ultrasound Classification
Thin Medium Thick
Probe Classification Mean gingival thickness measurements
Thin 3 2 7
Medium 1 3 7
Figure 4. Mean GT grouped into thin, medium, and thick pheno-
Thick 1 0 5
types as determined by probing.

Angle Orthodontist, Vol 00, No 00, 0000

GINGIVAL THICKNESS MEASURED DIRECTLY AND INDIRECTLY 5

Table 3. Visual Classification Summary for Each Patient

Mean gingival thickness and % visual responses
Thin Medium Thick
Patient 1 42 (40.38%) 50 (48.08%) 12 (11.54%)
Patient 2 6 (5.77%) 33 (31.73%) 65 (62.5%)
Patient 3 19 (18.27%) 70 (67.31%) 15 (14.42%)
Patient 4 70 (67.31%) 29 (27.88%) 5 (4.81%)
Patient 5 37 (35.58%) 54 (51.92%) 13 (12.5%)
Patient 6 3 (2.88%) 47 (45.19%) 54 (51.92%)
Patient 7 3 (2.88%) 45 (43.27%) 56 (53.85%)

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Patient 8 11 (10.58%) 58 (55.77%) 35 (33.65%)
Patient 9 37 (35.58%) 46 (44.23%) 21 (20.19%)
Mean gingival thickness measurements
Patient 10 76 (73.08%) 26 (25%) 2 (1.92%)
Patient 11 65 (62.5%) 36 (34.62%) 3 (2.88%)
Patient 12 31 (29.81%) 66 (63.46%) 7 (6.73%) Figure 5. Mean GT grouped into thin, medium, and thick pheno-
Patient 13 57 (54.81%) 44 (42.31%) 3 (2.88%) types as determined by assessors using visual assessment.
Patient 14 18 (17.31%) 69 (66.35%) 17 (16.35%)
Patient 15 13 (12.5%) 41 (39.42%) 50 (48.08%)
Patient 16 12 (11.54%) 51 (49.04%) 41 (39.42%) This was consistent with other studies that compared
Patient 17 29 (27.88%) 63 (60.58%) 12 (11.54%) direct and indirect methods.1,31 For instance, Alves
Patient 18 57 (54.81%) 38 (36.54%) 9 (8.65%)
Patient 19 14 (13.46%) 71 (68.27%) 19 (18.27%)
et al. compared the probe with transgingival probing
Patient 20 90 (86.54%) 12 (11.54%) 2 (1.92%) and CT methods and found slight agreement in both
Patient 21 49 (47.12%) 53 (50.96%) 2 (1.92%) cases (j ¼ 0.19, 0.12).1
Patient 22 9 (8.65%) 68 (65.38%) 27 (25.96%) In contrast, the findings in this study differed from Kan
Patient 23 43 (41.35%) 48 (46.15%) 13 (12.5%) et al. in which probe transparency was statistically insig-
Patient 24 78 (75%) 21 (20.19%) 5 (4.81%)
Patient 25 7 (6.73%) 35 (33.65%) 62 (59.62%) nificant compared to direct caliper measurements.3 How-
Patient 26 51 (49.04%) 46 (44.23%) 7 (6.73%) ever, their measurements were taken from a single tooth
Patient 27 30 (28.85%) 59 (56.73%) 15 (14.42%) compared to multiple points of measurements, contribut-
Patient 28 13 (12.5%) 57 (54.81%) 34 (32.69%) ing to the differing results.
Patient 29 88 (84.62%) 15 (14.42%) 1 (0.96%)
An increasing trend in the GT values of thin, medi-
um, and thick phenotype probe categories was found,
though this was not statistically significant. This por-
counts of GP determinations made by the US and vi-
trayed apparent difficulties for the probe to determine
sual methods.
phenotypes of borderline thicknesses especially in
Figure 5 shows the proportion of each phenotype
the range from 0.7 to 0.9 mm. Although this was
recorded by assessors using the visual method ar-
shown with only a small sample size of 29 patients in
ranged in GT of 0.05-mm increments. For patients
this study, a similar conclusion was made by Kan
with mean GT of 0.7–0.75 mm and 0.85–0.9 mm, the
et al. in which the ability of the probe to correctly iden-
responses were comparable.
tify GP was questionable for GT values between 0.6
The first and second GP determinations by each as-
and 1.2 mm.3 Alves et al. also found this with a small-
sessor for the six repeated patient images is summa-
er sample size.1 Interestingly, the mean GT found in
rized in Tables 5–10.
this study similarly ranged from 0.58 to 1.22 mm
(mean ¼ 0.9 mm; SD ¼ 0.32 mm). Fischer et al. also
DISCUSSION noted difficulty of the probe to discriminate between
Comparison of the probing method to determinations marginal cases of thin and thick phenotypes with
of GT made by US yielded slight agreement (j ¼ 0.12). mean values between 0.53 and 0.62 mm.32 These re-
sults suggest that, although the probing method is
sufficient in identifying different GP, it may not be suf-
Table 4. Correlation of Visual Classification and Ultrasound
ficiently discriminatory to overcome subjectivities of
Phenotype Classifications. Visual Assessment Correctly Identified 60%
of Thin and 21% of thick Phenotypes. Visual Assessment Identified 15
Medium Phenotypes, of Which Five Were Considered Correct Table 5. Visual Classification Counts for Repeated Patient 5
Ultrasound Classification Second Seen
Thin Medium Thick Thin Medium Thick
Visual Classification First Seen
Thin 3 0 6 Thin 15 15 7
Medium 1 5 9 Medium 8 35 11
Thick 1 0 4 Thick 1 5 7

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6 KONG, APS, NAOUM, LEE, MIRANDA, MURRAY, HARTSFIELD, GOONEWARDENE

Table 6. Visual Classification Counts for Repeated Patient 12 Table 8. Visual Classification Counts for Repeated Patient 17
Second Seen Second Seen
Thin Medium Thick Thin Medium Thick
First Seen First Seen
Thin 9 19 3 Thin 18 11 0
Medium 4 51 11 Medium 6 53 4
Thick 0 4 3 Thick 0 2 10

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the user, especially in borderline phenotype cases of Limitations
similar GT. This study classified GT into three categories to corre-
This study found clinicians unable to identify GP ac- spond with the categories of the CBP used in this study.
curately or consistently when using the visual method. Although a third category provides an extra level of preci-
This was also evident in the spread of different GP de- sion, determining GT threshold values for each pheno-
terminations among assessors for the same patient. type was difficult due to fewer studies employing a tertiary
Previous studies have also demonstrated poorer ability classification system.14,32 Without accepted, standardized
to identify GP visually, compared to other indirect and threshold values, the nonsystematic approach to deciding
direct methods.1,3 Figure 4 further illustrates a similar di- these values will always remain a key drawback.
vision of all three phenotype determinations, which was Most previous studies have homogenized ethnicities
most markedly distinct across the 0.7–0.9 mm range. by sampling only Caucasians.3,9,14 In this study, the ma-
This suggests risk of misinterpretation of thin pheno- jority identified as Asian. It is conceivable that degrees of
types for thick phenotypes, which may have a significant gingival color pigmentation may have influenced clinician
impact on treatment planning and, eventually, the final subjectivity during probing and visual assessment.
outcome. Although it remains common in clinical practice to as-
Understanding an assessors’ rationale for their sess individual sites to make an overall GP determination
determination of phenotype by visual assessment for the whole dentition, this study found different GP exists
may have illustrated partialities to certain teeth or in different teeth. Thus, there is a possibility of overesti-
morphological features. If more assessors were pre- mating GP and overlooking thin phenotype, which is at
disposed to a certain feature than others, then this most risk of mucogingival problems.
may explain the poor agreement found with the visu- US is technique-sensitive and there may be difficul-
al method. ties with accessibility.2,11,14,28 This remains the major
For all repeated images in the questionnaire, there barrier for clinical adoption of this device.
were changes in GP determination by the assessors.
The agreement for each repeated image ranged from CONCLUSIONS
poor to moderate, indicating internal inconsistency
Within the limitations of the present study, the fol-
during phenotype determination. This was demon-
lowing can be concluded:
strated in another study evaluating clinician determi-
nations of phenotype by visual assessment alone.10 • The probe method is sufficient in differentiating be-
There was also no significant pattern observed to sug- tween different categories of GP. However, further
gest clinicians might reliably determine one phenotype research is required to assess the sensitivity of the
over another. probe method in recognizing phenotypes in the most
Thus, visual examination alone may not be a sat- marginal of cases.
isfactory technique for accurate diagnosis of GP or • Assessors using the visual method lack the ability
sufficient as a predictor of gingival esthetics after or- to identify GP accurately and consistently among
thodontic treatment. themselves.

Table 7. Visual Classification Counts for Repeated Patient 14 Table 9. Visual Classification Counts for Repeated Patient 20
Second Seen Second Seen
Thin Medium Thick Thin Medium Thick
First Seen First Seen
Thin 4 12 2 Thin 84 6 0
Medium 3 55 11 Medium 5 7 0
Thick 0 9 8 Thick 0 2 0

Angle Orthodontist, Vol 00, No 00, 0000

GINGIVAL THICKNESS MEASURED DIRECTLY AND INDIRECTLY 7

Table 10. Visual Classification Counts for Repeated Patient 26 discriminate thin from thick gingiva. J Clin Periodontol.
Second Seen 2009;36(5):428–433.
13. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial
Thin Medium Thick
gingival tissue stability after connective tissue graft with single
First Seen immediate tooth replacement in the esthetic zone: consecutive
Thin 32 19 0 case report. J Oral Maxillofacial Surg. 2009;67(11):40–48.
Medium 13 27 6 14. Kloukos D, Koukos G, Doulis I, Sculean A, Stavropoulos A,
Thick 0 2 5 Katsaros C. Gingival thickness assessment at the mandibu-
lar incisors with four methods: a cross-sectional study. J

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