Journal of Periodontology - 2019 - Kim - Effect of Gingival Phenotype On The Maintenance of Periodontal Health An American

Received: 3 June 2019 Revised: 6 September 2019 Accepted: 25 September 2019
DOI: 10.1002/JPER.19-0337
BEST-EVIDENCE CONSENSUS
Effect of gingival phenotype on the maintenance of periodontal

health: An American Academy of Periodontology best evidence
review
David M. Kim1 Seyed Hossein Bassir2 Thomas T. Nguyen3
1 Advanced Graduate Program in

Abstract
Periodontology, Department of Oral
Medicine, Infection and Immunity, Harvard Background: Gingival thickness, keratinized tissue width, and bone morphotype are
School of Dental Medicine, Boston, MA three important parameters used to categorize periodontal phenotypes. These ele-
2 Advanced Specialty Education Program in ments all play an important role in the maintenance of periodontal health. The aim
Periodontics, Department of Periodontology,
Stony Brook School of Dental Medicine, of this review is to explore the importance of converting thin phenotype into a thick
New York, NY phenotype for periodontal health maintenance.
3 Division
of Periodontology, Department of
Oral Medicine, Infection and Immunity, Methods: Three clinically relevant focused questions were defined to understand the
Harvard School of Dental Medicine, role of gingival phenotype around teeth. 1) What are the factors affecting gingival
Boston, MA
phenotype (e.g., age, sex, dental arch, race, crown forms, etc.)? 2) Is there a difference
Correspondence between thin versus thick gingival phenotype in terms of gingival health? 3) Does
David M. Kim, Harvard School of Dental the conversion of gingivae from a thin to thick gingival phenotype in sites without
Medicine, 188 Longwood Avenue, Boston,
mucogingival defects help with periodontal health maintenance?
MA 02115, USA.
Email: dkim@hsdm.harvard.edu
Results: Extensive electronic and manual literature search identified a total of 1,129
citations. After title, abstract, and full-text screenings, 30 articles were included in the
present review. Twenty-five studies met the inclusion criteria and provided data for
focused question 1. It was found that periodontal phenotype varies among different
individuals and different areas of the mouth within the same individual. Asian indi-
viduals tend to have thinner gingival phenotype compared with white subjects. Eleven
studies met the inclusion criteria for the focused question 2. Prevalence and severity
of gingival recession was higher at the sites with thin gingiva compared with the sites
with thicker gingiva. No studies provided data for focused question 3.
Conclusions: Available evidence indicates that subjects with thin and narrow gingiva
tend to have more gingival recession compared with those with thick and wide gin-
giva. Currently, there is no published evidence to support conversion of thin to thick
gingival phenotype in sites without gingival recession or mucogingival deformity.
KEYWORDS
gingiva, gingival recession, phenotype, periodontium, systematic review
J Periodontol. 2020;91:311–338. wileyonlinelibrary.com/journal/jper © 2020 American Academy of Periodontology 311

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312 KIM ET AL
1 I N T RO D U C T I O N conditions of 47 patients with gingival augmentation sites

versus untreated homologous contralateral sites, with a
The 2017 World Workshop on the Classification of Peri- mean follow-up period of 23.6 ± 3.9 years. At the end of
odontal and Peri-Implant Disease and Conditions has recom- the follow-up period, 83% of the 64 treated sites showed
mended adoption of the term “periodontal phenotype” by the recession reduction while 48% of the 64 untreated sites
periodontal community.1 This term is based on both gingival experienced an increase in recession.
phenotype (three-dimensional gingival volume such as gin- Two systematic reviews from the 2014 American Academy
gival thickness (GT) and keratinized tissue width [KTW]) of Periodontology (AAP) Regeneration Workshop outlined
and thickness of the facial and/or buccal bone plate (bone the indications and assessed the efficacy of soft tissue non-
morphotype).1 The periodontal phenotype can be modified root coverage procedures as well as soft tissue root coverage
by environmental factors and clinical interventions such as procedures.15,19 Both reviews noted that autogenous gingival
overhanging restorations, orthodontics, or autogenous gingi- grafts and subepithelial connective tissue graft (SCTG)-based
val grafting procedures.1 Terms such as “scalloped and thin” procedures provided the best clinical outcomes.15,19 However,
or “flat and thick” gingiva coined by Ochsenbein and Ross2 there was a lack of selected studies that evaluated both com-
as well as “thick-flat” and “thin-scalloped” biotypes coined by ponents of gingival phenotype (GT and gingival width).20,21
Seibert and Lindhe3 are commonly used in dentistry. The lat- The purpose of this Best Evidence Consensus (BEC) was
est systematic review on gingival morphology assigned gin- to explore the importance of converting thin phenotype into a
gival biotypes to three types: “thin scalloped,” “thick flat,” thick phenotype for maintaining periodontal health and partic-
and “thick scalloped.”4 Gingival thickness, KTW and bone ularly before extensive restorative and orthodontic treatments.
morphotype were three important parameters used to catego- Three broad questions were considered:
rize biotypes and they were important in development or pro-
gression of mucogingival defects.4 However, by definition, 1) Does the conversion of gingivae from a thin to thick phe-
biotype is genetically predetermined, cannot be modified and notype offer clinical value for maintaining periodontal
does not incorporate environmental factors and clinical inter- health?
vention that can alter the periodontal tissue profile.1
2) In patients having a thin tissue phenotype that requires
The gingival phenotype (GT portion) has been previously
restorative treatment, will a surgical procedure to thicken
measured via different techniques, such as by direct visual
tissue phenotype improve tissue stability?
inspection, dental probe transparency, transgingival prob-
ing, ultrasonic transducer, parallel profile periapical radiog- 3) Does periodontal phenotypic conversion therapy, via soft
raphy, and cone-beam computed tomography.2,5–13 Among or hard tissue grafting, offer clinical value to patients
these various techniques, dental probe transparency is a requiring orthodontic treatment?
non-invasive way of measuring gingival phenotype and is
highly reproducible, with 85% agreement between duplicate The current BEC review group was commissioned to
recordings.5 review the literature specific to the first question.
Another aspect of gingival phenotype, KTW, can be deter-
mined by a vertical measurement using a periodontal probe
positioned between the gingival margin and the mucogingival 2 M AT E R I A L S A N D M E T H O D S
junction. A 1963 study by Bowers14 serves as a good reference
on understanding the significance of the width of attached gin- The authors (DMK, SHB, and TTN) critically reviewed and
giva (AG) in human. analyzed the literature associated with the topic of interest.
Several predisposing factors such as a thin periodontal phe- The present systematic review was conducted according to the
notype, as well as a lack of AG, can contribute to gingival PRISMA (Preferred Reporting Items for Systematic Review
recession.12,15 Areas of a thin labial bone plate and thin gin- and Meta-Analyses) guidelines.22
giva were commonly correlated with the canine eminences,
the mesial roots of maxillary first molars, and mandibular 2.1 Focused questions
incisors.16 Patient-contributed trauma and iatrogenic inter-
ventions, such as improper toothbrushing technique, deep cer- To answer the first broad question, three clinically relevant
vical restorative margins and orthodontic tooth movement focused questions were asked and answered following the sys-
have all been associated with gingival recession.1,12,15 tematic review:
A systematic review and meta-analysis of long-term out-
comes of untreated buccal gingival recessions has reported a 1) What are the factors affecting gingival phenotype (e.g.,
high probability of progression even in individuals with good age, sex, dental arch, tooth position, race, crown forms,
oral hygiene.17 Agudio et al.18 have compared periodontal etc.)?
KIM ET AL 313
2) Is there a difference between thin versus thick gingival Studies focusing on treating sites with gingival recession or
phenotype in terms of gingival health? mucogingival defects were excluded because the goal of this
3) Does the conversion of gingivae from a thin to thick gingi- focused question was to assess whether conversion of thin to
val phenotype in sites without mucogingival defects helps thick gingival phenotype in sites without gingival recession or
with periodontal health maintenance? mucogingival involvement offers additional clinical value for
maintaining periodontal health. The importance and indica-
tions of treating sites with gingival recession or mucogingival
2.2 Inclusion and exclusion criteria defects are well established and have been reported in the pre-
The Population, Intervention, Comparison, and Outcome viously published systematic reviews.15,17,19
(PICO) framework was used to guide the inclusion or exclu- All study designs were considered for inclusion in this
sion of studies for each question using the following criteria: systematic review, including randomized controlled trials
(RCTs), non-randomized controlled trials, prospective or ret-
rospective cohort trials, and cross-sectional studies.
Exclusion criteria included 1) studies that did not fulfill the
A. Focused Question 1: above-mentioned inclusion criteria for each focused question;
i. Population: studies in adult human subjects; 2) non-English studies; 3) in vitro studies, ex vivo and animal
ii. Intervention: studies with or without an intervention studies; 4) editorials, letters, and reviews.
were included;
iii. Comparison: included studies had to assess the gingi-
2.3 Search strategy and study selection
val phenotype by reporting the gingival width as well Details of search strategy and study selection are presented in
as GT or type gingival biotype/phenotype; the supplementary Appendix 1 in online Journal of Periodon-
iv. Outcome: studies had to report the effect of different tology.
variables such as age, sex, dental arch, tooth position,
race, crown forms, and etc. on the gingival phenotype. 2.4 Quality assessment
B. Focused Question 2: The level of evidence for each focused question was deter-
i. Population: studies in adult human subjects; mined according to the Strength of Recommendation Tax-
ii. Intervention: studies with or without an intervention onomy (SORT) criteria based on the following ranking
were included; system23 :
iii. Comparison: included studies had to have a

• SORT level A recommendation is for consistent, good-
group consisting of sites with thin gingival bio-
quality patient-oriented evidence.
type/phenotype and they had to have a group consist-
ing of sites with thick gingival biotype/phenotype; • SORT level B recommendation is based on inconsistent or
limited-quality patient-oriented evidence.
iv. Outcome: studies had to provide data on gingival or
periodontal outcome variables such as bleeding on • SORT level C recommendation is based on consensus,
probing, gingival index, plaque index, probing depth, disease-oriented evidence, usual practice, expert opinion,
clinical attachment level, radiographic bone loss or or case series for studies of diagnosis, treatment, preven-
gingival recession. tion, or screening.
C. Focused Question 3:
2.5 Statistical analyses
i. Population: studies in adult human subjects;
A meta-analysis was not possible to perform since the out-
ii. Intervention: site with thin gingival biotype/
come variables and methods used to assess gingival pheno-
phenotype that received periodontal conversion
type were varied among the studies. Hence, the results are
therapy;
presented in narrative form.
iii. Comparison: site with thin gingival biotype/
phenotype that did not receive periodontal conversion
therapy; 3 RESULTS
iv. Outcome: data on gingival or periodontal outcome
variables including bleeding on probing, gingival A flow diagram of the search strategy is presented in Figure 1.
index, plaque index, probing depth, clinical attach- The electronic and manual search identified a total of 1,129
ment level, radiographic bone loss, or gingival citations. Screening of the titles and abstracts of the articles
recession. resulted in exclusion of 996 articles that were irrelevant to the
314 KIM ET AL
(P <0.05) between them for the maxillary anterior teeth. Sev-

eral other studies have reported a similar positive correlation
between KTW and GT.26,27,31,33
However, no statistically significant difference for the mean
KTW and GT between men and women was found in the
Egreja et al. study.29 This latter finding conflicts with other
studies that have observed that GT was greater in men.5,27,34
Further, Egreja et al.29 study reports that maxillary cen-
tral incisors (CIs) exhibit a greater mean GT (1.17 mm) than
maxillary lateral incisors (LIs) (1.04 mm) and canines (Cs)
(0.87 mm). Goaslind et al.,24 Müller and Eger,26 and Shah
et al.31 have also reported similar results for the maxillary
anterior teeth, that is, CIs exhibiting the greater mean GT and
maxillary Cs exhibiting the smallest mean GT. With regard to
the gingival width, it is reported that LIs have the widest zone
of gingival keratinized tissue (KT; mean 5.54 mm) followed
by the CIs (mean 4.62 mm) and Cs (4.32 mm).29 Similarly,
Müller and Eger26 and Shah et al.31 reported that maxillary
LIs and Cs had the highest and lowest mean width of gingival
KT. Müller and Eger,26 in a white population, reported a KT
width of 4.8 mm for LIs, 4.44 mm for CIs and 4.21 mm for
Cs, while Shah et al.31 reported a KT width of 5.18 mm for
LIs, 4.38 mm for CIs and 4.16 mm for Cs in an ethnic Indian
population.
With regard to comparison GT and KTW of teeth, the data
indicates that maxillary CIs presented with the greatest mean
FIGURE 1 Flowchart diagram of the search strategy
GT, followed by LIs and Cs.24,26,29,31 On the other hand, max-
illary LIs have the greatest KTW, followed by the CIs and
Cs.26,29,31
topic of the present review. The full-text of the remaining 133 Therefore, the available evidence indicates that GT and
articles were obtained and reviewed. In total, 30 articles were WKT are positively correlated in maxillary anterior teeth with
included in the present review. Twenty-five studies5,8,10,24,45 CIs having the greatest mean GT and LIs having the widest
met the inclusion criteria and provided data for focused ques- WKT. It should be noted that the majority of the studies only
tion 1, and 11 studies8,25,27,28,31,36,46–50 met the inclusion cri- focused on maxillary anterior teeth. There is only limited evi-
teria for the focused question 2. No studies provided data for dence available regarding the correlation of GT and WKT for
the focused question 3. the other teeth.
3.1 Focused question 1

3.1.2 Association between gingival phenotype
What are the factors affecting gingival phenotype (e.g., age, and gingival thickness
sex, dental arch, race, crown forms, etc.)? The character- The association between GB and GT were evaluated in six
istics and results of the included studies for this clinically studies.30–33,35,36 The majority of studies that assessed max-
focused question are presented in Table 1. All 25 included illary anterior teeth found a positive relationship between
studies5,8,10,24–45 reported data for both KTW and GT. GB, GT, and KTW in maxillary anterior teeth.32,33,35 How-
ever, non-significant or weak correlations were found between
3.1.1 Association between keratinized tissue measuring GB using probe visibility and thickness of gingiva
width and gingival thickness in two studies were posterior teeth36 or mandibular anterior
The association between KTW and GT were addressed in teeth37 were included in the analysis.
eleven studies.8,24–33 In general, the majority of the studies Fischer et al.32 evaluated a possible relationship between
found a positive correlation between the KTW and GT in max- GB and GT, papilla height (PH) and KTW in maxillary ante-
illary anterior teeth.8,25,28–33 rior teeth of 36 periodontally healthy patients. A statistically
Egreja et al.29 evaluated whether there was a correlation significant difference was found in buccal GT, KTW and PH
between the KTW and GT and noted a positive correlation of patients with thin GB versus thick GB. After establishing
KIM ET AL
TABLE 1 Summary of the included studies evaluating factors affecting gingival phenotype
Study population; Country; Mean age
Study (sample size); ethnicity/ (range) and Evaluated Evaluation
Studies Objectives design groups race sex sites method Results Conclusions
Alkan et al., 1. To evaluate Cross- Periodontally Turkey; NR 17.27 (11-28); Maxillary GT: transgingival 1. Prevalence of thin gingival biotype 1. No relationship
201844 the relationship sectional healthy subjects; 63M/118F anterior probing was 29.8% while it was 70.2% for between Angle
of GT and (n = 181). Three teeth (endodontic file thick biotype. classification and
KTW with malocclusion with a rubber GT and KTW.
2. Maxillary Cs were observed to have
different groups (Angle stopper); KTW:
thin gingival biotype in all groups.
malocclusion Class I, II, and periodontal
groups and III) and divided probe 3. The KTW for maxillary Cs was
amount of into subgroups narrower in the severe crowding
crowding. according to group than in the mild/moderate
crowding (mild 0 crowding groups.
to 3 mm,
moderate 4 to 6
mm, and severe
>6 mm)
Alpiste- 1. To develop Cross- Periodontally Spain; NR NR (20 to 40); Maxillary left GT: parallel 1. 1.75 ± 0.24 mm for CT attachment 1. A statistically
Illueca, and evaluate a sectional healthy subjects; M/F: NR CI profile thickness, 0.45 ± 0.20 mm for significant
200410 radiographic (n = 88) radiograph bone plate thickness at crestal level. relationship
technique for technique; between gingival
2. The dimensions of the CT
measuring the KTW: width and
attachment are the least variable
dentogingival periodontal thickness of CT
component.
unit (epithelial probe attachment
and CT 3. The thickness of the facial bone
(P = 0.026) and
attachment). plate was the parameter with the
gingival sulcus
great variation (usually thinner at
depth (P = 0.018).
the bone crest level than at the
middle and apical thirds). 2. The gingiva was
thicker and sulcus
depth less
pronounced with
increasing
gingival band
length.
(Continues)
315
316
TABLE 1 (Continued)
Chou et al., 1. To examine the Cross- Periodontally Taiwan; 22.7 (19 to Maxillary GT: ultrasonic 1. Mean GT of males versus females 1. Crown forms and
200839 forms of the sectional healthy subjects; Asian 29); anterior device; KTW: were 1.3 mm versus 1.15 mm for corresponding
crowns in the (n = 112) (Tai- 58M/54F teeth periodontal CI, 0.96 mm versus 0.9 mm for LI gingival
maxillary wanese) probe and 1.07 mm versus 0.94 mm for C. characteristics are
anterior teeth different in
2. Mean KTW of males versus
and Taiwanese versus
females were 5.94 mm versus
corresponding Caucasians.
5.98 mm for CI, 5.76 mm versus
gingival
5.71 mm for LI and 5.51 mm versus
characteristics
5.22 mm for C.
among healthy
Taiwanese 3. Three crown-gingival
subjects. classification: narrow (N), square
(S) and compound ©.
4. N = 43%, thinnest GT, minimal
KTW, the slimmest crown shape.
0.90 ± 0.16 mm for GT and 4.88 ±
0.82 mm for KTW.
S = 23%, similar GT, medium KTW,
the stoutest form of maxillary
anterior teeth. 1.02 ± 0.12 mm for
GT and 5.58 ± 0.66 mm for KTW.
C = 34%, bulkiest GT, ample KTW,
mid crown width/crown length ratio
1.27 ± 0.19 mm for GT and 6.79 ±
0.77 mm for KTW.
Cook et al., 1. To evaluate the Cross- Subjects without United NR; NR Maxillary GB: probe 1. Thin biotype was associated with 1. Periodontal biotype
201128 difference in sectional periodontitis or States; anterior visibility; thinner labial plate thickness is associated with
labial plate severe gingivitis; NR teeth KTW: periodontal (P <0.001), narrower KTW labial plate
thickness in (n = 60). probe; (P <0.001), greater distance from thickness, alveolar
patients Thin biotype: Buccal bone the CEJ to the initial alveolar crest crest position,
identified as (n = 26) and thickness: (P =0.02). KTW, gingival
having thin thick/average CBCT architecture and
2. No relationship between biotype
versus biotype (n = 34) probe visibility, but
and tooth height-to-width ratio or
thick/average unrelated to buccal
facial recession.
periodontal GR.
biotypes.
(Continues)
KIM ET AL
TABLE 1 (Continued)
KIM ET AL

De Rouck 1. To identify Cross- Periodontally Belgium; 28 (19-56); Maxillary CI GB: probe 1. Thin gingiva, slender teeth, a 1. Thin gingiva in
et al., the existence sectional healthy subjects; white 50M/50F visibility; narrow KTW and a highly mainly female
20095 of gingival (n = 100) KTW: periodontal scalloped gingival margin in subjects and thick
biotypes in probe one-third of subjects (mainly gingiva in mainly
periodontally female). male subjects.
healthy
2. Thick gingiva, quadratic teeth, a
volunteers.
broad KTW and a flat gingival
margin in two-third of subjects
(mainly male).
Eger et al., 1. To determine Cross- Periodontally Germany; NR; 200M Maxillary and GT: ultrasonic 1. 1 In the maxilla, mean GT varied 1. There are
19968 the validity and sectional healthy males; NR mandibular device; between 0.9 and 1.3 mm. individual
reliability of (n = 200); non-molar KTW: periodontal differences in GT,
2. In the mandible, mean GT varied
measuring GT Three age groups: teeth probe; and a significant
between 0.8 and 1.5 mm.
with an 20 to 25 yrs (n = PD, GR: clinical influence of PD,
ultrasonic 80), 40 to 45 yrs examination; 3. Reproducibility of GT
GR, KTW and
device and (n = 60), 55 to 60 CW/CL: measurements with the ultrasonic
tooth type on GT.
measure GT in yrs (n = 60) Measurements device was high.
2. No association
relationship to on casts 4. GT was a significantly influenced
between GT and
tooth type and by PD, GR, KTW, and tooth type
shape and form of
age. on and not by CW/CL.
the tooth
Egreja et al., 1. To evaluate the Cross- Periodontally Brazil; NR NR (20-35); Maxillary GT: transgingival 1. LI has the largest mean KTW 1. A positive
201229 correlation sectional healthy subjects; 30M/30F right CI, probing (5.54 ± 1.09 mm) followed by correlation exists
between KTW (n = 60) LI, and C (endodontic file the CI (4.62 ± 1.02 mm) and between GT and
and GT. with a rubber C (4.32 ± 1.33 mm) KTW for the
stopper); maxillary anterior
2. CI has the largest mean GT
KTW: same teeth in patients 20
(1.17 ± 0.20 mm) followed by the
endodontic file to 35 years of age.
LI (1.04 ± 0.24 mm) and
and caliper
C (0.87 ± 0.27 mm).
3. No statistically significant
difference for the mean KTW and
GT between men and women.
4. Positive correlation (P <0.05) was
found between GT and KTW in CI,
LI, and C.
(Continues)
317
318
TABLE 1 (Continued)
Fischer 1. To determine Cross- Subjects without 23 (19-37); Maxillary CI GT: customized 1. Median GT was 0.43 mm (thin 1. The presence of a
et al., the difference sectional PD >3 mm and 21M/39F digital caliper; GB), 0.74 mm (moderate GB) thick gingiva is
201833 in mid-buccal gingival GB: probe and 0.83 mm (thick GB). associated with a
GT between recession; visibility; wide band of KT.
2. Significant differences in GT were
three different (n = 60); KTW:
found between thin GB versus 2. KTW directly
GBs. Thin GB (n = 30); periodontal
moderate GB (P = 0.002) and correlated with
moderate GB probe
2. To analyze the between thin GB versus thick GB GT.
(n = 15); and
association (P < 0.01).
thick GB (n = 15)
between GB 3. KTW was directly correlated with
and KTW. GT (P <0.001).
Fischer 1. To evaluate a Cross- Subjects without Germany; 24.9 (18-35) Maxillary GT: customized 1. GT: 0.40 ± 0.07 for thin GB 0.72 ± 1. Between thin and
et al., possible sectional PD >3 mm and white 17M/19F anterior digital caliper; 0.11 mm for thick GB (P <0.0001). thick GB, a
201532 relationship GR; teeth GB: probe statistically
2. PH: 3.76 ± 0.50 mm for thin GB
between GB, (n = 36). visibility; significance could
and 3.95 ± 0.41 mm for thick GB
GT, PH, and Thin GB (n = KTW: periodontal be detected in
(P =0.02).
KTW. 12); very thin GB probe; buccal GT, KTW,
(n = 6); thick GB PH: digital 3. KTW: 3.01 ± 1.26 mm for thin GB and PH.
(n = 12); very caliper; and 4.63 ± 0.86 mm for thick GB
thick GB (n = 6) PD: periodontal (P =0.04).
probe 4. When Stratification into moderate
and very “thin”/“thick” GB was
done, no significant differences
were found between the moderate
groups.
(Continues)
KIM ET AL
KIM ET AL
TABLE 1 (Continued)
Ghassemian 1. To evaluate Cross- Subjects with PD Italy; NR 40 (20-67); Mandibular GB: probe 1. Mean thickness of alveolar bone 1. Biotype does not
et al., correlations sectional <5 mm needing 40M/60F anterior visibility; ranged from 4.51 to 6.66 mm, and play a role in
201643 between clinical oral surgery in teeth KTW: periodontal mean thickness basal bone ranged influencing
and the posterior probe; from 8.2 to 8.9 mm. alveolar BT, while
tomographic mandible; GR: periodontal other variables
2. No statistically significant
parameters in (n = 100). probe; (tooth torque, sex,
differences were detected among
individuals with Thin GB (n = 50) Buccal bone age and smoking
biotypes, whereas other variables
thin and thick and thick GB thickness: habit) do influence
(tooth torque, age and smoking)
biotypes. (n = 50) CBCT alveolar BT.
were often predictors of reduction
in bone thickness (BT).
3. Male sex was often a predictor of
positive changes in BT.
4. Previous orthodontic therapy was a
protective factor against developing
bone loss >5 mm.
Goaslind 1. To explore GT Cross- Male subjects with United NR (25-36); Selected GT: a transformer 1. FG thickness averaged 1.56 mm, 1. GT varied
et al., in specific areas sectional clinically healthy States; 10M maxillary probe assembly AG thickness averaged 1.25 mm considerable
197724 of healthy FG gingiva; NR and excited by an and the total mean thickness for all within and
and AG and to (n = 10) mandibular oscillator and areas measured was 1.41 mm. between subjects.
relate these anterior and coupled to a
2. Thickness in mandibular free and 2. GT was greater at
measurements posterior digital
AG and maxillary free gingiva sites with the
to other teeth voltmeter;
increased from anterior to posterior. narrower gingiva.
anatomic KTW: periodontal
Thickness in maxillary AG
parameters. probe
remained fairly constant.
3. The mean width of AG was 3.54
mm (0.5 to 8.0 mm) and decreased
from anterior to posterior.
4. A significant inverse relationship
(P <0.05) was noted between the
width of AG and GT.
(Continues)
319
TABLE 1 (Continued)
320

Joshi et al., 1. To assess and Cross- Subjects without India; 21.33 for Maxillary GT: parallel 1. A decreased PH with thick GB in 1. Sex significantly
201735 compare the GB sectional PD >3 mm Indian males and anterior profile males. affects GB.
among sexes by and gingival 22.08 for teeth radiograph
2. Increased PH with a thin biotype in 2. Thinner gingival
clinical, recession; females technique;
females. biotype with
photographic, (n = 800) (18-25); GB: probe
3. Positive correlation between GB reduced alveolar
and 400M/400F visibility;
and alveolar BT among both BT in females
radiographic KTW: periodontal
genders. compared with
parameters. probe;
males.
Buccal BT:
parallel profile
radiograph
technique;
PH and CW/CL
ratio: digital
photographs
Kolte et al., 1. To determine Cross- Periodontally India; NR NR; 60M/60F Maxillary and GT: transgingival 1. Significantly greater GT and 1. GT and KTW are
201434 the variation in sectional healthy subjects; mandibular probing narrower KTW were found in influenced by age,
GT and KTW (n = 120). anterior (endodontic file younger age group compared with sex and dental arch
in the anterior Three age groups: teeth with a rubber the older age group. location.
segment with 16 to 24 yrs (n = stopper);
2. The mean GT and KTW were
respect to age, 40) 25 to 39 yrs KTW: periodontal
significantly less in females than
sex and dental (n = 40) >40 yrs probe fitted with
males.
arch location. (n = 40) an endodontic
rubber stopper 3. Greater GT and with smaller KTW
were found in mandible compared
with maxilla.
La Rocca 1. To determine Cross- Periodontally Spain; NR 29.53 (22-49); Maxillary and GT: transgingival 1. The mean KTW was 4.48 mm, and 1. No significant
et al., the relationship sectional healthy subjects; 8M/7F mandibular probing generally larger for maxillary teeth association was
201242 between GT (n = 15); anterior (endodontic file versus mandibular teeth. found between GT
and KTW with Maxillary sites teeth with a rubber and BT.
2. Mean GT: Crestal 1.01 mm, mid
regard to bone (n = 90 teeth); stop);
1.06 mm, and apical 0.83 mm 2. Significant
thickness in the mandibular sites KTW:
3. Mean BT: Crestal 1.24 mm, mid association exists
anterior (n = 90 teeth) periodontal
0.81 mm, and apical 2.78 mm. between KTW and
segment. probe;
crestal BT
PD: periodontal 4. 4. The GT was not significantly
probe; correlated to the BT, while KTW
Buccal bone was directly corelated with the
thickness: crestal BT (P <0.05).
CBCT
KIM ET AL
(Continues)
KIM ET AL
TABLE 1 (Continued)
Lee et al., 1. To assess tooth Cross- (n = 49) United 39 (NR) Seven teeth GB: probe 1. The mean KTW was greatest for 1. Asian patient
201340 morphology sectional States; 20M/29F (maxillary visibility; the maxillary CI (4.83 mm) and the exhibited high
and gingival Asian CI, C, 2nd KTW: lowest for the mandibular C. frequencies of thin
biotypes of (Chinese, PM, and periodontal GB, especially in
2. High positive frequencies of thin
Asian subjects. Japanese, 1st M, probe; the anterior teeth
biotype and moderate recession
Korean Mandibular GR: periodontal (>60% incidence)
(highest for the mandibular CI,
and Viet- CI, C and probe; as well as more
followed by mandibular C, and
namese 1st M) root/tooth length: recession in the
maxillary CI and C).
descent) panoramic posterior region
radiographs than in the anterior.
Lee et al., 1. To determine Cross- Subjects with Singapore; 30.3 (NR) Maxillary and GT: transgingival 1. Mean GT was 1.39 ± 0.52 mm, 1. A high frequency
201836 the facial sectional healthy normal Asian 24M/ 27F mandibular probing mean KTW was 4.59 ± 1.34 mm. of thin GB and
gingival profiles or reduced (Chinese, incisors to (endodontic low GT at the
2. Considerable variation within and
(GT and KTW) periodontium; Malay, the first file with a anterior teeth was
between subjects were found.
of periodontally (n = 51, 1,109 Indian, molars rubber stop); noted in this Asian
healthy sites in teeth). Sites with Eurasians) GB: probe 3. GT increased from anterior to
cohort.
an Asian healthy visibility; posterior areas. Lowest means of
population. periodontium: KTW: GT were found around mandibular 2. There is poor
CIs to first premolars and maxillary correlation
78.4%. Sites with periodontal
C. between
reduced probe
measuring GB
periodontium that 4. The lowest KTW was noted for the
using probe
previously treated mandibular CS and all premolars,
visibility and
for periodontitis: while the widest GW was found at
thickness of
21.6% the incisors.
gingiva.
5. GT and KTW were significantly
correlated with tooth type, plaque,
recession, but not age, sex and
ethnicity.
6. Poor correlation was found between
GT and GB
(Continues)
321
322
TABLE 1 (Continued)
Müller 1. To identify Cross- Periodontally Germany; NR (20-25) Maxillary and GT: ultrasonic 1. Mean GT ranged between 0.76 ± The data indicated the
and Eger, subjects with sectional healthy male whites 42M mandibular device; KTW: 0.14 mm to 1.28 ± 0.37 mm. existence of
199726 different subjects; non-molar periodontal different gingival
2. Mean GW ranged from 3.21± 1.02
gingiva (n = 42) teeth probe; phenotypes.
mm to 4.80 ± 1.49 mm.
phenotype. PD, GR: clinical
examination; 3. Existence of different gingival
CW/CL: phenotypes:
Measurements - Cluster A: two-third of
on casts individuals with normal GT,
GW, and CW/CL.
- Cluster B: 21% of individuals
with thicker and wider gingiva,
and quadratic maxillary anterior
teeth.
- Cluster C: 12% of individuals
with normal GT, high CW/CL
and a narrow KTW.
Müller 1. To study Cross- Periodontally Germany; (19-30) Maxillary and GT: ultrasonic 1. Clusters A1 and A2 (thin 1. Sex and
et al., thickness of sectional healthy young whites 19M/21F mandibular device; gingival/slender tooth form) periodontal
200027 masticatory subjects; (n = 37) teeth. KTW: comprised of 75% of all subjects. phenotype
mucosa and (n = 40) and periodontal significantly affect
2. Clusters A1 and A2 were
KTW in Asians probe; the thickness of
differentiated by gingival width
individuals with (n = 3) PD, CAL, GR: masticatory
(A2 wider).
different clinical mucosa
periodontal examination; 3. Cluster B (relatively thick/wide
gingiva and a quadratic tooth 2. Palatal gingiva
phenotypes. CW/CL:
shape). was at least 2× as
Measurements
thick as
on casts 4. Mean thickness of masticatory
facial/buccal
mucosa as well as KTW and crown
gingiva.
form differed significantly among
clusters. 3. Masticatory
mucosa is thinner
in women
compared with
men.
(Continues)
KIM ET AL
KIM ET AL
TABLE 1 (Continued)
Olsson et al., 1. To assess the Cross- 16 to 19 years old Sweden; 17.1 (16-19) Maxillary GT: transgingival 1. Individuals with a long-narrow 1. Subjects with a
199325 relationship sectional volunteers; white anterior probing form of the CIs displayed a narrow long-narrow CIs
between the (n = 108) teeth (syringe needed zone of KTW, shallow PD and a have a less GT, a
form of the with an pronounced scalloped contour of narrow KTW,
crowns and GT endodontic the gingival margin compared with shallow PD and a
as well a group depth marker); individuals with a short-wide pronounced
of KTW: periodontal crown. scalloped gingival
morphological probe; contour.
2. The GT in CI was significantly
characteristics GI, PD, CAL:
associated with the KTW,
in the maxillary clinical
buccolingual width of the crown
anterior teeth. examination;
and the presence of an
CW/CL:
interproximal gingival groove.
Photographs
3. The GT in LI was significantly
correlated with the PD at the buccal
surface.
4. No significant association was
found between GT and other
variables in canines.
Pascual 1. To determine Cross- Subjects without Spain; NR 29.53 8M/7F Maxillary and GT: transgingival 1. There were no significant 1. GT and BT
et al., whether there is sectional history of mandibular probing differences between maxillary and dimensions of
201738 a relationship in periodontal anterior (endodontic file mandibular teeth in terms of GT maxillary and
between disease; teeth with a rubber and BT at the crestal third and mandibular teeth
maxillary and (n = 15); stop); midpoint of (P >0.05). are comparable,
mandibular Maxillary sites KTW: especially in the
2. Apical BT measurements were
anterior teeth (n = 90 teeth); periodontal coronal third.
significantly greater around anterior
with regards GT Mandibular sites probe;
teeth in the mandible compared
and BT. (n = 90 teeth) PD: periodontal
with the maxillary.
probe;
Buccal bone
thickness:
CBCT
(Continues)
323
324
TABLE 1 (Continued)
Peixoto et al., 1. To assess how Cross- Subjects anterior Portugal; NR (18-30); Maxillary GB: probe 1. No significant correlation was 1. No significant
201545 GB and tooth sectional teeth without any NR 20M/30F anterior visibility found between sex and GB or KTW. association was
crown form are dental and teeth assessed on found between sex
2. A statistically significant
affected by PH, periodontal digital and GB
relationship between sex and PH (P
KTW, CW/CL, defects; photographs;
= 0.005), crown width/ 2. It was found that
and gingival (n = 50) KTW: assessed on
crown length ratio (P = 0.017) there is
angle. digital
and gingival angle (P = 0.041). association
photographs;
between sex and
PH, gingival angle
crown width/
and CW/CL:
crown length ratio,
digital
PH, and gingival
photographs
angle.
Shah et al., 1. To evaluate the Cross- NR; India; 28.82 (20-35); Maxillary GT: transgingival 1. The prevalence of thin GB was It was found that
201531 GT and its sectional (n = 400) Indian 200M/200F anterior probing 43.25% and thick GB was 56.75%. patients with thin
relation to sex, teeth (endodontic file GT presented with
2. The mean GT: CI (1.11 ± 0.17
presence of GR with a rubber a limited KTW.
mm), LI (1.01 ± 0.16 mm) and C
and the KTW in stop);
(0.82 ± 0.17 mm).
a subset of the GB: Thin for <1
Indian mm GT and 3. The mean GW: CI (4.38 ± 1.18
population. thick for mm), LI (5.18 ± 1.25 mm) and C
>1 mm GT; (4.11 ± 1.16 mm).
KTW: 4. There were no significant
periodontal associations between GB and age,
probe; sex, or the presence of recession.
PD: periodontal 5. GT and KTW were significantly
probe correlated (P <0.05)
(Continues)
KIM ET AL
TABLE 1 (Continued)
KIM ET AL

Shao et al., 1. To assess the Cross- Periodontally China; 22.2 (18-27); Maxillary and GT: transgingival 1. Thin tissue based on transgingival 1. The most common
201837 distribution of sectional healthy students; Asian 15M/16F mandibular probing probing: 28.49% and based on GB in this Chinese
periodontal (n = 31, 372 teeth) (Chinese) anterior (endodontic file probe visibility: 40.32% population was
biotype in a teeth with a rubber thick-flap type.
2. Mean GT via transgingival probing
young Chinese stop);
was 1.03 ± 0.31 mm and via CBCT
population. GB1: Thin for <
was 1.03 ±
0.8 mm GT
2. to assess the 3. Thick-flap biotype: 137 teeth
and thick for >
accuracy of (36.83%); Average-scalloped
0.8 mm GT;
different biotype: 96 teeth (25.81%);
GB2: probe
techniques for Average-flap biotype: 39 teeth
visibility;
the (10.48%); Thin-scalloped biotype:
KTW: periodontal
measurement 100 teeth (26.88%)
probe;
of GT.
GI, PD, CAL: 4. No significant differences was
periodontal found in buccal BT between four
probe; GBs.
Buccal BT: 5. Significant differences between
CBCT males and females in transgingival
probing and labial bone thickness
(P <0.05)
Stein et al., 1. To assess the Cross- Volunteers without Germany; 31.53 (18-61) Maxillary left GT: parallel 1. Mean GT ranged from 0.59 ± 0.17 1. Crown form and
201330 relation of sectional known white 24M/36F central profile mm to 1.46 ± 0.37 mm KTW are
different periodontal or incisor radiograph predictors for the
2. Mean KTW was 4.92 ± 1.01 mm.
morphometric dental diseases; technique; GT over the CEJ.
parameters with (n = 60) GB: probe 3. Mean buccal BT ranged from 0.57
± 0.23 mm to 0.85 ± 0.45 mm. 2. Crown form is
GT and buccal visibility;
predictor for
BT at different KTW: 4. Positive correlation between
buccal BT.
apico-coronal periodontal CW/CL and GT at CEJ.
levels. probe; 5. Negative correlation between GB
Buccal BT: and GT.
parallel profile
6. Positive correlation between the GT
radiograph
and the buccal BT
technique;
CW/CL and 7. CW/CL and KTW were significant
Height of the predictors of GT at CEJ.
gingival scallop:
digital
photographs
(Continues)
325
326
TABLE 1 (Continued)
Stellini et al., 1. To assess the Cross- Volunteers without Italy; white 23 (18-29) Maxillary GT: a needle fitted 1. Median KTW and GT were 1. The shape of the
201341 correlation sectional destructive (Italian) 31M/19F central with a rubber 4.8 mm and 1.51 mm. maxillary CI
between tooth periodontal dis- incisors stopper crowns correlate
2. Triangular teeth in 19% of male,
shapes and ease; measured by with the extent of
16% of female. Square teeth in 23%
gingival and (n = 50); electronic the KTW, GT, and
of male, 42% of female;
periodontal Groups based on gauge; PH.
square-tapered teeth in 58% of
characteristics. crown shapes: KTW: electronic
male, 42% of female.
Triangular (n = gauge;
9); Square (n = Bone sounding 3. Statistically significant differences
15); depth: were observed for GT (P =0.012)
Square-tapered (n periodontal and KTW (P < 0.001) and PH
= 26) probe; (P <0.001) between groups.
CW/CL and PH: 4. No significant differences in sex
digital among three tooth-shape groups
photographs (P = 0.34).
AG = attached gingiva; BT = bone thickness; C = canine; CAL = clinical attachment level; Cs = canines; CBCT = cone-beam computed tomography; CEJ = cemento-enamel junction; CI = central incisor; CL = crown length;
CT = connective tissue; CW = crown width; FE = free gingiva; GB = gingival biotype; GI = gingival index; GR = gingival recession; GT = gingival thickness; KTW = keratinized tissue width; LI = lateral incisor; LIs = lateral
incisors; M = molar; MGJ = mucogingival junction; NR = not reported; PD = probing depth; PH = papilla height; PM = premolar; M = molar; Yrs = years.
KIM ET AL
KIM ET AL 327
these clinically significant relationships, Fischer et al.33 then due to their thin gingival tissues.36,39,40 Most gingival and
evaluated the relationship between GB (determined by probe periodontal studies have focused on White subjects which
visibility) and GT (measured using a customized digital has resulted in a lack of similar information for other ethnic
caliper). In this study, 60 White dental school students’ groups. Thus, Chou et al.39 conducted a clinical study to
maxillary CIs were initially categorized into three groups evaluate gingival characteristics in an Asian (Taiwanese) pop-
(thin GB, moderate GB, and thick GB). The authors reported ulation. The authors examined gingival characteristics of 112
a median GT ranging from 0.43 mm to 0.83 mm. In addition, healthy Taiwanese subjects and reported Asian (Taiwanese)
the authors reported a significant difference in GT between subjects might be more prone to gingival recession and more
thin GB versus moderate GB (P = 0.002) and between thin challenging when performing esthetic reconstruction of the
GB versus thick GB (P <0.01). Moreover, they found that maxillary anterior teeth.
KTW was directly correlated with GT, and the presence of a Lee et al.40 conducted a cross-sectional comprehensive sur-
thick gingiva was associated with a wide band of KT. vey of tooth morphology and GB in Asian subjects (people of
In general, literature suggests that GT is correlated with GB Chinese, Japanese, Korean, and Vietnamese origin) living in
in the anterior maxilla. The data for regions other than anterior the United States. The authors noted that Asian patients exhib-
maxilla are limited and conflicting. ited a high percentage of thin GB as well as moderate reces-
sion. Müller and Eger26 reported 12% of white males exhib-
3.1.3 Association between gingival phenotype ited thin gingiva. In a similar study, De Rouck et al.5 reported
and age, sex, dental arch, and race a 33% prevalence rate of thin gingiva in mostly whites
Age and sex females. In contrast, Lee et al.40 reported a high incidence
The association between age and GT was assessed in six (>60%) of thin GB in the anterior teeth of Asian patients.
studies.8,28,31,34,36,43 Five out of the six studies demon- Lee et al.36 evaluated the gingival profile (GT and KTW)
strated that there is no relationship between age and the of teeth with a healthy periodontium in Asian populations
GT.8,28,31,36,43 (Chinese, Malay, Indian, and Eurasians). GT increased from
Eger et al.8 observed no difference in mean GT among indi- anterior to posterior teeth in both maxillary and mandibular
viduals ranging from 20 to 60 years of age. Cook et al.,28 arches. The maxillary molars exhibited the greatest GT while
in US subjects, reported no significant association between mandibular incisors showed the thinnest. Of the 370 maxil-
periodontal biotype classification and age or sex for maxillary lary anterior teeth, 63.8% were classified as having a thin GT
anterior teeth. Shah et al.,31 in 400 young Indian subjects, also (<1.5 mm) compared with 92.4% of mandibular anterior
reported no significant relationship between GB and age, sex. teeth. Both GT and KTW were not influenced by age, sex,
Thus, the current evidence does not support a relationship ethnicity (Chinese and non-Chinese) and type of periodon-
between age and GT and sex and GT. tium (healthy normal and reduced). In conclusion, there was
a high prevalence of thin GT and thin marginal gingiva asso-
ciated with the anterior teeth in this cohort.
Dental arch
The current evidence suggests that Asian subjects have a
Five studies compared the thickness of maxillary and
thin gingival phenotype compared with white subjects.
mandibular teeth.24,34,36–38 The majority of studies found that
GT varies within and between individuals. However, there is
no major difference between overall GT in the maxilla and the 3.1.4 Association between gingival and
mandible.36,38 periodontal phenotypes and crown forms
In terms of dental arch, Pascual et al.38 reported no In 1977, Weisgold reported an association between tooth
significant differences at the crestal and middle portions of shape and gingival architecture.51 A square tooth shape was
maxillary and mandibular anterior teeth in terms of their associated with a flat gingival architecture and a thick GT
gingival and facial bone thickness. However, the facial bone while a triangular shape tooth was associated with a scalloped
thickness was greater in mandibular anterior teeth com- gingival architecture and a thin GT.51
pared with maxillary teeth at the most apical aspect of the The relationship between gingival and periodontal
root.38 phenotypes and crown forms have been assessed in
twelve studies.5,8,25–27,30,35,37–39,41,45 However, these
Gingival tissue thickness in Asian population studies reported inconsistent findings regarding the crown
Differences in gingival tissue thickness between groups form as a predictor factor for gingival and periodontal
from different ethnic or racial backgrounds are known to phenotypes.8,25,30,35,41 The data on the association between
exist. Four studies evaluated the gingival phenotype in Asian gingival and periodontal phenotypes and crown forms is
populations.36,37,39,40 A common clinical impression is that presented in supplementary Appendix 2 in online Journal of
Asians tend to have susceptibility for gingival recession Periodontology.
328 KIM ET AL
3.1.5 Association between periodontal For this focused question, a total of 11

phenotype and thickness of labial plate references8,25,27,28,31,36,46–50 met our inclusion criteria.
The role of labial or buccal plate thickness on peri- Table 2 presents the characteristics and results of the
odontal phenotype has been investigated in eight included included studies assessing the difference between thin versus
studies.10,28,30,35,37,38,42,43 The available evidence indicates thick gingival phenotype in terms of gingival health.
there are variations in the buccal plate thickness within sub-
jects based on tooth positioning and location of the measured
3.2.1 Association between GT and PD, BOP,
point.10,28,30,35,37,38,42,43 Although the majority of the studies
and biofilm
suggest that periodontal phenotype is associated with thick-
ness of buccal plate,28,30,35,42 other studies found there is no Four studies investigated the role of gingival phenotype on
association between periodontal phenotype and labial or buc- periodontal health by assessing periodontal parameters such
cal plate thickness.37,43 The data on the association between as PD, BOP, and plaque index at sites with thin versus
periodontal phenotype and thickness of labial plate are pre- thick gingival phenotype.25,46–48 Three studies had a cross-
sented in supplementary Appendix 3 in online Journal of sectional design,25,47,48 and only one study had a prospective
Periodontology. There is a disagreement regarding the role cohort design.46
of the labial plate thickness on periodontal phenotype. Two studies assessed the relationship of GT and BOP in
subjects with healthy or mild gingivitis47 and in subjects
3.1.6 Gingival phenotype and malocclusion with mild to moderate gingivitis.48 According to Müller and
Heinecke,47 reporting the results of a cross-sectional study of
The data on the effect of on malocclusion of the gingival phe-
40 systemically healthy young adults (19 to 30 years) with
notype are presented in supplementary Appendix 4 in online
healthy or mild gingivitis, sites with thin gingiva and insuffi-
Journal of Periodontology.
cient KTW are not more likely to bleed after probing than sites
with thicker tissue. No association was found between GT and
3.1.7 Summary KTW on BOP. Nevertheless, a follow-up study by Müller and
A summary of the observations specific to the clinically rele- Könönen48 looked at the facial GT in 33 young female adults
vant focused question #1 are: (19 to 23 years) with mild to moderate plaque-induced gin-
givitis and found that sites with thin gingival phenotype had
• GT varies among different individuals as well as different higher tendency to bleed compared with sites with thick gin-
areas of the mouth within the same individual.24 gival phenotype. This data may suggest that the association of
• There was a positive correlation between the KTW and GT GT and BOP depends on the severity of gingivitis.
in maxillary anterior teeth.26,29,31,33 The relationship between GT and PD were assessed in
• Maxillary CIs presented with the greatest mean GT, fol- two studies.25,48 Olsson et al.,25 in a cross-sectional study,
lowed by LIs and Cs.24,26,29,31 assessed the relationship between the maxillary CI crown
forms and the thickness of the gingiva in 108 whites aged 16
• Maxillary LIs have the greatest KTW, followed by the CIs
to 19 years. The PD was consistently greater in subjects with
and Cs.26,29,31
short-wide form of the CI crowns versus those subjects with
• Gingival phenotype does not appear to be influenced by a long-narrow form of the CI crowns. In addition, the authors
either age or sex.8,28,31,36,45 However, other studies have found a positive association between GT and PD at the facial
reported higher prevalence of thin gingival phenotype in surface in CIs, LIs, and Cs. This association reached a level of
females versus males.5,27,35 significance (P <0.01) for LIs. Similar findings were reported
• Asian subjects seemed to have thin gingival phenotype in the study by Müller and Könönen.48 They reported greater
compared with white subjects.36,39,40 periodontal probing depths were associated with thick gingiva
• There is a disagreement in terms of tooth shape predicting and lower plaque index scores were noted at sites with thin
gingival phenotype8,25,30,35,41 and the role of thickness of gingiva.
the labial plate on periodontal phenotype.28,30,35,37,42,43 Only one study investigated the effect of GT on the outcome
of periodontal therapy. Claffey and Shanley46 assessed the
Conclusion: SORT Level B relationship of GT and BOP in shallow sites to attachment loss
after non-surgical periodontal therapy. Based on the GT, they
categorized sites into thin (≤1.5 mm) or thick (≥2.0 mm) GT.
Following non-surgical debridement in shallow probing depth
The second of the three clinically relevant focused questions sites (≤3.5 mm) initially non-bleeding thin GT sites displayed
is: Is there difference between thin versus thick gingival phe- a mean attachment loss of 0.3 mm, while non-bleeding thick
notype in terms of gingival health? GT sites displayed a less noticeable mean attachment loss. In
TABLE 2 Summary of the included studies evaluating the difference between thin versus thick gingival phenotype in terms of gingival health
KIM ET AL
Study population; mean

age (range); sex; evaluated
Study sites; intervention and Outcome variables and
Studies Objectives design groups evaluation methods Results Conclusions
Relationship between GT and plaque, BOP, and PD
Claffey and 1. To investigate the Prospective - 15 patients with Clinical examinations were 1. Thin and non-bleeding sites had a The attachment loss that
Shanley, relationship of GT cohort moderately or severely done at baseline and 3 mean attachment loss of 0.3 ± 0.8 mm observed after non-surgical
198646 and BOP in advance periodontal months after the treatment; after non-surgical therapy. periodontal therapy may be
shallow buccal disease GT: transgingival probing 2. No change in PD was observed for the primarily due to the changes
sites (≤3.5 PD) to - 34.7; (NR) (stainless steel wire with 1 thin and non-bleeding sites, whereas in shallow, thin healthy sites.
loss of probing mm increments); all other groups showed a reduction in
- Sex: NR
attachment after Relative CAL: using a stent PD compared with the baseline.
non-surgical - Maxillary and and periodontal probe;
mandibular non-molar 3. The mean attachment loss after
therapy. BOP, GR, PD, PI: clinical
teeth non-surgical therapy was significantly
examination
greater in non-bleeding thin sites
- A single appointment of
(baseline GT ≤ 1.5 mm) compared
supra- and subgingival
with bleeding thin sites and bleeding
instrumentation. Sites
thick sites (baseline GT ≥ 2.0 mm).
were grouped as follows:
4. Thin and non-bleeding group had
1. GT <1.5 mm with
more sites with attachment loss
BOP (n = 44)
compared with the other groups.
2. GT <1.5 mm without
BOP (n = 93)
3. GT >2.0 mm with
BOP (n = 39)
4. GT >2.0 mm without
BOP (n = 39)
Müller and 1. To study the effect Cross- - 40 systemically healthy GT: ultrasonic device; 1. BOP was significantly correlated with No association between GT and
Heinecke, of GT and KTW sectional young volunteers KTW: periodontal probe; smoking status, plaque and tooth type. KTW on BOP in patients
200247 on BOP in young - NR; (19 to 30) BOP, CAL, PD, PI: clinical 2. When adjusted for smoking, tooth type with mild plaque-induced
subjects with mild examination and clinical variables, gingival gingivitis.
- 19M/21F
plaque-induced phenotype did not affect bleeding
gingivitis. - Maxillary and
tendency.
mandibular teeth
- None
(Continues)
329
330
TABLE 2 (Continued)
Müller and 1. To evaluate cross- - 33 subjects mild or GT: ultrasonic device; 1. A positive significant association was 1. Higher bleeding tendency
Könönen, subject variation sectional moderate plaque-induced Bleeding index, BOP, CAL, PI, found between GT and PD and was found in subjects with
200548 of buccal GT in gingivitis PD, % of calculus: clinical between GT and PI. thin gingiva.
young subjects - 22 (19 to 23) examination 2. A negative significant associated with 2. PD was associated with GT.
with mild GT and average bleeding index.
- 33F 3. Lower PI scores were found
gingivitis.
- Maxillary and for subjects with thinner
mandibular teeth gingiva.
- None
Olsson et al., 1. To assess the Cross- - 108 volunteers GT: transgingival probing 1. The GT in CIs is significantly affected 1. There is a strong
199325 relationship sectional - 17.1 (16 to 19) (syringe needed with an by the bucco-lingual width of the relationship between KTW
between the form endodontic depth marker); crown, KTW and the presence of and GT.
- Sex: NR
of the crowns and KTW: periodontal probe; interproximal gingival groove. 2. There is a positive
GT as well a - Maxillary anterior teeth GI, PD, CAL: clinical 2. GT was positively associated with PD relationship between GT
group of - None examination at the buccal surface in CIs, LIs, and and PD.
morphological Cs. This association reached a level of
characteristics in significance (P <0.01) for LIs.
the maxillary
3. The mean CAL was significantly
anterior teeth.
greater in LIs with long-narrow
crowns compared with those with
short-wide crowns. No significant
differences were found for CIs and Cs
for this variable.
(Continues)
KIM ET AL
TABLE 2 (Continued)
KIM ET AL

Relationship between GT and gingival recession
Cook et al., 1. To evaluate the Cross- - 60 subjects without GB: probe visibility; 1. Subjects with a thin GB were more 1. Subjects with thick/average
201128 difference in labial sectional periodontitis or severe KTW: periodontal probe; likely to have scalloped gingival GB have thicker labial plate
plate thickness in gingivitis BOP, GR, PD, CAL: clinical architecture. and a smaller distance from
patients identified - Age: NR examination; 2. No significant relationship was the CEJ to the alveolar crest
as having thin Buccal bone thickness: CBCT observed between GB and GR. than those with thin
- Sex: NR
versus However, only 6.1% of all examined biotype.
thick/average - Maxillary anterior teeth
teeth had GR. 2. GR is not associated with
periodontal - None; Groups: GB. However, this finding
biotypes. 1. Thin GB (n = 26) should be interpreted with
2. Thick/Average GB caution due to the limited
(n = 34) sample size of sites with GR
Eger et al., 1. To determine the Cross- - 42 subjects with healthy GT: ultrasonic device; 1. At a site-level analysis, GT was GT is significantly associated
19968 validity and sectional gingivae or mild KTW: periodontal probe; significantly associated with PD with PD, GR, KTW, and
reliability of gingivitis PD, GR: clinical examination (P <0.0001), GR (P = 0.034), KTW tooth type.
measuring GT - NR (20 to 25) (P <0.0001) and tooth type
with an ultrasonic (P <0.0001)
- 42M
device and 2. At a subject-level analysis, GT was
measure GT in - Maxillary and
significantly associated with PD (P =
relation to tooth mandibular non-molar
0.018), KTW (P <0.0001) and tooth
type and age. teeth
type (P <0.0001).
- None
Lee et al., 1. To determine the Cross- - 51 Chinese subjects with GT: transgingival probing 1. Sites with recession had significantly Sites with no recession
201836 facial gingival sectional healthy normal or (endodontic file with a thinner GT (1.28 ± 0.54 mm) displayed significantly
profiles (GT and reduced periodontium rubber stop); compared with sites with no recessions greater KTW and GT
KTW) of - 30.3 (NR) GB: probe visibility; (1.40 ± 0.52 mm) (P = 0.01). compared with sites with
periodontally KTW: periodontal probe 2. Sites with recessions had significantly recession.
- 24M/27F
healthy sites in an narrower KTW (3.83 ± 1.13 mm)
Asian population. - Maxillary and
compared with sites with no recession
mandibular incisors to
(4.72 ± 1.33 mm) (P <0.0001).
the first molars
- None
(Continues)
331
332
TABLE 2 (Continued)
Liu et al., 1. To assess the Cross- - 50 Chinese subjects GT: transgingival probing 1. Mean GT in periodontally healthy GT in subjects with treated
201750 gingival biotype in sectional - 23.5 (NR) for subjects (customized digital caliper); subjects was 1.05 ± 0.31 mm, and it periodontitis is significantly
subjects with and with healthy GR: standardized digital was 0.89 ± 0.29 mm in periodontitis correlated with GR.
without a history periodontium and 46.4 photographs; patients.
of periodontal (NR) for subjects with CW/CL: clinically using 2. Patients with treated periodontitis had
disease in a treated chronic periodontal probe significantly thinner GT compared
Chinese periodontitis with healthy patients (P <0.05).
population.
- 24M/26F 3. Sites with thin gingiva (GT < 1 mm)
- Maxillary CIs and LIs had significantly greater GR compared
with sites with thick gingiva (GT > 1
- None; groups:
mm) in subjects with treated
1. Subjects with healthy periodontitis (P <0.05).
periodontium (n = 30)
4. There was a significant correlation
2. Subjects with treated between the GT and GR (P = 0.032)
chronic periodontitis in subjects with treated periodontitis.
(n = 20)
Maroso et al., 1. To assess the Cross- - 55 subjects without GT: transgingival probing (a 1. Mean GT was 1.40 mm with a range GT is negatively associated
201549 relationship sectional history of periodontitis needle with a rubber stent of 1 to 1.97 mm. with GR in young adults
between GT and - 24.82 (18 to 35) and a digital caliper); 2. A statistically significant negative with low degrees of gingival
GR in subjects BOP, CAL, GBI, GR, PD, PI: correlation was found between GT and inflammation.
- 24M/31F
without history of clinical examination GR (P = 0.02). The smaller the GT,
periodontitis. - Maxillary and
the greater the GR.
mandibular anterior teeth
- None
(Continues)
KIM ET AL
KIM ET AL
TABLE 2 (Continued)
Müller et al., 1. To study thickness Cross- - 40 Periodontally healthy GT: ultrasonic device; 1. The mean PD was significantly greater Subjects with thick and wide
200027 of masticatory sectional subjects KTW: periodontal probe; in subjects with thick and wide gingiva gingiva as well as quadratic
mucosa and KTW - NR; (19 to 30 years) PD, CAL, GR: clinical and quadratic shape of teeth (2.00 ± shape of teeth had
in individuals examination 0.15 mm) compared with the subjects significantly greater PDs
- -19M/21F
with different with thin and narrow gingiva with compared with those with
periodontal - Maxillary anterior teeth slender shape teeth (1.69 ± 0.26 mm) thin and narrow gingiva with
phenotypes. - None (P <0.01). slender shape teeth.
2. Subjects with thin and narrow gingiva
tended to have more GR and higher
bleeding/plaque ratio, but these
differences were not statistically
significant.
Shah et al., 1. To evaluate the Cross- - 400 Indian subjects GT: transgingival probing 1. 66 Patients presented with GR. This observational study did
201531 GT and its sectional - 28.82 (20 to 35 years) (endodontic file with a Among those, 32 subjects had thick not find any correlation
relationship to rubber stop); GB and 34 had thin GB. between GT and the
- 200M/200F
sex, presence of GB: Thin for <1 mm GT and 2. For subjects presenting with GR, the presence of GR
GR and the KTW - Maxillary anterior teeth thick for >1 mm GT; mean GT was 1.12 mm for CIs,
in a subset of the - None KTW: periodontal probe; 1.00 mm for LIs, and 0.79 mm for Cs.
Indian population. PD: periodontal probe
3. No significant difference was observed
between the overall GT and GT of
subjects with gingival recession.
BOP = bleeding on probing; C = canine; CAL = clinical attachment level; CBCT = cone-beam computed tomography; CEJ = cemento-enamel junction; CI = central incisor; CL = crown length; CW = crown width; F = female;
GB = gingival biotype; GBI = gingival bleeding index; GI = gingival index; GR = gingival recession; GT = gingival thickness; KTW = keratinized tissue width; LI = lateral incisor; Lis = lateral incisors; M = male; NR = not
reported; PI = plaque index; PD = probing depth.
333
334 KIM ET AL
addition, no reduction in PD was observed for the thin and (P <0.05). In addition, in subjects treated for chronic peri-
non-bleeding sites, while all other sites had a reduction in PD odontitis, sites with thin gingiva had significantly greater
compared with the baseline. They authors concluded that the recession than sites with thick gingiva (P <0.05). The study
observed attachment loss following non-surgical periodontal concluded that GT, in subjects with treated periodontitis, is
therapy was likely the result of changes in healthy sites with significantly correlated with gingival recession.
shallow PD and thin gingival tissue. Two studies reported no association between GT and
Therefore, the available limited evidence indicates that PD recession.28,31 A study by Cook et al.28 was designed to evalu-
is greater in subjects with thick gingival phenotype.25,48 It ate labial bone plate thickness of maxillary anterior sites with
should be noted that this statement is based only two cross- thin versus thick/average periodontal biotypes in 60 healthy
sectional studies. In addition, there is conflicting evidence subjects. Interestingly, a secondary finding of the study was
regarding the association of BOP and thin gingival tissue. the lack of a significant association between periodontal bio-
type classification and GR. However, it should be noted that
only 6.1% of all evaluated teeth demonstrated gingival reces-
3.2.2 Association between GT and gingival sion, suggesting that the results should be considered with
recession caution. Shah et al.31 examined the anterior maxillary teeth of
The association between GT and recession were evaluated 400 ethnic Indian subjects between the ages of 20 and 35 years
in seven articles.8,27,28,31,36,49,50 Several studies reported that and reported that 66 (16.5%) patients presented with GR, 32
subjects with thin and narrow gingival width tend to have (8%) of which had thick GB and 34 (8.5%) had thin GB. The
more recession.8,27,36,49,50 Maroso et al.49 conducted a cross- authors reported no significant difference between the over-
sectional study investigating the correlation between GT and all GT (n = 400) of those presenting with gingival recession
GR in healthy adults (aged 18 to 35 years) without a history (n = 66) and those not presenting with gingival recession
of periodontitis. The study reported that GT was inversely (n = 334).31 It should be noted that power analysis was not
correlated to gingival recession in this cohort (P = 0.02); performed to calculate the sample size in this study. So it is
the thinner the GT, the greater the recession. Eger et al.8 in not clear whether this study had enough power to detect a true
a cross-sectional study of 42 healthy males between age 20 difference.
to 25 years with healthy gingivae or mild gingivitis used an Based on the available evidence, it can be concluded that
ultrasonic device to investigate the influence of GT on clini- subjects with thin tissue and narrow gingival width tend to
cal periodontal parameters. The study reported that GT is sig- have more gingival recession.8,27,36,49,50
nificantly correlated with PD, gingival recession, and KTW.
Müller et al.27 studied the thickness of masticatory mucosa 3.2.3 Summary
and gingival width in subjects with different periodontal phe- A summary of the observations specific to the clinically rele-
notypes. The study assessed the maxillary anterior teeth of 40 vant focused question #2 are:
subjects (19 to 30 years) using cluster analysis to define peri-
odontal phenotypes. It was found that subjects with thin and • PD was greater in subjects with thick gingival
narrow gingiva tended to have more gingival recession and a phenotype.25,48
higher bleeding/plaque ratio, although these differences were • There is disagreement regarding the association of BOP and
not statistically significant. thin gingival tissue.27,47,48
Similar findings are reported in the Asian population. Lee
• Subjects with thin tissue and narrow gingival width tend to
et al.36 in a study consisting of 51 Chinese subjects, evaluated
have more gingival recession.8,27,36,49,50
the facial gingival profile of teeth with a healthy or reduced
periodontium. It was reported that sites with recession have Conclusion: SORT Level B
thinner GT (1.28 ± 0.54 mm versus 1.40 ± 0 .52 mm) and
narrower KTW (3.83 ± 1.13 mm versus 4.72 ± 1.33 mm)
compared with sites with no recession. Significantly greater
GT and KTW were observed in sites with no recession com- The last of the three clinically relevant focused questions is:
pared with those with recession. Another study by Liu et al.50 Does the conversion of gingivae from a thin to thick gingival
studied GB in Chinese subjects with and without a history of phenotype in sites without gingival recession or mucogingival
periodontal disease. Thirty periodontally healthy subjects and involvement offer clinical value for maintaining periodontal
20 subjects with treated chronic periodontitis were included in health?
the study. The mean GT in periodontally healthy subjects was Reviewers were not able to find any relevant articles that
1.05 ± 0.31 mm while the mean GT in periodontitis patients met the inclusion criteria for this focused question. Studies
was 0.89 ± 0.29 mm. Patients with treated periodontitis focusing on treatment of already existing gingival recession or
had significantly thinner GT compared with healthy patients mucogingival defects were excluded because the goal of this
KIM ET AL 335
focused question was to assess whether conversion of thin to reported a flap thickness of >0.8 mm was associated with
thick gingival phenotype in sites without gingival recession or 100% root coverage.53 Huang et al.54 reported that when a
mucogingival involvement offered a clinical value for main- coronally advanced flap was used to treat gingival recession,
taining periodontal health. an initial GT of ≥1.2 ± 0.3 mm was associated with complete
root coverage. Hwang and Wang52 reported that GT influ-
Conclusion: SORT Level C ences the mean gain in root coverage and the incidence of
complete root coverage, especially for connective tissue graft-
based and guided tissue regeneration-based root coverage pro-
4 DIS CUSSI O N cedures. In surgical crown lengthening procedures, Pontoriero
and Carnevale55 noticed the coronal regrowth of the soft tis-
Resistance to trauma and recession, superior soft tissue sue margin at interproximal and buccal/lingual sites was sig-
handling property compared with thin tissue, promotion of nificantly more pronounced (P <0.001) in patients with a
creeping attachment, reduction in clinical inflammation and thick tissue biotype as compared with the thin tissue biotype.
enhancing predictable surgical outcomes were all positive The effect of gingival phenotype on periodontal health
characteristics of thick gingival tissue quality that have been parameters of restored teeth has also been investigated. Koke
reported in the literature.52 It is believed that a high volume et al.56 reported that intracrevicular crown margin placement
of extracellular matrix and collagen, as well as increased vas- lead to early gingival recession and attachment loss despite
cularity, allow for the survival of thick soft tissue.52 careful supportive therapy. Recession was also more likely
For clinically relevant focused question #1, a positive cor- to occur at sites with a narrow band of KT. Tao et al.57
relation was noted between KTW and GT/GB in maxillary conducted a prospective clinical study to assess 5-year out-
anterior teeth. Asian subjects seemed to have thin gingival comes of metal-ceramic crown restorations for maxillary CIs
phenotype compared with white subjects. For clinically rel- for patients with thin and thick gingival biotypes in a Chinese
evant focused question #2, PD was greater in subjects with Population. The failure-free rate of the metal-ceramic crowns
thick gingival phenotype and subjects with thin and narrow for patients with a thin biotype was 78.0%, and for patients
gingiva tend to have more gingival recession. The reviewers with a thick biotype it was 94.0% following these patients up
were unable to identify any articles related to the outcome to 65 months of function (P = 0.02). Thus, a patient’s gingi-
question (clinically relevant focused question #3). However, val biotype had a significant effect on the outcomes of metal-
the 2017 World Workshop on mucogingival conditions in the ceramic crown restorations in maxillary CIs.
natural dentition provides guidelines for clinicians to answer With respect to dental implants, Kois58 found a greater
this question.12 For cases with no gingival recession, two dif- thickness of peri-implant mucosa in the presence of a thick
ferent case scenarios can be considered: gingival biotype compared with a thin biotype. Thin gingi-
Case a. Thick gingival biotype without gingival recession: val tissues tended to be delicate and almost translucent in
Prevention through good oral hygiene technique and close appearance, contributing to an undesirable visibility of metal
monitoring is recommended. copings through the tissue, resulting in a grayish appearance
Case b. Thin gingival biotype without gingival recession: at the gingival margin.59 A thick biotype was significantly
This is a case that may lead to a greater risk for future reces- associated (P <0.05) with maintaining the presence of the
sion. Clinicians should pay close attention to prevention and gingival papilla in immediate dental implants restored with
careful monitoring. Cases of severe thin gingival biotype can a fixed single-crown prosthesis,60 while there was a trend
be considered for prophylactic mucogingival surgery, espe- toward more recession in patients with a thin tissue biotype.59
cially before orthodontic treatment, restorative dentistry with Sites with thin tissue biotype, particularly those in a facial
intrasulcular margins, or dental implant therapy. or buccal position, should be regarded as at risk of marginal
Thus, it is important for the clinician to identity the types tissue recession.59,61 The presence of a thick peri-implant
of gingival and periodontal phenotype as well as the surgical soft tissue also contributes to a more stable crestal bone
technique to best enhance the quality of soft tissue and treat- levels.62–65
ment outcomes. The gingival phenotype likely has an important role in
A patients’ gingival and periodontal phenotypes have an voiding periodontal problems during orthodontic treatment.15
important role in the outcomes of non-surgical and surgical Several authors reported that gingival recession may develop
periodontal therapies, restorative treatment, implant treatment during orthodontic therapy when teeth have an inadequate
and orthodontic treatment.11 zone of gingiva.66–68 It has been recommended that areas with
In those mucogingival surgical procedures using a coro- <2 mm of AG should undergo gingival augmentation before
nally advanced flap for root coverage, it has been suggested the initiation of orthodontic therapy.69 Anterior teeth are com-
that an initial flap thickness of 0.8 to 1.2 mm is best for monly proclined during orthodontic treatment and maxillary
achieving complete coverage.53,54 For example, Baldi et al.53 anterior teeth tend to have thin tissue, they are at high risk
336 KIM ET AL
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Received: 3 June 2019 Revised: 6 September 2019 Accepted: 25 September 2019

Effect of gingival phenotype on the maintenance of periodontal

David M. Kim1 Seyed Hossein Bassir2 Thomas T. Nguyen3

1 Advanced Graduate Program in

J Periodontol. 2020;91:311–338. wileyonlinelibrary.com/journal/jper © 2020 American Academy of Periodontology 311

1 I N T RO D U C T I O N conditions of 47 patients with gingival augmentation sites

iii. Comparison: included studies had to have a

(P <0.05) between them for the maxillary anterior teeth. Sev-

3.1 Focused question 1

Study (sample size); ethnicity/ (range) and Evaluated Evaluation

Study population; Country; Mean age

Study (sample size); ethnicity/ (range) and Evaluated Evaluation

3.1.5 Association between periodontal For this focused question, a total of 11

Study population; mean

age (range); sex; evaluated

65. Linkevicius T, Linkevicius R, Alkimavicius J, Linkeviciene L, S U P P O RT I NG IN FO R M AT I O N

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