introduction and techniques to increase width of attached gingiva with articles

1. Attached Gingiva
and Techniques to
Increase its Width
Dr. Rinisha Sinha
MDS Part II
Department of Periodontology

2. 2

3. Oral cavity is lined by three different kind of mucosa :
• Masticatory Mucosa – Hard palate and the gingiva of
alveolar process
• Lining Mucosa – lips, cheek and vestibular fornix
• Specialized Mucosa – covering the dorsum of the tongue
3
Reference: Orban & Sicher
The term Mucogingival Surgery was introduced in the periodontal
literature by Friedman in 1957 and was defined as
“Surgical procedures to preserve gingiva, remove aberrant
frenulum or muscle attachments and increase the depth of the
vestibule”
Reference: Glossary of periodontal terms, 1992
Miller in 1988 suggested the term Periodontal plastic surgery to be
more appropriate; defined as
“Surgical procedures performed to correct or eliminate
anatomic, developmental or traumatic deformities of the gingiva
and alveolar mucosa” Reference: Proceedings of the World Workshop in Periodontics, 1996

4. 4
Reference: Carranza 10th edition
Reference: AAP, 1992
Anatomically,
divided
into
three
parts:
FREE GINGIVA
ATTACHED
GINGIVA
INTERDENTAL
GINGIVA

5. What is
Attached
Gingiva ???
“That portion of gingiva that extends
from base of the gingival crevice to
the mucogingival junction.”
“It is the combination of epithelium
and connective tissue defined as a
portion of mucous membrane in
complete post-eruptive dentition of a
healthy young individual; it is
attached to teeth and alveolar
process.”
Reference: Glossary of Periodontal terms, 1972
Reference: Schroeder, 19
“That part of gingiva that is firmly
attached to the underlying tooth
and bone and is stippled on its
surface.”
“The portion of the gingiva
extending from the base of the
gingival crevice to the MGJ.
It is firm, dense, stippled and
tightly bound down to the
underlying periosteum and tooth”.
Reference: Orban; 1948
Reference: Glossary of Periodontal terms; 1977

6. 6
Continuous with the marginal gingiva
Firm, resilient and tightly bound to the
underlying periosteum of the alveolar bone.
Variation in color seen.
Presence of stippling

7. 
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7
Reference: Clinical Periodontology and
Implant Dentistry – Jan Lindhe, 5th edition

8. 
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8
Reference: Clinical peridontology 8, 9, 1Oth
edition - Carranza F.A., Michael G. Newman.

9. 
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9
Deep rete pegs
Thick lamina propria
Abundant collagen with no elastic fibers
Indistinct submucosa
Reference: Clinical peridontology 8, 9, 1Oth
edition - Carranza F.A., Michael G. Newman.

10. 
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Reference: Wennstrom J.L. Lack of association between width of the attached gingiva and development of soft tissue recession: A 5-year
longitudinal study. J Clin Periodontol 1987; 14; 181-184.
Reference: Wennstrom J.L, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkets. Journal
of Clinical Periodontology 1987; 14; 121-9.
It is the distance between mucogingival junction and projection on external surface of bottom of
sulcus.
Reference: Ainamo J, Loe H. Anatomical characteristics of gingiva. A clinical and microscopic study of the free and attached gingiva. J Periodontol
1996; 37:5.

11. 
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
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1 1
Maxillary
Anterior
• 3.5 – 4.5 mm
Mandibular
Anterior
• 3.3 – 3.9 mm
Maxillary
Premolar
• 1.9 mm
Mandibular
Premolar
• 1.8 mm
Reference: Ainamo J, Loe H. Anatomical characteristics of gingiva. A clinical and microscopic study of the free and
attached gingiva. J Periodontol 1996; 37:5.
Width of Attached Gingiva : the distance between the mucogingival junction to projection
of the external surface of the bottom of the sulcus or the periodontal pocket
Reference: FiorelliniJP, Kim DM, Ishikawa SO. Thegingiva. In: Newman MG, Takei H, Klokkevold PR, Carranza FA, editors.
Carranza’s Clinical Periodontology. 10th ed. Missouri: Saunders Publishers; 2006. p. 46-7.
The mucogingival junction serves as an important clinical landmark in periodontal evaluation

12. 
1 2
Reference: Hall WB. Can attached gingiva be increased non-surgically? Quintessence Int, 1992; 4: 455 – 462.
Methods to determine
mucogingival junction:
Visual
method
Functional
method
Visual methods after
histochemistry
staining
Reference: Guglielmoni P, Promsudthi A, Tatakis DN, Trombelli L. Intra- and inter-examiner reproducibility in keratinized tissue width assessment with 3
methods for mucogingival junction determination. J Periodontol 2001;72:134-9.

13. 1 3
An adequate width of
attached gingiva is
considered as critical for
maintenance of periodontal
tissue health by many
distinguished researchers.
Reference: Friedman and Levine, 1964;
Nabers, 1966; Lang and Löe, 1972;
Bernimoulin and Mühlemann, 1973;
Ochsenbein and Maynard, 1974; Hall, 1981;
Matter, 1982
An inadequate zone protect
the periodontium from injury
occurs due to frictional
forces encountered during
mastication and dissipate the
pull on the gingival margin
created by the muscles of the
adjacent alveolar mucosa
Reference: Friedman, 1999; Ochsenbein,
1960

14. High frenum
attachment
Recurrent
inflammation
Recession
Malpositioned
teeth
Osseous
dehiscence
1 4
Reference: Clinical Periodontology and
Implant Dentistry – Jan Lindhe, 5th edition

15. 


1 5
People born without sufficient attached gingiva 
gingival recession and bone loss.
Abnormal frenal attachment
Vigorous brushing in people with thin tissue or when
tissue is stretched during orthodontic treatment.
Deep pockets that reaches up to the level of
mucogingival junction

16. Enhances plaque
removal around the
gingival margin
Improves esthetics
Reduces
inflammation around
restored tooth
1 6
Reference: Clinical peridontology 8, 9, 1Oth
edition - Carranza F.A., Michael G. Newman.

17. Apical to Recession
• Free Gingival Autografts
• The Classic Technique
• Variant Techniques (Accordian, Strip, or
Combination)
• Free Connective Tissue Autografts
• Apically Displaced Flaps
• Other Techniques
• Vestibular Extension
• Fenestration Operation / Periosteal
Separation
Coronal to Recession
• Free Gingival Autografts
• Free Connective Tissue Autografts
• Pedicle Autografts
• Laterally (horizontal) positioned flap
• Coronally positioned flap (Semilunar Pedicle;
Tarnow)
• Subepithelial connective tissue graft
• Guided Tissue Regeneration
• Pouch and Tunnel Technique
1 7
Reference: Clinical peridontology 8, 9, 1Oth edition - Carranza F.A., Michael G. Newman.

18. 
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Reference: Gujar and Kathariya, 2014
Reference: Bohannan, 1962
Reference: Freidman and Levine, 1964
Reference: Pennel et al., 1965

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1 9
Reference: Ochsenbein
1960; Corn 1962;
Wilderman 1964
Reference: Staffileno et
al. 1962,1966;
Wilderman 1963;
Pfeifer 1965
Reference: Costich and
Ramjford 1968

20. 2 0
Advantage :
Postsurgical Increase in Width of
Gingiva
Disadvantage :
Postsurgical Gingival Recession

21. 2 1
Reference: Carnio, J. 1996. The modified technique of apically
repositioned flap. Periodonto., 46:1-6.
Advantage :
• Minimal surgical trauma with no prerequisite of
sutures
• Time requirement is less
Reference: Carnio and Miller, 1999.

22. 2 2

23. 3 / 1 / 2 0 X X S A M P L E F O O T E R T E X T 2 3

24. 2 4
AIM: A clinical study was carried to compare the CARF with MARF technique in terms of changes in the
width of attached gingiva, gingival recession (apparent), sulcus depth and clinical attachment level
MATERIALS AND METHODS:
A total no of 14 patients (11 males and 3 females), mean age being 32.14±6.48 (ranges from 23-42
years) involving 28 sites comprised the study samples. The study was carried out in split mouth design
and the sites were designated as
Site ‘A’: treated with conventional apically repositioned flap (CARF)
Site ‘B’: treated with modified apically repositioned flap (MARF)
INCLUSION CRITERIA:
• At least 2 sites with Miller’s Class I recession with sulcus depth of at least 0.5mm
• Adequate vestibular depth
• Positive tension test
• No periapical pathology, dehiscence, trauma from occlusion and within normal arch form
• Healthy, nonsmoker with no systemic diseases
CLINICAL PARAMETERS:
• Width of attached gingiva
• Gingival recession (apparent)
• Sulcus depth
• Clinical attachment level

25. 2 5
• The clinical parameters were assessed by UNC-15 periodontal probe.
• The cementoenamel junction (CEJ) was used as a fixed reference point.
• A stent was fabricated with self cure acrylic resin covering the occlusal/incisal 1/3rd both buccally and
lingually of the teeth to be recorded extending to two adjacent teeth, one on mesial and other on the distal
side.
• Vertical groove corresponding to the midline on the facial aspect of the tooth to be treated was
made on the stent to guide the probe during measurements at different time points to make sure that all
measurements were made at the same orientation to avoid any discrepancy.
• The surgical sites were stained with an iodine solution (Betadine, 0.5% w/v iodine) to differentiate
between alveolar mucosa and keratinized gingiva.
• This procedure done in each measurement highlighted the MGJ and facilitated the measurement.
MEASUREMENTS TAKEN:
• CEJ to base of sulcus (A)
• CEJ to gingival margin (B)
• CEJ to mucogingival junction ( C)
PARAMETERS CALCULATED:
• Width of Attached Gingiva: Distance between base of sulcus to MGJ (C
minus A)
• Apparent Gingival Recession: CEJ to gingival margin(B)
• Sulcus Depth: Measured from the crest of the gingival margin to the
base of sulcus (A minus B)
• Clinical Attachment Level: Distance from CEJ to base of sulcus (A)

26. All the parameters were recorded preoperatively on day 0 and post operatively on day 90 and 150.
The entire procedure was explained in detail to each patient and written consent was obtained from them.
Oral hygiene instructions and brushing technique demonstration were done.
Intraoral periapical radiographs of selected teeth was obtained.
Scaling and root planing were performed.
Haematological investigation included total leucocyte count and differential leucocyte count, bleeding and clotting
time, haemoglobin percentage and random blood sugar.
The subjects with haematological investigations falling within the normal range were selected.
The surgery was performed 6 weeks after the initial preparation.
A broad spectrum antibiotic (Cap. Amoxycillin 500 mg, 8 hourly) was prescribed 2 days prior to the surgery and
asked to continue for 3 more days post surgically along with an NSAID in SOS.
Patients were asked to rinse the oral cavity with 0.2 % Chlorhexidine gluconate mouthwash half an hour before
surgery
2 6

27. 
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RESULTS:
1. CHANGES IN WIDTH OF ATTACHED GINGIVA
 SITE A: the total gain from day 0 to 90 was 1.72mm and from day 0 to 150 was 2.15 mm
(significant)
 SITE B: the total gain from day 0 to 90 was 2.07mm and from day 0 to 150 was 2.25 mm (highly
significant)
 The gain in attached gingiva in Site B was more than that of Site A at different time points
2. CHANGES IN GINGIVAL RECESSION
 SITE A: the total gain from day 0 to 90 was 0.36mm and from day 0 to 150 was 0.50 mm (highly
significant)
 SITE B: the total gain from day 0 to 90 was 0.43mm and from day 0 to 150 was 0.36 mm
(significant)
 On day 150, the mean difference in the amount of gingival recession in Site B was less than
that of Site A, the difference being 0.14 mm.

28. 2 8
3. CHANGES IN SULCUS DEPTH
 SITE A: the total gain from day 0 to 90 was 0.43mm and from day 0 to 150 was 0.61 mm (highly
significant)
 SITE B: the total gain from day 0 to 90 was 0.11mm and from day 0 to 150 was 0.21 mm (NOT
significant)
 On day 150, the total increase of sulcus depth in Site A was more than that of Site B; the
mean difference being 0.40 mm.
3. CHANGES IN CLINICAL ATTACHMENT LEVEL
 SITE A: the total gain from day 0 to 90 was 0.71mm and from day 0 to 150 was 1.04 mm (highly
significant)
 SITE B: the total gain from day 0 to 90 was 0.36mm and from day 0 to 150 was 0.33 mm (NOT
significant)
 On day 150, the mean clinical attachment level in Site A was more than that of Site B; the
difference being 0.71 mm
CONCLUSION:
MARF technique may be preferred over the former considering the fact that there is no
further attachment loss, easy to execute, minimal surgical trauma, less time consuming
and, predictable and excellent esthetic results with less/ no resultant gingival recession.

29. 3 / 1 / 2 0 X X S A M P L E F O O T E R T E X T 2 9

30. A gold standard for the gingival augmentation procedures
3 0
Autogenous FGG has been considered the most predictable and popular procedure for increasing the
width of keratinized tissue around a tooth with mucogingival defect.
Reference: Bjorn H. Free transplantation of gingiva propria. Symposium
in Periodontology in MalmöOdontol Revy. 1963; 14:323.
Nabers JM. Free gingival grafts. Periodontics. 1966; 4:243–5.
Nabers JM. Extension of the vestibular fornix utilizing a gingival graft –
Case history. Periodontics. 1966; 4:77–9.
Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of
successful grafting. Periodontics. 1968; 6:121–9.
Advantage :
High degree of predictability in achieving
satisfactory outcome
Disadvantage (at Donor Site) :
• Requires an additional donor surgical site
• Availability of limited amount of donor
tissue
• Leaves a wound of considerable size in the
palatal donor area to heal by secondary
intention causing postoperative pain
Disadvantage (at Recipient Site) :
• Esthetic problems due to discrepancies of
color and texture between the healed graft
and surrounding mucosa
• A bulky appearance
Reference: Haggerty 1966; Nabers 1966; Sullivan & Atkins 1968; Hawley
& Staffileno 1970; Edel 1974

31. 3 1
PREOPERATIVE PHOTOGRAPH
POSTOPERATIVE PHOTOGRAPH
15 DAYS 9
MONTHS

32. Recently introduced in Periodontics as an alternative to FGG in
 Increasing the width of attached gingival around the teeth
 Implants
 In the treatment of gingival recession
3 2
It is a freeze-dried, cell free, dermal matrix comprised a structurally integrated basement
membrane complex and extracellular matrix in which collagen bundles and elastic fibers
are the main components
Reference: Shulman J. Clinical evaluation of an acellular
dermal allograft for increasing the zone of attached gingiva.
Pract PeriodonticsAesthet Dent. 1996; 8:201–8.
Reference: Callan DP, Silverstein LH. Use of acellular dermal matrix for increasing keratinized
tissue around teeth and implants. PractPeriodontics Aesthet Dent.1998; 10:731–4.
Reference: Achauer BM, VanderKam VM, Celikoz B, Jacobson DG.
Augmentation of facial soft-tissue defects with Alloderm dermalgraft. Ann
Plast Surg. 1998; 41:503–7
It is able to act as a bioactive scaffold for migration of fibroblasts, epithelial and endothelial
cells and could consistently integrate into the host tissue.
Reference: Jhaveri HM, Chavan MS, Tomar GB, Deshmukh VL, Wani MR, Miller PD., Jr Acellular dermal matrix seeded withautologous gingival fibroblasts for the
treatment of gingival recession: A proof-of-concept study. J Periodontol. 2010; 81 :616–25

33. 3 3
PREOPERATIVE PHOTOGRAPH
POSTOPERATIVE PHOTOGRAPH
15 DAYS 9
MONTHS

34. 3 4
AIM: To evaluate and compare the clinical efficacy of free gingival graft (FGG) and acellular dermal
matrix (ADM) allograft in the ability to increase the width of attached gingiva.
MATERIALS AND METHODS:
Fifteen patients (seven females and eight males) aged 20–55 years, having two sites with attached
gingiva ≤1 mm bilaterally on the facial aspect of the mandibular teeth were selected.
INCLUSION CRITERIA:
• Limited amount of attached gingiva
• Good oral hygiene
• Facial probing depths (PSs) ≤2 mm
• No removable partial denture in the area to be treated
• Not allergic to any antibiotics or any other drug to be prescribed for the patient
• No systemic, autoimmune or dermal diseases
• Nonsmoker
CLINICAL PARAMETERS:
• Plaque index (PI)
• Gingival index (GI)
• Probing Depth (PD)
• Gingival Recession (GR)
• The width of attached gingiva
Were measured at the mid-buccal point of the teeth

35. 3 5
• The junction of the attached and movable tissue was determined by rolling the alveolar mucosa
coronally with the side of a probe.
• During surgery, the extents of the recipient bed and the graft were measured in both the mesio-distal
and corono-apical directions.
• Both pre and postsurgical measurements were made by one examiner (C.A.)only.
• Measurements were made to the nearest 0.5 mm using a University of North Carolina-15 periodontal
probe (Hu-Friedy) and occlusal stent (with guiding grooves).
• For each variable, a patient mean was calculated which was finally subjected for statistical analysis..
POST-SURGICAL CARE:
• Antibiotics (amoxicillin, 500 mg, three times a day (t.i.d), for 7 days), analgesics (ibuprofen, 400 mg,
t.i.d for 3 days) and chlorhexidine (0.12%) mouthwash twice daily for 6 weeks was prescribed to every
patient.
• The patient was advised to refrain from retracting the lips and cheeks and to avoid brushing or
flossing in the grafted area for 6 weeks.
• After 15 days, periodontal dressing and remaining sutures were removed, and the area was
thoroughly irrigated with normal saline.
• The patient was recalled at regular intervals and followed for 12 months postoperatively and at every
visit, patient's oral hygiene status was monitored.

36. 3 6
RESULTS:
1. CLINICAL OBSERVATIONS
 The wound healing was uneventful without any graft-related adverse effects.
 The postoperative examination after 12 months revealed increased zone of attached gingiva
both in FGG and ADM allograft groups though FGG showed far superior results than the
ADM group.
 On the other, there was an excellent blending of color and texture with the adjacent native
tissues at the ADM-treated sites though FGG-treated sites were associated with the slightly
different color of the healed tissues with visible borders demarcating the adjacent areas.
 In ADM allograft group, the epithelization appeared at 4 weeks and keratinization of newly
formed attached tissue was not obvious until 6–8 weeks postoperatively. Maturation and
stability of the attached gingiva were achieved at 12 weeks and were maintained till 12 months
postoperatively.
 However, the healing period appeared slightly longer for ADM allograft than the FGG.
2. CLINICAL MEASUREMENTS
• On comparison between baseline and 12 months postoperative evaluation, no statistically
significant difference was found for any of the variables.
• The width of attached gingiva increased significantly following both the treatments.
• However, the sites treated with ADM allograft demonstrated a comparatively lesser gain in the
width of attached gingiva than the FGG-treated sites at 12 months of post-surgery (2.13 mm
vs. 4.8 mm, respectively).
• Comparison of the percentage shrinkage of the grafts between the two groups at baseline and 12
months showed that ADM site had significantly more shrinkage (76.6%) than FGG site (49.7%)

37. 3 7
CONCLUSION:
 ADM allograft has resulted in sufficient increase in width of attached gingiva
although lesser than FGG.
 Considering the disadvantages of FGG, it can be concluded that ADM allograft can
be used as an alternative to FGG in increasing width of attached gingival in certain
clinical situations.
 The results of the present clinical investigation comparing the effectiveness of FGG
and ADM allograft support further studies in this direction to explore the possibility
of using ADM allograft as a substitute to FGG in augmenting the areas deficient in
keratinized gingiva.

38. REFERENCES
1. Clinical Periodontology and Implant
Dentistry – Jan Lindhe, 5th edition
2. Clinical peridontology 8, 9, 1Oth edition -
Carranza F.A., Michael G. Newman
3. Nabers JM. Free gingival grafts.
Periodontics. 1966; 4:243–5.
4. Sullivan HC, Atkins JH. Free autogenous
gingival grafts. I. Principles of successful
grafting. Periodontics. 1968; 6:121–9.
5. Bjorn H. Free transplantation of gingiva
propria. Symposium in Periodontology in
MalmöOdontol Revy. 1963; 14:323.
6. Achauer BM, VanderKam VM, Celikoz B,
Jacobson DG. Augmentation of facial soft-
tissue defects with Alloderm dermalgraft.
Ann Plast Surg. 1998; 41:503–7
7. Haggerty 1966; Nabers 1966; Sullivan &
Atkins 1968; Hawley & Staffileno 1970;
Edel 1974

39. The way to get
started is to
quit
talking and
begin doing.
Walt Disney
3 9