ATTACHED GINGIVA

1/7/2018 Attached gingiva 1
Dr Mushahida Anjum JR-1
Deptt. Of Periodontology
Dental College Azamgarh
ATTACHED GINGIVA

Introduction
Definition
Width of attached gingiva
Thickness of attached gingiva
Microscopic features
Stippling
Measurement of width
Measurement of thickness
Function
Methods of increasing attached gingiva
CONTENTS

INTRODUCTION
Historically a certain amount of attached gingiva has
been considered important to maintain gingival health
and prevent gingival recession.
Mucogingival surgery or periodontal plastic surgery
still remains a valid alternative for increasing the
amount of attached gingiva.

Orban and sicher - oral cavity is lined by
three different kind of mucosa.
Masticatory mucosa - hard palate and
gingiva of alveolar process
Lining mucosa - lips, cheeks and
vestibular fornix
Specialized mucosa covering the
dorsum of tongue.
Masticatory mucosa-
Gingiva & covering of
hard palate
Specialized mucosa-
Dorsum of tongue
Oral mucous membrane-
Lining of oral cavity
Oral
mucosa

Gingiva is the part of the oral mucosa that covers the
alveolar processes of the jaws and surrounds the
necks of the teeth - Carranza 10th ed
The fibrous investing tissue, covered by keratinized
epithelium, which immediately surrounds a tooth
and is contiguous with its periodontal ligament and
with the mucosal tissues of the mouth. - AAP 1992
GINGIVA

Anatomically gingiva is divided
into:
Free
Attached and
Interdental gingiva.

ATTACHED GINGIVA
Definitions
GPT (1972)
Attached gingival is that portion of gingiva that extending from
base of gingival crevice to the mucogingival junction.
Schroder
It is combination of epithilium & C.T. defined as a portion of
mucous membrane in complete post-eruptive dentition of a
healthy young individual, is attached to teeth & alveolar
process.

It is continuous with marginal gingiva. firm,
resilient & tightly bound to underlying
periosteum of alveolar bone

 Facial aspect of attached gingiva extends to relatively
loose & movable alveolar mucosa & is demarcated
by mucogingival junction

 On the lingual aspect of
mandible, the attached gingiva
terminates at the junction of
lingual alveolar mucosa, which is
continuous with mucous
membrane lining the floor of the
mouth. Wide in molar region,
narrow in incisor region, varies
1-9mm
 The palatal surface of
attached gingiva in maxilla blends
imperceptibly with equally firm
and resilient palatal mucosa.

Classification
There are 3 types of attached gingiva
Type 1: there is a minimum of 5mm of attached gingiva
covering edentulous ridge from lingual & buccal tangent to
buccal side of proposed implant site.
(flap can be apically positioned to increase zone of keratinized tissue on facial aspect)
Type 2: there is keratinized tissue on top of ridge & at lingual /
palatal tangent to proposed implant site.

• Divided into two classes
 class 1; Enough lingual keratinized gingiva at proposed
implant site
(a free gingival graft is recommended on facial aspect to increase zone of
keratinized tissue)
 class 2; most keratinized tissue will be eliminated on lingual
side if gingiva is festooned around implant
(A gingival graft is performed on buccal side & apically positioned flap on
lingual side to increase zone of keratinized gingiva)

Type 3: keratinized tissue of alveolar ridge is present only on
lingual /palatal side of propsed implant side
(A free gingival graft is used to increase zone of keratinized tissue)

WIDTH OF ATTACHED GINGIVA
It is distance b/w mucogingival junction & projection on
the external surface of bottom of gingival sulcus or
periodontal pocket.
On facial aspect differs in different areas of mouth
Greatest in incisor region-
3.5-4.5mm in maxilla
3.3-3.9mm in mandible
Narrowest in posterior region-
1.9mm in maxilla
1.8mm in mandible

presence of an ‘adequate’ zone of gingiva was considered
critical for maintenance of marginal tissue health & for
prevention of continuous loss of connective tissue
attachment.
Inadequate zone of gingiva
1) facilitate subgingival plaque formation
because of improper pocket closure resulting from
mobility of marginal tissue. [Friedman (1962)]
2) favour attachment loss & soft tissue recession
b/c of less tissue resistance to apical spread of
plaque-associated gingival lesion. [stern et al(1976)]

Adequate or sufficient dimension
dimension of gingiva varied
 Bowers et al 1963 suggested <1mm may be
sufficient
 Corn et al 1962 suggested apico-coronal height of
keratinized tissue ought to exceed 3 mm
 De trey and Bernimoulin 1980,Friedman 1962
suggested
Any dimension of gingiva which is compatible with
gingival health, prevents retraction of gingival margin
during movement of mucosa.

 Lang & loe 1972
Based on observation 2mm keratinized gingiva is
adequate of which 1mm must be attached.
On basis of observation it seems justified to assume
that the anatomical width of the attached gingiva is in
direct proportion to the amount of past tooth eruption.

THICKNESS OF THE GINGIVA
In 1977 Goslind et al, reported that gingival
thickness varied considerably among subjects,
within individual thickness varied among areas.
The average thickness of the attached gingiva was
1.25mm +/-0.42mm.
The thickness increased in the mandible from anterior
to posterior and was inversely proportional to the
width.
The mean thickness was 1.41mm

MICROSCOPIC FEATURES

Histologically, the attached gingiva is better suited than
non-keratinized mucosa to withstand mechanical irritations.
 The epithelium of attached gingiva is keratinized,
predominantly cellular in nature, & contains prominent
epithelial ridges.
 The connective tissue is less cellular, composed primarily
of collagen fibers & ground substance.

Epithelium of attached gingiva
is lined by four layers.
 Stratum Basale.
 Stratum spinosum
 Stratum granulosm
 Stratum corneum.

Proliferation of keratinocytes takes place by mitosis in
basal layer & less frequently in supra basal layers.
Differentiation involves process of keratinazation,
which consists of progression of biochemical &
morphologic events

Main morphologic changes are
• Progressive flattening of cells with increasing
prevalence of tonofilaments ( corneum)
• Intercellular junction coupled to production of
keratohyaline granules.( granulosum)
• Disappearance of nucleus (corneum)

There is a basal lamina (300-400Å) below stratum basale
divided into
 Lamina lucida 30-50nm ( glycoprotein laminin)
towards epithelium
 Lamina densa 30-60nm ( collagen type IV) towards
C.T.
Lamina lucida connected to stratum basale through
hemidesmosome
Lamina densa connected to papillary part of
connective tissue through anchoring fibers ( type collagen IIV)

Connective tissue of gingiva,
also known as lamina propria
and consists of:
1. Papillary layers
subjacent to epithelium
consisting of papillary
projection between
epithelial rete pegs.
2. Reticular layers
contiguous with
periosteum of alveolar
bone.

CELLS
Principal cell type of gingival epithelium is
keratinocytes.
Other cells found in epithelium are clear cells or
non keratinocytes. include langerhans cells,
Merkel cells & melanocytes

Feature which are specific to attached
gingiva are
Deep rete pegs.
Thick lamina propria.
Abundant collagen
with no elastic fibers
Indistinct sub mucosa.

Attached gingiva is tough, inflexible and resistant to
abrasion.
Collagenous nature of connective tissue and its
adherence to underlying muco-periosteum determine
the firmness of attached gingiva.
Elongated papilla provides good mechanical attachment
and prevents epithelium being striped under shear forces.
Thick network of closely packed collagen fibers resist
the loading. Thus attached gingiva can bear the
compressive and shear forces.

SURFACE TEXTURE OF ATTACHED GINGIVA
stippling
Stippling is a form of adaptive specialization or
reinforcement for function.
The attached gingiva presents a textured surface like that
of an orange peel and is referred to as being stippled.
Stippling is best viewed by drying the gingiva in natural
light.

Surface texture is also related to the presence & degree
of epithelial keratinization.
Keratinization is considered a protective adaptatation
for function.
It increase when gingiva is stimulated by tooth
brushing

Microscopic appearance of stippling
Microscopically stippling is produced by the alternate
protuberances and depressions in the gingival surface.
papillary layer of the connective tissue projects into the
elevations and both the elevated and the depressed areas
are covered by stratified squamous epithelium.
The degree of keratinization and the prominence of
stippling appear to be related.

At low microscopic examination the surface appears
rippled, interrupted by irregular depressions 50μm in
diameter, at higher magnification cell pits can be seen
(Cleaton-Jones et al 1978).
Attached gingiva binds with marginal gingiva by
gingival fibers. Anatomically there is variation in
color and also the presence of stippling.

Measurement of width of attached gingiva;
HALL said that the width of attached gingiva is
determined by subtracting the sulcus or pocket
depth from total width of gingiva.

Methods to determine mucogingival junction
1. Visual method.
2. Functional method.
3. Visual methods after histochemistry staining
4. OPG assessment
5. Anaesthesia method

I. Mucogingival junction assessed as a scalloped
line separating attached gingiva from the
alveolar mucosa.

Visual method
AG = total width of gingiva ̶ pocket depth
This is done by stretching the lip or cheek to
demarcate the mucogingival line while pocket is
being probed.

Roll test / functional method
II. Assessed as a borderline between movable and
immovable tissue.
Tissue mobility waas assessed by
running a horizontally positioned
probe from the vestibule toward
the gingival margin using light force.

III. Assessed visually after staining the mucogingival
Junction with potassium iodide solution. Attached
gingiva is iodine-negative.

If mucogingival junction is distinct
this is done by stretching the lip or
cheek to demarcate Mucogingival
junction while pocket is being
probed.

If Mucogingival junction is indistinct its
position can be gauged by placing a probe
horizontally flat against the mucosal
surface and sliding it coronally.

Methods of measuring thickness of attached gingiva
Gosalind et al – Average thickness of attached gingiva is
1.25 ± .42mm.
Transgingival probing
Earlier method of measuring the thickness of attached
gingiva includes traumatic technique like probing and
injecting needles.

Now a day’s new methods include
measuring atraumatically with the
help of newer device called
“KRUPP SDM”

This device uses pulse echo principle with aids of pulse
generator and measurement frequency of 5MHz, a
piezoelectric crystal is allowed to oscillate.
Ultrasonic pulses are transmitted through the sound
permeable gingiva. On reaching bone or teeth surface, it is
reflected.

A transducer probe of 4mm diameter moistened with
saliva is applied to measure site with slight pressure to
produce acoustic coupling.
By timing received echo with respect to transmission of
pulse, thickness is digitally displayed.

Eager divided attached gingiva based on
periodontal type
 Shallow thin gingiva with slender crown formation.
 Wide thick gingiva with quadrant crown formation.
 Unknown combination
Thin gingiva – more recession as
compared to pockets
Thick gingiva – more pockets as
compared to recession

Wide thick
combination

Clinical implication of thickness of attached gingiva
Gingiva thickness is genetically determined and associated
with tooth form.
Therefore surrounding soft tissue should carefully be
considered when tooth form or size has to be altered.
Successful clinical outcome of both regenerative and
periodontal surgical procedures, highly rely on the
thickness of attached gingiva covering it.
Claffey et al said that in case of thin gingiva, there is
increased amount of recession following non-surgical
periodontal treatment.

Factors Affecting Width Of Attached
Gingival
 High frenum attachment
 Recurrent inflammation
 Recession
 Malpositioned teeth
 Osseous dehiscence

Functions
 Acts as buffer zone/ neutral zone
b/w movable & immovable zone
 Esthetic
 Bears trauma from occlusion
 Reduce plaque b/c of proper margin closure
 Reduce inflammation around tooth
 Bears masticatory forces
 Braces gingiva firmly against tooth
 Maintain oral hygiene by removing food away
from gingival margin
 Prevent transmission of frenal pull

 Prevent attachment loss & soft tissue recession b/c
of more tissue resistance
 Maintain vestibular depth
 Prevent root caries, chemical erosion
 Hygiene aids are more comfortable to use within the
keratinized tissue as it’s more resistant to abrasion.
 Provides tight collar around implants.

Dissipating physiological forces exerted by the
muscular fibers of the alveolar mucosa on the gingival
tissue
Increase resistance to
external injury and
contribute in stabilization of
gingival margin.
Against frictional forces.

1/7/2018 Attached gingiva 541/7/2018 Attached gingiva 54
keratinized attached gingiva around implants:
The needs for keratinized gingiva around dental
implant are more controversial, the color,
contour and texture of soft tissue drape should be
similar around implants.
Absence of keratinized mucosa increases the
suseptibility of peri-implant lesions and plaque
induced destruction.

Amount of keratinized gingiva did not affect the
success rate of implants.
However, implants with less than 2mm of keratinized
gingiva exhibited increased bleeding upon probing,
redness, and inflammation, which may contribute to
later failure.

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 and 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.

Patient experiencing
discomfort during tooth brushing
and chewing – Deep periodontal
Pockets.
In cases where orthodontic
treatment planned and final
position is expected to result in
recession.
Indication to increase width of attached gingiva

To improve aesthetic – The
coverage of denuded root
surface for aesthetic which
increase the attached gingiva.
For teeth that serve as an
abutment for fixed or removable
partial denture, as well area in
relation to denture.

TISSUE BARRIER CONCEPT
Goldman and Cohen outlined a “tissue barrier” concept
for mucogingival surgery.
They postulated that a dense Collagenous band of
connective tissue retard or obstruct the spread of
inflammation better than does the loose fiber arrangement
of the alveolar mucosa.
They recommended increasing the zone of keratinized
tissue to achieve an adequate tissue barrier

GENERAL PRINCIPLES FOR MUCOGINGIVAL
SURGERY
1. Existing keratinized gingiva should always be maintained.
2. Exposing bone to increasing the zone of keratinized gingiva is
contraindicated (wilderman1964).
3. When an adequate zone of keratinized gingiva exists,
vestibular depth is not a factor.

METHODS OF INCREASING OF ATTACHED
GINGIVA
Gingiva augmentation apical to
recession
• Free gingival autograft
• Free C.T. autograft
• Apically displaced flap
Gingival augmentation coronal to
recession ( root coverage )
• Free gingival autograft
• Free C.T. autograft
• pedicle graft
1) horizontally positioned flap
2) coronally positioned flap
• subepithilial C.T. graft
• GTR
• Pouch & tunnel technique

METHOD OF INCREASING THE WIDTH OF
ATTACHED GINGIVA
• The earliest of these technique
are the vestibular extension operations
– 1. Denudation techniques. (Ochsenbein 1960, Corn 1962,
Wilderman 1964) - Removal of all soft tissue within an
area extending from below the the gingival margin to a
3mm apical to the mucogingival junction leaving the
alveolar bone completely exposed.

Stripping of buccal half of the mucoperiosteum by
sharp dissection ½ to 1 cm apical to muco-buccal fold
bone is covered with periosteum.
Insertion of surgical cement.
2. Periosteal retention
procedure or Split flap
procedure (Staffileno et al.
1962, 1966, Wilderman 1963,
Pfeifer 1965)

A mucogingival flap consists of epithelium & a layer of
C.T. was reflected & then excised.
Gingival fibers attached to tooth were also removed.
No exposure of bone & wound was covered by a layer
of C.T. of varied thickness.
 Results showed an average increase in attached
gingiva tissue of 2.1mm. MGJ moved apically the same
distance

3. Free grafts have been used
for gingival augmentation
(Nabers 1966, Sullivan &
Atkins 1968, Hawley
&Staffileno 1970, Edel 1974).
If alveolar mucosa separated from periosteum & then
stripping the periosteum from bone, called double flap
procedure.
This same periosteum would be sutured over the bone to
act as biological pack

The FGGs had been utilized to increase amounts of
keratinized tissue and obtain root coverage.
This extremely predictable procedure has been used to
treat various types of mucogingival defects, Including
recession, the aberrant frenum, and the shallow vestibule.
However, probably the procedure’s most common use is to
increase the amount of keratinized tissue.
FREE GINGIVAL GRAFT

Technique
• Prepare the recipient site
• Obtain the graft from donor site
• Transfer & immobilized the graft
• Protect the donor site

Prepare the recipient site
• prepare a firm C.T. bed to receive the graft
• Site can be prepared by incising at existing mucogingival
junction with a #15 blade to desired depth, blending the
incision on both ends with existing mucogingival line.
• Periosteum should be left covering the bone.

• Another technique site consists of outlining the recipient site
with two vertical incision from cut gingival margin into
alveolar mucosa
• extend incision approximately twice the desired width of
attached gingiva.

Obtain the graft from donor site
• conventional FGG technique consists of transferring a piece
of keratinized gingiva approximately size of recipient site.
• A partial thickness graft is taken from palate.

separate graft with blade
place the template over the donor site, & make a shallow
incision around it with a #15 blade.
insert the blade to desired thickness at one edge of the graft

Transfer & immobilize the graft
• Remove the sponge from recipient site
• Position the graft & adapt it firmly to recipient site b/c dead
space impairs vascularization & jeopardize the graft.
• suturing take place

Protect the donor site
• Cover the donor site with a periodontal pack
• Sutures may be used in order to stabilize the blood clot during
early phases of healing.
• Fabrication of an acrylic or
plastic stent before surgical
procedure is most effective.

Apically displaced flap
• An internal bevel incision is made
• It should be no more than about 1mm from crest of gingiva &
directed to crest of the bone.
• Crevicular incision are made followed by initial elevation of
flap, then interdental incision is performed, & wedges of tissue
that contains pocket wall is removed.
• Vertical incisions are made extending beyond mucogingival
junction.
• Full thickness flap is elevated by blunt dissection with
periosteal elevator.
• Split thickness elevated using sharp dissection with BP blade.

• After removal of granulation tissue, scaling & root
planing, & osseous surgery if required, flap is displaced
apically.
• Sling suture in full thickness, direct loop in split thickness
flap.
• A dry foil is placed over the flap before covering it with
pack.

Modified apically repositioned flap (MARF)
It is indicated to be used should
present with minimal or no
inflammation, physiologic
sulcus depth, & at least .5 mm of
attached gingiva.
A horizontal beveled incision is
made with a # 15 blade
approximately .5mm coronal to
MGJ into attached gingiva.

• Blade makes a contact with
periosteum at a point slightly apical
to alveolar crest.
• Incision should be parallel to MGJ
so that approx .5mm of attached
gingiva remains along the coronal
portion.
• A split thickness flap is elevated,
dissection is extended in apical
direction as far as deemed necessary.
( 5-6mm usually sufficient )

• Flap is moved apically & secured to periosteum with
inturrepted sutures using 6-0 gut.
• With a moist gauge, gentle digital pressure is applied for 3-5
minutes to maintain close contact with underlying
periosteum.

CONCLUSION
The adequate width attached gingiva cover the
essential component for Maintaining Healthy
Periodontium .
Adequate keratinized gingiva provides a firm and
stable Base for maintaining good oral hygiene,
restorative and esthetic procedure.
Restoring dentist should be aware of the biology of
keratinized Gingiva and methods for increasing the
attached gingiva for a successful treatment Outcome.

Thank you

ATTACHED GINGIVA

More Related Content

What's hot

Similar to ATTACHED GINGIVA

Recently uploaded

ATTACHED GINGIVA