Andrea Parpaiola Dimensions of the healthy gingiva and

Denis Cecchinato
Marco Toia
peri-implant mucosa
Eriberto Bressan
Stefano Speroni
Jan Lindhe

Authors’ affiliations: Key words: implants, probing depth, teeth, transmucosal sounding
Andrea Parpaiola, Denis Cecchinato, Marco Toia,
Franci Institute, Padova, Italy
Eriberto Bressan, Department of Neurosciences, Abstract
University of Padova, Padova, Italy Objective: To determine the dimensions of the soft tissue cuff present at various aspects of teeth
Stefano Speroni, Department of Orthodontics,
and to compare these dimensions to those of the mucosa surrounding single implants.
School of Dentistry, Milano, Italy
Jan Lindhe, Department of Periodontology, Material and methods: Fifty volunteers were recruited that were ≥25 years of age and exhibited
Sahlgrenska Academy, Gothenburg, Sweden no signs of (i) untreated caries; (ii) loss of periodontal tissue support in the incisor, canine, and

Corresponding author:
premolar regions; (iii) systemic or local disease. Furthermore, among the 50 patients recruited (iV),
Dr. Andrea Parpaiola 27 had one single implant in the maxilla with teeth present mesial and/or distal to the implant.
Franci Institute, Andrea via guizza 256, Padova Probing pocket depth (PPD) and transmucosal sounding depth (TS) were assessed by five
35100, Italy
Tel./Fax: +39 429 73071 experienced, carefully calibrated examiners and with the use of a periodontal probe at the
e-mail: [email protected] proximal (mesial, distal) and flat (facial, buccal and palatal/lingual) surfaces of all teeth/implants.
The width of the keratinized mucosa (KM) was also determined.
Results: It was demonstrated that (i) PPD and TS were greater at proximal than at flat surfaces at
both tooth and implant sites. In addition, both PPD and TS were deeper at implant than at tooth
sites. The TS values documented that the cuff of healthy soft tissue that surrounded a tooth varied
between 2 mm at flat surfaces and 4 mm at proximal surfaces, while at implant sites, the mucosa
at proximal as well as flat surfaces was 1–1.5 mm greater.
Conclusion: The probing pocket depth (PPD) and the transmucosal sounding depth (TS) values
were greater at proximal than at flat, that is, facial/palatal (lingual) surfaces at tooth sites and
frequently also at implant sites. Furthermore, the PPD and the TS dimensions were greater at
implant than at adjacent tooth sites.

In a clinical examination of a periodontal indicated that this was not the case (e.g., Or-
patient, a graduated probe is used to distin- ban et al. 1956; Listgarten et al. 1976; Armit-
guish between gingival health and disease age et al. 1977; Spray et al. 1978; Robinson &
but also to determine the depth of the so- Vitek 1979; Van der Velden 1979; Magnusson
called gingival pocket and/or the clinical & Listgarten 1980; Polson et al. 1980). Thus,
attachment level. it was reported that in an inflamed site, the
It was demonstrated that “bleeding upon tip of the periodontal probe consistently pene-
gentle probing” (BoP positive sites) indicated trated beyond the dento-gingival epithelium.
that the gingival unit harbored an inflamma- This resulted in an overestimation of the
tory cell infiltrate (i.e., was diseased). BoP “true” (i.e., histological) pocket depth (Armit-
negative (BoP-) sites on the other hand were age et al. 1977). At sites with healthy gingiva,
shown to signify gingival health, and “BoP- on the other hand, the soft tissue offered sub-
score” was regarded as an important indicator stantial resistance (so-called “tonus of the
of periodontal stability (Lang et al. 1990; Joss gingiva”; Beardmore 1963) to the mechanical
et al. 1994). manipulation and the probe tip failed to reach
Date: For many years, it was assumed that the tip the apical base of the epithelium. This
Accepted 22 January 2014
of the periodontal probe in a pocket depth resulted in an underestimation of the “true”
To cite this article: measurement identified the apical level of the pocket depth (e.g., Armitage et al. 1977; Mag-
Parpaiola A, Cecchinato D, Toia M, Bressan E, Speroni S,
Lindhe J. Dimensions of the healthy gingiva and peri-implant dento-gingival epithelium (Waerhaug 1952). nusson & Listgarten 1980).
mucosa.
Results from subsequent clinical examina- Different factors including patient charac-
Clin. Oral Impl. Res. 26, 2015, 657–662
doi: 10.1111/clr.12359 tions and experimental studies, however, teristics (Grossi et al. 1996) have been

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 657
Parpaiola et al " Soft tissue dimensions

identified that, in addition to inflammation, more voluminous than the gingiva of contra- instruction and professional tooth debride-
could influence the result of a probing mea- lateral teeth (e.g., Berglundh et al. 1991; Abra- ment. They were subsequently included in a
surement including (i) the shape and diame- hamsson et al. 1996, 1999; Berglundh & Lind- plaque control program and re-evaluated after
ter of the probe used, (ii) the pressure applied he 1996). This finding was supported by data 2 months of preventive measures.
on the instrument (Van der Velden & Jansen from probing depth measurements at teeth Clinical examinations:
1981), and (iii) the use of multiple examiners and implants in man (for review see Chang
Probing pocket depth (PPD) was assessed
(Grossi et al. 1996). To overcome some of the 2009). Thus, Chang et al. (1999) studied soft
by the use of a periodontal probe (PCP-15;
problems inherent in clinical probing, pres- tissue dimensions at single implants and con-
Hu-Friedy Manufacturing Co., Chicago,
sure sensitive and/or automated probes were tra-lateral teeth and found that PPD was dee-
IL) at the mesial, distal, facial,/buccal, pal-
introduced that allowed the clinician to per at implants than at teeth at facial, lingual
atal/lingual aspects of all teeth/implants
examine the gingival site with a predeter- as well as proximal surfaces (facial = 2.9 vs.
in the target regions. The PPD was mea-
mined pressure (e.g., Van der Velden & de 2.5 mm, lingual = 3.5 vs. 2.1 mm, proxi-
sured to the nearest 0.5 mm.
Vries 1978; Vitek et al. 1979; Polson et al. mal = 3.5 vs. 2.5 mm).
Sounding depth (TS) was assessed follow-
1980; Gibbs et al. 1988; Magnusson et al. “Transmucosal sounding” (TS) or “bone
ing local anesthetic administration and
1988). In studies using such devices, it was sounding” is a measure that is frequently
with the use of the PCP-15 probe at the
documented that the repeatability of the used to overcome problems related to PPD
mesial, facial, palatal/lingual, and distal
measurements in comparison with tradi- measurements and to determine the “true”
aspects of all teeth/implants in the target
tional probing was much greater (Jeffcoat dimension of the soft tissue (e.g., Tarnow
regions. The TS was measured to the
et al. 1986). The use of this kind of instru- et al. 1992; Kan et al. 2003). Such studies
nearest 0.5 mm.
ments is, however, time-consuming, cumber- indicated that the “height” of the peri-
Keratinized mucosa (KM) was assessed
some and is therefore not frequently used in implant mucosa was greater than that of the
following topical application of an iodine
clinical practice settings. gingiva, the difference at proximal surfaces
solution (Schiller0 s solution) that stained
In studies evaluating the effect of various being about 1.5 to 2 mm (Kan et al. 2003).
the glycogen in squamous cells, imparting
modalities of therapy of chronic periodontitis The aim of the present clinical study was
a dark brown color to keratinized epithe-
(e.g., surgical vs. non-surgical, flap procedures to determine whether the dimensions of the
lium. The distance between the facial soft
vs. gingivectomy), the outcome was frequently soft tissue cuff (i) are different at various
tissue margin and the muco-gingival line
related to the pretreatment PPD value. Thus, tooth surfaces and (ii) differ between teeth
was measured with the PCP-15 probe. KM
groups of sites were identified such as (i) shal- and single implants.
was measured to the nearest 0.5 mm.
low pockets (1–3 mm), (ii) medium deep pock-
ets (4–6 mm), and (iii) deep pockets (>6 mm) The clinical assessments were performed
(Morrison et al.1980; Ramfjord et al. 1987; Material and methods by 5 experienced and calibrated examiners. In
Westfelt et al. 1985; Becker et al. 1988; Kal- a calibrating session, the clinicians examined
dahl et al. 1988; for review, see Heitz-Mayfield The human review board at the University of all incisor, canine, and premolar sites in one
et al. 2002). The reason for this grouping of Padova, Italy, approved the study protocol. patient with respect to PPD and TS. It was
PPD sites was most likely related to the error The subjects were informed of the study pro- observed that 95% of PPD and 97.5% of TS
inherent in individual measurements but also cedures and provided written consent to par- measurements were within the 1-mm range.
to the fact that limited data were available ticipate in the examinations. The study was The variance between examiners with
characterizing PPD at various groups of teeth performed in accordance with the Helsinki respect to PPD and TS was 0.23 mm (PPD)
and surfaces in the healthy human dentition. Declaration. and 0.22 mm (TS), respectively, and the cor-
Glavind & L€ oe (1967) studied the accuracy and The volunteers were recruited from 5 den- responding SD 0.48 mm and 0.47 mm.
reproducibility of pocket depth measurements tal centers in Italy, 10 subjects from each cen-
at 1,335 sites (mesial, distal, facial, oral ter. For inclusion in the study, a patient must
Data analysis
surfaces) in 63 men aged 20–40 years. The be ≥25 years of age and exhibit no signs of (i)
Mean values, standard deviations, and fre-
authors reported that the mean PPD was untreated caries, (ii) loss of periodontal tissue
quencies were calculated for the various mea-
2.66 ! 0.50 mm (20–30 years = 2.56 ! 0.4 support in the incisor, canine, and premolar
surements using the subject as the statistical
mm, 30–40 years = 2.79 ! 0.59 mm) and that regions (target regions: 15. . .. 25, 35. . ..45), (iii)
unit. Differences between groups of teeth
the mean error of duplicate pocket depth mea- systemic or local disease that would compro-
(incisors, canines, premolars) and surfaces
surements was !0.10 mm. Olsson et al. mise the periodontal tissues. Furthermore,
(mesial, facial, palatal/lingual, distal) and dif-
(1993) studied the pocket depth at maxillary among the 50 volunteers included, 27 had lost
ferences between implants and teeth were
incisors and canines. They observed that PPD one tooth as a result of trauma in the maxil-
examined by analysis of variance. The Statis-
was about 0.9–1.3 mm at facial, 1.5–1.7 mm lary target region. These teeth had all been
tical Analysis System package (SAS Institute
at palatal, and 2–2.4 mm at proximal surfaces. replaced with single implants of the Astra
Inc., Cary, NC, USA) was used for all calcula-
This finding was confirmed by Chang et al. Tech Implant System! (DENTSPLY IH AB,
tions. Significant differences between various
(1999) who examined the pocket depth at teeth M€ olndal, Sweden). The implants had been
groups of sites were identified at P < 0.05.
in the maxillary front and premolar regions installed and subsequently restored according
(region 14. . .24) and reported that PPD was to the manuals of the manufacturer.
deeper at proximal (2.5 mm) than at facial Results
(2.5 mm) and lingual (2.1 mm) surfaces. Procedures
Experimental studies demonstrated that the Infection control: Following a screening exam- An initial analysis of the individual mea-
cuff of soft tissue that surrounds implants is ination, all subjects received oral hygiene surements collected revealed that PPD, TS,

658 | Clin. Oral Impl. Res. 26, 2015 / 657–662 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Parpaiola et al " Soft tissue dimensions

and KM values from contra-lateral teeth only between 2.4 ! 0.7 mm (position 15/25) (Table 2) representing various groups of teeth
were similar. Hence, measurements from and 2.0 ! 0.8 mm (position 31/41). This dif- was similar and varied only between 3.0 m
contra-lateral groups of teeth as well as ference was not statistically significant (NS) and 3.4 mm (NS). The TS value at the flat
implant sites were collapsed (e.g., 15 and (Tables 1 and 2). surfaces in the maxillary dentition varied
25, 14 and 24 etc.), and the mean values The PPD (Table 1) at facial and palatal/lin- between 2.7 ! 0.5 and 2.9 ! 0.9 mm (NS) in
from such groups used in the statistical gual surfaces (flat surfaces) in the maxillary the mandibular dentition between 2.5 ! 0.7
analysis. dentition varied between 1.7 ! 0.5 mm and and 2.9 ! 0.8 (NS). The TS at proximal sites
The mean PPD and TS (transmucosal 2.0 ! 0.5 mm (NS) and in the mandibular den- varied between 3.5 ! 0.6 and 4.0 ! 0.6 in the
sounding) values for different groups of teeth tition between 1.4 ! 0.6 and 1.9 ! 0.6 mm maxilla (NS) and between 3.4 ! 0.7 and
and surfaces (facial, palatal/lingual, mesial, (NS). The PPD at mesial and distal surfaces 3.8 ! 0.7 in the mandible (NS). Thus, TS at
distal) are presented in Tables 1 and 2, while (proximal surfaces) varied between 2.4 ! 0.5 proximal surfaces was about 0.5 to 0.8 mm
the corresponding values for implant site are and 2.9 ! 0.6 mm in the maxilla and between deeper (P < 0.05) than at corresponding flat
reported in Tables 3 and 4. 2.3 ! 0.7 and 2.7 ! 0.6 mm in the mandible surfaces.
(NS). Thus, PPD at proximal surfaces was In summary, (i) the PPD value as well as
Teeth about 0.5 to 1.0 mm deeper (P < 0.05) than at the TS value at tooth sites was significantly
The overall mean individual PPD value was corresponding flat surfaces. greater at proximal than at flat surfaces and
2.2 ! 0.4 (SD). Also the mean PPD for vari- The overall individual mean TS value was (ii) the PPD value was significantly smaller
ous groups of teeth was similar and varied 3.2 ! 0.5 mm, and the mean TS value than the corresponding TS value.

Implants
Table 1. Tooth sites 27 of the 50 subjects had one implant-sup-
Position Overall Facial Mesial Palatal/Lingual Distal ported restoration in the maxilla. There were
15/25 2.4 ! 0.7 1.9 ! 0.5 2.8 ! 0.7 2.0 ! 0.5 2.9 ! 0.6 8 implants in position 15/25, 7 in position
14/24 2.3 ! 0.8 1.8 ! 0.7 2.8 ! 0.7 1.9 ! 0.5 2.7 ! 0.8 14/24, 3 in position 13/23, 3 in position 12/
13/23 2.3 ! 0.7 1.8 ! 0.6 2.7 ! 0.5 1.9 ! 0.5 2.7 ! 0.8
12/22 2.1 ! 0.7 1.8 ! 0.6 2.6 ! 0.6 1.7 ! 0.5 2.5 ! 0.5
22, and finally, 6 implants in position 11/21.
11/21 2.1 ! 0.7 1.9 ! 0.6 2.5 ! 0.6 1.7 ! 0.5 2.4 ! 0.5 No implant restoration occurred in position
35/45 2.2 ! 0.7 1.7 ! 0.6 2.7 ! 0.5 1.9 ! 0.6 2.6 ! 0.5 13 (Tables 3 and 4).
34/44 2.2 ! 0.7 1.7 ! 0.6 2.7 ! 0.6 1.8 ! 0.5 2.6 ! 0.6
The individual mean PPD value was
33/43 2.2 ! 0.8 1.7 ! 0.6 2.6 ! 0.6 1.6 ! 0.5 2.7 ! 0.6
32/42 2.1 ! 0.8 1.6 ! 0.6 2.5 ! 0.6 1.5 ! 0.6 2.6 ! 0.6 3.4 ! 0.8 mm. The PPD (Table 3) represent-
31/41 2.0 ! 0.8 1.6 ! 0.5 2.3 ! 0.7 1.4 ! 0.6 2.5 ! 0.7 ing the flat surfaces varied between 2.5 ! 0.8
and 3.7 ! 2.1 mm and the proximal surfaces
Probing pocket depth (PPD mm) at various groups (positions) of teeth and tooth surfaces. Mean !SD
(SE). between 3.0 ! 1.7 and 4.6 ! 1.6 mm. PPD at
PPD at flat surfaces (Facial/Palatal-Lingual) was smaller than at approximal surfaces (Mesial/Distal); proximal surfaces at implants was about 0.5
P < 0.05. to 1.0 mm deeper than at flat surfaces
(P < 0.05).
The individual mean TS value was
Table 2. Tooth sites
4.4 ! 0.8 m, while the TS (Table 4) at flat
Position Overall Facial Mesial Palatal/Lingual Distal
surfaces varied between 3.3 ! 0.6 and
15/25 3.4 ! 0.8 2.9 ! 0.6 3.9 ! 0.6 2.9 ! 0.6 4.0 ! 0.6 4.4 ! 1.0 mm and at proximal surfaces
14/24 3.4 ! 0.9 2.9 ! 0.9 3.9 ! 0.7 2.9 ! 0.7 3.7 ! 0.8
13/23 3.3 ! 0.8 2.8 ! 0.7 3.6 ! 0.6 2.9 ! 0.6 3.7 ! 0.7 between 3.7 ! 0.6 and 5.4 ! 0.5 mm. At
12/22 3.2 ! 0.7 2.8 ! 0.6 3.6 ! 0.7 2.7 ! 0.5 3.5 ! 0.6 most implant sites, the TS at proximal sur-
11/21 3.1 ! 0.7 2.9 ! 0.7 3.5 ! 0.7 2.7 ! 0.6 3.5 ! 0.6 faces was about 1 mm deeper than at corre-
35/45 3.3 ! 0.8 2.7 ! 0.8 3.7 ! 0.6 2.9 ! 0.8 3.7 ! 0.6
sponding flat surfaces (P < 0.05).
34/44 3.2 ! 0.9 2.7 ! 0.8 3.8 ! 0.7 2.8 ! 0.7 3.6 ! 0.7
33/43 3.2 ! 0.9 2.7 ! 0.9 3.7 ! 0.7 2.6 ! 0.7 3.7 ! 0.7 In summary, (i) both the PPD and the TS
32/42 3.1 ! 0.9 2.6 ! 0.8 3.6 ! 0.6 2.5 ! 0.7 3.7 ! 0.7 values at implant sites were greater at proxi-
31/41 3.0 ! 0.9 2.6 ! 0.7 3.4 ! 0.7 2.5 ! 0.7 3.5 ! 0.7 mal than at flat surfaces and (ii) the PPD
Transmucosal sounding depth (TS; mm) at various groups (positions) of teeth and tooth surfaces. value at implant sites was significantly smal-
Mean ! SD (SE). ler than the corresponding TS value.
TS at flat surfaces (Facial/Patalal-Lingual) was smaller than at approximal surfaces (Mesial/Distal);
P < 0.05.
Proximal surfaces at implants and adjacent
teeth
The overall mean PPD value for proximal
Table 3. Implant sites surfaces at implant sites adjacent to teeth
Position Overall Facial Mesial Palatal Distal was 4.0 ! 1.2 mm (Table 5a). The PPD dif-
15/25 3.4 ! 1.0 2.8 ! 0.7 3.8 ! 1.0 3.1 ! 1.1 4.1 ! 0.8 fered, however, considerable between various
14/24 3.9 ! 1.4 3.1 ! 1.1 4.3 ! 1.7 3.6 ! 0.8 4.6 ! 1.6 such implant sites; from 3.0 ! 1.7 mm to
13/23 3.1 ! 1.5 3.7 ! 2.1 3.0 ! 1.7 3.0 ! 1.7 4.3 ! 1.2 5.0 ! 2.0 mm, the corresponding overall
12/22 3.2 ! 0.6 3.3 ! 0.6 3.3 ! 0.6 3.3 ! 0.6 3.3 ! 0.6
11/21 3.2 ! 1.0 3.7 ! 0.8 3.3 ! 1.0 2.5 ! 0.8 4.0 ! 0.9
mean PPD for proximal surfaces at adjacent
teeth (2.7 ! 0.8 mm) was significantly smal-
Probing pocket depth (mm) at different implant sites (positions) in the maxilla. Mean ! SD (SE).
ler than at adjacent implant sites (P < 0.05).

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 659 | Clin. Oral Impl. Res. 26, 2015 / 657–662
Parpaiola et al " Soft tissue dimensions

The overall mean TS value (Table 5b) at dimensions of the keratinized mucosa in agreement with findings by Glavind & L€ oe
proximal implant sites was 5.1 ! 0.8 mm, the front tooth regions are calculated on (1967) who reported that the overall mean
but the measurements from different sites few observations. probing depth in a group of 20- to 40-year-old
varied markedly, between 5.8 ! 1.0 mm and men was about 2.6 mm and that PPD was
The width of KM at maxillary implant
4.3 ! 2.6 mm. The corresponding overall marginally deeper in older than in younger
sites varied between 2.7 ! 2.3 mm (canine
mean TS representing adjacent tooth surfaces subjects. In the current study, it was also
position) and 5.0 ! 1.7 mm (lateral incisor).
was >1 mm smaller (P < 0.05) that at implant documented that mesial and distal surfaces
Hence, the KM value was smaller in the
sites and the site-to-site variation much had greater PPD values than corresponding
canine and premolar regions than at incisors.
less pronounced (mean = 3.8 ! 0.9 mm; flat surfaces. This finding is consistent with
max. = 4.0 mm and min. = 3.5 mm). data presented by, for example, Olsson et al.
Discussion (1993) who showed that in the maxillary inci-
Keratinized mucosa (KM) at facial aspects sor tooth region, the PPD was 0.5 to 1 mm
Tooth sites: The width of KM varied in The findings of the present study demon- greater at proximal than at facial and palatal
the maxilla between 3.4 ! 1.4 mm and strated that the probing pocket depth (PPD) surfaces.
4.8 ! 2.0 mm. KM was widest in the inci- and the transmucosal sounding depth (TS) In the present study, it was observed that
sor-canine tooth regions and about 1 mm values were greater at proximal than at flat, the PPD value at facial and proximal sites
narrower in premolar regions (P < 0.01) that is, facial / palatal (lingual) surfaces at was significantly greater (P < 0.001) at
(Table 6). Also in the mandible, KM was both tooth and implant sites. Furthermore, implants than at tooth sites (Tables 1 and 3).
wider in the region of the incisors (3.5 to both PPD and TS were deeper at implant This finding is corroborating data by Chang
3.7 mm) and narrower in the canine than at tooth sites. & Wennstr€ om (2013) who studied the soft
(3.0 mm) and premolar regions (2.6 to tissue dimensions lateral to single implant-
2.9 mm) (P < 0.01). Probing pocket depth supported restorations. They noted that the
Implant sites: It should be observed that The overall PPD values varied within narrow PPD values at facial sites were 3.0 mm
no implants were present in positions 13, limits (2.0 to 2.4 mm) between different (implants) and 1.8 mm (teeth), while at proxi-
12. Hence, the data describing the groups of teeth. This observation is in mal sites, the corresponding dimensions were
3.9 mm and 2.7 mm. A larger soft tissue vol-
Table 4. Implant sites ume and a less optimal tissue tone (fiber ori-
Position Overall Facial Mesial Palatal Distal entation) of the peri-implant mucosa
15/25 4.6 ! 1.1 3.9 ! 1.0 5.2 ! 1.1 4.1 ! 0.1 5.1 ! 0.8 (Berglundh et al. 1991) may explain why PPD
14/24 4.6 ! 1.1 3.9 ! 1.3 4.9 ! 0.7 4.4 ! 1.0 5.4 ! 0.5 is greater at implants than at teeth.
13/23 4.4 ! 1.8 3.7 ! 2.1 4.3 ! 2.3 4.3 ! 2.3 5.3 ! 1.2
12/22 3.8 ! 0.6 3.3 ! 0.6 3.7 ! 0.6 4.0 ! 0.0 4.3 ! 0.6
Transmucosal sounding
11/21 4.2 ! 1.1 3.7 ! 0.8 4.3 ! 1.0 3.5 ! 0.8 5.3 ! 1.0
By transmucosal sounding (or bone sounding),
Transmucosal sounding depth (TS mm) at different implant sites (positions) in the maxilla. Mean !SD the height of the entire soft tissue cuff around
(SE).
a tooth or an implant can be determined.

Table 5. (a) Probing pocket depth (PPD mm) at interproximal sites between teeth and adjacent implants. (b) Transmucosal sounding depth (TS mm)
at interproximal sites between teeth and adjacent implants
Tooth Implant Tooth Tooth Implant Tooth
(a)
15 d 15 m 14 d 11 d 21 m 21 d 22 m
4.0 ! 0.8 3.8 ! 1.0 2.6 ! 0.7 2.4 ! 0.6 3 3.5 ! 0.7 2.5 ! 0.6
15 m 14 d 14 m 13 d 21 d 22 m 22 d 23 m
2.8 ! 0.7 5.0 ! 2.0 4.8 ! 2.2 2.7 ! 0.8 2.4 ! 0.7 3.0 4.0 2.5 ! 0.6
14 m 13 d 13 m 12 d 22 d 23 m 23 d 24 m
2.7 ! 0.7 ND ND 2.5 ! 0.6 2.5 ! 0.7 3.0 ! 1.7 4.3 ! 1.2 2.9 ! 0.7
13 m 12 d 12 m 11 d 23 d 24 m 24 d 25 m
2.8 ! 0.7 3.0 3.5 ! 0.7 2.4 ! 0.6 2.7 ! 0.9 3.7 ! 0.6 4.0 ! 1.0 2.9 ! 0.8
12 m 11 d 11 m 21 m 24 d 25 m 25 d
2.7 ! 0.8 4.3 ! 1.0 3.5 ! 1.3 2.5 ! 0.7 2.7 ! 1.0 4.0 ! 1.2 4.3 ! 1.0
(b)
15 d 15 m 14 d 11 d 21 m 21 d 22 m
5.0 ! 0.8 5.3 ! 1.3 3.8 ! 0.9 3.4 ! 0.7 4.0 4.5 ! 0.7 3.5 ! 0.7
15 m 14 d 14 m 13 d 21 d 22 m 22 d 23 m
4.0 ! 0.8 5.3 ! 0.5 5.0 ! 0.8 3.7 ! 0.7 3.5 ! 0.7 4.0 5.0 3.5 ! 0.7
14 m 13 d 13 m 12 d 22 d 23 m 23 d 24 m
3.9 ! 0.8 ND ND 3.5 ! 0.6 3.5 ! 0.7 4.3 ! 2.3 5.3 ! 1.2 3.9 ! 0.8
13 m 12 d 12 m 11 d 23 d 24 m 24 d 25 m
3.7 ! 0.8 4.0 3.5 ! 0.7 3.4 ! 0.7 3.7 ! 0.9 4.7 ! 0.6 5.7 ! 0.6 4.0 ! 0.7
12 m 11 d 11 m 21 m 24 d 25 m 25 d
3.7 ! 0.9 5.8 ! 1.0 4.5 ! 1.3 3.5 ! 0.7 3.8 ! 1.0 5.3 ! 1.0 5.3 ! 1.0

Note that the PPD value at all sites examined was greater at implant than at tooth sites. d = distal aspect, m = mesial aspect. Mean ! SD.
The TS value was consistently greater at implant than at adjacent tooth sites. d = distal aspect, m = mesial aspect. Mean ! SD.

660 | Clin. Oral Impl. Res. 26, 2015 / 657–662 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Parpaiola et al " Soft tissue dimensions

Table 6. Width (mm) of the zone of Keratinized Mucosa (KM) at the facial aspect at different dogs (e.g., Abrahamsson et al. 1996; Bergl-
groups of teeth and implant sites. Mean ! SD
undh & Lindhe 1996). They reported that
Position Tooth sites Implant sites both the gingiva and the peri-implant mucosa
15/25 3.8 ! 1.5 2.9 ! 1.8 harbored (i) one zone of epithelial attachment
14/24 3.4 ! 1.4 3.4 ! 1.7 that in both tissues was about 2 mm long
13/23 4.4 ! 1.7 2.7 ! 2.3 (only 23)
12/22 4.8 ! 2.0 5.0 ! 1.7 but also that (ii) the zone of connective tissue
11/21 4.6 ! 1.8 4.0 ! 2.4 (only 11) attachment was longer at implants than at
35/45 2.9 ! 1.3 teeth.
34/44 2.6 ! 1.2
33/43 3.0 ! 1.3
32/42 3.7 ! 1.4 Keratinized mucosa
31/41 3.5 ! 1.3 The width of the keratinized mucosa (KM) in
the current subject sample was greater in the
front than in the premolar regions of both
The TS values calculated from the current gingiva is bordered by epithelium (sulcus and jaws. This finding is in agreement with data
measurements demonstrated that the cuff of attachment epithelium) and that the zone of presented in a study by Ainamo & Talari
healthy soft tissue that surrounded a tooth supra-alveolar connective tissue attachment (1976) who determined the width of the
varied between 2 mm at flat surfaces and is about 1 mm high. There are also reasons to attached gingiva in different age groups. It
4 mm at proximal surfaces. This observation suggest that the greater TS values recorded at was also noted that in most volunteers, KM
is in agreement with data presented by, for proximal than at flat surfaces in the current in the maxilla was wider at tooth than at
example, Gargiulo et al. (1961) and Vacek clinical study may reflect the presence of a implant sites; one exception was the lateral
et al. (1994) who in human, autopsy speci- longer sulcus epithelium at mesial and distal incisor (Table 6). Also this finding corrobo-
mens analyzed the structures of the gingiva than at facial/lingual surfaces. rates previous findings. Thus, Chang et al.
that faced the tooth surface. Gargiulo et al. From the measurements made in the cur- (1999) and Chang & Wennstr€ om (2013)
(1961) reported that at healthy sites, the (i) rent study, it was observed that the TS value, reported that the keratinized mucosa in the
sulcus depth was on the average 0.8 mm, (ii) at flat as well as at proximal surfaces, was maxilla was wider at teeth than at contra-lat-
attached epithelium about 1.4 mm, and (iii) consistently about 1–1.5 mm greater at eral implant sites (4.6 mm vs. 3.9 mm and
the connective tissue attachment 1.1 mm. implants than at teeth. This is in agreement 4.0 mm vs. 3.3 mm). As the apical border of
Similar findings were presented by Vacek with data presented by, for example, Kan the keratinized mucosa seems to be stable
et al. (1994) who also examined the dimen- et al. (2003) who studied the dimension of over time (Ainamo et al. 1992), the reduction
sions of the soft tissue cuff in human cadaver the mucosa at single implants and adjacent in its width following tooth extraction and
jaws. They stated that (i) the sulcus depth teeth in the anterior maxilla using a “bone implant placement must be related to altera-
(non-attached tissue) was on the average sounding” (in the current study, “transmuco- tions in the marginal portion of this tissue.
1.3 mm, (ii) the epithelial attachment was sal sounding”) technique. The dimension of Following tooth removal, the tissue modeling
1.1 mm long, and (iii) the connective tissue the mucosa at mesial and distal implant sites process results in loss of bone. This hard tis-
attachment about 0.8 mm. The authors also was 6.2 ! 1.3 and 5.9 ! 1.2 mm, while the sue loss is most pronounced in the facial
concluded that there were no differences corresponding values at adjacent tooth sites wall of the socket site (Pietrokovski & Mass-
between sites (buccal, lingual mesial, distal) were 4.2 ! 0.8 and 4.2 ! 0.6 mm. This indi- ler 1967; Schropp et al. 2003; Botticelli et al.
with respect to the lengths of epithelial and cates that the soft tissue cuff around 2004; Ara" ujo & Lindhe 2005; , 2013, Sanz
connective tissue attachments. Thus, based implants has a greater dimension than that et al. 2010). Based on the current and previ-
on the current TS data and findings from the at teeth. This suggestion is in agreement ous observations, it is suggested that this
histometric studies reported above, there are with findings from histometric measure- hard tissue modeling is accompanied also by
reasons to suggest that about 1–3 mm of the ments performed in biopsies sampled from loss of keratinized mucosa.

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