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Thick vs. Thin Gingival
S Biotypes: A Key
Determinant in Treatment
Planning for Dental Implants
richard t. kao, dds, phd; mark c. fagan, ms, dds; and gregory j. conte, ms, dmd
P
authors acknowledgment reviously, the importance of Thick and Thin Gingival Biotypes
Richard T. Kao, DDS, PhD, This paper is dedicated to
taking into consideration the Historically, Ochsenbein and Miller
is in private practice in Drs. Ivan Ancell and Joseph differences in gingival tissue have discussed the importance of “thick
Cupertino, Calif., associate Zingale who helped guide during treatment planning has vs. thin” gingiva in restorative treat-
clinical professor, the authors during our been emphasized. Specifically, ment planning.1 In a population study,
University of California, periodontal training in the
it was pointed out how thick and thin thick periodontal biotypes (85 percent)
San Francisco, and development and thought
associate adjunct process behind this paper.
gingival biotypes respond differently to were found to be more prevalent than
professor, University inflammation, restorative trauma, and thin scalloped forms (15 percent).3
of the Pacific Arthur A. parafunctional habits.1,2 These traumatic Subsequently, the authors published a
Dugoni School of events result in various types of periodon- paper that further analyzed thick and
Dentistry, San Francisco.
tal defects, which respond to different thin tissue biotypes in terms of their
Mark C. Fagan, MS, DDS,
treatments. The authors also pointed gingival and osseous architecture.2
is in private practice in out how periodontal surgery techniques Thick gingival tissue is probably
San Jose, Calif., assistant have made it possible to change a thin the image most associated with peri-
clinical professor, gingival biotype into a thick gingival odontal health (figure 1a, table 1) .
University of California,
form. This provides a more favorable The tissue is dense in appearance with
San Francisco.
restorative environment and increases a fairly large zone of attachment. The
Gregory J. Conte, MS, the predictability of treatment outcomes. gingival topography is relatively flat
DMD, is in private practice In this paper, the authors extend with the suggestion of a thick underly-
in San Francisco. their earlier observations of thick vs. thin ing bony architecture. Surgical evalua-
gingival tissues and describe why it is tion of these areas often reveals
important to appreciate tissue biotypes relatively thick underlying osseous
during implant treatment planning. forms (figure 1b) .
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TABLE 1
TABLE 2
TABLE 3
Thin gingival tissue tends to be tration and dehiscence (figure 2c) . that current periodontal surgical tech-
delicate and almost translucent in ap- In the authors’ previous paper, it niques have the potential to improve
pearance (figures 2a-b, table 2) . The was suggested that since these two tissue quality, thereby enhancing the
tissue appears friable with a minimal tissue biotypes have different gingival restorative environment. The paradigm
zone of attached gingiva. The soft and osseous architectures, they exhibit shift proposed was that by taking into
tissue is highly accentuated and often different pathological responses when consideration the gingival tissue biotype
suggestive of thin or minimal bone subjected to inflammatory, traumatic, during treatment planning, more appro-
over the labial roots. Surgical evalu- or surgical insults2 (table 3) . These priate strategies for periodontal man-
ation often reveals thin labial bone different responses dictate different agement may be developed, resulting in
with the possible presence of fenes- treatment modalities. It also was noted more predictable treatment outcomes.
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fig u re 4 a. Lower left lateral incisor No. 23 was f ig ur e 4b. Bone graft material and a resorbable f igure 4c. Re-entry at five months, which
extracted and extensive bone loss was present. A membrane were placed, (Biomend Extend. Zimmer illustrates bone regeneration up to the top of the
12-mm tenting bone screw was placed to support the Dental. Carlsbad, Calif.) bone screw.
graft material and prevent collapse of the membrane.
remodeling when compared to the thicker to the osseointegration of the dental ramus or mandibular symphysis. Allograft
alveolar plate associated with thick bio- implants. For that reason, slow resorp- block grafts can be obtained from several
types. Not only is atraumatic extraction tion graft materials such as xenografts commercial providers. The advantage of
critical to minimize this postextraction and nonresorbable alloplastic materials this technique is that the graft is placed
remodeling, it is important to consider (durapatite, hydroxyapatite) should be as a block instead of in particulate form,
strategies to preserve the alveolar bone, avoided. When there is excessive volume providing increased structural support.
such as socket preservation or ridge of nonresorbable graft materials, there A case of block grafting is presented
preservation procedures. A number of is inadequate room for bone ingrowth where there is a narrowed anterior
studies have shown that without inter- to provide implant osteointegration. maxillary ridge defect (figure 5a) . These
vention, significant alterations in most Additionally, the ridge preservation situations generally require two-stage
extraction ridge dimensions will occur.6-9 strategy is only successful if the graft ma- surgical procedures that included a bone
This loss can be 1.5 to 2.0 mm over the terial is retained in the extraction socket. graft surgery followed by implant place-
first 12 months with most loss occurring A variety of approaches can be utilized to ment after graft healing. In this situa-
during the initial three months.9 A variety achieve socket closure. These include the tion, it is critical that soft tissue incisions
of approaches can be employed to address use of barrier membranes, tenting pins, be carefully planned to allow for flap
this problem, but most involve grafting collagen plugs, connective tissue grafts, relaxation over the increased volume
the extraction socket and using mem- free gingival grafts, acellular dermal gained by the graft and to ensure ten-
branes to support missing/perforated grafts, and advancement of the buccal sionless primary closure. Once adequate
bony walls. Ridge preservation should flap. An advanced case of socket preserva- access was gained, the graft and recipient
be considered for most thin biotype tion with regeneration of the labial plate bed were prepared to obtain intimate,
cases and in thick biotype cases where and vertical dimension is seen in figure 4 . broad contact between the surfaces.
excessive trauma or a previous history Whereas simple cases with intact buccal The recipient bed was perforated to
of endodontic surgery/fistula tracts may and lingual plates can be easily man- enhance revascularization and the graft
have compromised the alveolar plate. aged with grafting and socket coverage, was stabilized using fixation screws to
Classically, socket or ridge preserva- advanced cases may require space-main- maintain close bone contact and prevent
tion involves the use of a graft material taining devices such as tenting pins and graft rotation (figure 5b) . Adequate prima-
placed in the socket followed by a variety membranes. All of these options work to a ry fixation is essential for graft survival.
of other substances such as demineralized certain extent and the selection should be Particulate bone can be packed around
freeze-dried bone allograft, mineralized based on individual cases/requirements. the block and a resorbable collagen
freeze-dried bone allograft, xenograft When excessive bone is lost to membrane can be placed over the entire
(mostly of bovine source), and alloplas- resorption, leaving a narrow ridge with graft. The soft tissue flap is then advanced
tic materials (B-tricalcium phosphate, a large buccal deficiency or decreased and sutured for primary closure. After
durapatite, hydroxyapatite). Since the site vertical height, a block graft is gener- a healing period of five to six months,
will be used for implant placement ap- ally the technique that yields predict- the site can be re-entered and integra-
proximately three months to four months able results.10-11 The block graft material tion of the graft to the recipient bone
after grafting, it is important to select a can be of autologous or allograft origin. confirmed. Using an appropriate surgi-
graft material that resorbs quickly since Autologous graft material is commonly cal stent, implants can then be properly
only newly formed bone will contribute harvested from either the mandibular placed into the widened ridge (figure 5c) .
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f ig ur e 5a. Extensive defect noted upon flap figu r e 5b. The area was prepared and a block f igure 5c. Re-entry at six months. Note the
elevation. allograft was trimmed and fixated with two bone excellent ridge width obtained and the ideal
screws (J Block Cortico-Cancellous Bone Allograft, implant placement in the augmented site.
Zimmer Dental).
pulled coronally, possibly resulting in
a lack of adequate attached tissue, and
thereby creating a “thin” case that will
compromise future implant placement.
A technique for covering the socket
after tooth extraction using a pediculated
connective tissue graft was described by
Mathews.12 Utilizing this closure tech-
nique over the grafted socket permitted
complete soft tissue coverage. Addition-
figure 6a. The initial defect after tooth extraction. figu r e 6b. The defect was filled with FDBA and ally, it maintained both vertical and
The defect is mainly a three-wall defect with almost a tenting pin was placed for space maintenance.
horizontal soft tissue components, and
complete loss of facial bone.
increased the thickness of facial attached
tissue (figure 6c) . After healing for five
to six months, the site was re-entered
and an implant was placed (figure 6d) .
This case illustrates the transformation
of a severely “thin” defect into a more
advantageous “thick” periodontium.
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