Original Article
Correlation between periodontal soft tissue and hard tissue surrounding
incisors in skeletal Class III patients
Jeong-Ho Parka; Ji-Yeon Hongb; Hyo-Won Ahnc; Su-Jung Kimd
ABSTRACT
Objectives: To investigate the association between the periodontal soft tissue, alveolar bone and
dental parameters surrounding the incisors at baseline in patients with skeletal Class III
malocclusion.
Materials and Methods: The study sample comprised 154 teeth from 28 patients with skeletal
Class III malocclusion (19 men and 9 women, 21.15 6 4.02 years). Periodontal soft tissue
examination and hard tissue measurements with cone-beam computed tomography (CBCT) were
performed. Factor analysis was used to reduce the CBCT variables, and correlation analysis
between the hard tissue factors and soft tissue parameters was performed. Differences in hard
tissue parameters between thick and thin gingival types were evaluated.
Results: CBCT measurements were reduced to three hard tissue factors: lingual plate, coronalbuccal plate, and apical-buccal plate. Keratinized gingiva width and thickness were positively
correlated with the coronal-buccal plate factor and negatively correlated with the apical-buccal plate
factor. In the thin gingival biotype, mandibular incisors were more proclined, and the apical part of
the buccal alveolar plate and the coronal part of lingual alveolar plate were thicker than in the thick
gingival biotype.
Conclusions: In the anterior teeth in cases of skeletal Class III malocclusion, hard tissue structures
on the buccal side can be grouped based on coronal and apical factors that are significantly
correlated with keratinized gingival width and thickness. Thick and thin gingival biotypes exhibited
differences in tooth inclination and alveolar plate thickness with regard to the mandibular incisors.
(Angle Orthod. 2018;88:91–99.)
KEY WORDS: Periodontal soft tissue; Periodontal hard tissue; Incisors; Class III; Factor analysis;
Correlation
odontal tissue includes that of both soft and hard tissue
structures. Soft tissue characteristics of the periodontium are usually defined by gingival biotype.1 When the
gingival biotype is thin, orthodontic tooth movements
may be considered unfavorable, increasing the risk of
gingival recession.2 Melsen and Allais3 found significant correlations between keratinized gingival width,
gingival biotype, and the development of or increase in
gingival recession.
Alveolar bone is the hard tissue part of periodontium,
which is a major remodeling site during orthodontic
tooth movement. It has been suggested that a thin
alveolar plate is an anatomic risk factor for the
development of a periodontal problem, and tooth
movement beyond the alveolar plate may cause
vertical alveolar bone loss and subsequent gingival
recession.4–7
Depending on the vertical and sagittal skeletal
relationship, there is a characteristic periodontal
INTRODUCTION
The characteristics of periodontal tissue surrounding
teeth are critical for periodontal health during and after
orthodontic treatment. The anatomic integrity of peria
Postgraduate Student, Department of Orthodontics, Graduate School, Kyung Hee University, Seoul, Korea.
b
Assistant Professor, Department of Periodontology, Kyung
Hee University School of Dentistry, Seoul, Korea.
c
Assistant Professor, Department of Orthodontics, Kyung
Hee University School of Dentistry, Seoul, Korea.
d
Associate Professor, Department of Orthodontics, Kyung
Hee University School of Dentistry, Seoul, Korea.
Corresponding author: Su-Jung Kim, Department of Orthodontics, Kyung Hee University School of Dentistry, 1 HoegiDong, Dongdaemoon-Ku, Seoul 130-701, Korea
(e-mail: ksj113@khu.ac.kr)
Accepted: September 2017. Submitted: June 2017.
Published Online: October 26, 2017
Ó 2018 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/060117-367.1
91
Angle Orthodontist, Vol 88, No 1, 2018
92
Figure 1. Clinical periodontal soft tissue measurements. (A) Probing
to determine gingival biotype. (B) Keratinized gingival width. (C)
Keratinized gingival thickness.
condition that is closely related with dental compensation. The occurrence of gingival recession might be
more common, especially in the mandibular incisors, in
patients with skeletal Class III malocclusion and
mandibular prognathism because the teeth are inclined
lingually and then are moved forward on the narrow
alveolus during presurgical orthodontic treatment.8–11
As three-dimensional cone-beam computed tomography (CBCT) is widely available, comprehensive
integration of soft and hard tissue parameters of the
periodontium is essential for optimized treatment
planning. Unfortunately, it is not known which hard
tissue factors are good predictors of soft tissue
characteristics and vice versa. Recently, several
studies have reported correlations between gingival
biotype and labial plate thickness in individual teeth.
However they have focused mainly on the buccal plate
of maxillary anterior teeth.2,12–16 To the best of the
authors’ knowledge, no studies have investigated the
relationships between soft tissue biotypes and the
buccolingual alveolar structures, particularly in patients
with skeletal Class III malocclusion.
The aim of this study was to investigate associations
between the periodontal soft tissue, alveolar bone, and
dental parameters surrounding incisors at baseline in
patients with skeletal Class III malocclusion.
MATERIALS AND METHODS
Subjects
The subjects consisted of patients with skeletal
Class III malocclusion who visited the Department of
Orthodontics at Kyung Hee University Dental Hospital,
Seoul, Korea, between June 2011 and March 2016.
Before orthodontic treatment, periodontal examination
of the maxillary and mandibular incisors was performed. Lateral cephalograms and CBCT scans were
obtained for diagnostic purposes. The study protocol
was approved by the Institutional Review Board of
Angle Orthodontist, Vol 88, No 1, 2018
PARK, HONG, AHN, KIM
Kyung Hee University Dental Hospital (IRB No.
KHDRIB 1612-6).
Initially, 32 patients were selected according to the
following inclusion criteria: (1) age .18 years, (2)
Angle Class III molar relationship, (3) anterior crossbite, and (4) ANB ,08. The following exclusion criteria
were then applied: (1) previous history of orthodontic
treatment, (2) severe periodontitis, (3) missing teeth,
(4) dental trauma, (5) severe rotations, (6) marked root
resorption, (7) dental restoration involving the cementoenamel junction (CEJ), and (8) blurry imaging.
The final sample consisted of 28 patients (19 men and
9 women, 21.15 6 4.02 years), in whom 154 teeth
were analyzed.
Periodontal Soft Tissue Examination
The condition of the maxillary and mandibular incisor
periodontal soft tissues was evaluated using a periodontal probe. Gingival biotype was classified as either
thin or thick based on the visibility of the underlying
periodontal probe through the gingival tissue (Figure
1).17 Soft tissue measurements included gingival
recession, probing pocket depth, keratinized gingival
width and thickness (Table 1).
CBCT Orientation and Periodontal Hard Tissue
Measurement
CBCT scanning was performed via an Alphard Vega
instrument (Asahi Roentgen Ind Co, Ltd, Kyoto,
Japan). The following parameters were used: 80 kV,
5 mA, 0.39-mm voxel resolution, 17.0-second scan
time, and a 199.68 3 199.68 mm field of view. CBCT
images were reconstructed using InVivo-Dental software (version 5.3, Anatomage, San Jose, Calif).
To examine the morphologic features of the alveolar
bone, each CBCT image was oriented along the long
axis of the root and the sagittal plane running
transversely through the midpoint of the incisal edge–
root apex. The measurement variables used are
described in Table 1 and Figure 2. Root length was
defined as the distance from the CEJ to the root apex
and was divided into four sections of equal length
(where level 0 was the CEJ and level 4 was at the root
apex), and the thickness of the alveolar plate was
measured at four locations (levels 1, 2, 3, and 4). In
addition, alveolar crest height and thickness, alveolar
plate area, and tooth inclination relative to the basal
bone or alveolar ridge were evaluated.
Statistical Analysis
Power analysis showed that, with a significance level
of .05, a sample size of 154 teeth was sufficient to
provide power above 80% to detect correlations of 0.5.
PERIODONTAL TISSUE RELATIONSHIP IN CLASS III
93
Table 1. Definitions of Measurement
Measurement
Definition
Periodontal Gingival biotype
soft tissue Gingival recession
Probing pocket depth
Keratinized gingiva width
Keratinized gingiva thickness
Visibility of the periodontal probe through the gingival margin
Distance from the CEJa to the free gingival margin
The distance between the free gingival margin and the most apical part of the pocket base
The distance between the free gingival margin to the mucogingival junction
The thickness of gingival tissue at the gingival margin 1mm apical from the periodontal
pocket base
Periodontal Alveolar crest height
Vertical distance from the CEJ to the buccal (or lingual) alveolar crest parallel to the long axis
hard tissue
of the tooth
Alveolar crest thickness
Alveolar plate thickness perpendicular to the long axis of the tooth at 0.5 mm apical to the
buccal (or lingual) alveolar bone crest
Alveolar plate thickness
Buccal (or lingual) alveolar plate thickness perpendicular to the long axis of the tooth at each
quarter of root length from CEJ
Alveolar plate area
Buccal (or lingual) alveolar plate area between alveolar crest and root apex perpendicular to
the tooth axis
Alveolar ridge thickness
Buccolingual thickness of alveolar ridge perpendicular to the long axis of the tooth at each
quarter of root length from CEJ
Tooth inclination to basal bone Angle between the long axis of incisors and palatal plane (mandibular plane)
Tooth inclination to alveolar ridge Angle formed by root apex, CEJ, and A point (B point)
a
CEJ indicates cementoenamel junction.
All measurements were performed by one orthodontist (Dr Park). To determine the intraexaminer measurement reliability of the method, 50 randomly
selected samples were remeasured at least 2 weeks
after the initial measurements by the same investigator. A paired t-test comparing the first and second sets
of values showed no significant difference between the
two sets (P . .05), and the intraclass correlation
coefficient of 0.925 indicated good reliability.
The Shapiro-Wilk test was used to test for normality
and demonstrated that not all variables were normally
distributed. Therefore, the Mann-Whitney U test was
used to compare buccal and lingual alveolar plate
measurements.
Factor analysis was used, and the 20 CBCT
variables were collated into groups of factors, each
comprising a combination of the original variables.
These grouped factors were then used as hard tissue
factors in subsequent correlation analysis. Spearman’s
rank correlation analysis was applied to identify
relationships between soft tissue parameters and hard
tissue factors. The Mann-Whitney U test was used to
assess differences in CBCT variables between thick
and thin gingival types.
All statistical analyses were performed using SPSS
software for Windows (version 22.0, IBM Corp,
Armonk, NY). The significance level of all tests was
established at .05.
hyperdivergent vertical pattern (MPA 30.818 6 4.428),
and dental compensations (U1 to FH 121.928 6 5.638;
IMPA 80.318 6 7.048).
The means and standard deviations of all variables
are shown in Table 2. The difference between buccal
and lingual vertical bone loss was only statistically
significant in the maxillary incisors (P , .01; Figure 3).
The buccal plate of the maxillary incisors was thinner
than the lingual plate at all positions except at the
alveolar crest level (all P , .001, except level 1, P
,.05). In the mandibular incisors, the thickness of the
buccal plate was greater than that of the lingual plate at
the alveolar crest level and level 1 (P , .01 and P ,
.05, respectively), whereas the lingual alveolar plate
was thicker than the buccal alveolar plate at levels 2, 3,
and 4 (P , .01, P , .001, and P , .001, respectively).
Factor Analysis of CBCT Measurements
Using factor analysis, three hard tissue factors were
derived based on eigenvalue greater than one,
explaining 74.71% of the variance of the original 20
variables (Table 3). Each factor was a combination of
the original variables representing the vertical position
of the alveolar crest and the thickness of the alveolar
plate on the buccal and lingual aspects. Correlations
can be summarized as follows (Table 4):
RESULTS
Descriptive Data Assessment
The initial cephalometric data showed a skeletal
Class III relationship (ANB –3.968 6 3.668), normal to
Factor 1 (lingual plate factor): positively correlated
with lingual alveolar plate thickness and total alveolar
ridge thickness at all heights and negatively correlated with vertical bone loss of the lingual plate.
Factor 2 (coronal-buccal plate factor): positively
correlated with buccal alveolar crest thickness and
buccal alveolar plate thickness (levels 1 and 2) and
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PARK, HONG, AHN, KIM
gingival width (P , .05) and keratinized gingival
thickness (P , .001). Lingual plate factor was not
significantly correlated with any soft tissue parameters.
Gingival recession and probing pocket depth at
baseline were not significantly associated with any
hard tissue factors.
Comparisons of Hard Tissue Parameters between
Thick and Thin Gingival Biotypes
Differences in hard tissue parameters between thick
and thin biotypes are shown in Table 6. No statistically
significant differences in any of the variables in the
maxilla were detected between the two biotypes. In the
mandibular incisors, the thin biotype was associated
with greater thickness of the buccal plate at the apex
and third quarter of the root level, (P , .05 and P , .01,
respectively) and on the lingual plate at the alveolar
crest and first quarter of the root level (all P , .05).
Mandibular incisors were more proclined to the
alveolar ridge and basal bone in the thin biotype (P
, .01 and P , .001, respectively).
DISCUSSION
Figure 2. CBCT measurements. (A) Alveolar crest height (buccal/
lingual). (B) Alveolar crest thickness (buccal/lingual). (C) Alveolar
plate thickness at each quarter of root length (buccal/lingual). (D)
Alveolar plate area (buccal/lingual). (E) Alveolar ridge thickness at
each quarter of root length. (F) Tooth inclination to the alveolar ridge.
(G) Tooth inclination to basal bone.
tooth inclination to basal bone and negatively
correlated with vertical alveolar bone loss at the
buccal surface.
Factor 3 (apical-buccal plate factor): positively
correlated with buccal plate thickness (levels 3 and
4) and tooth inclination to the alveolar ridge.
Correlations Between Soft Tissue Parameters and
Hard Tissue Factors
Correlations between soft tissue parameters and
hard tissue factors are shown in Table 5. Coronal
buccal plate factor was positively correlated with
keratinized gingival width (P , .001) and keratinized
gingival thickness (P , .01). Conversely, apical buccal
plate factor was negatively correlated with keratinized
Angle Orthodontist, Vol 88, No 1, 2018
In this study, the correlation between soft tissue
characteristics and three hard tissue factors extracted
from factor analysis of the periodontium in patients with
Class III malocclusion was reported. Because of the
thin buccal plate overlying the root surface, the
variables defining total alveolar ridge thickness and
lingual plate thickness were grouped together as a
single factor, referred to as the ‘‘lingual plate factor.’’
However, no significant association was found between the lingual plate factor and buccal soft tissue
parameters.
The variables derived from buccal alveolar plate
measurements were grouped into two collective
factors: ‘‘coronal-buccal plate factor’’ and ‘‘apicalbuccal plate factor.’’ Coronal-buccal plate factor was
a combination of vertical and horizontal dimensions in
the coronal part of the buccal plate of incisors and tooth
inclination to basal bone. Apical-buccal plate factor
included the thickness of the buccal plate in the apical
region and tooth inclination to the respective alveolar
ridge. Tooth inclination to basal bone and to the
alveolar ridge was included in different hard tissue
factors. Tooth inclination to basal bone reflects the
characteristics of the coronal part by measuring the
angle around the root apex, while tooth inclination to
the alveolar ridge reflects the characteristics of the
apical part by measuring the angle around the CEJ.
As expected, gingival morphology, including keratinized gingival width and thickness, was associated
with the buccal alveolar plate overlying the incisors in
patients with skeletal Class III malocclusion. The
PERIODONTAL TISSUE RELATIONSHIP IN CLASS III
95
Table 2. Descriptive Data for Measured Variables
Maxilla (n ¼ 59)
Measurement
Mean
SD
Mean
SD
Buccal alveolar crest height
Lingual alveolar crest height
Buccal plate area
Lingual plate area
Buccal alveolar crest thickness
Buccal plate thickness 1
Buccal plate thickness 2
Buccal plate thickness 3
Buccal plate thickness 4
Lingual alveolar crest thickness
Lingual plate thickness 1
Lingual plate thickness 2
Lingual plate thickness 3
Lingual plate thickness 4
Alveolar ridge thickness 1
Alveolar ridge thickness 2
Alveolar ridge thickness 3
Alveolar ridge thickness 4
Tooth inclination to basal bone
Tooth inclination to alveolar ridge
Gingival recession
Probing pocket depth
Keratinized gingiva width
Keratinized gingiva thickness
1.44
1.09
13.33
31.46
0.71
1.05
1.15
1.21
2.75
0.66
1.24
2.30
3.61
6.42
7.92
8.30
8.54
9.17
116.05
12.66
0.04
1.95
5.51
0.96
0.61
0.57
5.42
14.78
0.21
0.33
0.45
0.58
1.10
0.24
0.50
0.85
1.49
2.07
0.84
1.07
1.58
2.13
7.52
5.01
0.28
0.41
1.23
0.34
2.31
2.91
7.74
16.13
0.49
0.61
0.50
0.60
2.68
0.39
0.43
0.98
2.02
4.66
6.54
6.52
6.48
7.32
81.85
12.43
0.00
2.04
4.26
0.79
1.78
2.34
3.48
8.21
0.21
0.40
0.37
0.46
1.25
0.15
0.39
0.73
1.02
1.29
0.79
0.94
1.25
1.54
7.40
5.42
0.00
0.39
1.40
0.30
Category
Alveolar bone
Dental
Periodontal soft tissue
a
Mandible (n ¼ 95)
a
SD indicates standard deviation.
correlation between soft tissue and hard tissue in the
mandibular incisors of patients with Class III malocclusion were opposite in the coronal and apical parts of
the buccal plate. Keratinized gingival width and
thickness were positively correlated with the coronalbuccal plate factor but negatively correlated with the
apical-buccal plate factor. It may be advisable to
evaluate the periodontal tissue before treatment by
dividing the region into the coronal-buccal part and the
apical-buccal part in the mandibular incisors of patients
with skeletal Class III malocclusion.
On the other hand, gingival recession and probing
pocket depth before orthodontic treatment were not
significantly associated with hard tissue factors. In a
study by Fu et al.,13 there was no significant association
between gingival recession and bone morphology, and
Table 3. Variance Explained by the Three Extracted Factors
Total Variance Explained
Rotation Sums of Squared Loadings
Factora
Total
% Variance
Cumulative %
1
2
3
9.709
4.145
1.835
39.752
17.798
17.158
39.752
57.550
74.708
a
Factor 1 indicates lingual plate factor; factor 2, coronal-buccal
plate factor; factor 3, apical-buccal plate factor.
the conclusion was that, rather than gingival recession
at baseline being strongly associated with tissue
biotype or underlying bone thickness, it was more
dependent on multiple factors, including age, etiology,
and tooth type.
Previous CBCT studies18–22 investigating facial bone
thickness in various regions of the maxilla and
mandible have found that a thin alveolar bone wall is
usually present in both jaws. In the current study, at the
first quarter of the root level, the thickness of the buccal
and lingual alveolar plates was less than 1 mm in
81.5% and 87.0% of the lower incisors, respectively.
The amount of vertical bone loss was greater on the
buccal side of maxillary incisors and on the lingual side
of mandibular incisors due to the dental compensation
in skeletal Class III malocclusion. Substantial anteroposterior movement of the mandibular incisors during
orthodontic treatment might be critical and could lead
to progressive bone loss of the buccal and lingual
plates.
In the current study, there were significant differences in underlying bone structure between thick and thin
biotypes in the mandible but not in the maxilla. In the
mandibular incisors, the apical part of the buccal plate
and the coronal part of the lingual plate were thicker in
the thin biotype. In addition, more proclination was
found in mandibular incisors in the thin gingival biotype.
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PARK, HONG, AHN, KIM
Figure 3. Comparisons between buccal and lingual alveolar structure measurements. * P , .05; ** P , .01; *** P , .001.
Angle Orthodontist, Vol 88, No 1, 2018
PERIODONTAL TISSUE RELATIONSHIP IN CLASS III
97
Table 4. Factors Extracted Using Varimax Rotation
Rotated Component Matrix
Factor 1
Factor 2
Factor 3
Lingual Plate Factor
Coronal-Buccal Plate Factor
Apical-Buccal Plate Factor
Lingual alveolar crest height
Lingual alveolar crest thickness
Lingual plate thickness 1
Lingual plate thickness 2
Lingual plate thickness 3
Lingual plate thickness 4
Lingual plate area
Alveolar ridge thickness 1
Alveolar ridge thickness 2
Alveolar ridge thickness 3
Alveolar ridge thickness 4
Buccal alveolar crest height
Buccal alveolar crest thickness
Buccal plate thickness 1
Buccal plate thickness 2
Tooth inclination to basal bone
Buccal plate thickness 3
Buccal plate thickness 4
Buccal plate area
Tooth inclination to alveolar ridge
–0.511
0.453
0.821
0.935
0.952
0.909
0.950
0.706
0.869
0.936
0.899
–0.577
0.765
0.858
0.792
0.528
0.695
0.935
0.554
0.933
In agreement with the results of previous studies,14,23
the more proclined the mandibular incisor was, the
greater the bone thickness of the labial alveolar plate at
the apex level tended to be. It could be suggested that
tooth inclination affects marginal bone thickness and
gingival biotype in the mandibular incisor regions in
patients with skeletal Class III malocclusion. Although
patients with Class III malocclusion and a thick biotype
have thicker marginal bone on the buccal side, the
amount of decompensation during presurgical treatment would also be greater than in patients with a thin
biotype. Therefore, it cannot be concluded that the risk
of gingival recession is low in the thick gingival biotype
during orthodontic treatment in patients with skeletal
Class III malocclusion.
This study evaluated soft tissue and hard tissue
structures before orthodontic treatment in Korean
patients with Class III malocclusion. The 0.39-mm
voxel size of the CBCT system may have limited the
ability to accurately measure the thin alveolar plate due
to low contrast resolution. Further studies in other
populations and with various skeletal malocclusions
would be necessary to apply the results beyond this
sample. In addition, it would be interesting in future
studies to investigate changes in the parameters
studied over the course of orthodontic treatment.
CONCLUSIONS
Hard tissue parameters of the periodontium were
categorized as coronal-buccal, apical-buccal, and
lingual plate factors.
Keratinized gingival width and thickness were positively correlated with the coronal-buccal plate factor
but negatively correlated with the apical-buccal plate
factor.
Morphologic differences in hard tissue between thick
and thin gingival biotypes were observed in the lower
incisors. In the thin biotype, mandibular incisors were
more proclined, and the apical part of the buccal
plate and the coronal part of lingual plate were
thicker.
Table 5. Correlation Analysis Between Soft Tissue Parameters and Hard Tissue Factors
Gingival Recession
Coefficient P Valuea
Lingual plate factor
Coronal-buccal plate factor
Apical-buccal plate factor
0.014
0.018
–0.380
.896
.867
.723
Periodontal Probing Depth
Keratinized Gingiva Width
Keratinized Gingiva Thickness
Coefficient
P Valuea
Coefficient
P Valuea
Coefficient
P Valuea
–0.040
–0.690
–0.122
.707
.511
.245
0.220
0.522
–0.226
.135
.000***
.030*
–0.290
0.314
–0.441
.787
.002**
.000***
a
Spearman’s rank correlation analysis was performed.
* P , .05; ** P , .01; *** P , .001.
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PARK, HONG, AHN, KIM
Table 6. Comparisons of Hard Tissue Parameters Between Thick and Thin Gingival Biotype, Mean 6 Standard Deviation
Maxilla
Thick
Coronal-buccal plate factor
Buccal alveolar crest height
Buccal alveolar crest thickness
Buccal plate thickness 1
Buccal plate thickness 2
Tooth inclination to basal bone
Apical-buccal plate factor
Buccal plate thickness 3
Buccal plate thickness 4
Buccal alveolar plate area
Tooth inclination to alveolar ridge
Lingual plate factor
Lingual alveolar crest height
Lingual alveolar crest thickness
Lingual plate thickness 1
Lingual plate thickness 2
Lingual plate thickness 3
Lingual plate thickness 4
Lingual alveolar plate area
Alveolar ridge thickness 1
Alveolar ridge thickness 2
Alveolar ridge thickness 3
Alveolar ridge thickness 4
Mandible
P Value
Thin
a
Thick
P Valuea
Thin
1.42
0.64
1.04
1.01
117.62
6
6
6
6
6
0.43a
0.16
0.26
0.42
8.73
1.43
0.76
1.09
1.29
114.59
6
6
6
6
6
0.76
0.24
0.39
0.47
6.01
.522
.265
.845
.079
.216
1.61
0.56
0.75
0.64
77.40
6
6
6
6
6
0.70
0.23
0.42
0.46
7.47
2.33
0.44
0.60
0.47
85.22
6
6
6
6
6
1.94
0.19
0.32
0.30
5.36
.413
.073
.112
.553
.000***
1.10
2.72
13.57
11.82
6
6
6
6
0.66
1.34
6.17
5.65
1.32
2.80
13.41
13.62
6
6
6
6
0.51
0.94
5.14
4.68
.167
.337
.861
.208
0.44
2.18
7.99
9.91
6
6
6
6
0.29
0.92
3.11
3.56
0.78
3.18
8.61
14.59
6
6
6
6
0.53
1.37
3.80
5.77
.014*
.008**
.878
.002**
1.16
0.61
1.28
2.50
3.93
6.88
36.25
7.97
8.43
8.82
9.67
6
6
6
6
6
6
6
6
6
6
6
0.71
0.21
0.49
0.92
1.65
2.28
16.36
0.64
0.91
1.55
2.09
1.06
0.69
1.16
2.15
3.36
6.05
27.49
7.84
8.20
8.33
8.78
6
6
6
6
6
6
6
6
6
6
6
0.46
0.25
0.55
0.83
1.40
1.94
13.32
1.02
1.23
1.67
2.25
.804
.260
.369
.164
.279
.265
.078
.726
.516
.274
.204
2.98
0.34
0.37
0.82
1.77
4.58
15.15
6.54
6.48
6.10
6.85
6
6
6
6
6
6
6
6
6
6
6
2.44
0.17
0.32
0.64
0.92
0.97
8.09
0.70
0.71
1.13
1.66
2.00
0.40
0.62
1.25
2.25
4.74
18.22
6.75
6.77
6.89
7.86
6
6
6
6
6
6
6
6
6
6
6
1.94
0.12
0.38
0.73
1.01
1.24
8.14
0.79
1.01
1.31
1.50
.043*
.048*
.024*
.069
.082
.713
.193
.246
.414
.031*
.049*
a
Mann-Whitney U test was performed.
* P , .05; ** P , .01; *** P , .001.
REFERENCES
1. Kao RT, Fagan MC, Conte GJ. Thick vs. thin gingival
biotypes: a key determinant in treatment planning for dental
implants. J Calif Dent Assoc. 2008;36:193–198.
2. Rasperini G, Acunzo R, Cannalire P, Farronato G. Influence
of periodontal biotype on root surface exposure during
orthodontic treatment: a preliminary study. Int J Periodontics
Restorative Dent. 2015;35:665–675.
3. Melsen B, Allais D. Factors of importance for the development of dehiscences during labial movement of mandibular
incisors: a retrospective study of adult orthodontic patients.
Am J Orthod Dentofacial Orthop. 2005;127:552–561.
4. Slutzkey S, Levin L. Gingival recession in young adults:
occurrence, severity, and relationship to past orthodontic
treatment and oral piercing. Am J Orthod Dentofacial Orthop.
2008;134:652–656.
5. Dominiak M, Gedrange T. New perspectives in the diagnostic of gingival recession. Adv Clin Exp Med. 2014;23:857–
863.
6. Årtun J, Krogstad O. Periodontal status of mandibular
incisors following excessive proclination: a study in adults
with a surgically treated mandibular prognathism. Am J
Orthod Dentofacial Orthop. 1987;91:225–232.
7. Fuhrmann R. Three-dimensional evaluation of periodontal
remodeling during orthodontic treatment. Semin Orthod.
2002;8:23–28.
8. Yagci A, Veli I, Uysal T, Ucar FI, Ozer T, Enhos S.
Dehiscence and fenestration in skeletal Class I, II, and III
malocclusions assessed with cone-beam computed tomography. Angle Orthod. 2012;82:67–74.
9. Kim Y, Park JU, Kook YA. Alveolar bone loss around incisors
in surgical skeletal Class III patients. Angle Orthod.
2009;79:676–682.
Angle Orthodontist, Vol 88, No 1, 2018
10. Kook YA, Kim G, Kim Y. Comparison of alveolar bone loss
around incisors in normal occlusion samples and surgical
skeletal class III patients. Angle Orthod. 2012;82:645–652.
11. Chung CJ, Jung S, Baik HS. Morphological characteristics of
the symphyseal region in adult skeletal Class III crossbite
and open bite malocclusions. Angle Orthod. 2008;78:38–43.
12. Cook DR, Mealey BL, Verrett RG, et al. Relationship
between clinical periodontal biotype and labial plate thickness: an in vivo study. Int J Periodontics Restorative Dent.
2011;31:345–354.
13. Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL.
Tissue biotype and its relation to the underlying bone
morpholgy. J Periodontol. 2010;81:569–574.
14. Khoury J, Ghosn N, Mokbel N, Naaman N. Buccal bone
thickness overlying maxillary anterior teeth: a clinical and
radiographic prospective human study. Implant Dent.
2016;25:525–531.
15. Ghassemian M, Lajolo C, Semeraro V, et al. Relationship
between biotype and bone morphology in the lower anterior
mandible: an observational study. J Periodontol.
2016;87:680–689.
16. La Rocca AP, Alemany AS, Levi P Jr, Juan MV, Molina JN,
Weisgold AS. Anterior maxillary and mandibular biotype:
relationship between gingival thickness and width with
respect to underlying bone thickness. Implant Dent.
2012;21:507–515.
17. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an evaluation of maxillary
anterior single implants in humans. J Periodontol.
2003;74:557–562.
18. Nowzari H, Molayem S, Chiu CH, Rich SK. Cone beam
computed tomographic measurement of maxillary central
incisors to determine prevalence of facial alveolar bone
PERIODONTAL TISSUE RELATIONSHIP IN CLASS III
width 2 mm. Clin Implant Dent Relat Res. 2012;14:595–
602.
19. Braut V, Bornstein MM, Belser U, Buser D. Thickness of the
anterior maxillary facial bone wall—a retrospective radiographic study using cone beam computed tomography. Int J
Periodontics Restorative Dent. 2011;31:125–131.
20. Januario AL, Duarte WR, Barriviera M, Mesti JC, Araujo MG,
Lindhe J. Dimension of the facial bone wall in the anterior
maxilla: a cone-beam computed tomography study. Clin Oral
Implants Res. 2011;22:1168–1171.
99
21. Shen JW, He FM, Jiang QH, Shan HQ. Measurement of
facial bone wall thickness of maxillary anterior teeth and
premolars on cone beam computed tomography images.
Zhejiang Da Xue Xue Bao Yi Xue Ban. 2012;41:234–238.
22. Zekry A, Wang R, Chau AC, Lang NP. Facial alveolar bone
wall width—a cone-beam computed tomography study in
Asians. Clin Oral Implants Res. 2014;25:194–206.
23. Tian YL, Liu F, Sun HJ, et al. Alveolar bone thickness around
maxillary central incisors of different inclination assessed
with cone-beam computed tomography. Korean J Orthod.
2015;45:245–252.
Angle Orthodontist, Vol 88, No 1, 2018