Amid et al. J Adv Periodontol Implant Dent.

2020; 12(1): 3-10

doi:10.34172/japid.2020.003

https://japid.tbzmed.ac.ir

Research Article

Effect of gingival biotype on orthodontic treatment-induced

periodontal complications: A systematic review

Reza Amid1,2 , Mahdi Kadkhodazadeh1,2 , Anahita Moscowchi2* , Shiva Tavakol Davani3 ,

Milad Soleimani3 , Anahita Dehghani Soltani3 ,Muna Al-Shuhayeb2
1
Dental Research Center, Research Institute of Dental Sciences, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2
Department of Periodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3
Department of Orthodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran

ARTICLE INFO Absrtact

Background. It is crucial to maintain periodontal health in patients undergoing orthodontic treatment.
Article History: Biotype is a critical factor to be considered in this regard. This systematic review investigated the
Received: 30 Oct. 2019 scientific evidence on the relationship between gingival biotype and marginal periodontal alterations
Accepted: 15 Mar. 2020 induced by orthodontic interventions.
ePublished: 14 Apr. 2020 Methods. An electronic search was conducted for pertinent studies in three databases: PubMed, Scopus,
and Cochrane up to August 1, 2019 based on a detailed protocol according to the PRISMA statement.
Keywords: The authors also completed a hand search in six dental journals and the bibliographic lists of the relevant
Gingival biotype, studies.
gingival recession, Results. Of 1512 citations retrieved through the electronic search, 602 were duplicate entries. By
gingival thickness, evaluating titles, abstracts, and full texts, eight articles conformed to the inclusion criteria; however,
orthodontics. no relevant studies were found through hand searching. The evidence suggested that recession was
inversely related with the thickness of the facial margin. These findings were more evident in proclined
teeth and patients using fixed appliances.
Conclusion. The existing evidence suggests that orthodontic therapy might result in mild detrimental
effects on the periodontium, especially in patients with thin biotype. However, due to the limited
investigations and their inconsistent methodology, further well-designed prospective studies are
necessary.

Introduction the width and thickness of the facial gingiva vary

M alocclusion is the third most prevalent oral

health problem worldwide.1,2 Orthodontic
treatments facilitate oral hygiene measures and
from one individual to another, and even in different
regions of a mouth. Therefore, there are diverse
“gingival phenotypes,” a term used by Muller and
establish occlusal stability and lip competency by Eger14 for the first time. Studies have shown that
eliminating traumatic occlusion and crowding; gingival thickness plays a fundamental role in
thus, some investigators have considered these mucogingival problems. As the attachment level is
interventions as potential means to improve minimal in thin biotype, it is more prone to trauma
periodontal health.3,4 However, orthodontic and inflammation.15-17 Consequently, accurate
appliances might increase plaque accumulation pre-orthodontic evaluation of the biotype has
and impede proper oral hygiene, which raise the been recommended in order to preclude potential
possibility of making these treatments detrimental complications.17-19
to periodontal tissues.5-9 Given the increasing demand for orthodontic
Lindhe and Seibert10 used the term “periodontal treatments and the importance of maintaining
biotype” to describe morphologic characteristics of periodontal health, the nature and extent of the
the periodontium. In general, there are two types complications related to these interventions in
of gingival biotype: “thin scalloped” and “thick patients with different biotypes should be taken into
flat.”11,12 The biotype depends on many factors, account. Despite the conflicting opinions about the
including age, sex, genetic factors, as well as the relationship between orthodontic treatments and
shape, position, and size of the teeth.13 In addition, periodontal health, few studies have addressed the

*Corresponding authors: Anahita Moscowchi. Tel:+98- 21 29902314 E-mail: [email protected]

© 2020 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.
org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Amid et al

orthodontic-related changes affecting marginal Hand search: Five journals, American Journal
periodontal tissues. This study investigated the of Orthodontics and Dentofacial Orthopedics,
scientific evidence on the relationship between Angle Orthodontist, Journal of Periodontology,
gingival biotype and periodontal changes caused by Journal of Dental Research and Journal of Clinical
orthodontic movements. Periodontology, were hand-searched for studies
reporting on the periodontal effects of orthodontic
Methods
treatment in patients with different types of gingival
Protocol biotype.
The titles and abstracts of the retrieved articles
A detailed protocol was developed and followed, were screened independently by two authors
according to the PRISMA statement.20, 21 (RA and AM) to assess the fulfillment of the
Search strategy inclusion criteria. Full-text articles were obtained
in case the supplementary data were needed. Any
The eligibility criteria were as follows: disagreements during the process were resolved by
-Study design: We evaluated randomized discussion.
controlled trials (RCTs) and prospective,
retrospective, and cross-sectional studies. Quality assessment
-Population: We included only studies on Two of the reviewers (RA and MK) independently
humans, with no restrictions in terms of patient’s assessed the quality of the identified studies and
age or occlusion characteristics, although we did resolved any disagreements through discussion.
exclude studies that included patients with severe For cohort, case–control and cross-sectional
periodontal diseases or craniofacial anomalies. studies, we used the Newcastle-Ottawa Quality
-Intervention: We focused on studies assessing Assessment Scale, which consists of eight items:
fixed or removable orthodontic appliances, or four items regarding selection, one item regarding
both. Since orthognathic surgery and distraction the comparability of the groups, and three items
osteogenesis might have different consequences regarding the outcome assessment.24 Then, we
compared to nonsurgical orthodontic therapy, classified the bias status as low (all quality items
we agreed to exclude studies comprising these met), moderate (one or two quality items not met),
procedures. or high (three or more criteria not met).
-Comparison: We assessed periodontal outcomes Data Extraction and Synthesis
in patients with different types of gingival biotype, Four reviewers (STD, MS, ADS, and MAS)
who underwent orthodontic treatment. independently extracted the relevant data by
-Types of outcome measures: Owing to the using a predefined data extraction table to report
heterogeneity of endpoints in periodontal studies,22 on the study design, participants, orthodontic
we could formulate no single periodontal outcome intervention, periodontal outcomes, and the
measure. Instead, we included all studies with at gingival biotype.
least one type of periodontal parameter.
Search methods Results

Two authors (RA and AM) extracted articles Search results

through an electronic search and a hand search Of the 1512 citations retrieved through the
of the specific journals. The reference lists of the electronic search, 602 were duplicate entries. Eight
selected full-text articles were also screened for the articles were eligible to be included in the study
unidentified or unpublished relevant studies. through evaluation of the titles, abstracts, and full
-Electronic search: PubMed, Scopus, and the texts (Figure 1). We found no studies that met the
Cochrane Library (including the Cochrane Central inclusion criteria through the hand searching of
Register of Controlled Trials [CENTRAL] and the the literature. The characteristics of the included
Cochrane Database of Systematic Reviews [CDSR]) studies are presented in Table 1.
were searched up to August 1, 2019. We did not The participants were 8–65 years of age, with
limit our search strategy regarding the study design, the majority undergoing orthodontic treatment
as doing so could have excluded some pertinent as adolescents or young adults. They had various
publications.23 No publication status and language forms of malocclusion. Three studies25-27 did not
or time restrictions were applied. report the malocclusion status. One study restricted
Search terms included the following keywords the inclusion criteria to those who had infraversion
and were modified appropriately for each database. or open bite,28 and one study included only subjects
Search #1: Orthodontic* AND (“gingival biotype” with Class I and Class II malocclusion.29 The types
OR “periodontal biotype” OR “gingival thickness”) of orthodontic treatments were fixed appliances,8, 16,
Search #2: Orthodontic* AND (“gingival 25, 29, 30
fixed appliances with premolar extraction,8,27
recession” OR “gingival side effect” OR “periodontal functional appliances,8 or not reported.26,28
side effect” OR mucogingival) The selected articles reported various markers

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Table 1. The characteristics of the included studies

Characteristic Study
Ji et al (28) Stappert et al Rasperini et Boke et al (8) Yared et al (25) Szarmach et Melsen, Allias Ngan et al (26)
(27) al (16) al (30) (29)
Study Design Retrospective Prospective Prospective Retrospective Retrospective Cross- Retrospective Retrospective
sectional
Participants 403 29 16 251 34 18 150 20

(285 F, 118 M) (6 F, 10 M) (177 F, 74 M) (11 F, 7 M) (114 F, 36 M) (12 F, 8 M)

Age 11–43 ≤13 Mean age: 8-17.8 (mean 18-33 12-39 F: 22-65 11-16
21±8.20 13.37 ± 2.06)
14–18 M: 23-50

≥19
Biotype Probing Transgingival Biotype Intra-oral Scaled Periodontal Intra-oral Visual
determination transparency probing photographs, probe photographs, inspection
probe Visual digital caliper, Visual

(Hu-Friedy) inspection of inspection of

the gingival the gingival
texture and texture and
capillary capillary
transparency transparency
Biotype Thin Thin (≤2.5mm) Thin Thin <0.5 mm Thin gingiva Thin Thin
classification
Thick Thick Medium Thick ≥0.5 mm and the root Thick Moderate
(>2.5mm) bone layer
Thick Thick

Very thick
Intervention NM Fixed appliance Fixed 58 Fixed Fixed appliance Fixed Fixed appliance NM
with premolar appliance appliance with appliance without
extraction extraction extraction

173 Fixed
appliance
without
extraction

20 Functional
appliance
Periodontal GI, PI, GR, and Gingival cleft PPD, GR, GR, Plaque, Plaque index, GR GR, Plaque, GR,
Outcome CAL, KTW, Inflammation GI, PPD, CAL, Inflammation Inflammation
plaque index FMBS GR
Quality *** **** ****** *** *** *** *** ****
assessment*
F = Female, M = Male, GI = Gingival Index, PI = Periodontal Index, GR = Gingival Recession, PPD = Probing Pocket Depth, CAL = Clinical Attach-
ment Level, KTW = Keratinized Tissue Width, FMBS = Full-mouth Bleeding Score
NM = not mentioned
*Number of the stars represents quality of the study based on the Newcastle-Ottawa Quality Assessment Scale

of periodontal status as follows: gingival gingiva and gingival thickness. Rasperini et al16
recession,8,16,25,26,28-30 probing pocket depth,16,25 demonstrated that the thin biotype and incisor
clinical attachment level,16,25 inflammation,8,16,25,26,28,29 proclination could induce gingival recession (0.17
periodontal index,28 plaque index,8,25,28,29 and mm) and reduce the width of keratinized gingiva
keratinized tissue width.16,25 One study reported (-0.67 mm), which was not evident in the alignment
gingival clefts,27 but none of them reported on and retroclination movements. However, only one
tooth loss, tooth mobility, or other adverse effects. of their patients showed a gingival recession of 1.5
In addition, Szarmach et al30 evaluated crowding, mm on a mandibular left central incisor. Their study
protrusion, improper frenal attachment, and the also revealed no significant relationship between
depth of the oral vestibule. the biotype and changes in probing depth and
Regarding gingival biotype determination, attachment loss.
Rasperini et al,16 Melsen and Allais,29 and Ngan et Boke et al8 reported that in patients treated with
al26 used the four mandibular incisors, while Yared fixed appliances, the mean values of visible plaque,
et al25 evaluated the mandibular central incisors. visible inflammation, and gingival recession
The results of these investigations indicated that were 2.93±6.78, 2.76±6.20, and 0.11±0.40 before
some periodontal complications, such as increased treatment, respectively. These parameters increased
probing depth, attachment loss, and gingival significantly after orthodontic treatment and
recession might be more prevalent in orthodontic reached 5.92±9.08, 17.75±18.74, and 0.48±1.13,
patients; five studies16,25,28-30 reported that recession respectively; however, such a relationship was not
was inversely related with the width of keratinized evident for functional appliances. The canines were
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Amid et al

Figure 1. The flowchart of the study selection process.

the most affected teeth by gingival recession (9.48% complications.16,25,27-30 However, there are some
for maxillary and 7.76% for mandibular canines limitations, including a limited number of studies,
in the extraction group; 4.04% for maxillary and potential of bias, inconsistent methods for
3.76% for mandibular cuspids in the non-extraction biotype determination, and various orthodontic
group). interventions, making the comparison of the results
Szarmach et al30 reported that cases with thin gingival difficult.
margin and thin buccal bone had more recession, An issue that might provoke debate is the
which was evident more frequently in skeletal class inconsistent and inaccurate methods used for
III patients. Melsen and Allais29 demonstrated that biotype determination, including visual inspection
only 2.8% of the subjects developed recession >2 and indirect measurements on dental casts or
mm, and 5% of the pre-existing gingival recessions intraoral photographs. Usually, simple visual
improved. They concluded the baseline recession, inspection is used in clinical practice and even in
width of keratinized gingiva, gingival biotype, and research to identify the gingival biotype. However,
gingival inflammation were correlated with gingival the accuracy of this method has never been
recession. documented. Egbhali et al32 reported that by using
Discussion visual evaluation for gingival thickness, the biotype
was accurately identified in about half of the cases,
Orthodontic appliances might damage periodontal regardless of the clinician’s experience. As a result,
tissues by creating retentive areas for dental plaque; other methods, such as direct measurements,33
even with excellent oral hygiene, the appliances gingival transparency,34 ultrasonic devices,37 and
cause a change in the intraoral microflora, leading cone-beam computed tomography (CBCT)35 have
to a bacterial array similar to that present in sites been proposed.
affected by periodontal disease.31 Several studies have addressed the effects of
In contrast to patients with thick gingiva, those different therapeutic methods on periodontal
with a thin-scalloped biotype are considered at complications; gingival recession has been the main
risk; therefore, identification of these high-risk periodontal adverse outcome evaluated. Although
subjects is warranted. The evidence identified by this problem is not often attributable to the type
this systematic review suggested that there might of orthodontic appliance,36,37 there is debate in this
be an association between the gingival biotype regard. Some investigations have indicated that fixed
and orthodontic treatment-induced periodontal appliances are associated with inflammation and
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 Amid et al

even gingival recession,38-41 while some others have One of the questions this review aimed to answer
demonstrated no detrimental effects induced by the was the necessity of periodontal intervention
long-term presence of these appliances.6,42 However, for orthodontic patients with different gingival
it should be noted that these controversies might be biotypes. As excessive labial inclination might lead
due to the complex etiology of gingival recession, to dehiscence and gingival recession on the labial
in which orthodontic appliances and fixed retainers surface,47,59-61 patients whose teeth are being moved
are only two contributing factors.43-47 For example, labially (>95 degrees) should be informed about the
thin soft tissues are more prone to the detrimental risk of gingival recession.17,58,62,63 Therefore, bodily
effects of environmental factors, such as plaque, movement of the lower incisors should be preferred2,
calculus, and gingivitis;13,17,48-50 tooth position and 64
and exercised with caution in patients with thin
alveolar bone anatomy might also play a role.51 In gingival biotype and keratinized gingiva <2 mm.11
addition, there is insufficient evidence on some It has been indicated that as long as the orthodontic
orthodontic parameters, such as force magnitude, movements are confined to the alveolar process, the
location, and type of movement, which might result risk of periodontal lesions would be minimal.50,65-69
in dehiscence and gingival recession.52 The width of the keratinized tissue plays a
Similar to biotype, different methods have been significant role in the decision-making process. It
used to evaluate gingival recession. The measurement seems that periodontal intervention is rational in
of the gingival recession on dental casts29,53 could case of progressive recession or tooth movement
be misleading due to factors, such as extrusion, out of the alveolar process (Figure 2). It should be
crown fracture, attrition, or restoration.54,55 Crown noted that the recession (<2 mm) reported in some
length measurement for indirect estimation of studies is usually not progressive and might be
gingival recession8 is also not reliable, as the tooth related to the heterogeneity of tissue quality.55,70-72 If
length might be affected by different factors, such as gingival recession is observed after the orthodontic
gingival hyperplasia. therapy, the treatment alternatives depend on its
Although some studies have demonstrated no severity73 and the probability of elimination by
significant association between malocclusion and orthodontic intervention (Figure 3). It should also
biotype,2,13,56 some others have reported minimal be kept in mind that the clinical relevance of the
gingival thickness in mandibular central and lateral induced recession is unclear, and most studies have
incisors in class III patients.5,30,57 The periodontal only documented the pre- or post-orthodontic
tissue response has frequently been evaluated in class incidence of gingival recession.7,36,60,74,75
II patients, while it might be different in individuals The strengths of this systematic review include
with class III malocclusion. Six studies included in the comprehensive search of the relevant literature,
this review described the Angle classification for no restriction on the language or study design, and
their participants, but only one30 clearly addressed the quality assessment of the included studies.
the correlation between gingival biotype and the
Conclusions
type of malocclusion.

Figure 2. The management of pre-orthodontic treatment mucogingival problems.

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Amid et al

Figure 3. The management of post-orthodontic treatment mucogingival problems.

The existing evidence suggests that orthodontic periodontal disease. Dental press journal of orthodontics.
treatment might result in small detrimental effects 2011;16(4):87-94.
2. Staufer K, Landmesser H. Effects of crowding in the lower
on the periodontium, especially in patients with anterior segment--a risk evaluation depending upon the
thin gingival biotype. However, the available data do degree of crowding. Journal of orofacial orthopedics
not make it possible to determine whether adverse = Fortschritte der Kieferorthopadie : Organ/official
periodontal changes are indicative of site-specific journal Deutsche Gesellschaft fur Kieferorthopadie.
changes, host-specific factors, a direct consequence 2004;65(1):13-25.
3. Sharma K, Mangat S, Kichorchandra MS, Handa A,
of the orthodontic forces, or study bias. It seems Bindhumadhav S, Meena M. Correlation of Orthodontic
that due to the limited investigations and their Treatment by Fixed or Myofunctional Appliances and
inconsistent methodology, further well-designed Periodontitis: A Retrospective Study. The journal of
prospective studies are necessary. contemporary dental practice. 2017;18(4):322-5.
4. Bock NC, Saffar M, Hudel H, Evälahti M, Heikinheimo K,
Acknowledgments Rice DPC, et al. Long-term effects of Class II orthodontic
treatment on oral health. Journal of Orofacial Orthopedics.
None. 2018;79(2):96-108.
Competing Interests 5. Kaya Y, Alkan Ö, Keskin S. An evaluation of the gingival
biotype and the width of keratinized gingiva in the
The authors declare no conflict(s) of interest related to mandibular anterior region of individuals with different
the publication of this work. dental malocclusion groups and levels of crowding.
Korean journal of orthodontics. 2017;47(3):176-85.
Authors’ Contributions 6. Juloski J, Glisic B, Vandevska-Radunovic V. Long-term
influence of fixed lingual retainers on the development
Design of the work: RA; acquisition of data: STD, of gingival recession: A retrospective, longitudinal cohort
MS, ADS, and MAS; analysis of data: RA, and AM; study. The Angle orthodontist. 2017;87(5):658-64.
interpretation of data: RA, and MK; drafting the work: 7. Ciavarella D, Tepedino M, Gallo C, Montaruli G,
AM; revision: MK. All authors read and approved the Zhurakivska K, Coppola L, et al. Post-orthodontic position
final manuscript. of lower incisors and gingival recession: A retrospective
study. Journal of clinical and experimental dentistry.
Funding 2017;9(12):e1425-e30.
No funding. 8. Boke F, Gazioglu C, Akkaya S, Akkaya M. Relationship
between orthodontic treatment and gingival health:
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