This document discusses the anatomy, histology, and clinical significance of the attached gingiva. It defines attached gingiva as the portion of gingiva firmly bound to the underlying alveolar bone. The normal width of attached gingiva is described to be greater in the anterior regions. Inadequate width is associated with increased risk of recession and plaque formation. Methods for measuring width and increasing width through surgery are presented. The importance of keratinized tissue for protection and force distribution is explained.

2. DR. LILLY PAELAGO
&
DR. CARLOS CAPITAN II

3. INTRODUCTION
ANATOMY
MICROSCOPIC AND MACROSCOPIC FEATURE
NORMAL WIDTH OF ATTACHED GINGIVA
MEASUREMENT OF WIDTH OF ATTACHED GINGIVA
INADEQUATE WIDTH OF ATTACHED GINGIVA
INDICATION TO INCREASE WIDTH OF ATTACHED GINGIVA
KERATINIZED ATTACHED GINGIVA AROUND IMPLANTS
CLINICAL SIGNIFICANCE OF ATTACHED GINGIVA AROUND IMPLANTS
KERATINIZED GINGIVA WIDTH ALTERATION DURING ORTHODONTIC TREATMENT
METHODS OF MEASURING THICKNESS OF ATTACHED GINGIVA
CLINICAL IMPLICATION OF THICKNESS OF ATTACHED GINGIVA
METHOD OF INCREASING THE WIDTH OF ATTACHED GINGIVA (GINGIVAL AUGMENTATION)
REPOSITIONING THE ATTACHED GINGIVA
TISSUE BARRIER CONCEPT
GENERAL PRINCIPLES FOR MUCOGINGIVAL SURGERY
PERIODONTAL PLASTIC SURGERY
CONCLUSION
REFERENCES

4. 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.

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

6. gingiva is a part of keratinized gingiva
which aids in
Increase resistance to external injury and
contribute in stabilization of gingival
margin.
Against frictional forces.
Dissipating physiological forces exerted by
the muscular fibers of the alveolar mucosa
on the gingival tissues.

7. many years the presence of an “adequate”
zone of gingiva was considered critical for the
maintenance of marginal tissue health & for the
prevention of continuous loss of connective tissue
attachment.
In the early 1980s, Wennstrom et al.* conducted a
series of well-designed experiments to prove that
the attached gingiva and its width, have little role
in maintaining periodontal health.
4-6 Successive studies went on to prove that it is
not the width but the volume of attached gingiva
that is critical around restored or orthodontically
moved teeth.*
1. Wennstrom J.L. Lack of association between width of attached gingiva and development of soft tissue recession: A 5 year longitudinal study. J Clin Periodontol 1987;14: 181-184
2. Wennstrom J.L. Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkeys. Journal of Clinical Periodontology 1987; 14:121-9.

8. Glossary of periodontal term (1972) -
Attached gingiva is that portion of
gingiva that extends from the base of
gingival crevice to mucogingival
junction. It is firm, resilient and tightly
bound to underlying periosteum, tooth
of alveolar bone through connective
tissue.
Orban (1948) - first to describe attached
gingiva, he divided gingiva into free and
attached gingiva demarcated by free
gingival groove (FGG). According to him,
FGG is at appropriate level of the
bottom of gingival sulcus.

9. * and loe (1966) - published a study to
show that FGG was present only in one-third of
cases examined so it was unreasonable to
assume that FGG represent the dividing line
between free gingiva and attached gingiva.
They suggested a better parameter “an
imaginary horizontal plane which can be drawn
from the bottom of sulcus to surface of gingiva”.
Imaginary
Horizontal Line
3. Ainamo J, Loe H: Anatomical characteristics of gingiva. A Clinical and microscopic study of the free and attached Gingiva. J Periodontol 1996; 37:5.

10. of attached gingiva extend to
relatively loose and 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.
The palatal surface of gingiva in maxilla blends
imperceptibly with firm and resilient palatal
mucosa.

11. Histologically, the attached gingiva is better suited
than non-keratinized mucosa to withstand
mechanical irritations.
The epithelium of attached gingiva is keratinized
and has thin, prominent epithelial ridges.
The connective tissue contains no elastic fibers.
These characteristics are exactly the opposite of
the histology of alveolar mucosa.

12. layers:
1. Stratum Basale.
2. Stratum spinosum.
3. Stratum granulosm
4. Stratum corneum.

13. of gingiva, also known
as lamina propria and it 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.
Pink color of attached gingiva is governed by factor like thickness of epithelium,
vascular supply and degree of keratinization and presence of pigmentation.

14. 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.
Thick network of closely packed collagen fibers resist the loading*. Thus
attached gingiva can bear the compressive and shear forces.
4. Bartold PM, Narayanan AS: biology of periodontal connective tissue. Chigao quintessence 1998.

15. Elongated papilla provides good mechanical attachment and prevents
epithelium being striped under shear forces.
Attached gingiva presents a surface texture similar
to orange peel which is referred as a stippled.
It varies among different individual and different
areas of mouth.
It is less prominent on the lingual surface then on
the facial surface.
It is absent in infancy and appear around 5 year of
age.
It is a form of adaptive specialization.
It is produced by elevation and depression in
surface of gingival tissue.

16. It is the distance between mucogingival junction and projection on
external surface of bottom of sulcus.
Width:*
It is greater in incisor region.
3.5-4.5 mm in maxilla anterior.
3.3-3.9 mm in mandible anterior.
It is narrower in posterior tooth region:
1.9mm in maxilla premolar
1.8 mm in mandible premolar
Width of attached gingiva is minimal in newly erupted permanent
teeth and increase with permanent teeth eruption.
Ainamo et al. Anatomical Characteristics of Gingiva A Clinical and Microscopic Study of the Free and Attached Gingiva. J Periodontol 1966; 37:5

17. * - measured the width of facial attached gingiva in both primary and
permanent dentition.
The width of gingiva varies from 1-9mm, being greatest at the incisor
region especially in the lateral incisor and smallest in the canine and first
premolar region.
5. Bowers. G, M. A study of the width of attached gingiva. Journal of Periodontology ,1963; 47:412-414

18. Voigt* et.al - measured the width of attached gingiva in clinically normal
subjects.
first and second molar demonstrated the greatest
width (4.7mm) and decrease at premolar and third molar
sites.
The incisor and canine demonstrated the smallest width
(1.9mm).
With the progression from primary to permanent
dentition the width of attached gingiva is decreased.
6. Voigt JP, Goran ML, Flesher RM. The width of lingual mandibular attached gingiva. J periodontol. 1978; 49:77-80.

19. * et.al - in different studies said that,
mucogingival junction remains stationary throughout
life and changes in width of attached gingiva are
caused by modification in position of coronal
gingival.
The width of attached gingiva increases with age and
in supra-erupted teeth.*
Maze land et.al - said that, width depends on height
of alveolar process and vertical dimension of face.
7. Ainamo A: Influence of age on the location of the maxillary Mucogingival Junction. J Periodont Res 1978; 13:189.
8. Ainamo A, Ainamo J: The width of attached gingiva on Supraerupted teeth. J Periodont Res 1978; 13:194.
9. Ainamo j, talari A: the increase with age of the width of attached ginigva.j periodontal Res1976; 11:182.

20. -sobocki* and bodin - in a series of studies over
2 year - used longitudinal observational to confirm
the pattern of Facial keratinized tissue in children.
Both primary and permanent teeth demonstrated an
increase in facial keratinized tissue as the age
advances.
The increase of gingival widths was greatest for
sites with the smallest baseline width of attached
gingiva, and smallest for sites with the greatest
baseline width.
Zone of attached gingiva was narrower on facially
positioned teeth then on lingually positioned teeth or
well-aligned.
10. Anna Andlin-Sobocki, Changes of facial gingival dimensions in children A 2-year longitudinal study. Journal of Clinical Periodontology March 1993; 20(3):212-218.

21. 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.
11. Hall WB. Can attached gingiva be increased nonsurgically? Quintessence Int, 1982; 4: 455-462,

22. separating attached gingiva from the alveolar mucosa.
II. Assessed as a borderline between movable and
immovable tissue.
Tissue mobility is 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 iodine solution.
Attached Gingiva - Keratinized - No glycogen in the
superficial layer - Iodine Reactive Negative

23. 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.

24. Friedman* - Said that ‘‘inadequate’’ zone of
gingiva would facilitate Subgingival plaque
Formation because of improper pocket closure
resulting from the movability of the Marginal
tissue.
The amount of attached gingiva is generally
considered to be insufficient when stretching of
the lips or cheeks induce movement of free
gingival margin.
12. Friedman M.T. Barber PM, Mordan NJ, Newman HN. The ‘‘plaque-free zone’’In health and disease: a scanning electron microscope study. J Periodontol. 1992; 63:890-896

25. It may be due to:
which results in muscles of alveolar mucosa to pull the
gingiva down - Gingival recession as well as bone loss is
seen.
Abnormal free attachment, which exaggerates the pull on
gingival margin.
Vigorous brushing in people with naturally thin tissue or
when the tissues have been stretched during orthodontic
treatment.
Deep pockets that reaches the level of mucogingival junction.

26. * and loe - Reported a study on the relationship between the gingival
width and inflammation, in an effort to determine the adequate amount.
In 100% of teeth with less than 2mm of
keratinized tissue, inflammation and exudates
was present.
76% of cases with greater than 2mm of
keratinized tissue there was no exudates and
was considered as clinically healthy.
They concluded that 2mm of keratinized gingiva, with less than 1mm of
attached gingiva is adequate to maintain gingival health.
13. Lang, N.P. &Loe, H. 1972. The relationship between the width of keratinized Gingiva and gingival health./, Periodontol.43: 623-627.

27. * mentioned few critical factors to be considered in determination of
adequate attached gingiva.
Patients age,
Level of oral hygiene practice,
Teeth involved any - Tooth Malposition,
Existing recession with esthetics or sensitivity problem,
Patients’ dental needs - Dehiscence.
14. Hall W.B. Present status of soft tissue grafting. J Periodontol 1977;48:587-97.

28. amount which is sufficient to prevent recession in opinion of
individual practioners.*
Thus No minimum width of attached gingiva has been established
as standard necessary for gingival health.
Miyasato* et al in his study concluded that there is no relationship
between inflammation and amount of attached gingiva whether or
not plaque is present.
De tray and bernimoulin - Adequacy of attached gingiva cannot be
determined by measurement of its width alone.
15. Ericsson I, Lindhe J. Recession in sites with inadequate width of the keratinized gingiva. An experimental study in the dog. Journal of Clinical Periodontology 1984; 11:95-103.
16. Miyasato M, Crigger M, Egelberg J, Gingival condition in areas of minimal and appreciable width of keratinized gingival. J Clin Periodontol. Aug 1977; 4(3):200-9.

29. 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.
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.

30. Absence of keratinized mucosa increases the
suscipility of peri-implant lesions and plaque induced
destruction.
Keratinized gingiva around implant has more
hemidesmosomes.
Orientation of collagen fiber in the connective tissue
zone of an implant often appear perpendicular to
implant surface, but in mobile non keratinized tissue
these fiber run parallel to surface of the implant.*
17. James RA, Schultz RL: Hemidesmosome and the adhesion of junctional epithelial cells to metal implants a preliminary report, J Oral Implantology; 1974; 4:294.

31. * et al - mobile mucosa may disrupt the implant
epithelial attachment zone and contribute to an increased
risk of inflammation from plaque.
keratinized non mobile tissue and keratinized mobile
tissue are the two type of mucosa that may be found
around implants.
Hygiene aids are more comfortable to use within the
keratinized tissue as it’s more resistant to abrasion.
Mehdi Adibrad* et al said that there is a significant
influence of width of keratinized mucosa on health of the
peri-implant tissues.
18. Schroeder, H.E. &Listgarten, M.A. (1997). The gingival tissues: the architecture of Periodontal protection. Periodontology 2000; 13: 91-120.
19. Mehdi Adibrad, Mohammad Shahabu, MahastiSahabi, significance of the Width of Keratinized mucosa on the health status of the supporting tissue Around implants Supporting overdentures journal of Oral Implantology. 2009; 35(5)

32. implants supporting over dentures was associated
with higher plaque accumulation, gingival
inflammation, bleeding on probing, and mucosal
recession.
Listgartan and Schroeder - it is preferable to locate
the implants in masticatory mucosa (Keratinized
Mucosa) - Hence if there is inadequate gingiva
present it is better to augment the gingiva before
placement of fixture.
20. AdellR, LekholmU, RocklerB, Branemark P-I, Lindhe J, Eriksson B, Sbordone L. Marginal tissue recession at osseointegrated titanium fixture (I).A 3-year longitudinal prospective study. Int J oral maxillofacial surgery.1986; 15: 53-61.
21. Meffert RM, Langer B, Fritz ME: Dental implant: a review, J Periodontol.1992; 63: 859-870.

33. * et al - Attached mucosa is necessary to
prevent movement of mucosa around an exposed
cover screw from inflecting trauma upon to marginal
soft tissue.
Meffert* et al. prefer to obtain keratinized tissue
before implant placement.
20. AdellR, LekholmU, RocklerB, Branemark P-I, Lindhe J, Eriksson B, Sbordone L. Marginal tissue recession at osseointegrated titanium fixture (I).A 3-year longitudinal prospective study. Int J oral maxillofacial surgery.1986; 15: 53-61.
21. Meffert RM, Langer B, Fritz ME: Dental implant: a review, J Periodontol.1992; 63: 859-870.

34. Prevent spread of inflammation.
Prevents recession of marginal tissue.
Provides tight collar around implants.
Enable patients to maintain good oral hygiene.

35. Gosalind* et al - Average thickness of attached
gingiva is 1.25mm.
Earlier method of measuring the thickness of
attached gingiva includes traumatic technique
like probing and injection needles.
Now a day’s new methods include measuring
atraumatically with the help of newer device
called “KRUPP SDM”.
23. Gosalind GD, Robertson PB, Mahan C J, Morrison WW, Olson JV. Thickness Of facial ginigva JP. 1977; 48(12):768-71.

36. 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.

37. Shallow thin gingiva with slender crown formation.
Wide thick gingiva with quadrant crown formation.
Unknown combination
Shallow, Thin Wide, Thick Combination

38. A Dannan* et al conducted a study to evaluate changes of keratinized
gingiva width of frontal teeth during the phase of orthodontic alignment
and leveling.
10 patients having front teeth crowding (120 teeth divided into 20 groups)
were recruited in the study.
Orthodontic alignment and leveling movements were initiated.
Periodontal assessment was achieved including plaque index, probing
depth, gingival index and papillary bleeding index.
*A Dannan, M Darwish, M Sawan. Keratinized Gingiva Width Alteration during Orthodontic Alignment and Leveling Phase; a Preliminary Investigation. The Internet Journal of Dental Science Volume 7 Number 2

39. gingiva was measured at every tooth in every group
and expressed as the average of keratinized gingiva width (aKGW).
All clinical parameters and aKGW were assessed at baseline, at 1 month, at 3
months and at 6 months.
No statistically significant changes were observed in the scores of
periodontal indices and aKGW records during the whole period of
observation (P>0.05).
Conclusion - Orthodontic tooth alignment and leveling do not lead to
significant changes in the width of keratinized gingiva when adequate plaque
control is maintained.

40. 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.
The successful clinical outcome of both regenerative
and periodontal surgical procedures, highly rely on the
thickness of attached gingiva covering it.
Claffey* et al - In cases of thin gingiva, there is
increased amount of recession following non-surgical
periodontal treatment.
24. Claffey N, Shanley D, Relationship of gingival thickness and bleeding to loss Of probing attachment in shallow sites following nonsurgical periodontal therapy. J Clin Periodontal 1986;13: 654-657

41. The earliest of these techniques are the vestibular extension
operations
1. Denudation techniques. (Ochsenbein 1960, Corn 1962,
Wilderman 196425) - Removal of all soft tissue within an
area extending from the gingival margin to a level apical to
the mucogingival junction leaving the alveolar bone
completely exposed.
2. Periosteal retention procedure or Split flap procedure
(Staffileno et al. 1962, 1966, Wilderman 1963, Pfeifer
1965)
3. Free grafts have been used for gingival augmentation
(Haggerty 196626, Nabers 1966, Sullivan & Atkins 1968,
Hawley &Staffileno 1970, Edel 1974).

42. important to dissipate the force of muscle pull and
unattached mucosa due to its mobility collects more
plaque.
Friedman* - Surgical technique to provide a
functionally adequate zone of keratinized attached
gingiva is known as mucogingival surgeries.
The apically positioned flap, free gingival graft, and Sub
epithelial connective tissue graft are the most common
surgical procedures used for augmenting the zone of
attached gingiva effectively and predictably.
27. Freidman, N.mucogingival surgery .The Apically repositioned flap. Journal of periodontology 33,328-340.

43. periodontal complex - A complex capable of withstanding the stress of
mastication, tooth brushing, trauma from foreign bodies, tooth preparation
associated with a crown and bridge, Subgingival restoration, orthodontic
treatments, inflammation and frenum pull.*
PRF GBR Bone Graft
Collagen
Membranes
28. Stetler K, Bissada NF: significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restoration, J Periodonto, l1987; 58:696-700,

44. 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
29. Goldman H. Periodontal therapy. 6th ed. St. Louis: CVMosby; 1979; 5.

45. *
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.
30. Carranza Jr FA, Carraro JJ. Mucogingival techniques in periodontal surgery. Journal of Periodontology 1970; 41:294-9.

46. Soft Tissue Grafting
Indications and Procedures

47. When is gingival grafting needed and when is it not?
Why do I need it? What happens if I don’t do it?
Does it hurt?
What is the recovery time?
Does it work? Does it have to be redone?
How much does it cost?

48. Attached Gingiva - The portion of the gingiva that is firm, dense,
stippled and tightly bound to the underlying periosteum, tooth,
and bone.
Free Gingiva - That part of the gingiva that surrounds the tooth
and is not directly attached to the tooth.

49. Junction - the area of union of the gingiva and
alveolar mucosa
Alveolar Mucosa - Loosely attached mucosa covering the basal
part of the alveolar process and continuing into the vestibular
fornix and the floor of the mouth

50. Defect - A departure from the normal dimension
and morphology of the relationship between the gingiva and the
alveolar mucosa

51. - A soft tissue graft that is completely
detached from one site and transferred to a remote site. No
connection with the donor site is maintained.
Subepithelial Connective Tissue Graft (CTG) - A detached
connective tissue graft that is placed beneath a partial thickness
flap. This variation of the free gingival graft provides the tissue
graft with a nutrient supply on two surfaces.

52. 1930’s - Frenectomies and vestibuloplasties
1948 - First Gingivoplasties
1956 - Grupe and Warren publish Laterally Positioned Flap
1963 - Bjorn publishes the Free Gingival Graft
1982 - P.D. Miller introduces the FGG for root coverage. Fernandez
does first CT graft
1989 - AAP renames Mucogingival Surgery to Periodontal Plastic
Surgery

53. Gingival Augmentation
Free Gingival Graft
Connective Tissue Graft
Root Coverage
Coronally positioned flap
Semilunar flap
Laterally positioned flap
Double papilla flap
Free Gingival Graft
Connective Tissue Graft
Guided Tissue Regeneration using allograft

54. APF - Aically Positioned Flap
CAF - Coronally Advanced Flap
ADM - Acellular Dermal Matrix
GTRC - Guided Tissue Root Coverage

55. Bowers 1963 - felt that gingival health could be maintained with a
narrow zoned of KG (<1mm) but some is required for healing.
Lang & Loe 1968 - suggested 2mm
Maynard and Wilson 1979 - 5mm of KG with 3mm attached gingiva
when subgingival restorations are planned
Kennedy 1985 - over a 6 year period, in patients with inconsistent OH
saw recession with thin tissue.
Bottom Line: some attached gingiva is necessary for health, but
patients with good OH can maintain thin AG.

56. When there is,
Recession progressing.
Tooth planned for orthodontic care or prosthetic treatment.
Root sensitivity.
Difficulty cleaning the root surface by the patient.
An esthetic concern.

57. Indications
• To increase keratinized tissue around teeth, implants or crowns
• To increase keratinized tissue under removable prostheses
• To increase vestibular depth
Disadvantages
• Difficult to achieve root coverage
• High esthetic demand
• Large, uncomfortable donor site
• Graft site, slow uncomfortable healing

58. Classic “Gum Graft”
Will increase keratinized gingiva
Results in “Tire Patch” look

59. Pre-op

60. Donor Site
Recipient Site

61. Before Long-term follow-up

62. Class I. Recession that has not
extended to MGJ. No bone loss
Class II. Recession to or beyond the
MGJ. No bone loss
Class III. Recession to or beyond
MGJ. Bone loss with or without tooth
malposition.
Class IV. Recession beyond MGJ.
Bone loss to the base of recession
defect with tooth malposition.

63. Predisposing Factors:
Minimal attached gingiva/thin tissue biotype
Frenum pull / shallow vestibule
Tooth malposition
Precipitating Factors:
Inflammation related to plaque
Restorations adjacent to thin tissue
Occlusal Trauma including orthodontic treatment
Bone loss at an adjacent site

64. Advantages
Very predictable for root coverage
Smaller donor site (than FGG)
Smaller recipient site (than FGG)
Less soreness overall (than FGG)
Uses patient’s own tissue
Excellent esthetics
Can cover multiple, large recessions even on teeth with a previous
gingival restorations.

65. Disadvantages
Two surgical sites
Technique sensitive
Bleeding from palate (potential)

66. Surgical technique
Root preparation
Thorough root planing of exposed root to remove infected cementum
and affected dentin
Etch root surface with tetracycline (pH 2.0)
Exposes collagen tufts to promote fibroblast adhesion

67. Incision design (tunnel technique)
Create “pouch” using full/split thickness incision between gingiva and
bone/root
Maintain papilla for bilateral blood supply
Extend incision to adjacent teeth
Undermine flap

68. Surgical Technique
Donor site incision (Buser)
First palatal incision perpendicular to long axis of teeth and
approximately 2 to 3 mm apical to the gingival margin.

69. Surgical Technique
Donor site incision (Buser)
Second palatal incision parallel to long axis of teeth and approximately 1
to 2 mm apical to first incision.
More apical the second incison, more thicker the donar tissue will be.
Height of the palate determines the extent of the palatal incision.

70. Donor Site
Harvest Tissue Suture Palate

71. Recipient site
Insert Graft Into Tunnel Suture using interrupted and sling sutures

72. Before
After

73. Occlusal Trauma
Pre-op
Post-op

74. Miller Class IV with supra-eruption of central incisor
Only minimal root coverage was possible

75. Before 3 years post-op

76. The common perception is that Connective Tissue Grafting is
VERY PAINFUL!!
This is often the patient’s perception

77. Reality
In 20 years of performing CT grafts, very few patients ever complain
about significant pain afterwards
Most are pleasantly surprised at how little pain they had
Very little post-op bleeding, swelling or bruising
Of course, everyone’s pain threshold is different͙

78. Recovery times vary from individual to individual
Post-op instructions include:
Soft foods for a week
Avoid chewing in the donor or recipient sites if possible for the first
week
Bleeding from the palate is possible for the first 24 hours and
sometimes longer
Don’t brush the donor site for 1 week͖ the recipient site for 3 weeks.
Patient should use Chlorhexidine mouthwash in the meantime
Ibuprofen 800mg 3/day for 2 - 3 days

79. Patients may report of some soreness during the first week, but that will
subside eventually.
Some swelling of the recipient site is normal and occasionally some
bruising can be seen.
Resorbable sutures - Sutures resorb in the palate in 2 - 3 days and in
about 1 week in the recipient site.
Most people resume normal activities either the next day or two days
after.
In smokers healing is more slow and results are less predictable.

80. Mucogingival defects are very common across all age groups and
both genders
Mucogingival defects can be either congenital or acquired with
both predisposing and precipitating factors
Periodontal Plastic Surgery can be used to correct mucogingival
defects via a variety of methods and techniques
Indications for Periodontal Plastic Surgery can vary depending on
rate of progression or the impact of local factors

81. The adequate width attached gingiva should 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.

84. 1. Wennstrom J.L. Lack of association between width of attached gingiva and development of soft tissue recession: A 5
year longitudinal study. J Clin Periodontol 1987;14: 181-184,.
2. Wennstrom J.L. Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in
monkeys. Journal of Clinical Periodontology 1987; 14:121-9.
3. Ainamo J, Loe H: Anatomical characteristics of gingiva. A Clinical and microscopic study of the free and attached
Gingiva. J Periodontol 1996; 37:5.
4. Bartold PM, Narayanan AS: biology of periodontal connective tissue. Chigao quintessence 1998.
5. Bowers. G, M. A study of the width of attached gingiva. Journal of Periodontology ,1963; 47:412-414
6. Voigt JP, Goran ML, Flesher RM. The width of lingual mandibular attached gingiva. J periodontol. 1978; 49:77-80.
7. Ainamo A: Influence of age on the location of the maxillary Mucogingival Junction. J Periodont Res 1978; 13:189.
8. Ainamo A, Ainamo J: The width of attached gingiva on Supraerupted teeth. J Periodont Res 1978; 13:194.
9. Ainamo j, talari A: the increase with age of the width of attached ginigva.j periodontal Res1976; 11:182.
10. Anna Andlin-Sobocki, Changes of facial gingival dimensions in children A 2-year longitudinal study. Journal of Clinical
Periodontology March 1993; 20(3):212-218,

85. 11. Hall WB. Can attached gingiva be increased nonsurgically? Quintessence Int, 1982; 4: 455-462,
12. Friedman M.T. Barber PM, Mordan NJ, Newman HN. The ‘‘plaque-free zone’’In health and disease: a scanning electron
microscope study. J Periodontol. 1992; 63:890-896
13. Lang, N.P. &Loe, H. 1972. The relationship between the width of keratinized Gingiva and gingival health./, Periodontol.43:
623-627.
14. Hall W.B. Present status of soft tissue grafting. J Periodontol 1977;48:587-97.
15. Ericsson I, Lindhe J. Recession in sites with inadequate width of the keratinized gingiva. An experimental study in the dog.
Journal of Clinical Periodontology 1984; 11:95-103.
16. Miyasato M, Crigger M, Egelberg J, Gingival condition in areas of minimal and appreciable width of keratinized gingival. J
Clin Periodontol. Aug 1977; 4(3):200-9.
17. James RA, Schultz RL: Hemidesmosome and the adhesion of junctional epithelial cells to metal implants a preliminary
report, J Oral Implantology; 1974; 4:294.
18. Schroeder, H.E. &Listgarten, M.A. (1997). The gingival tissues: the architecture of Periodontal protection. Periodontology
2000; 13: 91-120.
19. Mehdi Adibrad, Mohammad Shahabu, MahastiSahabi, significance of the Width of Keratinized mucosa on the health
status of the supporting tissue Around implants Supporting overdentures journal of Oral Implantology. 2009; 35(5) .
20. AdellR, LekholmU, RocklerB, Branemark P-I, Lindhe J, Eriksson B, Sbordone L. Marginal tissue recession at
osseointegrated titanium fixture (I).A 3-year longitudinal prospective study. Int J oral maxillofacial surgery.1986; 15: 53-61.

86. 21. Meffert RM, Langer B, Fritz ME: Dental implant: a review, J Periodontol.1992; 63: 859-870.
22. Ono Y, Navins M. Capetta M: The need for keratinized tissue for implants. In Nevins M, 2009Mellonig JT, editors:
Implant therapy, Chicago, 1998, Quintessence.
23. Gosalind GD, Robertson PB, Mahan C J, Morrison WW, Olson JV. Thickness Of facial ginigva JP. 1977; 48(12):768-71.
24. Claffey N, Shanley D, Relationship of gingival thickness and bleeding to loss Of probing attachment in shallow sites
following nonsurgical periodontal therapy. J Clin Periodontal 1986;13: 654-657.
25. Wilderman, M.N. Exposure of bone in periodontal surgery. Dental Clinics of North America March, 1964; 23-26.
26. P C Haggerty, The use of a free gingival graft to create a healthy environment for full crown preparation. Case history.
Periodontics 01/1966; 4(6):329-31.
27. Freidman, N.mucogingival surgery .The Apically repositioned flap. Journal of periodontology 33,328-340.
28. Stetler K, Bissada NF: significance of the width of keratinized gingiva on the periodontal status of teeth with
submarginal restoration, J Periodonto, l1987; 58:696-700,
29. Goldman H. Periodontal therapy. 6th ed. St. Louis: CVMosby; 1979; 5.
30. Carranza Jr FA, Carraro JJ. Mucogingival techniques in periodontal surgery. Journal of Periodontology 1970; 41:294-9.