The International Journal of Periodontics & Restorative Dentistry

155

The Dimensions of the iHuman

Dentogingivai Junction

Jomes S. Vacek, DOS' The dentogingivai junction has

Mariin E. Gher, DDS. MEd' been described as a functional
Daniel A. Assad. DDS'
unit composed oi the connec-
A. Charles Richardson, DDS'
tive tissue attachment of the
Leo i. Giambarresi, Pt¡D'
gingiva and the epifheliai
attachment.' Gargiuio et ai^
This study examined the naturally occurring dimensions of the denfoglngi- reported that the connective
vai ¡unction In 10 adult human cadaver jaws. The connective tissue tissue attachment varied in
attachment, epitheliai attachment, ioss of attachment, and sulcus depth iength from 0,0 to 6,84 mm with
were measured tiistomorphometricaliy for 171 tooth surfaces. iVIean mea- a mean of 1,07 mm; this mea-
surements were 1.34 ± 0.84 mm for sutcus depth: hl4 ±0.49 mm for epithe-
surement combined with the
liai attachment: 0.77 ± 0.32 mm for connective tissue atfachment; and
mean length ot the epitheiial
2 92 + 1 69 mm tor lass Of attachment. These dimensions, os measured in
attachment (0.97 mm) has
this study, support the concept that the connective tissue attachment is a
variabie widtf^ within a more narrow distribution and ronge than the
been called the physiologic
epitheiioi attachment, sulcus depth, or toss of attachment. The ievei ot the dentogingivai junction,^ or bio-
ioss ot attachment was not predictive ot the connecfive tissue attachment logic width.3" Aithough these
iength (IntJ Periodont Rest Dent 1994;14:155-ló5.) individuai measurements were
found fo vary greatly from
tooth to tooth, the combined
*Penodantics DeporTmenf. Navol Dental School, Nofionol mean dimension has been
Naval Dental Center, Bethesda. Mary [ond used as a guideiine for reestab-
iishing the ideai attachment
Correspondence fa: CAPT iviorlin E. Gner, DC, USN. 2014
Subida Terrace, Carlsbod. Calitornio 92009.
dimensions when performing
clinicoi crown iengthening
Reprinf requesfs to: Lbrorion, Naval Dental School, Nafionol surgery.^"" The need to con-
Noval Denfol Center, Befnesda. Maryland 20889-5077.
sider a variable supracrestal
Ttiis article is a work ot the US government and may be repiinteö with- attachment area to aliow for
out peimissioh The opinions or assertions contained tierein are the pri- the range of epitheiiai and
vate views of the authors ond ore not to be construed as official ar as
reflecting the views ot the Department of the r^Iavy or any ottier
connective tissue attachments
department or agency ot the US government has also been discussed.'^''^

Volume 14, Number 2, 1994

156
The importance of the bio-
logic width in relation to gingi-
vai health and as a guide for
placing dentai restorations has
been studied.'''-" Clinicaiiy,
Newcomb''' found that the
greatest degree of gingivai
inflammation was seen when
subgingival crown margins
were placed near the base of
the gingivai crevice, while
Richter and Ueno'^ noted no
ditferenoe in gingivai health
when crown margins were
placed subgingivally. From his-
tologie observations on dog
and human autopsy moteriai,
Waerhaug'* concluded that
pocket deepening in response
to artificial crowns did not
occur when the margin did not
come cioser than 0.4 mm to
the bottom of the pocket and
attached fibers were nof sev-
ered. Than et ai'^ found, how-
ever, that when the bioiogic
width was vioiated by dental
restorations there was a
greater mean ioss of connec-
tive tissue attachment adja-
cent ta surfaces with a dental
restoration than adjacent to
those without.
In a clinical investigation,
Tarnow et al'^ concluded that
subgingival crown margin
placement combined with
injury to the gingivai attach-
ment resulted in rapid gingival
repair in the form of recession
with limited gingivai inflamma-
tion, in a study in dogs. Tal et
al'^ faund that when amaigam
restorations were piaced at the
The Intematianal Journol of Periadontics & Restorative Dentistry
osseaus crest a bioiogic width
was reestablished at 1 year,
and that its dimension was 0,90
mm, compared to 4,47 mm on
surgically operated control
teeth without restorations. This
finding suggests that the bio-
logic width, if violated, may be
reestabiished at a minimai
a c c e p t a b i e dimension for
health. In humans the minimum
dimension ot biologic width for
the maintenance ot gingivai
health has not been estab-
iished.
The purpose of this study is
to provide additional informa-
tion on the dimensions of the
dentogingivai junction and
reiafed structures using nonde-
calcified human block sec-
fions.
Method and materials
A piiot study wos conducted to
estabiish appropriate process-
ing methods and sample size
for the study, Biock sections of
dentulous mandibles were
obtained from human cadav-
ers preserved wifh phenoi-
formaldehyde, glycerin, and
aicohol; one denfulous man-
dibie was aiso obfained from a
human fresh frozen cadaver,
Resuits of the piiot study indi-
c a t e d that tissues from fhe
fresh frozen cadavers were nof
suitable for histologie exomino-
tion, because of the destruc-
tion of the epithelial layer
resulting from the freezing
process. The preserved cadov-
er tissues yieided sections with
reodily identifiable structures
when stained histaiogically.
Measurements from these sec-
tions were used to estimate the
study sample size.
in the principal study, each
of 10 jaws, from cadavers rang-
ing in age from 54 to 78 years,
were used fa prepare seven
biock segmenfs of two or three
teeth each (Fig 1). These noh-
decalcified segments were
sectioned first in a mesiodistai
direction along the long axis
and contacts of the teeth (Fig
2), The remaining faoiai and lin-
gual portions were fhen sec-
tioned buccoiinguaily along
the iang axis of the feeth (Fig
3), All secfioning was done wifh
an EXAKT i cutting/grinding
device (Exakt) according to
the manufacturer's instructions.
The cutting/grinding device is
capabie of making 10- to 30-
pm-thick serial sections of non-
decalcified tissue approxi-
mately every 0,75 mm. The
resulting thin nondecaicified
secfions confained structures,
such as the enamel and dental
restorotions. for observation
and reference. Figures 4a to
4d. a ciinicai series, demon-
strate the sectioning of the
specimens in preparation for
histoiogic measurements.
The mesial (M), distal (D),
facial (F), and lingual (L) sur-
faces of every tooth were
each considered as individual
surfaces for measurement of
 157

Fig 1 Schematic representation of a

human mandible Dashed lines repre-
sent the approximate initial sectioning
planes. A = typical twa- to three-tooth
segment.

• Nandecalcified segment A was first sectioned in a mesiodistal direction Fig 3 The tacial and lingual partions
g the lang axis and contacts of the teeth to produce black 8. Block B ' was then (A and C from Fig 2) were sectioned
logically prepored to visualize the mesial and distal surfaces ot the teeth far buccotingually alang the lang axis of
surements. C = lingual partían that remained after sectioning. the teeth (dashed lines). Portion A ' was
histalogically prepared to visualize the
buccal and lingual surfaces.

Volume 14, Number 2,1994

 158

Fig 4a Nondecolcitied sections are prepared for histologie Fig 4b Mesial-to-distol block seotions were removed ond
anolysis: posterior mondibular blook segment is shown after used to prepare thin histologie seotiohs, Residuol buocol ond
initiol sectioning. lingual sections were then sectioned to permit meosure-
ments trom those surfaces.

fig dc Mesiol-to-distol seotions were then ground to o 10- Fig 4d Thin section stoined to enhonce identification of
to 30-ijm thickness in preparoticn for stoining. anatomic structures for meosurement.

The Internotionai Journol of Periodontics & Restorative Dentistry

 159

Fig Sa (left) Stained thin sectian per-

mits exominotion ot dental restorations,
enamel, and hard tissues in relation to
soft tissues without distortion. Nofe the
presence of calculus, which bridges
the interproximal space immediately
coronal to the gingivai soft tissues.

Fig Sb (right) Photomicragrabh of

interproximai space demonstrates
fransepfal collagen fibers, epithelial
attachment, which extends to the level
of the transepfai fibers, ond bacterial
plaque ond debris on the enamel sur-
face of the teeth coronal ta the inter-
proximaisaft tissues Vacuoles noted
within the gingivai tissues ore process-
ing artifacts.

the dentogingival junction.
Each surface yielded two to
four secfions for hisfomorpho-
metric measurement, depend-
ing on the width of the tooth
and its location within the arch.
Sections were stained with
Masson's triohrome or hema-
toxylin and eosin stain and
measured histomorphometri-
caliy by the same examiner
with a Zeiss Interactive Digital
Analysis System (ZIDAS; Zeiss)
(Figs 5a and 5b). Each fissue
section was viewed and mea-
sured through o Zeiss light
microscope (Zeiss) at x 40 mag-
nification, which was fitted with
a drawing tube. iVleosure-
ments of the foiiowing struc-
tures were recorded:
O) Suicus depth (SUL): the
distónos from the crest of the
free gingiva to the most coro-
nal extent of fhe epifheliai
attachment
(2) Epitheliai ottachment
(EA): the distonce from the
most coronal extent of fhe epi-
fheliai aftachment to the most
coronai extent of fhe connec-
five fissue attachment
(3) Connective tissue at-
tachment (CTA): the distance
from the most coronai extent of
the connective tissue attach-
ment to the most coronal ex-
tent of the periodontal liga-
ment (The coronoi extent of
fhe periodonfai iigoment was
defined os the levei at which
the PDL was first found to be of
uniform thickness when com-
pared with other areas of the
PDL on the tooth being exam-
ined.)
(4) Loss of affachment
(LOA): the distance from the
cementoenomel junction (CEJ)
to the most coronol extent of
the connective tissue attach-
ment
Also recorded were the
subject's identification number.

Volume 14, Number 2, 1994

 lóO
age, sex, tooth number, tooth
surtace (M = mesial; D = distai;
B - buccoi; L = iingual), the
type of restoration present, it
any, and the distance from the
apicai margin of the restoration
to the coronai extent af the
connective tissue attachment.
Only teeth with subgingival
restoration margins and a
microscopicaliy visibie CEJ
were inciuded in the measure-
ments for subgingival restoro-
tions. The mean dimensions ot
the dentogingivai junction for
each tooth surface were deter-
mined on 171 surtaces. Mea-
surement error wos calculated
by making 124 replicate mea-
surements on a total ot 31 ran-
domly selected sites. A period
of ot ieast 24 hours eiapsed
between repiicate measure-
ments. The two measurements
were compared to determine
the precision of the measure-
ment technique.
Every eftort was made fo
section the teeth parallel to the
long axis ot the tooth. How-
ever, due to variations in root
contours, sectioning aiong the
iong axis resuited in tangential
cuts across some isolated areas,
such as furcation entrances,
because of curvature of the
root at fhe entrance into the
furcation.2'^"^^ This precluded
accurate dimensional measure-
ments in these areas. These few
areas were excluded from the
data set.
The internotionol Journoi of Periodontics & Restorative Dentistry
The mean, standard devia-
tion, range, and frequency dis-
tribution of the measurements
of the EA, CTA, LOA, and SUL
were determined. A one-way
analysis of varionce was used
to compare measurements
between surface locations (B,
L, M, D), orch position (anterior,
posterior), and surfaces with or
without a subgingivai dentai
restoration. Scheffe's method
for muitipie comparisons was
used tor discrimination,
i?egression analysis was used to
correlate the CTA dimension to
the corresponding LOA.
Results
Medn dentogingivai dimen-
sions for ail surfaces are shown
in Tabie 1. There were no signifi-
cant differences between the
meosurements for fhe foofh
surfaces (B, L, M, or D) for SUL,
LOA, EA, or CTA (Fig 6).
Regression analysis showed
there was no significant corre-
iation between the LOA and
the CTA, EA-i-CTA (biologic
width), or SUL-^EA-hCTA.
When tissue dimensions for
the anterior and posterior teeth
were compared, both the CTA
and EA were significantiy
greater in fhe posterior sex-
tants. When moiars and premo-
iars were analyzed separately,
only fhe CTA was signiticantiy
greater in the posterior teeth
{Tabie 2), When the dimensions
of the EA and the correspond-
ing CTA for that surface were
combined (bioiogic width) the
posterior teeth showed a sig-
nificantiy greater (P < .004) bio-
logic widfh than the anterior
teeth. When moiars and pre-
moiars were analyzed sepa-
rateiy, the bioiogic width of the
moiars was significantiy greater
(P < ,02) than that of the anteri-
or teeth, whiie the bioiogic
width of the premoiars was not
significantiy different from that
of the moiars or the anterior
teeth (Tabie 3).
Tooth surfaces wifh subgin-
givai restorations were found to
have a significantly longer EA
(P < .04) than nonrestored
teeth, but no significant differ-
ences were found for the CTA,
SUL, or LOA (Tabie 4), When the
mean measurements for the
combined dimensions of the
EA and OTA (bioiogic width) for
teeth that had restorations
were compared to the bioiogic
width for teeth without restora-
tions there was a significantiy
greater (P < .02) bioiogic width
in restored teeth. There was no
significant difference in any of
fhese dimensions when com-
paring fypes of restoration.
Analysis of the precision of
repiicate measurements dem-
onstrated 95% confidence
intervais of ± 0,08 mm for the
OTA, ± 0.12 mm for the ËA and
LOA, and ± 0.14 mm for the sui-
cus depth.
 loi

Table 1 Dentogingivai dimensions (mm) for the epithelial attactiment

(EA), connective tissue attachment (CTA). loss ot attachment (LOA), ond
sulcus depth (SUL) tar all surfaces

Measurement
(mean ± SD) Range

EA 1 Id ±0,49 0,32 - 3.27

CTA 0,77 ± 0,29 0.29-1.84
LOA 2,95 ± 1.70 0.60-8,73
SUL 1 32 - 0,BO 0,20 - 6,03

Fia 6 Graph disploys mean fissue dimensions for the epitheliol ottachment (EA).
connective tissue attochment (CTA). loss of ottachment (LOA), and sulcus depth
(SUL). for distal (0). mesiol (MX llnguaift),and buccal (B) surfaces.

Volume 14, Number 2. 1994

162

Table 2 Tissue d i m e n s i o n (mm) for the epittielial a t t a c t i m e n t (EA), c o n -

nective tissue a t t a c h m e n t (CTA). loss of ottachiment (LOA), a n d sulous
d e p t t i (SUL) for teeth g r o u p e d by arcti position

Meo sûrement
(meon ± SD) Range

EA
Anterior 1.03 + 0 45 0.38-2.4B
Premolar 1.20 ± 0.53 0.32 - 3.27
Moiar 1.22 ± 0.46 0.44 - 2 30
CTA
Anterior 0.71 ±0.24" 0.35 - 1.34
Premolar 0.77 ±0.31 0.29 - 1.84
Mclor 0.89 ±0.31" 0.40-1.77
LOA
Anterior 3.33 ± 1.99 0.76-8.73
Pfemolor 2.73 ± 1.37 0.S7-6.58
Molor 2.76 ± 1.65 0 60-6.50
SUL
Anterior 1.19 ±0.89 G.d3 - 6.03
Premolar 1.30±0.6S 0 26-3.24
Moiar 1.54 + 0.60 0.56-4.04

Table 3 Biologic width (epithelial o t t a o h m e n t plus c o n n e c t i v e tissue

a t t a c h m e n t ) ( m m ) tor teeth g r o u p e d b y a r c h position

Arch Meo sûrement

positron Cm eon ± SD) Range

Anterior 1.75 t 0 56' 0.75-3.29

Premolar 1.97-0 67 0.78-4.33
Molar 2.08 ± 0.55- 0.84 - 3.29

'P<.02.

The International Journal of Periodontics & iiestorative Dentistry

 1Ó3

Tabie 4 Tissue dimensions (mm) for surfaces witti subgingival restora- study. As tound in fhis study, the
tions (restored) and without subgingival restorations (nonrestored) for ttie connective tissue attachment
epittieiial attoctin-ient (EA), connective tissue attachment (CTA), loss ot
attachment (LOA), and suicus deptti (SUL) (CTA) voried in width, but with
a more narrow range ond vari-
Measurement
ance than that for the EA, SUL,
(mean ± SD) Ronge
or LOA. The hisforioal concept
of allowing 1 mm for the CTA
EA would adequotely include the
Restored 1.32 ±0.47' 0.69 - 2.29 CTA dimensions reported here.
Nonrestored 1.11 ±0.49* 0.32-3.27 When the measurements
CTA
for surfaces with subgingival
Restored 0.84 ±0.20 0.42 - 1.47
restorations were compored to
Nonrestored 0.76 ±0.29 0.29-1.84
the dimensions for surfooes
LOA
without restorations, there was
Restored 2 60 ± 1.53 0.60-8.73
a significantly longer EA tor the
Nonrestored 3.01 ±1.73 0 74-8.73
restored teeth thon for the non-
SUL
restored teeth. No signiticont
Restored 1.ÓO + 0 80 0 64 - 4.04
Nan restored 1.27 Í 0 79 0 26 - 6 03
ditterenoe was tound tor the
other dimensions. These results
•P< .04.
Restored (n = 37); norirestored (n = 1<14).
are not in agreement with stud-
ies by Than et oi^' or
KeszthelyF'' that have shown a
greoter loss of attachment
odjocent to restored surfoces:
Discussion ies that use decalcitied and his- however, both ot these studies
toiogicolly prepared tissue. used extrocted teeth without
Nondecalcified secfions were Because human cadaver ottached odjacent structures.
used in this study to minimize material was used in this study, In this sample population
the error introduced by the the duration ot inflommafion no correlation was found be-
dimensionol changes inherent present ot the time of tissue tween the LOA and the corre-
in decoiciticotion ond tissue preparotion couid not be sponding length of fhe CTA or
preparation. The preservation determined, and previous peri- biologic width. This finding sug-
of fissue with stondard histo- odontoi therapy on the sampie gests that ciinicol determina-
iogic methods has been shown population was not known. tion of the LOA wouid not be
to cause a measurabie change Within this somple popuiation usetui in predicting the length
(15% total shrinkage) in the there was a wide ronge ot ioss of the CTA (or concomitant
dimension of the soft tissue; of attochment. The sampie biologic width). Therefore the
therefore, the dimensions of fhe population in the present study clinician couid not use the
suicus would need fo be adjust- may represent a group of attachment levei as a guide-
ed for fhis factor.^'i jhg cieooici- patients that had a iow suscep- line to determine the necessory
fication ot the hard tissue also tibility to the development ot requirements for the reestab-
causes a dimensional change periodontoi diseose,^* beoouse iishment ot the EA ond CTA.
in the tissue.^^ These tactors oniy subjects with few missing The meon dimension of the
must be considered in aii stud- feefh were inciuded in the OTA plus EA (biologic width)

Volume 14, Number 2,1994

 164
was 0,33 mm greater on molar
teeth thon onterior teeth,
Aithough clinicaiiy smoli, this
result suggests that on molar
teeth a greater iength of bio-
logic width may have to be
allowed when attempting to
reestabiish naturaily occurring
dimensions of the dentogingi-
va[ junction. The range of bio-
logic widfh fhaf was observed
wos 0,75 mm fo 4.33 mm. The
ideal dimensions to use in a
particular clinical situation can-
not be determined by examin-
ing the results of this study.
The concept of a bioiogic
width, as currently accepted
(0.97 mm for the EA, and 1.07
mm for fhe CTA), requires a
minimum of 2,04 mm of sound
footh structure above the
osseous crest.^"^''° in the pre-
sent study, 15% of fhe restora-
tions vioiated these dimensions,
in these sompies the combined
measurement of fhe EA and
the CTA wos less than 2.04 mm,
and the restoration margin was
i ess than 2 mm from fhe
osseous crest. These findings
suggest that o minimum dimen-
sion for fhe reestablishment of
the biologic width may be less
than previously reported.^•^•'•'°
This couid be important when
restoring teeth thot hove un-
dergone root resective proce-
dures that create tooth onato-
my which does not allow for
the estoblishment of accept-
obie dimensions of bioiogic
width. For exampie, a recent
article concluded that the bio-
The Internatianal Journal af Periodontics & Restorative Dentistry
iogic width, as currentiy per- Aoknowledgments
ceived, is violated in 8ó% of dis-
tobuccai root resected maxil- The authors would like to thank ttie
Uniformed Services University of fhe
iory first molars.^^ Further
Health Services for its help in providing
research is required to clearly the specimens and Eskinder Dag-
establish the minimum dimen- nachew for his valuable ossistonce in
sions of the dentogingival junc- the preparation ond sectioning of fhe
teeth. We also thank the paftiology
tion compatibie with heolth in deparfment at the Navol Dental
humans. School, National Naval Dental Cerifer,
Bethesda, Maryland for their assistance
and valuable comments This proiect
wos funded by Naval Medical
Conclusion Researcn and Development Center.
Work Unit # 63706N M0095-06-3014
Within the limitations of this
study and the use of individuai
teeth as the experimental units
the foiiowing conclusions ore
presenfed:
(1) When comporing fhe
dentogingival tissue dimensions
befween tooth surfaces (B, L,
M, D), fhere were no significant
differences for any ot the tissue
dimensions.
(2) No correlation was
found between the LOA and
the corresponding length of
the CTA or bioiogic widfh
(CTA+EA).
(3) While significant varia-
tion was noted in the length of
the CTA, it was the least vari-
able ot the tissue dimensions
evaluated.
(4) The epithelial attooh-
ment wos signiticantly greater
on tooth surfoces odjocenf to
subgingival restorations.
(5) Both the CTA and EA
were significantly greater in the
posterior sextants.

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