Attached gingiva and procedures for gingival augmentation

Attached gingiva and
Procedures for gingival Augmentation
Copyright ©2021 Periowiki.com

Contents:
 Introduction
 Definition
 Clinical significance of attached gingiva
 Characteristics features of attached gingiva
(i) Width of attached gingiva
(ii) Gingival biotype
 Methods to measure attached gingiva
 When to consider increasing the width of attached gingiva

 Procedures to increase the width of attached gingiva
 Healing following gingival augmentation procedures
 Conclusion
 References

Introduction
1) The periodontium consists of 4 principal components :
- Gingiva - Cementum
- Periodontal ligament - Alveolar bone
2) Based on the functional criteria, the oral mucosa may be divided into
3 major types:
Masticatory mucosa Lining mucosa Specialized mucosa
( gingiva , hard palate)

Gingiva is divided anatomically into:
-Marginal
- Attached
- Interdental
The specific structure of different gingiva reflects its effectiveness as a
barrier to the penetration by microbes and noxious agents into deeper
tissue

Definition
Walter B. Hall (1984) – defined attached gingiva as
“ that gingiva extending from free margin of the gingiva
to mucogingival line minus the pocket or sulcus depth
measured with a thin probe in the absence of inflammation”

Clinical significance of attached gingiva
The structure of the gingival tissues is the basis for the
healthy gingival function.
The presence of thick keratinized gingival covering
serves as an effective barrier that resists damage from the
physical forces of mastication & thermal and chemical
stimuli.
 The integrity of the gingival connective tissue also
seems to counteract the forces applied to the gingiva by
the muscles of mastication and facial expression and
also frenal pull.

 Width
1. It is the distance between the muco-
gingival junction & the projection on the
external surface of the bottom of the
gingival sulcus or the periodontal pocket

Methods to measure the width of attached gingiva
Measurement
method
Histochemical
method
Tension test
Roll method

Measurement method
Clinical method Radiographic method
-MGJ was revealed with Schiller's iodine solution
& marked over each tooth with a piece of metal
wire before taking a panoramic radiograph.
- Width of RAG is measured from the
radiographs as the midfacial distance from the
cementoenamel junction to the mucogingival
junction
(Talari & Ainamo J 1976)

Histochemical method
Step 1 : Paint the gingiva & oral mucosa with
Schiller’s or Lugol’s solution
Step 2 : The alveolar mucosa takes on a brown
colour owing to its glycogen content, while
the glycogen free, attached gingiva remains
unstained
Step 3: Measure the total width of the unstained
gingiva and substract the sulcus/pocket
depth from it to determine width of attached
gingiva

Tension test
Step 1: Stretch the lip or cheek to demarcate the
mucogingival line
Step 2: See for any movement of the free gingival
margin
Step 3: If the free gingival margin moves during
stretching of lips then the attached gingiva
is considered to be inadequate

Roll method
It is done by pushing the adjacent mucosa
coronally with a dull instrument
If the gingiva moves with the instrument
then the width of the attached gingiva is
considered inadequate

Deciduous
&
Permanent
dentition
2. The width of attached gingiva in specific areas

The width of attached gingiva in specific areas

transition from
primary to
permanent
dentition
Supra-eruption of
teeth
Buccolingual
positioning of
teeth in the arch
Frenal attachment
Age
3. Width of attached gingiva is influenced by

Longitudinal and cross-sectional epidemiologic
studies have demonstrated that during the transition
from the primary to the permanent dentition, a decrease
in the width of the band of attached gingiva takes place
(Birnstein and Eidelman 1983; Tenenbaum and Tenenbaum 1986;
Bimstein et al. 1986)
After this initial decrease, with tooth eruption, a gradual
increase takes place leading to a band of attached
gingiva which is wider in adults than in the primary
Dentition
(Bowers 1963; Rose and App 1973; Vincent et al. 1976)
Transition from deciduous
to permanent dentition
Width of attached gingiva:

(Ainamo and Talari 1976)
There is a general increase in the width of attached gingiva from the primary to
permanent dentition as well as with increasing age

Ainamo & Talari et al 1976, 1978 :
The width of attached gingiva increases with age and in supraerupted teeth.

Methods to measure the thickness of attached gingiva
1. Conventional histology on cadaver jaws
2. Modified caliper
3. Transgingival probing
4. Histologic sections
5. Radiographs
6. Probe transparency
7. Ultrasonic devices
8. Cone Beam Computed Tomography

 Thickness
Thin
Mixed thick- thin
Thick

Comparison of Tissue Response to Inflammation, Crown Lengthening and
tooth extraction

Factors for prevalence of varying gingival biotype
Gender
Age
Tooth form

Role of attached gingiva in :
1. Periodontics:
Adequacy of
attached
gingiva various
concepts
Correlation
between attached
gingiva & gingival
recession

Adequacy of attached gingiva : various concepts
- Adequate zone of gingiva considered - Corn 1962 claimed that
critical for maintainance of the marginal apicocoronal height of keratinized
tissue health & for prevention of continuous tissue ought to exceed 3mm.
loss of connective tissue attachment
(Nabers 1954; Oschsenbein 1960; Friedman &
Levine 1964; Hall 1981; Matter 1982)
- Wennstrom, Lindhe & Nyman in early 1980s - Bowers 1963 suggested that less than
contradicted the previously believed concepts 1mm of gingiva may be sufficient
of minimum width of attached gingiva
- Friedman 1962; De Trey & Bernimoulin 1980 stated that an adequate amount of
gingiva is any dimension of gingiva which (1) is compatible with gingival health or
(2) prevents retraction of the gingival margin during movements of the alveolar
mucosa

(1972)
(1977)
(1983)
(1987)
(1999)

Correlation between attached gingiva & gingival
recession
.
Stoner and Masdyasna (1981) found no
association between calculus and gingival
recession but found that it was closely
related to the width of keratinized
gingiva.

Dorfman et al in 1982 - In a 4 yr follow up study of pts with bilateral gingival
recession with inadequate width of attached gingiva – No further recession in
areas with inadequate width of attached gingiva
Concluded that, recession sites with lack of attached gingiva will not develop
further attachment loss & recession , if the inflammation is controlled.
2) In a controlled animal study Gould et al in 1992, evaluated whether a gingival graft
to augment the attached gingiva would prevent development of gingival recession
Concluded that recession continued to develop to a similar degree as in a non
grafted sites & augmenting the width of AG does not prevent or retard the
marginal recession.

gingival width.
But the evidence from the prospective
longitudinal studies show that the attached
gingival width is not a critical factor for the
prevention of marginal tissue recession, but
that the development of a recession will
result in loss of gingival width.
Thus it can be concluded that,
-the evidence from the prospective longitudinal
studies show that the attached gingival width is not
a critical factor for the prevention of marginal tissue
recession, but that the development of a recession
will result in loss of gingival width
But the evidence from the prospective longitudinal studies
show that the attached gingival width is not a critical factor
for the prevention of marginal tissue recession, but that the
development of a recession will result in loss of attached
gingiva.

2. Restorative dentistry
Minimal width of attached gingiva for maintenance of periodontal
health and unaltered attachment levels, especially when
submarginal restorations are taken into account, is one of these
principles, which remains, up to date, an object of discussion
among researchers.
The degree and extent of the marginal inflammation is
influenced by four factors: failure to maintain proper
emergence profile, inability to adequately finish and/or close
subgingival margins, placement of subgingival margins in an
area with minimum to no attached gingiva, and violation of
the biologic width (Reeves WJ 1991)

AUTHORS CONCLUSION
Lang NP, Loe H 1972 :
Piniprato G 1995 : Günay
H 2000
In cases where prosthetic crowns are positioned close to
or below the free gingival margin,2 mm of attached
gingiva is necessary. This would avoid a persistent
inflammation and gingival recession due to recolonization
of dental plaque in disadapted areas, always present in
this type of restoration
Stetler KJ, Bissada et al
1987
(i) Subgingival restoration at teeth with narrow zone of AG
have higher GI than teeth with wide zone of AG (ii) No
such significant difference in GI was found in teeth with
no subgingival restoration

AUTHORS CONCLUSION
Ericsson I & Lindhe J (1984) In their study in 3 beagle dogs induced with
experimental periodontitis and then performed either
apically positioned flap or gingivectomy procedure
suggested that, the inflammatory reation due to plaque
retention at sites with subgingival margins is most likely
manifested as recession in sites with “inadequate”
volume of keratinized gingiva
Goldberg PV, Higginbottom
FL, Wilson Jr TJ (2001)
Concluded in his review article that in areas of
subgingival margins, especially in aesthetic areas you
require a minimum volume of AG. He also added that,
the width of AG is significant when the patient reports
an inability to brush at that site

In conclusion, the volume of gingival connective
tissue has greater significance than width in
determining the susceptibility to recession. The
presence of an adequate volume is even more crucial
in sites where restorations have subgingivally placed
margins

3. Orthodontic dentistry
A sufficient amount of keratinized gingiva is more
valuable for the gingival health and to allow the
orthodontic appliances, whether removable or
fixed, to achieve the corrective treatment without
any harmful effect on the periodontal hard and/or
soft tissues (Wennstrom J, Lindhe J, Nyman S)
Maynard and Ochsenbein (1975) suggested gingival grafting
for sites with less than 2mm of attached gingiva before
orthodontic treatment to prevent recession

A Dannan 2008
Orthodontic tooth alignment and leveling do not lead to
significant changes in the width of keratinized gingiva when
adequate plaque control is maintained
Wennstrom JL, Lindhe J, Sinclair F, Thilander B 1987
Studies by have shown that a narrow band of gingiva is capable of
withstanding the stress caused by orthodontic forces
Dorfman HS 1978 ; Coatoam GW, Behrents RG, Bissada NF 1981
Results from an experimental study, indicate that as long as the
tooth is moved within the envelope of the alveolar process, the risk
of harmful side-effects on the marginal soft tissue is minimal. Thin,
delicate tissue is far more prone to exhibit recession during
orthodontic treatment than in normal or thick tissue

We can see that in the fields of restorative
dentistry and orthodontics the presence of
attached gingiva may be significant to some
extent. If so, the next question that arises is
‘‘How much is adequate?’’—the truth of the
matter is that it is not the width but volume
that is critical.

4. Dental implants
The need for attached gingiva around an endosseous
implant is a controversial topic.
Longitudinal clinical studies have failed to reveal major
differences in the progression of recession around
implants in sites with or without keratinized mucosa.
(Wennström et al., Mericske-Stern et al., Adell et al.,
Lekholm et al., Schou et al.)
However, it was reported that the absence of adequate
zone of attached gingiva, was associated with high plaque
accumulation & gingival inflammation

The presence of adequate zone of attached gingiva
Makes the plaque control more effective
Dissipates muscular & frenal pull &
Prevents further gingival recession
The implant –mucosa interface differs from the
interface b/n natural teeth & mucosa- Important in
susceptibility of implants to infections.
The supracrestal fibers oriented parallel rather than
perpendicular configuration- Creates weaker
mechanical attachment compared to natural teeth
Thus, a necessity of a zone of keratinized tissue adjacent to dental implants
has been suggested (Warrer K et al 1995 )

(1986)
(1994)
(1995)
(2006)

(2006)
(2008)
(2009)
(2009)

Bouri et al in 2008- Cross sectional study was performed to
determine an association b/n width of keratinized mucosa
& health of implant supporting tissue
Implant with a narrow zone of keratinized tissue, had
significantly more plaque and signs of inflammation with
higher mean alveolar bone loss than those with wider zone
of keratinized tissue.
There is a significant influence of width of keratinized mucosa on
health of the peri-implant tissues. The absence of adequate
keratinized mucosa around implants supporting overdentures
was associated with higher plaque accumulation, gingival
inflammation, bleeding on probing, and mucosal recession. (Mehdi
Adibrad et al 2009)

An adequate band of keratinized mucosa promotes greater stability of peri-
implant tissues (Paiva RBM, Mendonça JAG, Zenóbio EG. Peri-implant
tissues health and its association to the gingival phenotype. Dental Press
Implantol. 2012 Oct-Dec;6(4):104-13.
Though implant survival rate is not merely dependent
on the width of keratinized tissues, in areas of esthetic concern
and difficulties in plaque control the presence or augmentation
of keratinized tissue around implants would
be desirable for routine oral hygiene maintenance without
causing discomfort

When to consider increasing attached gingiva…
Mucogingival surgical procedures should be strongly considered when the
patient’s plaque control is compromised.
For teeth with little or no attached gingiva that require prosthetic
restorations or orthodontic treatment or have an abnormal frenal
attachment, the zone of the attached gingiva must be increased.
Gingival augmentation may be considered when facial tooth movement in
the presence of thin keratinized gingiva may result in establishment of
bone dehiscences with resultant marginal tissue recession (Steiner et al
1981, Faushee et al 1985, Maynard 1987, Wenstrom et al 1987).

When to consider increasing attached gingiva…
Sato (2000)
Attached gingiva also needs additional width when the pocket depth extends beyond the alveolar mucosa.

Procedures for increasing the width of attached gingiva
Vestibular/ Gingival
extention procedures
Grafting procedures
1) Denudation technique
2) Split flap (periosteal retention)
3) Apically repositioned flap procedure
4) Modified Apically repositioned flap
5) Double flap
5) Vestibular fold extention
(i) Periosteal fenestration
(ii) Edlan Meicher technique
(iii) Subperiosteal Vestibule extention
(iv) Modified Edlan Meicher technique
Pedicle grafts Free grafts
1) Laterally positioned
2) Buccally positioned
3) Double papilla
4) Multiple interdental
papilla
5) Edentulous- area
pedicle
1) Free gingival
2) Connective tissue
3) Dermic allograft

Push back
technique
(Robinson and Fox
1953)
Pouch technique
(Schulger)
1) Full thickness flap was raised, the
gingiva was relocated apically, and
bone left denuded. Peridontal
dressing then was packed to protect
the wound.
2) Only in anterior area.
1) Instead of relocating the gingival margin
of the flap apically, dressing was packed
between the bone and the flap.
2) Modification of push back technique to
perform in the posterior area.

Goldman and Stewart
Staflileno and Orban showed this flap
operation heals better than the bone
denudation procedure.
Carranza, Glickman, and Donfefdnian pointed out that the mucogingival level is
initially relocated apically but then will move coronally in the case of periosteal
retention.
However, in the case of bone denudation, the scar tissue occur at the most apical
area and prevent the coronal movement of the new mucogingival level.

DISADVANTAGES for denudation and split flap technique
1) Severe bone resorption (Wilderman et al 1961; Costich &
Ramfjord 1968).
2) Recession of the marginal gingiva in the surgical area often
exceeding the gain of gingiva obtained in the apical portion of
the wound (Carranza and Carraro 1963; Carraro et al 1964).
3) Severe post operative pain

Apically repositioned flap procedure – Friedman 1962
DISADVANTAGES
1) Extensive bone resorption.
2) Presurgical width was most often retained or became only
slightly increased (Donnenfeld et al 1964; Carranza and Carraro
1970).

Modified Apically Repositioned flap – Carnio and Miller (1999)
-Involves a single horizontal incision. It is easy to execute, simple and
requires less chair time for the patient and the operator.
-The horizontal incision is made parallel to the MGJ so that 0.5 mm
gingiva remained coronal to the flap.
- Its extension allows the repositioning of the flap apically without the
use of vertical releasing incisions.

Modified Apically Repositioned flap – Features
- Easy to execute, gives predictable results and causes less discomfort
to the patient due to lack of donor site.
-From the esthetic point of view, the advantage of MARF is that it
prevents gingival recession that is seen in APF.
-The bevel created in the horizontal incision by having its end at the
point just apical to alveolar crest protects the bone crest from being
resorbed.
- A predictable gingival colour match with surrounding tissue (Karring
et al 1975).

Vestibular Fold extention procedure
(Periosteal fenestration) - Robinson

Periosteal Fenestration
Ito splint placed Periodontal dressing
1 week postoperatively 6 months postoperatively

Edlan & Mejchar technique

3 weeks postoperative view
Edlan-Mejchar Vestibular Deeping in a Failing Implant Case
Shabeer Mohamed Madani, Biju Thomas
International Journal of Oral Implantology and Clinical Research, September-December
2013;4(3):108-111

Laterally positioned flap technique
Recession + High frenal attachment Frenum released + Split flap disected
Mobilised flap placed on recipient site Broad band of keratinized tissue 1 year post treatment

Laterally positioned flap technique- Features
-Adequate donor gingiva required.
- Vestibule should be deep enough for flap
adaptation and stabilization.

Double papilla flap – Cohen and Ross (1968)
Horizontal incision Partial thickness flap Suturing
1 week post - operative 6 months post - operative

Double papilla flap
-When sufficient width and length of the interdental papilla
on both sides of the area of gingival recession are present.
- Provides dual blood supply.

Buccally positioned pedicle flap
Severe gingival recession with significant interdental spaces,
insufficient keratinized tissue, and high insertion of the buccal frenum

Partial-thickness pedicle flap prepared on the
palatal aspect
Final rotated pedicle flap after adaptation and
suturing
Palatal site 1 week after surgery At the 1-year follow-up. Note the sufficient and
stable keratinized tissue without a pale appearance.

-The main advantages of this procedure are that the pedicle flap
taken from the palatal area provides for a large amount of donor
mucosa with a blood supply, flap tissue which closely matches the
color of the surrounding tissue, and the potential to treat multiple
teeth.
-The exposed palatal wounds heal via secondary intention with
minimal postoperative discomfort, and the buccally positioned
pedicle palatal flap also heal well.
- However, the procedure is time-consuming, and only useful in the
maxillary area with adequate interdental spaces.

Free Gingival Graft (FGG) - Bjorn (1963) ; King and Pennel (1964)

Free connective tissue graft - Edel A (1974)

Dermic Allograft
Silverstein LH, Gornstein RA, Callan DP, Singh B (1999) Periodontal insights March 1999
Slight recession due to inadequate zone of
keratinized gingiva around `mandibular
right canine and around left premolar and
canine
Slight recession due to inadequate zone of
keratinized gingiva around left premolar
and canine

Dermic Allograft
Split thickness recipient bed Dermic allograft sutured 10 days after surgery
10 days after surgery
Palatal graft sutured
Split thickness recipient bed

Dermic Allograft
3 months after surgery
Palatal donor tissue

Advantages Limitations
-More shrinkage 1 year after
surgery.
- Thinner layer of epithelium
as compared to autogenous
graft.
Dermic Allograft
Wei PC, Laurell L, Geivelis M, Lingen
MW, Maddalozzo D (2000)
Vieiro EO et al (2009)

Bridge flap technique – Marggraf (1985) & modified by Romanos (1983)
This procedure deepens the vestibule with fenestration technique to increase the
width of attached gingiva.
Split thickness flap (Bridge flap)
Pre-operative
Coronally repositioned flap and sutured Post-operative

Bridge flap technique – features
-Combination of two surgical modalities can be successful for the
management of multiple teeth recessions.
-Clinical results 3-11 months postoperatively are favourable with
no recurrence.
- However, when a significant loss of the periodontal attachment
apparatus and osseous structure occurs, the long-term prognosis
becomes poor.

Healing following gingival augmentation procedures
Results of vestibular extention procedures depend on the degree to
which the various tissues contribute to the formation of granulation
tissue in the wound area (Karring et al 1975).
Due to the difference in the degree of bone resorption, a larger area of
the coronal portion of the wound is filled with granulation tissue from
the PDL following denudation than following the split flap technique.
Since granulation tissue from the PDL possesses the ability to induce
keratinized epithelium, ‘denudation ‘usually results in a wider zone of
keratinized tissue than is the case following the ‘ split flap ‘ technique.

Healing following gingival augmentation procedures
“For free soft tissue grafts as studied by Oliver et al (1968) and Nobuto et al (1988)”
The initial phase
( from 0-3 days)
Thin layer of exudate
between the graft and
the recipient bed.
Plasmatic circulation
Revascularization
phase (from 2-11
days)
Capillary proliferation
resulting in dense
network of blood
vessels in the graft.
Fibrous union
between the graft and
the underlying
connective tissue bed.
Tissue maturation
phase (from 11-42
days)
No. of blood
vessels becomes
gradually reduced
Epithelium
gradually matures
with the formation
of keratin layer

1. Partial thickness, Apically positioned flap surgery
2. Pedicle gingival grafts (full or partial thickness)
• Laterally positioned flap
• Buccally positioned flap
• Double papilla flap
• Multiple interdental papilla grafts
• Edentulous- area pedicle grafts
3. Free autogenous gingival grafts
4. Connective tissue grafts
• Free connective grafts
• Subepithelial connective tissue grafts

5. Bridge flap technique
6. Dermic allograft
7. Fenestration operation
• Conventional
• Modified
8. Push back technique
9. Vestibular fold extension

. Fiorellini JP, Kim DM, Ishikawa SO. The gingiva. In: Newman MG, Takei
HH, Klokkevold PR, Carranza FA. Carranza’s Clinical periodontology 10th edn.
Saunders Elsevier; 2007.Pg 46.
. Wennstrom JL, Zucchelli G, Giovan P, Prato P. Mucogingival surgery –
periodontal plastic surgery. In: Lang NP, Lindhe J. Clinical periodontology &
implant dentistry 5th edn. Wiley Blackwell; 2008. Pg 955.
. Attached gingiva: Histology and surgical augmentation
Se-Lim General Dentistry July/August 2009
References:

. Fundamentals of periodontics 2nd edition Wilson TG, Kornman KS
. Color atlas of dental medicine periodontology
Vol 1 2nd edition (1989)
Klaus H & Ratiet Schak
Herbert F Wolf
Thomas M Hassell
. Hall WB. Establishing the adequacy of attached gingiva. In: Critical decisions in
Periodontology , 4th edition , Volume 1.
. Mehta P, Peng LL. The width of the attached gingiva – Much ado about nothing?
Journal of Dentistry 2010; 38: 517-525.

. Oh SL. Attached gingiva: Histology and surgical augmentation
General Dentistry 2009 July/August.
. Esfahrood R, Kadkhodazadeh M, DDS,Talebi Ardakani MR. Gingival
biotype: a review
General Dentistry 2013 July.
. Bhat V, Shetty S.Prevalence of different gingival biotypes in individuals
with varying forms of maxillary central incisors: A survey. Journal of Dental
Implants
2013 July/Dec: 3(2).
. Kao RT, Pasquinelli K. Thick Vs Thin gingival tissue: A key determinant in
tissue response to disease and restorative treatment. CDA Journal 2002
July; 30(7).

. Gingival tissue augmentation in conjuc-tion with regenerative periodontal
procedures
Christina Popova, Velitchka Dosseva
Journal of IMAB- annual proceeding (scientific papers) 2007, vol. 13, book 2.
. Similarities between an acellular dermal allograft and a palatal graft, for tissue
augmentation: Clinical report.
Silverstein LH, Gornstein RA, Callan DP, Singh B.
. Increasing the keratinized gingiva of the teeth with a buccally positioned pedicle
flap from the palatal mucosa ── case report.
Pei-Lien Lee, Lih-Sheng Chen.
J Dent Sci 2006‧Vol 1‧No 1. 37-43.

. Pushpendra Kumar Verma, Ruchi Srivastava, T. P. Chaturvedi,
Krishna Kumar Gupta. Root coverage with bridge flap. Journal of
Indian Society of Periodontology - Vol 17, Issue 1, Jan-Feb 2013.
.Dnyaneshwari Gujar, Rahul Kathariya. Modified apically repositioned
flap: A novel technique for increasing the width of attached gingiva: A
case series. Journal of Dental & Oro-facial Research Vol 10 Issue 1 Jan-
Jun 2014.
. Kumar PM, Reddy NR, Kumar SS, Chakrapani S. Double papilla flap
technique for dual purpose. Journal of Oral facial sciences 2012 June ;
4(1): 75-78.
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