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Attached gingiva: Histology and surgical augmentation

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Periodontics
CDE
2 HOURS
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Attached gingiva: Histology and


surgical augmentation
Se-Lim Oh, DMD, MS

The keratinized attached gingiva provides the periodontium with gingiva effectively and predictably. The newly obtained keratinized
increased resistance to external injury, contributes to the stabiliza- gingiva can be maintained for a long period; in addition, these
tion of the gingival margin, and aids in dissipating physiological periodontal procedures halt the progression of gingival recession
forces exerted by the muscular fibers of the alveolar mucosa and could lead to gaining more keratinized gingiva from creeping
on the gingival tissues.1 Increasing attached gingiva should be attachment after the surgery. This article reviews the biology of
strongly considered in cases where the patient’s plaque control attached gingiva and presents cases related to the functional role
is compromised. The apically positioned flap, free gingival graft, of periodontal plastic surgery.
and subepithelial connective tissue graft are the most common Received: July 14, 2008
surgical procedures used for augmenting the zone of attached Accepted: August 11, 2008

T
he keratinized gingiva includes rationalized the introduction of periodontal treatment that involves
both free and attached gingiva numerous surgical procedures to mucogingival surgery, there are
and extends from the gingival increase the width of attached gin- some indications for surgical inter-
margin to the mucogingival junction. giva.3 However, more recent studies vention.4-6 Mucogingival surgical
Histologically, the attached gingiva have challenged this notion.4-6 procedures should be strongly con-
is better suited than nonkeratinized As people age, the width of sidered when the patient’s plaque
mucosa to withstand mechanical the band of anatomical attached control is compromised. For teeth
irritations.2 The epithelium of gingiva continues to increase due to with little or no attached gingiva
attached gingiva is keratinized and the continuous compensatory erup- that require prosthetic restorations
has thin, prominent epithelial ridges. tion of teeth. As a result, the width or orthodontic treatment or have
The connective tissue contains no of keratinized gingiva will continue an abnormal frenal attachment, the
elastic fibers. These characteristics are to increase unless there is a concur- zone of the attached gingiva must
exactly the opposite of the histology rent reduction in height of the be increased.7 Attached gingiva also
of alveolar mucosa. gingival tissue due to periodontal needs additional width when the
The width of the keratinized breakdown.4,5 pocket depth extends beyond the
gingiva may vary from 1–9 mm.3 According to Wennstrom, the lack alveolar mucosa.
A 1972 study by Lang and Loe of a minimal amount of attached
reported that even when tooth gingiva does not necessarily result Surgical procedures to
surfaces are kept free of clinically in soft tissue recession.6 The narrow increase attached gingiva
detectable plaque, areas with less attached gingiva apical to a localized One of the earliest surgical tech-
than 2 mm of keratinized gingiva recession is a result of the recession niques designed to correct the lack
(which means less than 1 mm rather than a cause.6 Proper plaque of attached gingiva was the apically
of attached gingiva) remained control technique prevents soft repositioned flap.8,9 This technique
inflamed.3 Such persistent tissue recession, even without an allowed surgeons to increase or pre-
inflammation did not correlate adequate zone of attached gingiva.6 serve the existing attached gingiva
with muscle pulling from by moving the tissue apically or by
frenum insertions. When to consider increasing exposing a variable band of crestal
Lang and Loe strongly sug- attached gingiva bone, depending on how much
gested that an adequate width of While the implications of find- attached gingiva was desired.10
keratinized gingiva is important for ings from previous studies should A free gingival graft (FGG) refers
maintaining gingival health and be considered when planning to grafting of a piece of gingiva

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Periodontics  Attached gingiva

Fig. 1. A patient with no clinical crown but Fig. 2. The patient in Figure 1, after the pre- Fig. 3. The patient in Figure 1 eight weeks
adequate keratinized gingiva on tooth No. 6. existing gingival margin was sutured apically. later, upon receiving the final prosthesis.

(including the keratinized epithe- keratinized alveolar mucosa. The bone loss. Class IV refers to severe
lium and periodontal connective gingival CTGs were covered with recession with accompanying severe
tissue) to the recipient site after keratinized epithelium, displaying bone loss. Interdental bone loss,
it has been detached completely the same characteristics as those soft tissue loss, and tooth extrusion
from the donor site.11 Prior to the found in normal gingival epithe- can prevent placement of a gingival
re-establishment of vascularization, lium, while the alveolar mucosa graft at the cementoenamel junction
the FGG survives by consuming transplants were covered with non- (CEJ) and thus make complete root
nutrients from the cut blood vessels keratinized epithelium.13 coverage nearly impossible.
of the recipient site into the graft. The success of subepithelial
By the second day, the blood supply CTGs has been attributed to Case report No. 1
is re-established in the graft through the double blood supply at the A 37-year-old man needed a clini-
anastamosis; it continues to mature recipient site from the underlying cal crown-lengthening procedure
for the next 28 days.11 connective tissue base and the over- on tooth No. 6, which was going
The subepithelial connective tissue lying recipient flap.12 Compared to serve as an abutment for a
graft (CTG) refers to submerging to an FGG, a subepithelial CTG four-unit bridge spanning teeth
gingival connective tissue (without offers minimal palatal denudation No. 6–9 (Fig. 1). Tooth No. 6 had
covering epithelium) under a par- (and thus smoother postoperative 3 mm pocket depth. Upon bone
tial-thickness flap or in a prepared healing) and a closer color blend sounding, the tooth required only
gingival pouch. This procedure can of the graft with adjacent tissue, soft tissue reduction and not an
be used to treat isolated or multiple avoiding the “keloid” healing pres- ostectomy; however, a gingivec-
root exposures (in combination ent with FGGs. tomy would leave the tooth with
with minimal attached gingiva) little or no attached gingiva. Since
and recession adjacent to an eden- Recession beyond the tooth No. 6 had enough attached
tulous area that also requires ridge mucogingival junction gingiva, an apically positioned flap
augmentation.12 According to Miller, marginal was chosen to preserve the kerati-
Gingival connective tissue is tissue recessions can be divided nized zone.
capable of inducing the formation into four classifications.14 Class I Using two vertical release inci-
of keratinized gingival epithelium.13 refers to recession that is coronal sions, a crevicular incision was made
A 1975 study by Karring et al to the mucogingival junction with around the labial surface and a split-
investigated the role of gingival no interproximal bone loss. Class thickness flap was reflected. The pre-
connective tissue in determining II refers to recession apical to the existing gingival margin was sutured
the differentiation of the overlying mucogingival junction with no adja- apically (Fig. 2). After eight weeks,
epithelium. Free grafts of connec- cent interproximal bone loss. Class the patient had an optimal zone of
tive tissue, without epithelium, III describes recession apical to the attached gingiva with 2 mm pocket
were transplanted from either the mucogingival junction with mild depth and the final prosthesis was
keratinized gingiva or the non- to moderate adjacent interproximal made (Fig. 3).

382 July/August 2009 General Dentistry www.agd.org


Fig. 4. A patient whose labial frenum extended Fig. 5. The patient in Figure 4, after the donor Fig. 6. A photo of the patient in Figure 4
into the marginal gingiva of tooth No. 25. tissue was sutured in place. taken two weeks postoperatively, showing an
increased zone of attached gingiva.

Fig. 7. A patient who had a muscle pulling on Fig. 8. The patient in Figure 7, after donor Fig. 9. The patient in Figure 7 three months
tooth No. 21 and no attached gingiva on tooth tissue is secured by suture. later, after the final restoration is placed.
No. 20.

Case report No. 2 with 1–2 mm pocket depths on Case report No. 4
A 44-year-old woman had a labial both teeth (Fig. 7). In addition, A 51-year-old woman had 5 mm
frenum extending into the marginal tooth No. 20 needed clinical crown of recession on tooth No. 24 and
gingiva of tooth No. 25 with 1 mm lengthening. The initial crevicular 2 mm of recession on tooth No.
pocket depth (Fig. 4). The recipient incisions were made on the buccal 25, with the loss of interproximal
site was prepared by making a hori- and lingual sides. A split-thickness papillae (Fig. 10). A radiograph
zontal split-thickness incision just flap was reflected on the buccal showed interproximal bone loss
above the mucogingival junction. side to receive an FGG and a between teeth No. 23, 24, and 25
The horizontal incision was sufficient full-thickness flap was reflected (Fig. 11). The recession on tooth
to remove all muscle insertion from on the lingual side for the clinical No. 24 was apical to the muco-
the frenum. The palatal gingiva crown-lengthening procedure. The gingival junction. Based on Miller’s
was used as the donor site and the ostectomy was completed on the classification, only partial root
graft was sutured in place (Fig. 5). lingual side and the donor tissue coverage could be expected.
This FGG increased the width of from the palate was secured on A horizontal incision was made
attached gingiva and prevented the buccal side (Fig. 8). The final at the level of interproximal bone
further recession from the abnormal restoration was placed three months (from the distal of tooth No. 22 to
frenum attachment (Fig. 6). later. Since the incision design the distal of tooth No. 27) and sharp
removed the entire zone of attached dissection was performed to create
Case report No. 3 gingiva, there was no keloid healing a partial-thickness flap. The donor
A 40-year-old woman had a muscle line between the previously existing tissue taken from the palate was
pulling on tooth No. 21 and no attached gingiva and the new graft covered by the flap and stabilized
attached gingiva on tooth No. 20, tissue (Fig. 9). with interrupted sutures (Fig. 12).

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Periodontics  Attached gingiva

unpredictably after the healing


of FGGs.18 Based on the author’s
experience, FGG procedures could
provide better esthetics by avoid-
ing the keloid line between the
previous gingiva and the new graft
tissue (Fig. 9).
Despite these positive aspects,
attempts to cover areas of deep,
Fig. 10. A patient with recession on teeth No. Fig. 11. A radiograph of the patient in Figure wide gingival recession with FGG
24 and 25 and a loss of interproximal papillae. 10, showing interproximal bone loss between procedures were unpredictable
teeth No. 23 and 25. for many years.19 A 1983 study
by Holbrook and Ochsenbein
reported that FGG provided
complete root coverage in 22 of
50 cases (44%).20 Ten years later,
Jahnke et al reported a mean root
coverage of 43% following FGG.21
Although Miller demonstrated
that successful root coverage was
possible for Class I and Class II
recessions, root coverage was not
Fig. 12. The patient in Figure 10, after the Fig. 13. The patient in Figure 10, four months the immediate and primary goal of
donor tissue was stabilized with interrupted after treatment. FGG procedures.14,19,22
sutures. Gingival recession related to
periodontal disease or developmen-
tal problems can result in trapped
plaque, root sensitivity, root caries,
and esthetic compromises. Langer
Figure 13 shows postoperative heal- recession is the major risk from an and Langer described a subepithe-
ing after four months. A zone of apically positioned flap, this pro- lial CTG technique for root cover-
attached gingiva (with 2 mm pocket cedure is recommended primarily age in which a partial-thickness flap
depths) was created around the labial when pocket depth exists or when with two vertical incisions was used
side of tooth No. 24. a gingivectomy could remove all or to prepare the recipient site.12
most of the attached gingiva. In the cases presented here, the
Discussion One of the most common subepithelial connective tissue
Depending on the patient’s situa- approaches for gingival aug- procedure was performed according
tion, various techniques can be per- mentation, the FGG procedure to Bruno’s technique, in which only
formed to increase attached gingiva has proven to be efficient and a horizontal incision is made to
effectively. An apically positioned predictable for increasing the apico- prevent cicatricial lines and avoid
flap should be the first choice when coronal dimension of attached compromising the blood supply.19
attached gingiva is available. The gingiva.7,15,17 A 2008 retrospective Several studies have shown
apically positioned flap has been study reported that FGGs provided that the subepithelial CTG is a
used for gingival pocket reduction long-term (10–25 years) stability.17 predictable procedure for obtain-
while preserving or increasing kera- One potential advantage of FGGs is ing esthetic root coverage.23,24 A
tinized attached gingiva. Studies that postoperative migration of the 2002 study reported that the root
have proven that apically positioned gingival marginal tissue in a coro- coverage (measured by reduction of
flap techniques can establish nal direction may occur and cover gingival recession) gained from a
adequate zones of attached gingiva a previously denuded root surface subepithelial CTG was maintained
without deforming the dentogingi- partially or even totally; however, for a long period (mean 27.5
val junction.1,10,15,16 Because gingival such “creeping attachment” occurs months). There was a statistically

384 July/August 2009 General Dentistry www.agd.org


significant increase in the mean Author information 13. Karring T, Lang NP, Loe H. The role of gingival
root coverage between the short- Dr. Oh is an assistant professor, connective tissue in determining epithelial dif-
ferentiation. J Periodontal Res 1975;10(1):1-11.
term follow-up (97.1%) and the University of Maryland Dental 14. Miller PD Jr. A classification of marginal tissue
long-term follow-up (98.4%).25 The School in Baltimore. recession. Int J Periodontics Restorative Dent
fact that the mean root coverage 1985;5(2):8-13.
15. Fagan F. Clinical comparison of the free soft tis-
improved with time supports the References sue autograft and partial thickness apically po-
concept of creeping attachment 1. Carnio J, Camargo PM, Passanezi E. Increasing sitioned flap—Preoperative gingival or mucosal
the apico-coronal dimension of attached gingi- margins. J Periodontol 1975;46(10):586-595.
when autogenous soft tissue grafts va using the modified apically repositioned flap 16. Dordick B, Coslet JG, Seibert JS. Clinical evalua-
are used.25 Based on the signifi- technique: A case series with a 6-month follow- tion of free autogenous gingival grafts placed
cant decrease in recession and an up. J Periodontol 2007;78(9):1825-1830. on alveolar bone. Part II. Coverage of nonpatho-
2. Lozdan J, Squier CA. The histology of the muco- logic dehiscences and fenestrations. J Periodon-
increase in the quantity of kerati- gingival junction. J Periodontal Res 1969;4(2): tol 1976;47(10):568-573.
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thelial CTG is recommended when 3. Lang NP, Loe H. The relationship between the Prato G. Free gingival grafts to increase kerati-
width of keratinized gingiva and gingival health. nized tissue: A retrospective long-term evalua-
root coverage is attempted.21,25 J Periodontol 1972;43(10):623-627. tion (10 to 25 years) of outcomes. J Periodontol
4. Ainamo J, Talari A. The increase with age of the 2008;79(4):587-594.
Summary width of attached gingiva. J Periodontal Res 18. Matter J. Creeping attachment of free gingival
1976;11(4):182-188. grafts. A five-year follow-up study. J Periodontol
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16(6):595-599. Restorative Dent 1994;14(2):126-137.
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in this article presented situations width of attached gingiva and development of of the denuded root surface with a one-stage
in which the apically positioned soft tissue recession. A 5-year longitudinal gingival graft. Int J Periodontics Restorative
study. J Clin Periodontol 1987;14(3):181-184. Dent 1983;3(3):8-27.
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J Periodontol 1954;25:38-39. tol 1993;64(4):315-322.
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Acknowledgements attached gingiva using a modified apically repo- dontol 1996;1(1):671-701.
The author thanks Dr. Robert Sachs sitioned flap. J Periodontol 1999;70(9):1110- 24. Bouchard P, Malet J, Borghetti A. Decision-mak-
for his assistance with writing this 1117. ing in aesthetics: Root coverage revisited. Perio-
11. Serio FG, Hawley CE. Lexi-Comp’s manual of dontol 2000 2001;27:97-120.
article. clinical periodontics: A reference guide for diag- 25. Harris RJ. Root coverage with connective tissue
nosis & treatment, ed. 2. Hudson, OH: Lexi- grafts: An evaluation of short- and long-term
Disclaimer Comp;2002:95. results. J Periodontol 2002;73(9):1054-1059.
12. Langer B, Langer L. Subepithelial connective
The author reports no conflicts of tissue graft technique for root coverage. J Perio- Published with permission by the Academy of
interest related to this study. dontol 1985;56(12):715-720. General Dentistry. © Copyright 2008 by the
Academy of General Dentistry. All rights reserved.

www.agd.org General Dentistry July/August 2009 385

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