Biologic width dimensions - a systematic review
Supplementary files for online publication
Julia C. Schmidt1, Philipp Sahrmann2, Roland Weiger1, Patrick R. Schmidlin2 and Clemens Walter1, *
1Dept.
of Periodontology, Cariology and Endodontology, University of Basel, Switzerland
2Dept.
of Preventive Dentistry, Periodontology and Cariology, Center of Dental Medicine, University of
Zurich, Switzerland
Running title: dimensions of the biologic width
Keywords: biologic width, junctional epithelium, connective tissue attachment, crown margins, crown
lengthening
Conflict of Interest: The authors state that there is no conflict of interest.
*Corresponding author:
Clemens Walter
Dept. of Periodontology, Endodontology and Cariology
University of Basel
Hebelstrasse 3, CH-4056 Basel (Switzerland)
Tel.: +41 61 2672628
Fax: +41 61 2672659
Email: clemens.walter@unibas.ch
Appendix 1
PRISMA 2009 Checklist.
Reported
on page #
Section/topic
#
Checklist item
TITLE
Title
1
Identify the report as a systematic review, meta-analysis, or both.
1
ABSTRACT
Structured summary
2
Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility
criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions
and implications of key findings; systematic review registration number.
2
INTRODUCTION
Rationale
3
Describe the rationale for the review in the context of what is already known.
4
Objectives
4
Provide an explicit statement of questions being addressed with reference to participants, interventions,
comparisons, outcomes, and study design (PICOS).
4
METHODS
Protocol and registration
5
Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide
registration information including registration number.
nr
Eligibility criteria
6
Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale.
4,5
Information sources
7
Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify
additional studies) in the search and date last searched.
5,6
Search
8
Present full electronic search strategy for at least one database, including any limits used, such that it could be
repeated.
Study selection
9
State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable,
included in the meta-analysis).
6,
Appendix 2
6,7
Data collection process
10
Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any
processes for obtaining and confirming data from investigators.
Data items
11
List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and
simplifications made.
4,5
Risk of bias in individual
studies
12
Describe methods used for assessing risk of bias of individual studies (including specification of whether this was
done at the study or outcome level), and how this information is to be used in any data synthesis.
6
Summary measures
13
State the principal summary measures (e.g., risk ratio, difference in means).
Synthesis of results
14
Describe the methods of handling data and combining results of studies, if done, including measures of
consistency (e.g., I2) for each meta-analysis.
6
6,7
7,
Appendix 5
Section/topic
#
Reported
on page #
Checklist item
Risk of bias across studies
15
Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective
reporting within studies).
Additional analyses
16
Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating
which were pre-specified.
7, Appendix
6
4,5
RESULTS
Study selection
17
Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at
each stage, ideally with a flow diagram.
7
Study characteristics
18
For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and
provide the citations.
7-9
Risk of bias within studies
19
Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).
Results of individual studies
20
For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each
intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
Synthesis of results
21
Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Risk of bias across studies
22
Present results of any assessment of risk of bias across studies (see Item 15).
Appendix 3,7
Additional analysis
23
Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).
Appendix 4,5
Summary of evidence
24
Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to
key groups (e.g., healthcare providers, users, and policy makers).
14,15
Limitations
25
Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of
identified research, reporting bias).
14,15
Conclusions
26
Provide a general interpretation of the results in the context of other evidence, and implications for future research.
15,16
27
Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the
systematic review.
Appendix 3,7
9-12
Appendix 5
DISCUSSION
FUNDING
Funding
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6):
e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma-statement.org.
16
Appendix 2
Electronic search strategy for the database Web of Science.
No.
Searches
#1
TS=(biologic* NEAR/1 width)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#2
TS=((gingiva* OR ligament OR periodontal) NEAR/2 width)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#3
#2 OR #1
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#4
TS=(oral or dent* or odont* or periodont*)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#5
SO=(oral or dent* or odont* or periodont*)
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#6
SO=periodont*
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#7
SO=journal of oral
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#8
SO=journal of oral*
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
#9
SO=journal of dent*
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
# 10
SO=journal of odont*
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
# 11
SO=journal of periodont*
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
# 12
#11 OR #10 OR #9 OR #8 OR #7 OR #6 OR #5 OR #4
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
# 13
#12 AND #3
Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=All Years
Lemmatization=On
Appendix 3
Phase of the study
Scores for assessment of methodological and reporting quality.
Item
Question
Answers
Ethic committee
Done?
No = 0, Yes = 1
Informed consent
Done?
No = 0, Yes = 1
Participantsb
Eligibility criteria
Described?
No = 0, Yes = 1
Variablesb
Ethnicity of participants
Described?
No = 0, Yes = 1
Age of participants
Described?
No = 0, Yes = 1
Data measurementb
Details of methods
Described?
No = 0, Yes = 1
Biasb
Standardization of clinical measurement
Done?
No = 0, Yes = 1
Examiner calibration/
assessment of method reproducibilitya
Done?
NR, not explained = 0, explained = 1
Operator`s experiencea
Described?
No = 0, Yes = 1
Number of participants
Reported?
No = 0, Yes = 1
Number of tooth sites
Reported?
No = 0, Yes = 1
Individual data
Reported?
No = 0, Yes = 1
Distribution of data (deviation, range)
Reported?
No = 0, Yes = 1
Tooth type
Reported?
No = 0, Yes = 1
Tooth site
Reported?
No = 0, Yes = 1
Presence of restorations
Reported?
No = 0, Yes = 1
Clinical state
Reported?
No = 0, Yes = 1
Independent funding
Described?
NR, private / industry = 0, university /
government / self = 1
Methods
Registrationa
Results
Participantsb
Main resultsb
Other analysesb
Other information
Fundinga,b
a
, Cochrane Collaboration`s Tool for assessing risk of bias (modified by Graziani et al. 2012); b, criteria based on STROBE statement (Pjetursson et
al. 2012)
Appendix 4
Heterogeneity regarding methods and outcome parameters in included studies.
*Periodontal disease: Probing depth, attachment loss and gingival inflammation indicate that these parameters were determined
in the respective study regardless of wether the parameters were increased or not.
The figure shows that the measurement of the biologic width by a specific method and for a certain combination of outcome
variables (tooth type, tooth site and periodontal disease) was performed by one or at most two studies. For example, the
biologic width, measured by a clinical/radiographic method, at anterior teeth on buccal sites with probing depths < 2 mm was
determined solely by Alpiste-Illueca (2004). Therefore, statistical meta-analyses were not appropriate and not performed.
Appendix 5
Meta-analyses
The statistical software Review Manager (RevMan), version 5.2, The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen, Denmark (Annibali 2012) was used to perform additional metaanalyses next to the full range of histologic and clinical estimates.
(a) Dimensions of the biologic width on anterior and posterior teeth in humans without a reported
history of periodontal disease (histological studies).
Out of six studies providing data of biologic width from histological measures, three studies (Vacek et
al. 1994, Xie et al. 2007, Xie & Chen 2007) were suitable for inclusion in a meta-analysis. In the
remaining three studies (Orban & Köhler 1924, Stanley et al. 1955 and Gargiulo et al. 1961) mean
values with standard deviation were not available.
(b) Dimensions of the biologic width in humans with attachment loss of ≥ 3 mm (clinical and/or clinical /
radiographical studies).
Out of eight studies providing data of biologic width from clinical measures, three studies (Lanning et
al. 2003, Novak et al. 2008, Shobha et al. 2010) were suitable for inclusion in a meta-analysis. In two
studies (Galgali & Gontiya 2011, Ganji et al. 2012) mean values with standard deviation were missing
and in three other studies (Alpiste-Illueca 2004, Al-Rasheed et al. 2005, Alpiste-Illueca 2012) data on
the loss of attachment were not available.
(a)
(b)
a,
premolars; b, molars; c, treated sites (pre-surgical data); d; non-adjacent sites (pre-surgical data); e,
adjacent sites (pre-surgical data).
Appendix 6 Studies excluded based on full text analysis, and reason for exclusion.
First author (year of publication)
Reason for exclusion
Andreana (2007)
Not original study (review)
Borowik et al. (1969)
No data on the dimensions of the biologic width
Brägger et al. (1992)
No data on the dimensions of the biologic width
Checchi & Felicori (1987)
Not original study (review)
Cook et al. (2011)
No data on the dimensions of the biologic width
Deas et al. (2004)
No data on the dimensions of the biologic width
Devore et al. (1988)
No data on the dimensions of the biologic width
Fitzgibbon (2007)
Not original study (review)
Flores-de-Jacoby et al. (1984)
No data on the dimensions of the biologic width
Flores-de-Jacoby (1985)
No data on the dimensions of the biologic width
Fugazzotto & Parma-Benfenati (1984)
Not original study (review)
Gunay et al. (2000)
No data on the dimensions of the biologic width
Herrero et al. (1995)
Dimension of the biologic width defined as distance of alveolar crest
postosseous reduction to planned restoration margin mark
Ingber et al. (1977)
Not original study (review)
Jedrzejewska & Heim (1987)
No data on the dimensions of the biologic width
Kamin (1989)
Not original study (review)
Kao et al. (2008)
Not original study (review)
Kumar & Patil (2012)
Not original study (case report)
Lins et al. (2003)
No data on the dimensions of the biologic width
McGuire & Nunn (2003)
No data on the dimensions of the biologic width
Nevins & Skurow (1984)
Not original study (review)
Perez et al. (2008)
Measurement of the distance alveolar crest to free gingival margin (no
data on the dimensions of the biologic width)
Quirynen et al. (2000)
No data on the dimensions of the biologic width
Rodriguez et al. (2011)
No data on the dimensions of the biologic width
Tal et al. (1989)
No data on the dimensions of the biologic width
Von Krammer (1990)
Not original study
Wei et al. (2002)
No data on the dimensions of the biologic width
Windisch et al. (2002)
No data on the dimensions of the biologic width
Wojcik et al. (1992)
No data on the dimensions of the biologic width
Zanatta et al. (2010)
Dimensions of the biologic width defined as distance of the most apical
portion of the tooth`s cavity/defect to the interproximal bone crest
Appendix 7
First author (year of
publication)
Orban & Köhler (1924)
Study characteristics of the included studies.
Population
characteristics
(ethnicity, age,
inclusion criteria)
Number of analyzed
probands, jaws, teeth and
tooth sites (mesial, distal,
buccal, oral)
Methods
Measurements
Analyzed parameters
ethnicity: nr
1.75 to 50 yearsa
38 probands
histological analysis
tooth type: anterior teeth, premolars, molars
number of jaws: nr
analysis of autopsy specimens of cadaver
jaws
distances by direct measurement (individual values):

pocket depth

bottom of pocket to deepest point of junctional
epithelium

deepest point of junctional epithelium to CEJ

CEJ to bone crest
exclusion criteria:
epithelial ulceration
b
248 teeth
b
356 sites
light microscopy analysis
(microphotograms)
sites: mesial, distal, buccal, oral
attachment loss
pocket depth
distances by indirect (calculated) measurement:

CEJ to bottom of pocket

deepest point of junctional epithelium to bone crest
Stanley (1955)
ethnicity: nr
age: nr
number of probands: nr
histological analysis
18 jaws
analysis of autopsy specimens of cadaver
jaws
inclusion criteria: nr
67 teeth
light microscopy analysis
119 sites
Gargiulo et al. (1961)
ethnicity: nr
19 to 50 years
inclusion criteria:
no extensive
pathology, clinically
normal specimens
number of probands: nr
histological analysis
30 jawsc
287 teeth
analysis of autopsy specimens of cadaver
jaws
(block sections)
325 sites (83, 82, 82, 78)c
light microscopy analysis
c
distances by direct measurement (mean, range):

top of junctional epithelium to alveolar crest
(biologic width)

gingival crest to alveolar crest

bottom of calculus to bottom of junctional
epithelium

bottom of calculus to alveolar crest

bottom of calculus to deepest level of inflammatory
cells

length of junctional epithelium

bottom of junctional epithelium to alveolar crest
sites: approximal (mesial and distal)
distances by direct measurement (mean, range):

dentogingival junction (total attachment)

sulcus depth

length of junctional epithelium

length of connective tissue attachment

most apical point of junctional epithelium to CEJ

sulcus bottom to CEJ

CEJ to alveolar bone crest
sites: mesial, distal, buccal, orald
tooth type and presence of an adjacent toothd
local pathologic factorsd:

supragingival calculus

subgingival calculus

ulceration of the marginal and crevicular
epithelia

inflammation of the lamina propria
attachment loss (mean, range):
 group I (0.00 mm, 0.00 - 0.00 mm)
 group II (0.43 mm, 0.03 - 2.36 mm)
 group III (0.74 mm, 0.16 - 1.04 mm)
 group IV (1.41 mm, 0.39 - 6.08 mm)
distances by indirect (calculated) measurement (mean):

biologic width (sum of junctional epithelium and
connective tissue attachment)
Vacek et al. (1994)
Caucasian
54 to 78 years
10 probands
histological analysis
10 jaws
number of teeth: nr
analysis of autopsy specimens of cadaver
jaws
(non-decalcified block sections)
171 sites
light microscopy analysis
inclusion criteria: nr
distances by direct measurement (mean ± SD, range):

biologic width (junctional epithelium plus
connective tissue attachment)

sulcus depth

length of junctional epithelium

length of connective tissue attachment
tooth type: anterior teeth, premolars, molars
sites: mesial, distal, buccal, orald
sites with subgingival restoration:

existent

non-existent

Lanning et al. (2003)
ethnicity: nr
28 to 72 years
inclusion criteria:
periodontally healthy
Alpiste-Illueca
(2004)
ethnicity: nr
20 to 40 years
inclusion criteria:
no restorations
between maxillary
canines,
no periodontal
pathology,
no previous
orthodontic movement,
no systemic pathology
with repercussions on
the periodontium,
≤ 2 teeth missing
Al-Rasheed et al.
(2005)
Asian
20 to 50 years
18 probands
clinical analysis
number of jaws: nr
measurements of gingival margin,
attachment level and bone level by
periodontal and transgingival probing,
using an acrylic stent for probing
standardization under local anesthesia
49 teeth (18 teeth requiring
crown lengthening and 31
adjacent teeth)
196 sites (72 sites of teeth
requiring crown
lengthening, 62 adjacent
sites and 62 non-adjacent
sites)
direct bone level after flap reflection,
before and after ostectomy
88 probands
clinical/radiographic analysis
88 jaws
clinical measurement of sulcus bottom by
probing, insertion of a gutta percha point
to the base of the sulcus
88 teeth
88 sites
PPRx technique:
two radiographs using the long-cone
parallel technique (frontal and lateral
projection)
CEJ to most coronal point of connective tissue
attachment (attachment loss)
distances by direct measurement (mean ± SD):

gingival margin to acrylic stent

base of the pocket to acrylic stent (attachment
level)

bone level to acrylic stent
distances by indirect (calculated) measurement (mean ± SD):

biologic width

PD
50 probands
clinical analysis
100 jaws
measurements of probing depths and
bone level by periodontal and
transgingival probing under local
anesthesia
300 teeth
inclusion criteria:
complete dentition
(except third molars),
PD ≤ 3 mm
follow-up:

prior to crown lengthening

3 months after crown lengthening

6 months after crown lengthening
distances by direct measurement (mean ± SD, range):

biologic width

sulcus depth

CEJ to alveolar bone crest

CEJ to gingival margin

thickness of connective tissue attachment

thickness of free gingiva

thickness of alveolar bone plate
tooth type: maxillary left central incisors
distances by direct measurement (mean ± SD, range):

PD
tooth type: Ramfjord teeth

maxillary right first molars, left central
incisors and left first premolars

mandibular left first molars, right central
incisors and right first premolars
distances by indirect (calculated) measurement (mean ± SD,
range):

biologic width
900 sites (300, 300, 300,
no oral sites)
Asian
25 to 48 years
sites: approximal (mesiobuccal, mesiolingual,
distobuccal and distolingual in treated sites, adjacent
sites and non-adjacent sites)
sites: buccal
measurement of the apical end of the
gutta percha point to the alveolar bone
crest on radiographs
inclusion criteria: nr
Xie et al. (2007)
tooth type: teeth requiring crown lengthening and
adjacent teeth
sites: mesiobuccal, buccal, distobuccal
5 probands
histological analysis
10 jaws
70 teeth
analysis of autopsy specimens of cadaver
jaws
(decalcified block sections)
280 sites (70, 70, 70, 70)
analysis by a micrometer microscope
distances by direct measurement (mean ± SD):

biologic width

length of junctional epithelium

length of connective tissue attachment
tooth type: anterior teeth, posterior teeth
sites: mesial, distal, buccal, oral
Xie & Chen (2007)
Novak et al. (2008)
Asian
3 probands
histological analysis
25, 29 and 48 years
6 jaws
inclusion criteria: nr
84 teeth
analysis of autopsy specimens of cadaver
jaws
(decalcified block sections)
336 sites (84, 84, 84, 84)
analysis by a micrometer microscope
28 probands
clinical/radiographic analysis
number of jaws, teeth and
sites: nr
measurements of probing depths and
clinical attachment levels by periodontal
probing
ethnicity: nr
29 to 45 years
inclusion criteria:
severe generalized
chronic periodontitis (≥
20 teeth with > 30% of
measured sites with ≥
5 mm CAL)
measurements of bone level from
periapical radiographs
distances by direct measurement (mean ± SD):

biologic width

length of junctional epithelium

length of connective tissue attachment
sites: mesial, distal, buccal, oral
distances by direct measurement (mean ± SD):

CEJ to alveolar bone crest (bone level)

clinical attachment level

PD
distances by indirect (calculated) measurement (mean ± SD):

biologic width
ethnicity: nr
15 to 72 years
inclusion criteria:
adequate width of
attached gingiva,
requiring crown
lengthening
exclusion criteria:
tooth mobility grade
II/III, PD  4 mm, bone
loss, unrestorable
teeth, local or systemic
contraindications to
surgery, molars with
less-than adequate
periodontal support
and furcation
involvement
sites: approximal (mesial and distal)
biologic width in relation to PD

< 2 mm

2-4 mm

5-7 mm

> 7 mm
biologic width in relation to CAL

0-2 mm

3-6 mm

> 6 mm
exclusion criteria:
non-surgical
periodontal treatment
or antibiotic therapy in
the three months prior
to screening,
periodontal surgery in
the 12 months prior to
screening
Shobha et al. (2010)
tooth type:

anterior teeth, premolars, molars,

central and lateral incisors, canines, first
and second premolars, first and second
molars each in the upper and lower jaw
15 probands
clinical analysis
number of jaws: nr
measurements of gingival margin,
attachment level and bone level by
periodontal and transgingival probing,
using an acrylic stent for probing
standardization under local anesthesia
number of teeth: nr
145 sites (53 sites of teeth
requiring crown
lengthening, 46 adjacent
sites and 46 non-adjacent
sites)
direct bone level after flap reflection,
before and after ostectomy
distances by direct measurement (mean ± SD):

gingival margin to acrylic stent

base of the pocket to acrylic stent (attachment
level)

bone level to acrylic stent
distances by indirect (calculated) measurement (mean ± SD):

biologic width

PD
tooth type: teeth requiring crown lengthening and
adjacent teeth
sites: approximal (mesiobuccal, mesiolingual,
distobuccal and distolingual in treated sites, adjacent
sites and non-adjacent sites)
follow-up:




prior to crown lengthening
1 month after crown lengthening
3 months after crown lengthening
6 months after crown lengthening
Galgali & Gontiya
(2011)
ethnicity: nr
20 to 40 years
inclusion criteria:
no restorations
between maxillary
canines,
no periodontal
pathology,
no previous
orthodontic movement,
no systemic pathology
with repercussions on
the periodontium
10 probands
1. clinical/radiographic analysis
10 jaws
clinical measurement of sulcus bottom by
probing, insertion of a gutta percha point
to the base of the sulcus
10 teeth
10 sites
PPRx technique:
two radiographs using the long-cone
parallel technique (frontal and lateral
projection)
1. distances by direct measurement (mean, range):

length of dentogingival unit (bottom of gingival
sulcus to bone crest)

thickness of gingiva
tooth type: maxillary central incisors
sites: buccal
2. distances by direct measurement (mean, range):

length of dentogingival unit (bottom of gingival
sulcus to bone crest)
measurement of the apical end of the
gutta percha point to the alveolar bone
crest on radiographs
2. clinical analysis
Ganji et al. (2012)
ethnicity: nr
20 to 40 years
20 probands
number of jaws: nr
inclusion criteria:
systemically and
periodontally healthy,
endodontically treated
or grossly destructed
tooth or part of fixed
partial denture
requiring full crown,
short clinical crown
length but adequate
root length
exculsion criteria:
systemically and/or
periodontally
compromised patients,
nonrestorable
dentition, unfavourable
crown-root ratio,
orthodontic intrusions
number of teeth: nr
number of sites: nr
measurements of probing depths and
bone level by periodontal and
transgingival probing under local
anesthesia
clinical analysis
measurements of gingival margin,
attachment level and bone level by
periodontal and transgingival probing,
using an acrylic stent for probing
standardization under local anesthesia
distances by direct measurement (mean):

gingival margin to acrylic stent

base of the pocket to acrylic stent (attachment
level)

bone level to acrylic stent
distances by indirect (calculated) measurement (mean):

biologic width

PD
tooth type: teeth requiring crown lengthening
sites: mesiobuccal, distobuccal, buccal and orald
crown lengthening procedure:

soft tissue removal (gingivectomy)

soft and hard tissue removal (ostectomy
with apically positioned flap)
follow-up:

prior to crown lengthening

3 weeks after crown lengthening and before
crown placement

6 and 12 weeks after crown placement
Alpiste-Illueca (2012)
ethnicity: nr
20 to 40 years
inclusion criteria: no
upper anterior tooth
restorations, no BOP
and no plaque in the
examination area, no
previous orthodontic
correction, occlusal
attrition index of Smith
and Knight ≤ 2
a
123 probands
clinical/radiographic analysis
123 jaws
clinical measurement of sulcus bottom by
probing, insertion of a gutta percha point
to the base of the sulcus
123 teeth
123 sites
PPRx technique:
two radiographs using the long-cone
parallel technique (frontal and lateral
projection)
distances by direct measurement (mean ± SD, range):

biologic width

sulcus depth

CEJ to alveolar bone crest

thickness of connective tissue attachment

thickness of free gingiva

thickness of buccal bone plate
tooth type: maxillary left central incisors
sites: buccal
measurement of the apical end of the
gutta percha point to the alveolar bone
crest on radiographs
, dimensions of the biologic width in deciduous teeth were not presented in the present systematic review; b, five deciduous teeth (with a total of six analyzed sites) included; c, material in Gargiulo et al. (1961) included measurements of specimens
published by Orban & Köhler (1924); d, precise values of the dimensions of the biologic width regarding this parameter are not available; CAL, clinical attachment loss; CEJ, cementoenamel junction; nr, not reported; PD, probing depth; PPRx, parallel
profile radiograph; SD, standard deviation.
Appendix 8
Phase of the study
Quality assessment (methodological and reporting scores) of included studies.
Item
Orban &
Köhler
(1924)
Stanley
(1955)
Gargiulo et
al. (1961)
Vacek et al.
(1994)
Lanning et
al. (2003)
AlpisteIllueca
(2004)
Al-Rasheed
et al. (2005)
Xie et al.
(2007a)
Xie &
Chen
(2007)
Novak et
al. (2008)
Shobha et
al. (2010)
Galgali &
Gontiya
(2011)
Ganji et
al. (2012)
AlpisteIllueca
(2012)
Ethic committee
0
0
0
0
1
0
1
0
0
0
0
1
0
1
Informed consent
NAp
NAp
NAp
NAp
1
1
1
NAp
NAp
0
1
1
1
1
Eligibility criteria
1
0
1
0
1
1
0
1
0
1
1
1
1
1
Ethnicity of participants
0
0
0
1
0
0
1
1
1
0
0
0
0
0
Age of participants
1
0
1
1
1
1
1
1
1
1
1
1
1
1
Details of methods
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NAp
NAp
NAp
NAp
1
0
0
NAp
NAp
0
1
0
1
0
NR
NR
NR
1
NR
1
0
NR
NR
0
NR
NR
NR
1
Operator`s experiencea
NAp
NAp
NAp
NAp
0
NAp
NAp
NAp
NAp
NAp
0
NAp
0
NAp
Number of participantsb
1
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
1
0
1
Individual data
1
0
0
0
0
0
0
0
0
0
0
1
0
0
Distribution of data
(deviation, range)a
1
1
1
1
1
1
1
1
1
1
1
1
0
1
Tooth type
1
0
0
1
0
1
1
1
1
0
0
1
0
1
Tooth site
1
1
1
0
1
1
1
1
1
1
1
1
0
1
Presence of restorations
0
0
0
1
0
1
0
0
0
0
1
1
1
1
Periodontal diseases
1
0
1
1
1
1
1
1
0
1
1
0
0
1
Independent funding
NR
NR
NR
1
1
NR
1
NR
NR
0
NR
NR
NR
1
77%
31%
62%
73%
71%
75%
71%
77%
62%
41%
69%
80%
44%
82%
Methods
Registrationa
Participants
b
Variablesb
Data
measurementb
b
Bias
Standardization of clinical
measurement
Examiner calibration/
assessment of method
reproducibilitya
Results
Participantsb
Number of tooth sites
Main results
b
Other analysesb
b
a
Other information
Fundinga,b
Proportion
a
, Cochrane Collaboration`s Tool for assessing risk of bias (modified by Graziani et al. 2012); b, criteria based on STROBE statement (Pjetursson et al. 2012)
Quality assessment of included studies
At least 50% of items relevant for quality assessment were considered in all included studies, except
in two studies. No study fulfilled all items for control of bias.
The protocol of four studies was ethically approved. Ethnicity of probands was considered in four
studies. All studies described the applied methods in detail. Examiner calibration and validation of
reproducibility were not always reported. Variability of results was presented by means with standard
deviations and/or range of individual values in thirteen studies. Two very recent studies reported data
on all outcome variables in terms of tooth type, tooth site, presence of restorations and/or periodontal
disease.
Appendix 9
Directions for further research
There may be additional factors with potential impacts on the dimensions of the biologic width.
It has been suggested that the periodontal biotype affects the dimensions of the marginal periodontal
tissues (Müller et al. 2000). Generally, thin, normal and thick biotypes can be distinguished upon
clinical examination (Müller & Eger 1997, Sanavi et al. 1998). The thin biotype was proposed to be
associated with a smaller biologic width (Müller et al. 2000). In the present systematic review, two
included studies analyzed the thickness of the gingiva (Alpiste-Illueca 2004, Galgali & Gontiya 2011).
However, the data on the different periodontal biotypes were not correlated with the biologic width.
Some of the included studies described the dimensions of the biologic width in different ethnic groups
(Gargiulo et al. 1961, Vacek et al. 1994, Al-Rasheed et al. 2005, Xie et al. 2007). As described above,
great variability was observed, and an impact of ethnicity on biologic width is likely. However, a direct
comparison of the dimensions of the biologic width has not yet been published.
Januario et al. (2008) described measurements of the dentogingival unit using soft tissue cone-beam
computed tomography (ST-CBCT) for anterior and posterior teeth. This approach may have potential
use in the measurement of biologic width but needs to be validated.
Other novel, non-invasive approaches have emerged for periodontal assessment in the last few
decades (Xiang et al. 2010). Imaging methods, such as optical coherence tomography, have the
potential to visualize hard and soft periodontal tissues (Otis et al. 2000). However, the preliminary data
should be interpreted with caution until these methods are clinically proven.
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