Depth of the Surrounding Young Permanent Teeth

BY EDWIN J. FUDER, D.D.S.* AND HOMER C. JAMISON, D.D.S., DR.P.H.,**

ANN ARBOR, MICHIGAN

N almost every phase of , the tachment was thought to mark the bottom operator must concern himself with the of the gingival sulcus which, then, could I gingival sulcus *** sometime during his not be situated at the cemento-enamel procedures. One of the important charac• junction but had to be located on the teristics of this sulcus is its depth; hence, surface of the enamel of the of the operator must become concerned and the . Other investigators11,16,17,19,20 informed about the changes which occur in agreed with Gottlieb's concept of a shallow the sulcus during life. gingival sulcus.

An investigation was undertaken with Kronfeld11 stated that neither age nor the following objectives in mind: (1) de• the location of the gingival crevice on the termine the mean depth of the gingival surface of the tooth had any effect on the sulcus of labial, lingual and approximating depth of the sulcus. Miller13 concurred with surfaces of young human permanent teeth, the preceding investigators in regard to the excluding third molars, and (2) determine depth of the sulcus that surrounds adults' whether the depth of the sulcus changes teeth. Miller, however, stated that the during adolescence. depth of the sulcus, surrounding erupting teeth and young permanent teeth usually REVIEW OF THE LITERATURE was two to three millimeters, and he re• Before 1921, it was accepted that as ported depths of up to six millimeters for soon as the tip of a tooth had broken the sulci of the labial surfaces of the max• through the into the oral cavity illary incisors. Since Miller agreed with the base of the gingival sulcus was located Gottlieb on the existence of an epithelial at the cemento-enamel junction.2,15 The attachment on enamel, he presumed, there• depth of the sulcus, therefore, could vary fore, that "the deeper sulcus in children is from many millimeters to a few milli• probably due to the lagging of active erup• meters as the tooth continued to erupt into tion behind the passive." occlusion. In clinical observations of the depth and In 1921, Gottlieb7,8 concluded that the location of the bottom of the gingival sul• epithelium of the gingival crevice was at• cus, Waerhaug22 found that the average tached to the enamel of the tooth by means depth of the sulcus was about four milli• of the primary enamel membrane. This at- meters and that the bottom of the sulcus ended at the cemento-enamel junction. In * Instructor in Dentistry, The University of Mich• a duplication of the investigation of igan, School of Dentistry, Ann Arbor, Mich. Waerhaug, Orban, et al.,18 found the bot• **Associate Professor of Dentistry, The Univer• tom of the gingival sulcus to be one milli• sity of Alabama Medical Center, Birmingham, Ala• bama. meter below the free in ***The gingival sulcus also may be known as the a histological specimen. As the blade was gingival crevice, gingival through, or subgingival inserted deeper, it progressed in epithelium space. Gingival pocket, however, in correct usage, between a layer of cells still attached to refers to a pathologic sulcus about a tooth, deeper the enamel and the remainder of the epi• than the normal sulcus. (Arey, L. B., ed. Dorland's Illustrated Medical Dictionary. 23 rd ed. Philadel• thelial attachment. Bodecker and Apple- phia, Saunders, 19 57. XVII 1598 p.) baum3 reported similar findings.

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Orban, et al.,18 criticized Waerhaug the use of a table of random numbers and sharply for stating that as soon as a tooth with proportional representation of each of erupts into the mouth, the crevice reaches the five strata.14 The fifth sample was used to the cemento-enamel junction. Orban by Jamison9 for the study of periodontal and colleagues maintained, in dogs, that disease. The population from which the even after the tooth has erupted into the sample was selected was defined as the non- oral cavity, amelogenesis continued in the institutionalized residents. In an attempt gingival areas of the crown and that the to eliminate potential problems while con• ameloblasts and enamel rods formed an or• ducting oral examinations of young chil• ganic union while the phase completed. dren, only those persons who had reached However, according to Wheeler23 human the age of five years before November 1, crowns of the permanent teeth are com• 1959, were included in the dental study. pleted three years or more before the teeth There were 810 persons in the sample, of erupt. which 690 people participated in the study and received extensive dental examinations Bodecker and Lefkowitz4 concluded that related primarily to . the epithelial attachment could not be de• fined clinically, and that the depth of the The clinical examination consisted of a crevice could be measured only to the be• number of observations. In an attempt to ginning of the attachment by connective make each observation as independent as tissue. Zander24 reported that the bottom possible from those preceding and follow• of the gingival sulcus and the most apical ing it, each assessment of the oral tissues epithelial cells were found to be at or near was completed before the next assessment the cemento-enamel junction. was begun for a given individual.

Three of the current textbooks on perio• All permanent teeth which had erupted dontology1, 5, 6 state that the gingival sul• into occlusion were included in the study. cus is shallow and usually ranges in depth If no antagonist were present, a given per• from 0.5-1.8 millimeters. Much of the lit• manent tooth was included if it had erature cited by these writers refers to erupted to what appeared to be the plane the publications of Gottlieb7 and Orban of occlusion. All other permanent teeth and Kohler.16 Beube1 and Goldman6 stated were designated as unerupted and no meas• that the gingival sulcus was deeper in urements were recorded for these teeth. young persons than during later periods In this investigation, therefore, the depths in life. of the gingival sulci were determined around the young permanent teeth of 217 Disagreement became apparent among persons who ranged in age from six years, investigators regarding both the depth of two months, to 18 years, eight months. the sulcus and the changes which occur in depth during adolescence. Further study, The measurements of the depths of the therefore, appeared important. sulci were obtained by Jamison9 by using a University of Michigan No. 0 probe. This MATERIALS AND INVESTIGATIVE METHODS probe was selected because of its thin, round, blunt nib and its versatile angula• The School of Public Health of The Uni• tion for probing the gingival crevices in versity of Michigan began planning an ex• all areas of the mouth. tensive study of health in an entire com• munity in 1956. The city of Tecumseh, The depth of the gingival sulcus of each Michigan, and the surrounding area was tooth was measured at four locations, the chosen as the site for the study. The area, distal, buccal, mesial and lingual surfaces. of about 56 square miles, was divided into The measurements of the sulci at the five geographic strata before sampling was mesial and distal surfaces of the tooth were begun. Ten samples then were selected by obtained by placing the probe into each GINGIVAL SULCUS DEPTH Page 63/459 sulcus buccal to the area of contact and questionable because it was difficult to ob• with the blade held parallel to the long tain these measurements. In all instances, axis of the tooth. The measurements ob• except maxillary second molars, the depth tained by Jamison and studied for this re• of the sulci at the mesial and distal surfaces port represent the distance in millimeters was greater than the depth at the buccal from the free margin of the gingiva to the and lingual surfaces by as much as one bottom of the sulcus. The periodontal millimeter. This difference in depth may be probes used were graduated at three, six illustrated by examining Tables 1-4; in all and eight millimeters from the end; it was instances, the measurements secured at the necessary, therefore, to estimate measure• buccal and lingual surfaces were shown ments which fall between these gradua• graphically to be less for a greater per• tions. All measurements were rounded to centage of the sample than those secured the nearest whole millimeter. In those in• at the mesial and distal surfaces. These stances in which the measurement appeared findings agree with those reported by to be half millimeters, it was decided arbi• Ramfjord,19 although the mean depth of trarily to round the half of the next lower the sulci in his study were slightly greater whole number. This procedure was adopted than those found in the present study. This knowing that the epithelial attachment was difference might have been observed be• somewhat resilient and might tend to pro• cause almost all of the individuals exam• vide measurements of the depth of the ined by Ramfjord had periodontal disease, sulcus which were in excess in the true even though similar age groups were depth. studied.

In obtaining these measurements, Waer- It also was found that the depth of the haug's assertions22 were accepted, namely, sulcus did not differ significantly between that the bottom of the clinical sulcus is the corresponding teeth of a dental arch. found at the deepest point of the epithelial To verify this conclusion, one tooth of each attachment, which is at the cemento- type, a molar, a bicuspid, a cuspid, and an enamel junction. When a cushioned sensa• incisor, was selected at random from the tion was felt as the probe stopped, it was data of the left side of the mouth and com• assumed that the epithelium was attached pared with a similar sample from the right at the cemento-enamel junction and that side. Table 5 shows that there was virtually this same junction had not been passed. If no difference between the mean depths of the probe encountered the cemento-enamel the sulci on the right and left sides. junction first (which was detected by a change in the direction of the tip of the As a step in the processing of the data, probe as it moved from enamel to cemen• a complete listing was prepared of the tum) , the exploration was continued depth of the gingival sulcus at each surface deeper, until a cushioned sensation accom• of each tooth studied. By close inspection panied the stopping of the probe. It was of these data, it appeared, as the age of assumed at this point that the base of the the person increased, that the depth of the clinical sulcus had been reached. sulcus decreased in most mouths. The ages ranged from 6 years, 2 months to 18 years,

FINDINGS 8 months.

The mean depth of the sulci ranged from To test an hypothesis about this obser• 1.12 millimeters on the buccal surface of vation, the number of people was deter• a maxillary cuspid to 2.91 millimeters on mined who had each tooth in both the the distal surface of a mandibular second maxillary and mandibular right quadrants. molar. The accuracy of the measurement Each such group then was divided about of the depth of the sulci at the distal sur• in half, taking care that a division did not faces of the maxillary second molars was occur between people whose ages were the Page 64/460 FUDER AND JAMISON

TABLE 1 A TABLE 1B same month and year, but only between very young adults (Table IB). The data different months of the same year, or be• from each of these groups were analyzed tween different years. This division yielded separately. This method often might yield two subgroups, according to age, a group subgroups of various sizes in which the of children (Table 1 A) and a group of span of ages could differ for each tooth

TABLE 2 A TABLE 2B GINGIVAL SULCUS DEPTH Page 65/461

TABLE 3 A TABLE 3 B studied, however, for the first and second sample increased. A further comparison of bicuspids identical age groups were com• Tables 2 A-4 B shows a decrease in mean pared. In a comparison of the mean depths depth in the older-age groups in every in• of the sulci listed in Tables 1 A and 1 B, it stance, frequently by almost one-half milli• became evident that the mean depth of the meter. For certain surfaces, there was a sulcus decreased as the age of the children decrease of the mean depth by about 2 5

TABLE 4 A TABLE 4 B Page 66/462 FUDER AND JAMISON percent (Tables 2 A and 2 B). Examination though without citing data to substantiate of the data verified what had appeared this conclusion. Because of the observations evident by inspection; the depth of the from the present investigation, the asser• gingival sulcus decreased during adoles• tion that a zero depth of crevice is ideal cence. may be questioned. It is difficult to accept pathological deepening in all of the gingi• DISCUSSION val sulci of 217 persons, approximately six to 18 years of age. As stated previously, the mean depth of the gingival sulci ranged from 1.12 to 2.91 It was stated earlier in this report that millimeters. In all of the measurements ob• the assertions of Waerhaug22 had been ac• tained by Jamison,9 the crevicular depth cepted and used as a guide in the interpre• recorded was found to be at least one tation of the sensations felt while probing millimeter. It will be recalled that estima• the gingival sulci. Waerhaug confirmed by tions between graduations on the probe radiograph the location of the tip of his were rounded to the nearest whole milli• probe at the cemento-enamel junction meter and that when the measurements when forces of less than five grams were appeared to be in half-millimeters, they applied. Yet, Orban and Mueller17 stated were rounded to the next lower whole that an explorer could not be pushed freely number. The statement, therefore, should to the cemento-enamel junction. It was be that the shallowest depth was more than stated later by Orban, et al.,18 that Waer- one-half millimeter. In Tables 1 A-4 B, it haug's insertion of the steel blade to the became apparent that for the mesial and cemento-enamel junction caused a break distal surfaces, most of the measurements in the epithelium and, thereby, destroyed of depth were two millimeters. Even on the part of the epithelial attachment. It is diffi• buccal and lingual surfaces, where the cult to understand, however, that forces of crevices usually were less in depth than on a few grams which Waerhaug used, could the proximal surfaces, frequently, most of separate the epithelium and the enamel to the measurements were two millimeters. which Orban and his colleagues stated it was attached firmly and organically. Kohler Orban and Kohler16 reported that more and Ramfjord10 found that a sharp-pointed than 75 percent of their measurements of probe should not be used for measuring the gingival sulci were one millimeter or the depth of the crevice and that the depth less in depth. More than four percent had of the sulcus always should be measured zero depth of crevices. Neither the type of before anesthesia is induced. When these tooth nor the surface of the tooth, were precautions were not observed, the probe stated and the type of instrument used was found to have passed the cemento- to measure the depths of the sulci was enamel junction and penetrated apically in not stated. connective tissue to the alveolar crest. Three other investigators12,19,20 stated that zero depth of crevice was ideal; al• To conclude that a very shallow gingival

TABLE 5 A Comparison in Millimeters of the Mean Depth of Sulci of Right and Left Dental Arches Distal Buccal Mesial Lingual Tooth Sample R L R L R L R L

Maxillary Central Incisor 94 2.29 2.47 1.44 1.50 2.45 2.37 1.86 1.84

Mandibular Cuspid 44 2.32 2.25 1.32 1.27 2.32 2.34 1.68 1.80

Mandibular Second Bicuspid 33 2.27 2.23 1.36 1.42 2.18 2.32 1.88 1.94

Maxillary First Molar 108 2.18 2.21 1.70 1.55 2.42 2.40 1.68 1.68 GINGIVAL SULCUS DEPTH Page 67/463 sulcus exists must depend largely upon Philadelphia, Saunders, 1958. XVII + 978 p. (p. one's assumptions regarding the epithelial 9-29) attachment. Denying or accepting the pres• 6. Goldman, H. M., and Cohen, D. W. Perio• dontia. St. Louis, Mosby, 19 57. 53 5 p. (p. 24-37) ence of an epithelial attachment is not a 7. Gottlieb, B. Der epithelansatz am zahne. part of this report. One may question, how• Deutch. Monatschr. Zahnhk., 39:142-7, Mar. 1921. ever, Gottlieb's assertion that the epithelial 8. . What is a normal pocket? Am. Dent. attachment can be bound firmly to en• A.J., 13:1747-51, Dec. 1926. amel, when based on two histological sec• 9. Jamison, H. C. Prevalence and severity of tions only.7 From these same two sections, periodontal disease in a sample of the population. one must keep in mind that Gottlieb "illus• Ann Arbor, The University of Michigan, School of Public Health, 1960. 153 p. thesis. trates" the base of the gingival crevice. 10. Kohler, C. A., and Ramfjord, S. P. Healing 17,20 The area which Gottlieb and others of gingival mucoperiosteal flaps. Oral Surg., Oral designated as the base of the sulcus was Med. and Oral Path., 13:89-103, Jan. 1960. actually the point at which the separatio11n. Kronfeld, Rudolf. The epithelial attachment of epithelium from the tooth during the and the so-called Nasmyth's membrane. Am. Dent. decalcification procedure ended, as de• A.J., 17:1889-907, Oct. 1930. scribed by Waerhaug.21 12. . Histopathology of the teeth. 3rd ed. Philadelphia, Lea and Febiger, 1949. 514 p. (p. 294-315) CONCLUSIONS 13. Miller, S. C. Textbook of periodontia. Phila• In this study of the depth of the gingival delphia, Blakiston, 1950. XVIII + 900 p. (p. 3 9-47, 619-20) sulcus surrounding young permanent teeth: 14. Napier, J. A. Field methods and response 1. The mean depth of the gingival sulci rates in the Tecumseh Community Health Study. varied from 1.12-2.91 millimeters; Am. J. Pub. Health, 52:208-16, Feb. 1962. 2. The depth of the sulci at the mesial 15. Noyes, F. B. Dental histology and embry• and distal surfaces of the teeth was greater, ology. Philadelphia, Lea and Febiger, 1921. VIII + by as much as one millimeter, than the 454 p. (p. 244) depth at the buccal and lingual surfaces; 16. Orban, B., and Kohler, J. Die physiologische 3. There were no significant differences zahnfleischtasche. Epithelansatz und epitheltiefen- wucherung. Ztschr. f. Stomat., 22:3 53-425, 1924. in depth between the sulci around corre• 17. Orban, Balint, and Mueller, Emil. The gingi• sponding teeth of the right and left sides val crevice. Am. Dent. A.J., 16:1206-42, July 1929. of the mouth; 18. Orban, Balint, et al. The epithelial attach• 4. The average depth of the sulci de• ment. J. Periodont., 27:167-80, July 1956. creases at all surfaces of the teeth during 19. Ramfjord, S. P. The periodontal status of adolescence. boys 11 to 17 years old in Bombay, India. J. Perio• dont., 32:237-48, July 1961.

BIBLIOGRAPHY 20. Skillen, W. G.; and Mueller, Emil. Epithe• lium and the physiologic pocket. Am. Dent. A.J., 1. Beube, F. E. . New York, Mac- 14:1149-64, July 1927. millan, 1953. XV + 752 p. (p. 6-12) 21. Toller, K. J. R. The gingival sulcus and the 2. Black, G. V. Special dental pathology. Chi• epithelial attachment. Brit. Dent. J., 82:2 5 5-60, cago, Medical Book Publishing, 1915. XXVIII+ June 18, 1948. 85:1-7, July 2, 1948. 489 p. (p. 22-9) 22. Waerhaug, Jens. The gingival pocket. Oslo, 3. Bodecker, C. F., and Applebaum, Edmund. Reistad and Sonns, 1952. 186 p. (Odont. Taskr., The clinical importance of the gingival crevice. vol. 60, 19 52, Supplementum 1.) Dent. Cosmos, 76:1127-42, Nov. 1934. 23. Wheeler, R. C. A textbook of dental anat• 4. Bodecker, C. F., and Lefkowitz, William. Gin• omy and physiology. 2nd ed. Philadelphia, Saunders, gival reattachment to the enamel and its relation to 1950. XIII + 428 p. (p. 32) operative dentistry. Dent. Cosmos, 77:1106-14, Nov. 24. Zander, H. A. A method for studying "the 193 5. epithelial attachment." J. Dent. Res., 3 5:308-12, 5. Glickman, Irving. Clinical periodontology. Apr. 1956.