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ORIGINAL RESEARCH Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 4  |  Page : 135-9
Comparative assesment of gingival thickness using transgingival probing and ultrasonographic method


Department of Periodontics, College of Dental Sciences, Davangere 577 004, India

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   Abstract 

A decided attitude of expectation among many patients has given a new perspective to regenerative and plastic periodonta surgery. With authors emphasizing on the importance of gingival thickness, attempts are being made to obtain necessary information atraumatically and rapidly. Hence in the present study an attempt has been made to compare the two methods of assessing gingival thickness i.e transgingival probing and ultrasonographic method and also assess the gingival thickness in relation to central incisor lateral incisor and canine in Indian population. The gingival thickness was assessed in patients with healthy gingiva by both the methods. It was observed that transgingival probing method significantly over estimated the thickness of gingiva than the ultrasonographic method and the thickness of gingiva varies with morphology of the crown. It was concluded that compared to transgingival probing ultrasonographic method assesses gingiva thickness more accurately, rapidly and atraumatically.

Keywords: Gingival thickness, periodontal diagnosis, transgingival probing method, ultrasonic method, anterior segment, toothwise

How to cite this article:
Savitha B, Vandana K L. Comparative assesment of gingival thickness using transgingival probing and ultrasonographic method. Indian J Dent Res 2005;16:135

How to cite this URL:
Savitha B, Vandana K L. Comparative assesment of gingival thickness using transgingival probing and ultrasonographic method. Indian J Dent Res [serial online] 2005 [cited 2019 Oct 22];16:135. Available from: http://www.ijdr.in/text.asp?2005/16/4/135/29908

   Introduction Top


The current expansion of the therapeutic spectrum in periodontics, as in for example, regenerative and plastic periodontal surgery has led to a decided attitude of expectation among many patients. In recent years, the dimensions of different parts of the masticatory mucosa, especially gingival thickness has become the subject of considerable interest in periodontics from both an epidemiologic and a therapeutic point of view. Since various studies have concluded that thickness of gingiva plays a vital role in development of muco-gingival problems, in the success of treatment for recession[1] and wound healing [2] assessment of gingival thickness is gaining a large momentum in clinical periodontics.

In the literature in majority of the studies, the thickness of masticatory mucosa was evaluated by conventional histology on cadaver jaws while few others used invasive methods such as injection needle or probe [2],[3] histologic sections [4] or cephalometric radiographs [5]. Though the above mentioned methods were invasive, non-invasive methods were performed using ultrasonic device. While A-mode measured thickness in edentulous patients (6,7), 13-mode along with measuring the thickness, also visually determined soft and hard tissue relationships [8].

Eger, Muller and Heinecke [9] measured the thickness of attached gingiva using a commercially available A-mode, intraoral ultrasonic device and reported that the validity and reliability of measuring gingival thickness with the ultrasonic device was found to be excellent They also assessed the gingival thickness in half mandibles of freshly slaughtered 6 month old pigs using an endodontic reamer for trans­gingival probing followed by an ultrasonic device, (SDM, Krupp corp Essen Germany) and reported an excellent validity of the result of the ultrasonic device.

Comparison of conventional transgingival probing measurement with the advanced ultrasonic measurement are scanty. Hence the aims of the presentstudy are

a) to compare the two methods of assessing gingival thickness i.e, transgingival probing (TGP) and ultrasonographic method (USG) in Indian population.

b) to compare the thickness ofgingivatoothwise.


   Materials and methods Top


Rajiv Gandhi University of Health Sciences review committee approved the protocol for human subjects. The study group included patients with healthy gingiva in upper and lower anteriors. The inclusion criteria were a) healthy periodontal tissues with no loss of attachment, b) presence of all anterior teeth in both upper and lower jaw. The following exclusion criteria were considered [10] a) pregnancy and lactation, b) gingival recession in the anteriors, c) systemic disease, d) extensive restorations. e) use of any medication possibly affecting the periodontal tissues such as cyclosporin A, calcium channel blockers and pheny toin. After receiving information about this study such as the objectives, expected outcomes and the degree of discomfort thatmigbtoccur, the subjects gave their informed consent. In the first visit plaque index (Silness and Loe 1964) and gingival bleeding index (Ainamo and Bay 1975) were recorded followed by scaling and polishing.

Procedural steps for measurement of gingival thickness

The gingival thickness was assessed mid-buccally in the attached gingiva, half way between mucogingival junction and free gingival groove [11] and at the base of the interdental papilla [Figure - 1]. The thickness of gingiva was assessed at both the measurement points tooth wise i.e. at central incisor, lateral incisor and canine by both TGP and USG methods. The measurement points on the facial gingiva were marked with a marking pencil.

Trans gingival probing measurements

The gingival thickness was assessed by anaesthetizing the facial gingiva with xylonar spray (Lignocaine 15.0g) and if required, infiltration was done using 2% lignocaine HCl with 1:80,000 adrenalin injection. Using aUNC-15 probe the gingival thickness was assessed at the measurement points 20 minutes after injection. Measurements were then rounded uptothenearest millimeter.

Ultrasound machine

The ultrasound A-scan* measuring 13.5"x 7", included a digital display, scan display, a transducer probe, built in printer and foot switch. The frequency is 10 MHZ 10%

Ultrasonic measurements

The ultrasonic measurement was done using A - scan which makes use of pulse echo principle. The transducer probe was adapted to the gingival surface coinciding with the bleeding point created during transgingival probing [Figure - 3]. The mechanism of action of ultrasound based on the transit time for the pulse (ultrasound wave)tutravelto the bone (hard tissue) and echoed back creates spikes on the monitor immediately. Utilizing the print out of this graph and with the help of the optical projector, the thickness of gingiva was determined.


   Results Top


This study included 32 patients of both sexes with 16 male and 16 female subjects ranging in age between 16-38 years who satisfied the selection criteria A total of 675 sites were assessed in the anterior segment of the mouth with minimum of 12 sites and maximum of 24 sites for each selected subject / patient and the results of the study are as follows.

The measurements done by both the methods are illustrated in table 1-3 and graphs 1-3.

The mean gingival thickness midbuccally at 338 sites determined by TGP measurements was 1.08 f 0.42 with measurements ranging from 0.5 to 2.5 mm and mean USG measurements was 0.86 f 0.33 with range of measurements between 0.4 to 1.6 mm [Table - 2]. Mean gingival thickness of interdental papilla at 337 sites determined by TGP was 1.26 f 0.60 ranging from 0.5 to 3 mm and USG was 0.77 f 0.38 with measurements ranging between 0.3 to 2.2 mm [Table - 2].

On comparing the two methods i.e. TGP and USG, the mean difference was 0.22 midbuccally which was significant (P<0.001) and a mean difference of 0.49 was recorded at the interdental papillary region which was also significant (P<0.001).

Tooth wise comparison of gingival thickness between the methods showed that, thickness of gingival varied between the central incisor, lateral incisor and canine.

The difference between the methods was found to be significant both at the mid-buccal and interdental papillary region, but the difference was insignificant at mandibular canine at the mid-buccal site [Table - 3].

A strong linear relationship (graph 1 and 2) between the TGP and USG measurements midbuccally and at interdental papillary region with a significant correlation coefficient (r=+0.55 and r=+0.19) was recorded.


   Discussion Top


Since predictability of post operative success has become a major aspect in the verification process of new therapies, advanced diagnostic techniques, including a careful analysis of the surrounding tissues as well as strict consideration of trologic principles, now basically characterise periodontics. Gingival thickness plays an important role in development of gingival recession[1], wound healing[2] and flap management during regenerative surgical procedures[2],[11] and also a significant predictor of the clinical outcome of root coverage procedures[1].

Gingival thickness was assessed by an invasive method using a disposable sterile needle[2], stainless steel wire[1] and bone sounding with a periodontal probe[1],[2], while non-invasive methods included the use of A-mode [6],[7] and B-mode[8] ultrasonic device.

Studies comparing invasive and non-invasive methods of assessing gingival thickness are scanty. Hence in the presence study an attempt was made to compare the two methods i.e. transgingival probing (TGP) and ultrasonographic method (USG). In this study USG measurements were done using an A-scan probe and the placement of straight ultrasonic probe tip was convenient in the anterior segment and the close adaptation of probe delivers ultrasonic waves at right angle to the tissues to be measured in the facial gingiva of anterior teeth. The frequency of the A-scan was l0MHz, higher than SDM device used by Muller[12] (5MHz), which provided better tissue penetration of the ultrasound waves.

The TGP measurements were overestimated in the range of 0.5- lmm than the USG measurements at a majority of the sites, which may be attributed to the crude way of measuring the thickness using a periodontal probe with lmm markings, as reported by Muller[12] and rounding of the measurement to the next millimeter marking. The discrepancy of TGP and USG measurements at the interdental papillary region may probably be due to the placement of the probe coronal to the alveolar crest leading to the scattering of the ultrasonic waves and the absorption of the waves by the soft tissue without being rebounded back. As observed by Sarti and Smith[13], the ultrasound waves when traveling unhampered (i.e. in the absence of bones) would be completely absorbed by the soft tissues without being rebounded. In addition, the inability of the close adaptation of the eye of the probe measuring 0.5mm coinciding with the bleeding point created by TGP method in the interdental papillary region might have led to the discrepancy in measurements. Daly and Wheeler[6] observed that the ultrasound waves which traveled at right angles to the bone margin gives rise to the spike on the display corresponding with the gingival thickness. However, change in angulation would lead to scattering of the waves.

The strong linear relationship expressed between the two methods of measuring gingival thickness midbuccally and interdental papillary regions shows that the gingival thickness assessed by both TGP and USG methods are dependable. Since the discrepancy between the measurements was minimal at the mid-buccal site, when the gingival thickness ranged 0 to 0.5mm, USG method was found to be on reliable. As the discrepancy in the measurements was more in interdental papillary region, USG method seemed to be unreliable. As observed in the present study thickness of gingiva varied with the teeth i.e, central incisor, lateral incisor and canine indicating that thickness of gingiva is dependent on the type of teeth. Muller[12] confirmed in a study that the thickness of the gingiva varies with the morphology of the crown. He classified the crown forms into 3 clusters based on the width and length of the crown and found that the thickness of the gingiva varied among these 3 clusters. However, as the purpose of the present study was to compare the two methods of assessing gingival thickness, no such cluster distribution was the criteria. However, it was observed that the thickness of the gingiva was greater in the canine, followed by central incisor and lateral incisor.

A decided attitude of expectation among many patients has given a new perspective to regenerative and plastic periodontal surgery. With authors emphasizing on the importance of gingival thickness, attempts are being made to obtain necessary information atraurnatically, rapidly and with relatively low cost. The most important indication for measuring soft tissue thickness is clearly plastic periodontal surgery. However the selection of periodontal therapy on gingival thickness and further, the influence of gingival thickness on treatment outcome is still not clear.

Within the limits of the present study it is demonstrated that thickness of gingiva varies with the tooth sites, i.e. midbuccally and interdental papillary region.

Both TGP and USG measurements are reliable in measuring gingival thickness midbuccally while USG measurements are not dependable in papillary region. Further, TGP method is cost effective and easy to perform as against USG measurements done atraumatically.[14]

 
   References Top

1.Carlo B. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage 7 A-19 case series. JPeriodonto11999;70:1077-1084.   Back to cited text no. 1    
2.Anderigg CK, Hetzler DG, Nicole BK. Gingival thickness in guided tissue regeneration and associated recession at facial f ncation defects. Journal of Periodontology 1995; 66: 397-402.   Back to cited text no. 2    
3.Claffey Shanley. Relationship of gingival thickness and bleeding to loss of probing attachment in shallow sites following non­surgical periodontal therapy. J Clin Periodontol 1986;13:654-657.  Back to cited text no. 3    
4.Ostlund SG. The effect of complete dentures on the gum tissues: ahistological and histopathological investigation. Acta Odontol Scand1958;16:1-40.  Back to cited text no. 4    
5.Lytle RB. The management of abused oral tissues in complete denture construction. J ProsthetDent 1957; 7:27 -42.  Back to cited text no. 5    
6.Daly CH, Wheeler JB. The use of ultrasonic thickness measurement in the clinical evaluation of the oral soft tissues. hit Dent J 1971; 21: 418­429.  Back to cited text no. 6    
7.Terakura T. Non-invasive thickness measurement of the oral soft tissue. J Clin ProsthodontSoc1986;30:1402-1411.  Back to cited text no. 7    
8.Uchinda H, Kobayashi K, Nagao M. Measurement in vivo of masticatory mucosal thickness with 20 MHz B-mode ultrasonic diagnostic equipment. J Dent Res 1989; 68:95­100.  Back to cited text no. 8    
9.Eger T, Muller HP, Heinecke A. Ultrasonic determination of gingival thickness, subject variation and influence of tooth type and clinical features. J Clin Periodontol 1996; 23 839-845.  Back to cited text no. 9    
10.Waraaswapati N, Pitiphat W, Chandrapho N, Rattanayatikul, Karimbux K. The thickness of palatal masticatory mucosa associated with age. JPeriodonto12001;72:1407-1412.  Back to cited text no. 10    
11.Goaslind GP, Robertson PB, Mohan CJ, Morrison WW Olsson JV Thickness of facial gingiva. Jperiodonta11974; 48: 768-771.   Back to cited text no. 11    
12.Muller HP. Masticatory mucosa in subject with different periodontal phenotypes. J Clin Periodonto12000; 27: 621-626.  Back to cited text no. 12    
13.Muller HP. Ultrasonic determination of thickness of masticatory mucosa a methodologic study. Oral Surg Oral Med Oral Pathol Oral RadiolEndod1999;88:248-53.  Back to cited text no. 13    
14.Sarti AD, Smith KC, Physics of diagnostic ultrasound. In: Diagnostic radiology, a text book of medical imaging. Graingee CG, Allison DJ. CV Mosby Company, 3rd edition, 1980:1-23.  Back to cited text no. 14    

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Correspondence Address:
K L Vandana
Department of Periodontics, College of Dental Sciences, Davangere 577 004
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.29908

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

    Tables

[Table - 1], [Table - 2], [Table - 3]

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