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Review Article Periodontal biotype: Basics and clinical

considerations
Rucha Shah, N. K. Sowmya, Raison Thomas, Dhoom Singh Mehta
Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Address for correspondence: Dr. Rucha Shah, E‑mail: srucha2k@yahoo.com

ABSTRACT
Gingival/periodontal biotype is now known to influence the indications and outcomes of various therapies routinely performed
in a dental clinic. The delicate thin biotype is more susceptible to injury and responds in a different way clinically as compared
to the sturdier thick biotype. Assessment, identification, and indicated treatment considerations are now becoming the key to
achieve predictable results, good esthetics, and stability of soft tissue margins. This review describes the various classifications,
methods of assessment and clinical considerations for both the thick and thin tissue biotypes.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

In the era of evidence‑based interdisciplinary dentistry, none of the dental disciplines are mutually exclusive. The treatment
plan, treatment response, and prognosis of dental procedures vary greatly between teeth with different biotypes. Hence, the
knowledge and assessment of gingival/periodontal biotype has become an important routine in clinical decision‑making.

Key words: Gingival biotype, periodontal biotype, periodontal therapy

INTRODUCTION morphology, namely the scalloped and thin or flat

and thick gingiva.[1] The term “periodontal biotype”

G ingiva is the part of the oral mucosa that

covers the alveolar processes of the jaws and
surrounds the necks of the teeth. A well‑scalloped
gingival line at the cemento‑enamel junction (CEJ) of
the teeth forms one of the pillars of a beautiful smile.
Clinicians handle gingiva in several dental procedures
and the resulting gingival architecture is not always
ideal. In the era of esthetics‑driven dentistry, it is
of paramount importance that a clinician should be
well‑aware of all the factors that may influence the
final esthetic outcome of a treatment. One such factor
that clinicians should consider before starting any
restorative, prosthetic, and periodontal procedure is
the “tissue biotype.”
Ochsenbein and Ross in their pioneer study
indicated that there were two main types of gingiva
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was later introduced by Seibert and Lindhe to
categorize the gingiva into “thick flat” and “thin
scalloped” biotypes.[2] In general, the term gingival
biotype has been used to describe the thickness of
the gingiva in the facio‑palatal dimension. Whereas
the term “periodontal biotype” encompasses not
only the thickness of gingiva, but also other features
such as contour of gingiva, alveolar bone contour
and thickness, amount of keratinized gingiva
present, and crown shape. [3] With the increase
in the amount of literature on the topic, it is now
understood that dif ferent gingival/periodontal
biotypes behave in a different manner under similar
clinical conditions. Furthermore, the treatment
considerations for individuals with dif fer ent
biotypes differ.
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DOI: How to cite this article: Shah R, Sowmya NK, Thomas R, Mehta DS.
10.4103/2229-5194.188172 Periodontal biotype: Basics and clinical considerations. J Interdiscip
Dentistry 2016;6:44-9.

44 © 2016 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow

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Shah, et al.: Periodontal biotype

GINGIVAL/PERIODONTAL BIOTYPE contour, thick flat osseous gingival contour, broad apical
CLASSIFICATIONS contact areas in teeth, and square anatomic crowns. It
is mostly associated with periodontal health. The tissue
Several classifications have been pr oposed for is dense with a wide zone of attached gingiva. The
gingival/periodontal biotypes. Even while classifying underlying bony architecture is considered to be thick.
periodontal biotypes, gingival thickness is considered an Surgical exposures in such cases demonstrate thick
important factor as gingival and periodontal biotypes are underlying osseous forms [Figure 2].[3,10] The prevalence
considered to be closely related. Gingival/periodontal of thick biotype is around 56%.[11,12]
biotype may differ from tooth to tooth in a person; may differ
with age, gender, and dental arch location.[4] There is no
universally accepted classification for gingival/periodontal METHODS OF MEASUREMENT OF
biotypes. There is also a lack of agreement between GINGIVAL THICKNESS
authors as to what thickness of gingiva would be
considered thin or thick. Gingival biotypes were initially Many methods have been proposed till date to analyze the
classified by Oschenbein and Ross as thin or thick. gingival tissue thickness. These are described as follows:
However, several classifications of gingival biotypes
have been presented over time [Table 1].[5‑8] In a recent Direct measurements
systematic review, it was concluded that the available The gingiva is anesthetized by topical application of an
definitions of gingival/periodontal biotypes are unclear, anesthetic gel. An endodontic spreader with a rubber stop/
and the three biotypes: Thin scalloped, thick flat, and caliper is inserted at a point at the center of the gingival
thick scalloped seem a comprehensive categorization margin and mucogingival junction in a perpendicular
in defining periodontal biotypes in the population.[9] In direction and this measurement is recorded against a
spite of a lack of agreement for the classification method, digital caliper. It is an accurate method of measurement,
most of the studies attribute similar features to a thick and however it is an invasive technique.[8]
a thin biotype. Each biotype possesses its own unique
characteristics. Visual examination
The thin and scalloped biotype is said to have a delicate The gingival biotype is clinically evaluated based on the
and thin periodontium, highly scalloped gingival tissue, general appearance of the gingiva around the tooth. The
usually may present slight gingival recession, presents gingival biotype was considered thick if the gingiva was
highly scalloped osseous contour, small incisal contact
areas in the teeth, and triangular anatomic crowns. Thin Table 1: Different classifications for gingival/
gingival tissue tends to be delicate and almost translucent periodontal biotype
in appearance. The tissue appears friable with a minimal
Authors Classification
zone of attached gingiva, and the soft tissue is highly Ochsenbein and Ross[1] Scalloped Flat and thick
accentuated and often suggestive of thin or minimal bone and thin
over the labial roots. Surgical exposure in such cases Seibert and Lindhe[2] Thick ≥2 mm Thin <1.5 mm
generally demonstrates thin labial bone with an increased Becker et al.[5] (distance Flat: 2.1 mm Scalloped: Pronounced
between interproximal 2.8 mm scalloped: 4.1 mm
incidence of fenestration and dehiscence [Figure 1].[3,10] The and mid‑facial level of
prevalence of thin biotype is around 43%.[11,12] alveolar bone)
Kan et al.[6] Thick >1 mm Thin ≤1 mm
Claffey and Shanley[7] Thick ≥2 mm Thin <1.5 mm
The thick and flat biotype is characterized by thick heavy
Egreja et al.[8] Thick >1 mm Thin <1 mm
periodontium, gingival margin usually placed coronal
to CEJ, wide zones of keratinized gingiva, flat gingival

Figure 1: Clinical presentation of thin gingival biotype Figure 2: Clinical presentation of thick gingival biotype

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Shah, et al.: Periodontal biotype
dense and fibrotic and thin if the gingiva was delicate,
friable, and almost translucent. The advantage of this
technique is that it is minimally invasive, however it has
been found to have a very low accuracy and a very high
interexaminer variation.[13]
Probe transparency
Sulcus probing of the mid‑facial aspect of the tooth
is performed. The gingival biotype is categorized as
either thin or thick according to the visibility of the
underlying periodontal probe through the gingival tissue
(visible = thin, not visible = thick). It is a minimally invasive
technique with a good accuracy.[14]
Ultrasonic devices
A sensitive, thin probe attached to an ultrasonic device
measures the biotypes ultrasonically. It uses the pulse echo
principle for the determination of biotype thickness. This
technique gives accurate measurement ‑ digital display,
avoids interexaminer variability, and noninvasive, but the
high cost of equipment and limited availability make it
less feasible.[15]
Cone beam computed tomography
It is used to visualize and measure the thickness of both
hard and soft tissues. Highly accurate results can be
achieved using cone beam computed tomography (CBCT),
and there is no interexaminer variation. However, there
is some amount of radiation exposure and increased cost
for the patients.[16,17]
When the reliability of assessing gingival biotype of
maxillary anterior teeth with and without the use of a
periodontal probe in comparison with direct measurements
was performed, the authors found that assessment
with a periodontal probe is an adequately reliable and
objective method in evaluating gingival biotype, whereas
visual assessment of the gingival biotype by itself is not
sufficiently reliable compared to direct measurement.[6]
Keeping in mind all pros and cons of the various analytical
modalities, direct measurement and probe transparency
are good methods to detect gingival biotype  clinically.
PERIODONTAL BIOTYPES: CLINICAL
APPLICATIONS
Tissue biotypes are associated with the outcomes
of a variety of dental clinical procedures. In several
dental procedures, the gingival tissue is subjected to
clinical/surgical insults and both the biotypes respond
differently to them. In the event of inflammation or any
other type of insult, soft tissue in a thick biotype responds
by more fibrotic changes and pocket formation, however
46
in thin biotype, we see more inflammatory changes and
recession of gingiva.[10] This basic difference in the response
of thick biotype tissue as compared to thin biotype is the
fundamental for the variation response and consideration
for these under various clinical scenarios. Patients with a
thin biotype are more vulnerable to connective tissue loss
and epithelial damage, thus they need special atraumatic
treatment and oral hygiene techniques.[18]
Crown lengthening procedure
In crown lengthening procedures, the amount of tissue
exposure required for further rehabilitation of the
tooth dictates the amount of bone removal during the
procedure. Significant postoperative tissue rebound has
been observed in cases of thick biotype as compared to
thin biotype.[19] Thus, tissue biotype is an important feature
to be assessed in such cases, and slight overcorrection or
immediate rehabilitation may be advised in such cases.
Orthodontic therapy
In the course of orthodontic therapy, teeth are moved
in various directions (buccally, lingually, coronally, and
apically). In an attempt to bring teeth in an ideal position,
it may sometimes lead to soft tissue recession or hard
tissue dehiscence and fenestration. It has been observed
that such tooth movement results in increased recession
and increased incidence of dehiscence and fenestration
formation in cases with thin biotype.[20] Hence, such
cases should be approached with more caution. Another
consideration could be placement of mini‑screws where
a thin biotype warrants more caution.
Prosthesis esthetics
The thin biotype is more prone to recession of gingiva. It has
been observed that in relation to metal ceramic prosthesis
over a period of 5 years, significantly more gingival
recession is observed after prosthesis placement in thin
biotype as compared to thick biotype.[21] This underscores
the importance of assessment and management of thin
biotype cases at the time of prosthesis placement. In areas
of high esthetic requirement, biotype enhancement can
prevent such unpleasant clinical scenario. On the basis
of these findings, it can be suggested that more caution
should be exercised while planning a subgingival margin
placement for patients with a thin biotype as minimal
tissue injury may result in adverse outcome in future.
More controlled studies on these conditions are required.
Root coverage in thick versus thin biotypes
It was proposed that thick gingival tissue eases
manipulation, maintains vascularity, and promotes wound
healing during and after surgery. A critical threshold
thickness (>1.1 mm) for root coverage success may exist
for predictable root coverage.[22] Hence, patients having a
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Shah, et al.: Periodontal biotype
thinner biotype can be treated preferably with techniques
that create a pseudo‑thick biotype such as a connective
tissue graft in conjunction with coronally advanced flap as
compared to a coronally advanced flap alone.[10] In another
study, it was mentioned that the thin gingival biotype may
impair the clinical outcome of root coverage procedures,
and to overcome this, the same coverage can be done
using sub‑epithelial connective tissue graft which provides
better results.[23]
Supragingival tissue
It has been observed that median supracrestal gingival
tissue is more in thick flat biotype as compared to thin
scalloped biotype.[24] Overhanging restorations can more
frequently and rapidly result in tissue destruction.
Flap handling
Owing to the delicate nature of gingival tissue in thin
biotype routine, procedures such as gingival curettage
needs to be performed more carefully. In cases of flap
surgery, careful handling of the flap is more significant in
thin biotype cases.
Extraction of teeth in thick versus thin
biotypes
Although extractions should always be atraumatic, teeth
with thin gingival biotypes merit more attention due to
their association with thin alveolar plates.[3,25] Atraumatic
extraction and preservation of the alveolar plate are
essential. Excessive force is more likely to fracture the
buccal alveolar plate in thin biotype and results in bone
resorption and unpredictable bone healing.
Ridge preservation in thick versus thin
biotypes
Given the thin alveolar plate associated with thin
periodontal biotypes, more extensive ridge remodeling
is seen in thin biotype when compared to thick biotypes
leading to exaggerated loss in hard and soft tissue volume.
Hence, in a patient with thin biotype, augmentative
procedures such as socket preservation/augmentation
may be performed to ensure an esthetic and functional
result in future.[26]
Tissue biotype in implant treatment planning
In thick biotype, significantly, less bone loss is seen after
implant placement as compared to thin biotypes.[27] In a
thick biotype environment, immediate placement of an
implant can be completed with predictable results. In a
thin biotype cases, the possibility of significant resorption,
which may have an impact on esthetics, is high. A delayed
implant placement should be preferred when the thickness
of the periodontal tissues is not sufficient. In thin biotype
Journal of Interdisciplinary Dentistry / Jan-Apr 2016 / Vol-6 / Issue-1
cases, preemptive biotype correction may be considered.
The tissue biotype is considered a key factor in implant
esthetics, preventing future mucosal recession, and
improving immediate implant success.[28‑30]
Another emerging concept in patients with thin biotype
is that of a flapless approach for implant placement. In
the conventional method, a full‑thickness buccal and
lingual/palatal flap is raised, osteotomy is prepared, and
implant placement is done. In the minimally invasive
flapless approach, a surgical guide is prepared using the
CBCT image. Using the guide, a circular punch is made on
the ridge and implant placement is done. This prevents the
disruption of blood supply to alveolar bone which would
be occurring when we raise a full thickness flap. Studies
have shown that after the placement of implants using a
flapless approach, the papillary recession and bone loss
were minimized in patients with thin gingival biotype.[31]
In addition, it has been shown in a study that laser
micro‑textured implant collar may prevent proximal bone
less in thin biotype cases.[27]
ENHANCING THE GINGIVAL BIOTYPE
A preexisting thin gingival biotype can impede ideal
esthetic result of many therapies. In such a scenario,
gingival biotype can be enhanced. This concept is in its
infancy and just emerging. A pseudo thick gingiva is
when an originally thin gingiva is converted to a thick
gingiva.[10] This can be done to achieve more stable results
to avoid soft tissue relapse. It can also aid in achieving
more esthetic results. A study demonstrated that bone loss
can be controlled in thin biotype patients, if the biotype is
augmented prior to the placement of implant.[30]
Few procedures can be performed to enhance the biotype of
gingival tissue. One such procedure is the use of connective
tissue grafts.[32] In this procedure, a connective tissue graft
harvested from palate/tuberosity is placed at the site of
thin biotype subepithelially. For the same, either a full or
partial dissection can be done. Once the graft is in position,
it is sutured. Once healing is completed, a thin biotype is
converted into a stable thick biotype. This can be attributed
to the primarily fibrous content of the graft and the bulk
that they provide at the recipient site. They have not only
been seen to improve gingival biotype, but also increase
the long‑term stability of the results. It is the most reliable
and frequently documented method of enhancing gingival
biotype. However, donor site morbidity, limited availability,
and increased operating time are the disadvantages
associated with connective tissue placement.
As an alternate to connective tissue, acellular dermal
matrix can also be used to enhance the biotype. The
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Shah, et al.: Periodontal biotype
procedure of placement and healing mechanism is similar
to that of the connective tissue graft. It has the advantage
of lowering the patient morbidity due to the absence of
a second donor site; however, the high cost and limited
availability are its drawbacks.
Another mode of enhancing the gingival biotype is the
placement of platelet‑rich fibrin (PRF) membrane. PRF is
a blood‑derived, autologous, second‑generation platelet
concentrate. It mainly consists of a three‑dimensional
fibrin matrix with platelets. These platelets then release
several growth factors including platelet‑derived growth
factor and vascular endothelial growth factor.[33] Shetty
et al. in their study demonstrated that placement of PRF
membrane over denuded root surface in conjunction with
coronally advanced flap results in the improvement in the
thickness of gingiva.[34]
Recently, use of fetal membranes such as amnion and
chorion membrane has demonstrated to enhance gingival
biotype.[35,36] These membranes are allografts derived
from the human placenta. The membranes are then
obtained, processed, and sterilized for human use. The
main advantage of their membranes is their excellent
revascularization, nil antigenicity, and easy availability.
They can be placed under a tunnel/pouch/coronally
advanced flap and sutured. This study demonstrated that
after the placement of amnion membrane in conjunction
with coronally advanced flap, the gingival thickness was
improved.[34]
However, such reports are few and more controlled
studies are required to evaluate the efficacy of both PRF
membranes and fetal membranes. The most effective
technique of biotype augmentation still remains connective
tissue grafting.
CONCLUSION
By understanding the nature of tissue biotype (thickness),
a practitioner can employ appropriate clinical procedures
to minimize soft tissue loss and alveolar resorption and
provide a more favorable tissue environment. Different
gingival biotype can influence the diagnosis and
treatment planning for different patients. In addition,
these techniques when appropriately applied can save on
treatment time and cost for patients. Inclusion of biotype
assessment in the diagnostic record of the patient can
give the clinician an idea about the care to be taken in
tissue handling, the type of procedure to be employed
in a certain situation as well as the expected outcome.
Financial support and sponsorship
Nil.
48
Conflicts of interest
There are no conflicts of interest.
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