Background A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. Methods Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. Results Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. Conclusion An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

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Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions: Classification and case definitions for periodontal manifestations of systemic diseases and developmental and acquired conditions

This study evaluated the reliability of assessing visually the facial gingival biotype of maxillary anterior teeth with and without the use of a periodontal probe in comparison with direct measurements. Forty-eight patients (20 men, 28 women) with a single failing maxillary anterior tooth participated in this study. Three methods were used to evaluate the thickness of the gingival biotype of the failing tooth: visual, periodontal probing, and direct measurement. Prior to extraction, the gingival biotype was identified as either thick or thin via visual assessment and assessment with a periodontal probe. After tooth extraction, direct measurement of the gingival thickness was performed to the nearest 0.1 mm using a tension-free caliper. The gingival biotype was considered thin if the measurement was =or 1.0 mm. The assessment methods were compared using the McNemar test at a significance level of a=.05. The mean gingival thickness obtained from direct measurements was 1.06+/-0.27 mm, with an equal distribution (50%) of sites with gingival thicknesses of =or 1 mm. The McNemar test showed a statistically significant difference when comparing the visual assessment with assessment using a periodontal probe (P=.0117) and direct measurement (P=.0001). However, there was no statistically significant difference when comparing assessment with a periodontal probe and direct measurement (P=.146). 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.

Gingival biotype assessment in the esthetic zone: visual versus direct measurement.

Background Mucogingival deformities, and gingival recession in particular, are a group of conditions that affect a large number of patients. Since life expectancy is rising and people are retaining more teeth both gingival recession and the related damages to the root surface are likely to become more frequent. It is therefore important to define anatomic/morphologic characteristics of mucogingival lesions and other predisposing conditions or treatments that are likely to be associated with occurrence of gingival recession. Objectives Mucogingival defects including gingival recession occur frequently in adults, have a tendency to increase with age, and occur in populations with both high and low standards of oral hygiene. The root surface exposure is frequently associated with impaired esthetics, dentinal hypersensitivity and carious and non-carious cervical lesions. The objectives of this review are as follows (1) to propose a clinically oriented classification of the main mucogingival conditions, recession in particular; (2) to define the impact of these conditions in the areas of esthetics, dentin hypersensitivity and root surface alterations at the cervical area; and (3) to discuss the impact of the clinical signs and symptoms associated with the development of gingival recessions on future periodontal health status. Results An extensive literature search revealed the following findings: 1) periodontal health can be maintained in most patients with optimal home care; 2) thin periodontal biotypes are at greater risk for developing gingival recession; 3) inadequate oral hygiene, orthodontic treatment, and cervical restorations might increase the risk for the development of gingival recession; 4) in the absence of pathosis, monitoring specific sites seems to be the proper approach; 5) surgical intervention, either to change the biotype and/or to cover roots, might be indicated when the risk for the development or progression of pathosis and associated root damages is increased and to satisfy the esthetic requirements of the patients. Conclusions The clinical impact and the prevalence of conditions like root surface lesions, hypersensitivity, and patient esthetic concern associated with gingival recessions indicate the need to modify the 1999 classification. The new classification includes additional information, such as recession severity, dimension of the gingiva (gingival biotype), presence/absence of caries and non-carious cervical lesions, esthetic concern of the patient, and presence/absence of dentin hypersensitivity.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jcpe.12948

Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations

Background: Tissue biotypes have been linked to the outcomes of periodontal and implant therapy. The purpose of this study is to determine the dimensions of the gingiva and underlying alveolar bone in the maxillary anterior region and to establish their association. Methods: Tissue biotypes of 22 fresh cadaver heads were assessed clinically and radiographically with cone-beam computed tomography (CBCT) scans. Maxillary anterior teeth were atraumatically extracted. The thickness of both soft tissue and bone were measured using a caliper to the nearest 0.1 mm by two calibrated examiners. Probing depths and gingival recession were measured at two points (mid-labial and mid-palatal). Clinical and CBCT measurements of both soft tissue and bone thickness were subsequently compared and correlated. Results: No statistically significant differences were observed between the clinical and CBCT measurements of both soft tissue and bone thickness except the palatal soft tissue measurements. The labial gingival thickness was moderately associated with the underlying bone thickness measured with CBCT (R = 0.429; P <0.05). Gingival recession was not associated with the thickness of both labial gingiva and bone. Conclusions: CBCT measurements were an accurate representation of the clinical thickness of both labial gingiva and bone. In addition, the thickness of the labial gingiva had a moderate association with the underlying bone radiographically. J Periodontol 2010;81:569-574.

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Tissue Biotype and Its Relation to the Underlying Bone Morphology

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

Rouhollah Eghbali

Papers

The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva