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J Clin Periodontol 2009; 36: 428–433 doi: 10.1111/j.1600-051X.2009.01398.

The gingival biotype revisited: Tim De Rouck1,2, Rouhollah

Eghbali1,3, Kristiaan Collys1,
Hugo De Bruyn3 and Jan Cosyn1,3

transparency of the periodontal 1

School of Dental Medicine, Free University
of Brussels (VUB), Brussels, Belgium;
Department of Prosthodontics, School of

probe through the gingival margin Dental Medicine, University of Ghent, Gent,
Belgium; 3Department of Periodontology and
Oral Implantology, School of Dental

as a method to discriminate thin Medicine, University of Ghent, Gent, Belgium

from thick gingiva

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: 428–433.
doi: 10.1111/j.1600-051X.2009.01398.x.

Aim: To detect groups of subjects in a sample of 100 periodontally healthy volunteers
with different combinations of morphometric data related to central maxillary incisors
and surrounding soft tissues.
Material and Methods: Four clinical parameters were included in a cluster analysis:
crown width/crown length ratio (CW/CL), gingival width (GW), papilla height (PH)
and gingival thickness (GT). The latter was based on the transparency of the
periodontal probe through the gingival margin while probing the buccal sulcus. Every
first volunteer out of 10 was re-examined to evaluate intra-examiner repeatability for
all variables.
Results: High agreement between duplicate recordings was found for all parameters,
in particular for GT, pointing to 85% (k 5 0.70; p 5 0.002). The partitioning method
identified three clusters with specific features. Cluster A1 (nine males, 28 females)
displayed a slender tooth form (CW/CL 5 0.79), a GW of 4.92 mm, a PH of 4.29 mm
and a thin gingiva (probe visible on one or both incisors in 100% of the subjects).
Cluster A2 (29 males, five females) presented similar features (CW/CL 5 0.77;
GW 5 5.2 mm; PH 5 4.54 mm), except for GT. These subjects showed a clear thick
gingiva (probe concealed on both incisors in 97% of the subjects). The third group
(cluster B: 12 males, 17 females) differed substantially from the other clusters in many
parameters. These subjects showed a more quadratic tooth form (CW/CL 5 0.88), a
broad zone of keratinized tissue (GW 5 5.84 mm), low papillae (PH 5 2.84 mm) and a
thick gingiva (probe concealed on both incisors in 83% of the subjects).
Conclusions: The present analysis, using a simple and reproducible method for GT
assessment, confirmed the existence of gingival biotypes. A clear thin gingiva was
found in about one-third of the sample in mainly female subjects with slender teeth, a
narrow zone of keratinized tissue and a highly scalloped gingival margin
corresponding to the features of the previously introduced ‘‘thin-scalloped biotype’’
(cluster A1). A clear thick gingiva was found in about two-thirds of the sample in
mainly male subjects. About half of them showed quadratic teeth, a broad zone of
keratinized tissue and a flat gingival margin corresponding to the features of the Key words: gingival biotype; gingival
previously introduced ‘‘thick-flat biotype’’ (cluster B). The other half could not be thickness; periodontal phenotype
classified as such. These subjects showed a clear thick gingiva with slender teeth, a
narrow zone of keratinized tissue and a high gingival scallop (cluster A2). Accepted for publication 11 February 2009

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Gingival biotype 429

Table 1. Tissue response to inflammation, surgery and tooth extraction (Kao et al. 2008)
Conflict of interests and source of
funding statement Thick gingival biotype Thin gingival biotype
The authors declare that they have no
Inflammation Soft tissues: marginal inflammation Soft tissues: gingival recession
conflict of interests.
with pocket formation, bleeding on without pocket formation
The study was supported by the dental
probing, oedema
department of the Free University of Brus-
Hard tissues: formation of infrabony Hard tissues: loss of the thin
sels (VUB).
defects vestibular bone plate
Surgery Predictable hard and soft tissue Delicate and unpredictable tissue
healing healing (recession)
Tooth extraction Minimal ridge resorption Extensive ridge resorption in the
Earlier reports showed that the clinical apical and lingual direction
appearance of healthy periodontal tis-
sues differs from subject to subject
(Olsson & Lindhe 1991). The bulky, Hitherto, a limited number of studies (iv) volunteers with clinical signs of
slightly scalloped marginal gingiva based on relatively small samples have periodontal disease defined as hav-
with short and wide teeth on the one been published using cluster analysis to ing pockets exceeding 3 mm.
hand and the thin, highly scalloped identify subject groups with different
marginal gingiva with slender teeth on combinations of morphometric data All subjects were provided with oral
the other may serve to illustrate the related to tooth and gingiva character- hygiene instructions and tooth polish-
existence of markedly different perio- istics (Müller & Eger 1997, Müller et al. ing. This was preceded by calculus
dontal entities or so-called ‘‘gingival 2000a). In these studies, gingival thick- removal, if necessary. All subjects con-
biotypes’’ (Weisgold 1977, Seibert & ness (GT) was determined using an sented to participate.
Lindhe 1989). The identification of the ultrasonic device. Although this non-
gingival biotype may be important in invasive method proved to be reprodu- Clinical parameters
clinical practice since differences in cible (Eger et al. 1996), drawbacks
gingival and osseous architecture have include difficulties in maintaining the Five clinical parameters were system-
been shown to exhibit a significant directionality of the transducer (Daly & atically recorded by one clinician at 1
impact on the outcome of restora- Wheeler 1971), unavailability of the week following oral hygiene instruc-
tive therapy (Table 1). In natural teeth, device (Vandana & Savitha 2005) and tions and dental cleaning:
Pontoriero & Carnevale (2001) showed high costs. These factors may be respon-
more soft tissue regain following crown- sible for the fact that the device has not (1) Crown width/crown length ratio
lengthening procedures in patients with a become part of the standard armamen- (CW/CL) of the right central incisor
so-called ‘‘thick-flat biotype’’ than in tarium of the clinician. Recently, a was determined according to Olsson
those with a ‘‘thin-scalloped biotype’’. simple method has been proposed to & Lindhe (1991). Assessments of
This observation is in line with a higher discriminate thin from thick gingiva width and length were recorded to
prevalence of gingival recession in the based on the transparency of the perio- the nearest 0.1 mm using a caliper.
latter as reported by Olsson & Lindhe dontal probe through the gingival mar- The crown length was measured
(1991). Also at implant restorations, gin (Kan et al. 2003). The objective of between the incisal edge of the
the gingival biotype has been descri- the present study was to identify the crown and the free gingival margin,
bed as one of the key elements decisive existence of gingival biotypes in a large or if discernible, the cemento-enam-
for a successful treatment outcome (Kois sample of periodontally healthy volun- el junction. The length of the crown
2004). In particular, papilla presence teers using this visual method for GT was divided into three equal por-
between immediate single-tooth implants assessment. tions of equal height. Crown width,
and adjacent teeth was significantly cor- i.e. the distance between the approx-
related with a thick-flat biotype (Romeo et imal tooth surfaces, was recorded at
al. 2008). In addition, a trend towards the border between the middle and
more gingival recession at immediate Material and Methods the cervical portion.
single-tooth implant restorations in Subjects (2) Gingiva width (GW) was measured
patients with a thin-scalloped biotype midfacially with a periodontal probe
was described (Evans & Chen 2008). This study included clinical data on 100 (CPU 15 UNC, Hu-Friedys, Chicago,
Also, the outcome of regenerative surgery medical students of the Free University IL, USA) to the nearest 0.5 mm.
seems to be negatively influenced by the in Brussels (VUB). Volunteers having This parameter was defined as the
thickness of the soft tissues (Anderegg et all maxillary front teeth were included. distance from the free gingival mar-
al. 1995, Baldi et al. 1999). These obser- The exclusion criteria were as follows: gin to the mucogingival junction.
vations illustrate that disparities in aes- Scores obtained from both central
thetic treatment outcome could arise as a (i) subjects with crown restorations or incisors were averaged.
result of variability in tissue response to fillings involving the incisal edge (3) Papilla height (PH) was assessed to
surgical trauma. The use of simple and on anterior maxillary teeth, the nearest 0.5 mm using the same
reliable methods to identify the gingival (ii) pregnant or lactating female volun- periodontal probe at the mesial and
biotype in clinical practice would be teers, the distal aspect of both central
advantageous as this could help to tune (iii) subjects taking medication with incisors. This parameter was defined
the treatment for the individual and pre- any known effect on the perio- as the distance from the top of the
dict its specific outcome. dontal soft tissues and papilla to a line connecting the
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430 De Rouck et al.

Table 2. Clinical characteristics of tooth form and gingiva in 100 subjects [mean (SD)]
Male Female Total Minimum–
participants participants maximum

Crown width/Crown length ratio 0.80 (0.11) 0.82 (0.11) 0.81 (0.11) 0.54–1.10
Gingival width (mm) 5.28 (0.88) 5.30 (0.93) 5.29 (0.90) 3.0–7.5
Papilla height (mm) 4.12 (0.95) 3.80 (0.97) 3.96 (0.97) 1.2–6.0
Pocket depth (mm) 1.47 (0.40) 1.32 (0.46) 1.40 (0.44) 0.50–2.75
SD, standard deviation.

Table 3. Frequency distribution for gingival thickness

Male participants Female participantsn Total

Score 0 (%) 10 46 28
Score 1 (%) 12 18 15
Score 2 (%) 78 36 57
Significant difference between male and female participants.

Fig. 1. Determination of gingival thickness ity was evaluated using Pearson’s corre- The reproducibility of the measure-
using the periodontal probe. lation coefficient. For GW and PH ments was evaluated in 10 volunteers.
percentile agreement within 1 mm Pearson’s correlation coefficients were
midfacial soft tissue margin of the deviation was also calculated. Categori- 0.948 (po0.001), 0.824 (po0.001) and
two adjacent teeth (Olsson et al. cal variables (GT) were analysed by 0.723 (po0.001) for, respectively, CW/
1993). The mean value was calcu- means of percentile agreement and CL, GW and PH. All but one measure-
lated for the three papillae. Cohen’s k statistics. ment of the GW and 87% of the
(4) GT was evaluated and categorized As already described, mean values assessed PH showed agreement within
into thick or thin on a site level. and standard deviations were calculated 1 mm deviation. The method to evaluate
This evaluation was based on the per subject for all continuous variables. GT proved to be highly reproducible,
transparancy of the same perio- Significant disparities between men and with 85% agreement between duplicate
dontal probe through the gingival women were assessed using the inde- measurements and a corresponding k of
margin while probing the sulcus at pendent-samples t-test. The Fisher’s 0.70 (p 5 0.002).
the midfacial aspect of both central exact test was adopted to evaluate the
maxillary incisors (Kan et al. 2003). impact of gender on GT. Clinical parameters
If the outline of the underlying Cluster analysis based on Euclidian
periodontal probe could be seen distances of four clinical parameters was Table 2 presents descriptive statistics of
through the gingival, it was categor- used to detect groups in the morpho- four clinical parameters. CW/CL was a
ized as thin (score: 0); if not, it was metric data. A division of 100 subjects reference for the crown form of the right
categorized as thick (score: 1). This into three clusters was iteratively central incisor and was on average 0.81.
resulted in three possible scores on a improved by non-hierarchical disjunct The mean GW was 5.29 mm, PH
patient level: 0 (both central incisors cluster analysis using a k-mean algo- 3.96 mm and PD 1.40 mm. There were
with score 0), 1 (one central incisor rithm in order to reduce the within- no significant differences between men
with score 1) or 2 (both central group sum of squares (Hartigan & and women for any of these parameters,
incisors with score 1) (Fig. 1). Wong 1979). In the search for signifi- although a trend was shown for PH
(5) Probing depth (PD) was measured to cant differences among the clusters, (p 5 0.101) and PD (p 5 0.097).
the nearest 0.5 mm at the midfacial one-way analysis of variance (continu- The frequency distribution for GT is
aspect of both central incisors. ous variables) and the Kruskal–Wallis depicted in Table 3. In more than half of
test (categorical variables) were applied. the patients (57%), the gingiva was
Post hoc tests included Scheffe’s test; thick enough to conceal the periodontal
Intra-examiner repeatability the Mann–Whitney test corrected for probe at both incisors (score 2). The data
multiple comparisons. on GT were significantly different
The intra-examiner repeatability of the between men and women (po0.001):
clinician who performed all clinical Seventy-eight per cent of the male par-
examinations was analysed. Therefore, ticipants displayed a score 2 correspond-
every first volunteer out of 10 was re- Results ing to a clear thick gingiva, while only
examined 1 week after the first record- The study population consisted out of 36% of the female participants showed
ing by the same clinician. 100 periodontally healthy medical stu- this score.
dents. Fifty male and 50 female Cauca-
Statistical analysis
sian volunteers were examined, with a Cluster analysis
mean age of 28 years (SD 9; minimum
For all continuous variables (CW/CL, 19; maximum 56). Sixteen per cent of The partitioning method identified three
GW and PH) intra-examiner repeatabil- the subjects were smokers. groups using the morphometric data
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Gingival biotype 431

Table 4. Clinical characteristics of tooth form and gingiva [mean (SD)] per cluster tissues may be most challenging and
can therefore be considered the ultimate
Cluster A1 Cluster A2 Cluster B
goal in terms of esthetics. Evidently, an
Prevalence (%) 37 34 29 insight into the morphological appear-
Crown width/Crown length ratio 0.79 (0.09) 0.77 (0.09) 0.88 (0.13)wn ance of the periodontal structures and
Gingival width (mm) 4.92 (0.80) 5.20 (0.89) 5.84 (0.79)wn teeth is a prerequisite to accomplish this
Papilla height (mm) 4.29 (0.70) 4.54 (0.65) 2.84 (0.58)wn goal in a predictable way.
Pocket depth (mm) 1.23 (0.40) 1.45 (0.39) 1.55 (0.47)n Previous studies have already shown
Significant difference between clusters A2 & B. considerable variation between indivi-
Significant difference between clusters A1 & B. duals with regard to the morphological
SD, standard deviation. characteristics of the periodontium and
teeth. Already in 1989 the existence
of distinct morphotypes – so-called
Table 5. Frequency distribution for gingival men and 28 women), cluster A2 34 (29 ‘‘periodontal biotypes’’ – was suggested
thickness per cluster men and five women) and cluster B 29 (Seibert & Lindhe 1989). Later on, the
Cluster Cluster Cluster Bn (12 men and 17 women). specific features of these biotypes were
A1 A2w Cluster A1 (Fig. 2) displayed a slen- well defined by Olsson et al. (1993). The
der tooth form (CW/CL 5 0.79), a GW objective of the present study was to
Score 0 (%) 73 0 3 of 4.92 mm, a PH of 4.29 mm and a evaluate whether groups of subjects
Score 1 (%) 27 3 14 thin gingiva (probe visible on one or with different morphometric combina-
Score 2 (%) 0 97 83 both incisors in 100% of the subjects). tions truly exist in a large sample using
Significant difference between clusters A1 & Cluster A2 (Fig. 3) presented similar simple diagnostic methods. We decided
A2. features (CW/CL 5 0.77; GW 5 5.2 mm; only to include central maxillary inci-
Significant difference between clusters A1 & B. PH 5 4.54 mm) with no significant dif- sors as reference teeth because differ-
ferences for these parameters in com- ences between biotypes are most
parison with cluster A1 (pX0.281). explicit for these teeth and because their
However, subjects of cluster A2 showed specific features are easily found in
a clear thick gingiva (probe concealed other parts of the dentition (Olsson &
on both incisors in 97% of the subjects) Lindhe 1991, Olsson et al. 1993, Müller
(po0.001). A trend towards slightly et al. 2000a).
deeper PD was also found in subjects Only one parameter, notably GT,
of cluster A2 when compared with those presented a significant difference be-
of cluster A1 (p 5 0.095). tween male and female subjects. That
Fig. 2. Clinical example of a subject of Twenty-nine participants comprising is, 84% of all measured central incisors
cluster A1. cluster B (Fig. 4) had a more quadratic of male participants showed a gingiva
tooth form (CW/CL 5 0.88) when com- that was thick enough to conceal the
pared with subjects of cluster A1 periodontal probe while probing the
(p 5 0.003) and A2 (po0.001). More buccal sulcus. The equivalent value for
apical contact areas and significantly females was only 45%. This disparity
lower papilla levels (PH 5 2.84 mm) in could be expected since previous reports
comparison with cluster A1 (po0.001) had already demonstrated a generally
and A2 (po0.001) were in line with this thinner masticatory mucosa for females
observation. The mean GW of 5.84 mm (Müller et al. 2000b, Vandana & Savitha
in cluster B was significantly higher 2005).
when compared with clusters A1 Cluster analysis encompasses a num-
Fig. 3. Clinical example of a subject of (po0.001) and A2 (p 5 0.014). A sig- ber of different algorithms and methods
cluster A2.
nificant disparity between clusters B and for grouping data of similar kind into
A1 was also found in terms of GT respective categories. Theoretically, any
(po0.001): 83% of the subjects of clus- number up to 100 partitions could be
ter B showed a clear thick gingiva. The generated by this exploratory approach;
mean PD of 1.55 mm for cluster B was yet, the identification of more than three
significantly higher in comparison with clusters resulted in partitions of ques-
cluster A1 (p 5 0.010). tionable clinical meaning. We applied
cluster analysis to categorize subjects
with similar morphometric characteris-
tics and identified three groups (clusters
Fig. 4. Clinical example of a subject of Discussion A1, A2 and B) with a comparable
cluster B. For a restoration to be a success, it number of individuals on the basis of
should closely resemble what once four clinical parameters, i.e. CW/WL,
obtained from the 100 participants. The existed in nature from a functional as GW, PH and GT. Our results indicated a
specific features of each cluster are from an aesthetic point of view. Com- high intra-examiner repeatability for GT
presented in Tables 4 and 5. Cluster plete harmony and symmetry of a assessment, substantiating the clinical
A1 comprised 37 participants (nine restoration with the surrounding soft usefulness of the simple method as
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432 De Rouck et al.

proposed by Kan et al. (2003). By and ler & Eger 1997, Müller et al. 2000a). however, seems negligible, and the proxi-
large, clusters A1 and A2 showed simi- Both studies described groups that could mity of the mean data suggests closely
lar tooth and gingiva characteristics. be identified with some of the clusters in overlapping pocket depth distributions,
Specific features included slender teeth, the present study. The subjects compris- making this parameter inappropriate to
a relatively narrow zone of keratinized ing clusters A and B in the study of predict the gingival biotype in a patient.
tissue and a highly scalloped gingival Müller & Eger (1997) resembled those Still, a comparable distinction in pocket
margin. In cluster A1, the vast majority of, respectively, clusters A1 and B in depth was noticed by Olsson et al.
of the subjects showed a clear thin this report. In the same manner we could (1993). These and our data confirm
gingiva. Because our results showed a identify clusters A1 and B in a subse- that shallower pockets may be expected
higher prevalence of a thin gingiva in quent report by Müller et al. (2000a), in patients with a thin-scalloped biotype
female volunteers, it should not be sur- which presented features comparable to and that deeper pockets coincide with a
prising that cluster A1 mainly consisted the similarly labelled clusters of the thick-flat biotype. An explanation for
of females. Interestingly, the character- current study including their prevalence this observation has been provided ear-
istics of this cluster seemed to corre- (A1: 35% and B: 28% in the study by lier: patients with a quadratic crown
spond to the features of the previously Müller et al. (2000a); A1: 37% and B: form have a thicker periodontium and
introduced ‘‘thin-scalloped biotype’’ 29% in this study). Interestingly, the may respond to gingival inflammation
(Weisgold 1977, Seibert & Lindhe remaining third cluster in the studies by means of pocket formation. In con-
1989). showed little resemblance. In particular, trast, individuals with a tapered crown
In contrast to the subjects of cluster cluster C in the report by Müller & Eger form and a comparatively thinner peri-
A1, those of cluster A2 were mostly (1997), characterized by a thin and odontium may be more susceptible to
male volunteers showing a clear thick narrow gingiva at the maxillary front gingival recession (Weisgold 1977, Sei-
gingiva. This observation failed to sup- teeth in conjunction with a quadratic bert & Lindhe 1989, Olsson & Lindhe
port the hypothesis that a slender tooth tooth form, could neither be identified 1991).
form always merges with a thin gingiva, with cluster A2 in their subsequent In conclusion, the present analysis,
which is in accordance with earlier report (Müller et al. 2000a), nor with using a simple and reproducible method
reports. Olsson et al. (1993) described the features of cluster A2 in the present for GT assessment, confirmed the exis-
the lack of a significant relationship study. The fact that the conditions of tence of gingival biotypes. A clear thin
between CW/CL and GT. Also, Eger two groups of the current study (clusters gingiva was found in about one-third of
et al. (1996) failed to observe a mean- A1 and B) can be compared with those the sample in mainly female subjects
ingful association between these para- of two groups in earlier studies may with slender teeth, a narrow zone of
meters. In addition, a relationship confirm the existence of two biotypes keratinized tissue and a highly scalloped
between tooth shape and bone morphol- within a population. At the same time, it gingival margin corresponding to the
ogy could not be confirmed (Becker et is clear that about one-third of the features of the previously introduced
al. 1997). population cannot be classified in a ‘‘thin-scalloped biotype’’ (cluster A1).
In the present study a third cluster uniform way, given the observed incon- A clear thick gingiva was found in about
could be identified (cluster B), in which sistencies. This observation highlights a two-thirds of the sample in mainly male
subjects mainly presented a thick gingi- possible impact of racial and genetic subjects. About half of them showed
va as in cluster A2. However, the other variation on the morphology of teeth quadratic teeth, a broad zone of kerati-
clinical parameters of cluster B differed and soft tissues (Vandana & Savitha nized tissue and a flat gingival margin
substantially from the other clusters. 2005). In addition, the influence of the corresponding to the features of the
Specific features included short and bucco-lingual tooth position within the previously introduced ‘‘thick-flat bio-
wide teeth, a broad zone of keratinized alveolar process should not be under- type’’ (cluster B). The other half could
tissue and a flat, slightly scalloped gin- estimated. In fact, Müller & Könönen not be classified as such. These subjects
gival margin. These characteristics (2005) showed that most of the variation showed a clear thick gingiva with
seemed to correspond to the features of in GT was related to this position and slender teeth, a narrow zone of kerati-
the previously introduced ‘‘thick-flat only to a minor extent to subject varia- nized tissue and a high gingival scallop
biotype’’ (Weisgold 1977, Seibert & bility (i.e. thin-scalloped and thick-flat (cluster A2).
Lindhe 1989). As a result, about two- biotype).
thirds of our sample (clusters A1 and B) In the present study, a low midfacial
showed high similarity to earlier defined pocket depth was systematically
gingival biotypes, whereas one-third recorded, which should not be surprising
(cluster A2) with a clear thick gingiva because only periodontally healthy
could not be classified as such. This patients were included. Still, the Anderegg, C. R., Metzler, D. G. & Nicoll, B. K.
observation is imperative as it shows observed disparity in pocket depth (1995) Gingiva thickness in guided tissue
that a clear thick gingiva only comes in between the clusters remained note- regeneration and associated recession at
about half of the cases with quadratic worthy. At buccal surfaces, the mean facial furcation defects. Journal of Perio-
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Baldi, C., Pini-Prato, G., Pagliaro, U., Nieri, M.,
and a flat gingival margin. (cluster A1) over 1.45 mm (cluster A2)
Saletta, D., Muzzi, L. & Cortellini, P. (1999)
Former studies using cluster analysis to 1.55 mm (cluster B). A statistically Coronally advanced flap procedure for root
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with different combinations of morpho- A1 and B was found, which may have tor to achieve root coverage? A 19-case
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Association 36, 193–198. crown lengthening: a 12-month clinical E-mail: tim.de.rouck@vub.ac.be

Clinical Relevance ods to produce these data has not yet a clear thick gingiva could not be
Scientific rationale for the study: The been described. classified as such.
identification of groups of subjects Principal findings: Two-thirds of the Practical implications: A clear thick
with different combinations of mor- subject sample corresponded well gingiva only comes in about half of
phometric data related to tooth and with the features of previously the cases with quadratic teeth, a
gingiva characteristics needs docu- described ‘‘thin-scalloped’’ and ‘‘thick- broad zone of keratinized tissue and
mentation in a large study sample. flat’’ biotypes. However, one-third with a flat gingival margin.
Furthermore, the use of simple meth-

r 2009 John Wiley & Sons A/S

Journal compilation r 2009 John Wiley & Sons A/S