Journal of Clinica!

Periodontoiogy 1982; 9: 75-85

Key words: keratinized giiK'^a - gingivitis - denial plaque.
Accepted for publication Januarj' 2S, 1981

The role of keratinized gingiva in

plaque-associated gingivitis in dogs
JAN WENNSTROM, JAN LINDHE AND STURE NYMAN

Department of Periodontoiogy, School of Dentistry, University of Goteborg, Goteborg, Sweden

Abstract. The present experiment was designed to examine if a dento-gingival unit with a wide zone of
keratinized gingiva (ICG) provides a more efficient sea! against plaque infection than a unit with a
narrow zone of KG or lack of such gingiva. Five beagle dogs were used. In a preparatory experiment
three categories of gingival units were established in each dog, namely (I) regenerated gingiva with a
wide zone of KG (healed following a "flap" procedure), (2) regenerated gingiva with an "insufficiently"
wide zone of KG (healed following a "gingivectomy" procedure), and (3) non-operated control gingiva
with a normal zone of KG. Clinical and histological examinations carried out at the end of the
preparatory period revealed that all gingival units, non-operated as well as regenerated units, met the
criteria of health. All tooth-cleaning meastires were abolished. After 40 days ofplaque accumulation the
clinical examination (Plaque Index, Gingival Index and Gingival Exudate) was repeated and biopsies
were sampled. Following preparation the biopsy material was subjected to histometric and mor-
phometric analysis, r h e results showed that the free gingiva of units with wide and narrow zones of KG
responded to microbial colonization by an inflammatory reaction, the location and extension of which
did not vary with the width of the keratinized gingiva. It wasconcluded that, in the presence of plaque, a
dento-gingival unit with a narrow zone of, or with lack of, gingiva has an equal capacity for
inflammatory response against plaque infection as a unit with a wide zone of KG.

It has been assutned that the absence of a
"sufficietitly" wide zone of keratinized gingiva is
incompatible with gingival health and main-
tained attachment level. This assumption is
derived from clinical observations iti individual
cases of aggravated signs of gingival inflam-
mation and/or recession in localized areas
devoid of keratinized gingiva (for review see
Wennstrom et al. 1981). Elaborate surgical
methods have been introduced to transplant
gingiva to sites deprived of such tissue.
Recently Hangorsky & Bissada (1980) re-
ported frotn clinical trials that grafted sites in
patients with proper oral hygiene did not ex-
hibit lower gingivitis scores than non-grafted
control sites with "insufficient" width of ging-
iva. Furthermore, a relationship between "the
width of attached gingiva and the state of
periodontal health" could not be ascertained
(Hangorsky & Bissada 1980). In another trial,
Dorfman et ai. (1980) studied the effectiveness
of gingivai grafts for the maintenance of the
attachment apparatus. Grafts were placed on
one of the bilateral areas with inadequate
attached gingiva while the contralateral area
served as control. The patients were enrolled in
a supervised maintenance program and the
results were evaluated after 2 years. "Both ex-
perimental (grafted) and control (unoperated)
sides showed marked reduction in the Gingival
Index and Plaque Index. Neither side demon-
strated further attachment loss. It would appear
that minimizing inflamtnation is sufficient to
maintain attachment levels despite the width of
keratinized, attached gingiva" (Dorfman et al.
1980).

0303-6979/82/010075-11 S02.50/0 © 1982 Munksgaard, Copenhagen

76 WENNSTROM, LINDHE AND NYMAN
In most respects, these findings are eompat-
ible with results from experiments recently
reported from our laboratory (Wennstrom et al.
1981).Hence, a study in the dog was undertaken
to determine whether subsequent to surgical
exeision of an advanced periodontal lesion, the
regenerated gingiva differed from that of a
normal, non-inflamed gingiva. Two different
modes of surgical exeision were used - a "flap"
procedure, in which the main part of the
keratinized tissue was preserved, and a "ging-
ivectomy" procedure in whieh the entire zone of
keratinized gingiva was removed. Healing was
evaluated after 120 days of meticulous plaque
control. The results showed that subsequent to
exeision of the periodontal lesion, a new free
gingiva developed, the structural composition
of which was, in most respects, similarto that of
a normal, non-inflamed gingiva. In addition,
the regenerated gingiva was free from clinical
and histologieal signs of inflammation inde-
pendent of absence or presence or width of the
keratinized zone.
The trials and experiment reported above
demonstrate that, provided plaque infection is
prevented, there seems to be no requirement for
presence of a zone of keratinized gingiva for the
maintenance of periodontal health. It remains
to be determined, however, if a dento-gingival
unit with a wide zone of keratinized gingiva
provides a better seal against plaque infection
than a unit with a narrow zone of keratinized
gingiva or lack of such gingiva. The present
experiment was designed to study this problem.
Material and Methods
The experimental procedure preceding the start
of the present study was described in detail by
Wennstrom et al. (J981). Five beagle dogs were
used. The teeth of the dogs were cleaned once
daily with toothbrtish and dentifrice in order to
establish healthy gingivae. Periodontal tissue
breakdown was subsequently induced on the
right side of the jaws {experimental side) by
placing cotton floss ligatures in a subgingival
position around the maxillary and mandibular
second, third and fourth premolars and the
mandibutar first molar (1i;'3;'2P,iM), and by allow-
ing plaque to accumulate. After 150 days of
progressive periodontal tissue breakdown,
when approximately 40% of the supporting
apparatus had been lost, the inflamed perio-
dontal tissues were removed, employing a
"gingivectomy" procedure in one of the experi-
mental jaw quadrants and a "flap" procedure in
the other. In the "gjngiveetomy" procedure all
keratinized gingiva was removed, while with the
"flap" procedure the main part of this tissue was
preserved. Following surgery, the mechanical
tooth-cleaning program was reinstituted and
continued for a period of 120 days. On the left
side of the jaws (non-operated control), the
plaque control program was maintained during
the entire 270-day period.
At the end of this period (in the present study
denoted Day 0), the following clinical para-
meters were recorded at the buecal surface of all
experimental (operated) teeth and contralateral
(non-operated) control teeth:
1) Plaque Index (Pil) - according to Silness &
Loe (1964)
2) Gingival Index (GI) - according to Loe &
Silness (1963)
3) Gingival exudate (GE) - the orifice tech-
nique (Loe & Holm-Pedersen 1965)
4) Width of the keratinized gingiva (WKG) -
the distance from the gingival margin to the
muco-gingival junction was measured with a
standardized periodontal probe to the near-
est 1 mm.
Al! assessments were confined to the mid-
buccal part of both roots of all test and control
teeth. Immediately after the clinical assessments,
biopsies were obtained from the following teeth
on experimental and control sites: "P'', ' P ' , 3P3.
2P2 in dogs 1,3 and 5; ' P ' , ^P^ sM,, 4P* in dogs 2
atid 4.
Following biopsy on Day 0 all tooth-cleaning
measures were abolished on both sides of the
jaws. After 40 days of plaque accumulation the
 KERATINIZED GINGIVA - GINGIVITIS
alCT
HFG
CTA
Fig. I. Schematic drawing illustrating the various
linear distances which were measured in the hisEo-
logical sections. SD = sulcus depth, aICT = apical
extension of the infiltrated connective tissue, HFG =
height of the free gingiva, WFG = width of the free
gingiva, CTA = length of the supracrestal connective
tissue attachment, Jgm and Ti. are location points,
JE = the apical border of the junctional epithelium.
Schematische Skizze zur Darstellung verschiedener
linearer Absidnde, die in den histologischen Schnitten
vermessen wurden. SD — Tiefe des Sulkus. alCT—
apikale Ausdehnung infiltrierten Bindegewehes.
HFG = Hohe der freien Gingiva. W-'f 6'= Breite der
freien Gingiva, CTA =Lange des supraalveolaren.
bindegeweblichen Attachments. T^ undTt, sind Orien-
tierungspunkte, JE~die apikale Grenze des Epithel-
ansatzes.
Representation schematique des differentes distances
Hneaires mesurees sur les coupes hi.stotogiques. SB ~
profondeur du sillon gingival, alCT= etendue du tissu
conjonctif infihre en direction apicaie. HFG=hauteur
de la gencive libre, WFG^largeur de ia gencive libre.
CTA = longueur de I'attachement de tissu conjonctif au
dessus de la crete osseuse. Tg^ et Tb sont des points de
repere. JE=limite apicale de I'epithelium de jonction.
clinical examination was repeated and biopsies
were harvested from all remaining test and
control teeth.
The biopsy procedures were carried out ac-
cording to the technique described by Schroeder
°t al. (1973) and the excised specimens were
processed in the manner previously described
t>y Wennstrom et al. (1981). The histologica!
examination was carried out in the light micro-
77
scope. A total of 160 experimental and 160
control sections from Day 0, and 120 experi-
mental and 120 control sections from Day 40
were examined. In each section the following
distances (Fig. 1) were measured (obj. X 20) and
expressed in microns (f<m):
1. The height of the free gingiva (HFG); i.e. the
gingivai margin (Tgm) - the apical border of
the junctional epithelium (JE)
2. The sulcus depth (SD); i.e. T,™ - the most
coronally located cells of the junctional
epithelium
3. The width of the free gingiva at its base
(WFG); i.e. JE - the surface of the oral
epithelium (Tb)
4. The length of the supracrestal connective
tissue attachment (CTA); i.e. JE - the crest
of the alveolar bone.
5. The apical extension of the infiltrated con-
nective tissue (alCT); i.e. Tgm - the apical
border of the infiltrated connective tissue.
In each section representing the free gingiva, a
morphometric point-counting procedure
(Weibel 1969, Schroeder & Munzel-Pedrazzoli
1973) was used (Level I; obj. X 20, Grid P42) to
determine the percentage volume of oral epi-
thelium (OE), junctional epithelium (JE), non-
infiltrated connective tissue (NCT)andconnect-
ive tissue infiltrated with inflammatory cells
(ICT).
The histologicai sections were also analyzed
for the presence of leucocytes within the junct-
ional epithelium. With the use of a microgrid
the junctional epithelium was divided into three
portions of equal length: a marginal (MA), a
middle (MI) and an apical (AP) portion and the
number of leucocytes within each of the three
portions was determined (OIDJ.XIOO, ocularX
10).
The histological assessments were carried out
by a person, unaware of the design of the
experiment. In each dog, the percentage dis-
tribution of Plaque and Gingival Index scores 0,
1, 2 and 3 and the mean value for all other
parameters were calculated for control, "flap".
78 WENNSTROM, LINDHE AND NYMAN

n.*aUE INDEX SCORES GmOIVAL INDEX SCORES

•I F 0 M s H F G
E

DAYO DAY 40 DAYO DAY 40

H: HON-OPEIMTED UNITS

•EOCNCIIATED UNITS
F '. -FLAP"

Fig. 2. Mean percentage number of tooth surfaces with Plaque Index scores 0,1, 2 and 3 and gingival units with
Gingival Index scores 0, 1, 2 and 3 on Days 0 and 40 for the three categories of units,
Mittlere Anzaht Zahnoberflachen inProzent mit den Beurteiltmgseinheiten (scores) 0. 1. 2 und3 desPlatjueind
sowie Gingivaleinheiten mit den scores 0. 1. 2 und 3 des Gingivalindexes. an den Tagen 0 und 40 bei den
Kategorien dieser Einheiten.
Pourcentage moyen du nombre defaces dentaires ayant les scores 0.1, 2 et 3 pour I'indice de Plaque etdu nombr
localisations gingivaies ayant les scores 0. I. 2 et 3pour I'indice Gingival atix Jours Oet 40. pour chaeune d
categories de localisations.

and "gingiveetomy" utiits, respectively, and

tjsed in the statistical analysis. Differences Results
between the three groups of units were analyzed Clinicat assessments
using Student's t-test. The results of the clinical assessments are
presented in Table 1 and Fig. 2. At the start of
the present observation period (Day 0) there
Table I. Amount of Gingival Exudate on Days 0 and were no marked differences regarding the
40. Mean value and standard error amount of plaque and the condition of the
Menge des gingivalen Exsudates an den Tagen 0 und 40.gingivae between the non-operated controls
Mittelwert und Stattdardirrtum and the units which had been surgically treated
Quantites dExsudat Gingival aux Jours 0 et 40. Valeur with "flap" or "gingivectotny" procedures. As a
moyenne et erreur-type result of the careful plaque control program all
DayO Day 40 buccal tooth surfaces studied were free from
Units (mm) (mm) clinically detectable plaque and 93-96% of the
Non-operated Traces L8±0.8 adjacent gingival units were classified as clinic-
Regenerated ally healthy (GI=O; Fig. 2). The remaining 4-
a) "Flap" 0.1±0,l 2.8±I.O
0.2±0.2 3.1 ±0,9* 1% ot the gingival units showed only minute
b) "Gingiveetomy"
signs inflammation (GI= 1). For all groups of
• "Gingiveetomy" vs non-operated /'<0.01 units, the Gingival Exudate values were close to
Units {Einheiten. localisations), non-operated (nicht-
operiert, non-opirees), regenerated (regeneriert. re-zero (Tabie 1). There were no significant dif-
generies). ferences between the three categories of units
 KERATINIZED GINGIVA - GINGIVITIS 79

regarding the i'rcquency of GI score 0 and the amount of Ginigval Exudate sampled on Day
amount of Gingival Exudate. 40 was slightly larger in the two regenerated
Table 2 gives the results from the ciinical ("flap" and "gingivectomy") groups than in the
measurements of the width of the keratinized non-operated controls (2.8 and 3.1 vs 1.8; Table
gingiva (WKG) from the teeth which remained 1). The difference regarding atnount of Gingival
after biopsy on Day 0. The mean WKG was 4.2 Exudate on Day 40 between the "gingivectomy"
mm for non-operated units, 3.7 mm for "flap" and the non-operated units was statistically
units and 1.6 mm for "gingivectomy" units. All significant {P<0.0\).
non-operated and all "flap"-treated units had a The clinical data describing the condition of
keratinized zone of gingiva of 3 mm or more the gingivae (Gingival Index scores and Ging-
whereas the WKG of all "gingivectomy" units ival Exudate values) on Day 40 are ptesented in
was 2 mm or less. Fig. 3 in relation to varying WKG values. For
The reexamination, perfortned at the end of the regenerated units (Reg; Fig. 3), there was a
the 40-day period of no tooth-eleaning, showed tendency towards more pronounced clinical
that the dogs had accumulated plaque and signs of gingivitis with decreasing WKG.
developed clinical signs of gingival inflam- Furthermore, regenerated units with a zone of
mation (Fig. 2). The amount of plaque fortned gingiva of 3 mtn or more ( = "nap" units) tended
was similar lor non-operated and regenerated to receive higher GI scores and larger Exudate
units. Thus, 64-69% ofthe buccal tooth sur- values than corresponding non-operated con-
faces in each of the three categories of units troi units.
examined harboured visible amounts of dental
deposits (Pll =2). The clinical signs of gingivi- Ilislologicat as.sessments
tis, however, showed marked differences be- The data obtained from the histometric assess-
tween the various gingival units. Thus, 70% of ments are presented in Table 3. Forty days of
the "gingivectomy" units teceived a Gingival plaque accumulation resulted in an increase of
Index score of 2. The corresponding figures for the height of the free gingiva (HFG) of around
the non-operated and "nap"-operated units 300//tn (312/nn in non-operated units, 324/nn
were 20 and 33%, respectively. The mean in "llap" units, 260/;m in "gingivectomy" units).

Table 2. Width of gingiva (WKG) and percentage distribution of gingival units with 0-6 mm of keratinized
gingiva in non-operated and regenerated sites (" llap" and "gingivectomy") on Day 0. Only those units have been
included which between Days 0 and 40 were subjected to plaque accumulation
Breile der Gingiva (WKG) und ptozenluale Verteilung gittgivaler Einheiten tnit 0-6 tntn keratini.sierter Gingiva in
nieht-operierteti und regenerierten Regionen (happen- und Gingivektomieoperatiott) atn Tage ft E.s werden nur
solehe Einheiten hier attfgefiihrt, die zwi.sehen detn Tage 0 und 40 der Plaqueansanutihtng ausgesetit wtirden.
Largeur de la geneive keratinisee (WKG) et di.stribution de.s loealLsations gittgivale.s avant 0-6 tntn de gencive
keratinisee dan.s le.s localisations noti-operces ou regenerces ("llap" = Uttnheau et "gingiveetotnie") au Jour ft Seules
onl cle considerees les localisations sur lesquelles la plaqtte s'etait aeeutttulee entre le Jour 0 et le Jour 40.
Percentage distribution
Units WKG(X±S.E.) 0 3 6 (mm)
Non-operated 4.2 ±0.2 - 20 43 30
Regenerated
a) "Flap" 3.7±0.1 - 31 69
b) "Gingivectomy" 1.6±0.2 29 64
X=mean value, S.E. =standard error {X = Millel\verl, S.E.=Standardirrliitn, X=valeur ttioyenne, S.E.=
erreut-type). Percentage distribution (j>rozentuale Verteilung. distribution (%)).
80 WENNSTROM, LINDHE AND NYMAN

GINGIVAL IWXX - fiAY 40 GMGtVAL EXUDATE - DAV 4 0

Fig, 3. Percentage number of gingival units with different Gingival Index scores (left diagram) and different
amounts of Gingival Exudate (right diagram) in reiation to the width of the keratinized gingiva on Day 40.
REG = regenerated units, N = non-operated units. The vertical lines indicate the number of gingival units with
<2, 2, 3 and > 3 mm of keratinized gingiva.
Anzahi gingiva/er Einheiien in Prozent mi! verschiedefien Gin^ivalindexscores (linkes Diagramm) und vcrsckied-
ener Menge gingivalen Exsudates frechrcs Diagramm) in Bezug auf die Brciie der keraiinisicnen Gingiva am
Versuckstage 40. REG=^ regenerierie Einheiien, N~nichl-opericrse Einheiien. Die venikalen Linien zeigen die
Anzahl gingivaler Einheiien mil < 2 . 2. 3 und >.? mm keraiinisierier Gingiva an.
Pourcentage moyen du nomhre de localisations gingivaies ayani differents seores pour i' Indice G ingival (diagramme
de gauche) et differentes quanlites d'Ex.sudai Gingivai (diagramme dc droite). par rapport a la largeur de la gencive
keratinisee au Jour 40. REG = localisations regenerees, A'= localisations non-operees. Les lignes venicales
indiquent le nombre de localisations gingivaies ayant < 2 , 2, 3 et > J mrt^ de gencive keratinisee.

Table 3. Results (in //m) from the histometric assessments of the gingival tissue on Days 0 and 40. Mean value
and standard error HFG ~ height of the free gingiva; SD = sulcus depth; WFG — width of the free gingivaat its
base; CTA = !ength of the supracrestal connective tissue attachment; alCT = apical extension of the infiltrated
connective tissue
Resuhate (in fim) hisiometrischer Beurteilung des gingivalen Gewehes an den Tagen 0 und 40. Miuehsert und
Standardirrtum. HFG—Hohe der freien Gingiva; SD = Sulkusiiefe; WFG~Breiie der freien Gingiva an ihrer
Basis; CTA—Ldnge des supraalveolaren bindegeweblichen Atiaehments; alCT—apikale Ausdeknunginfiltrierien
Bindegewebes
Resultats (en^m) des mesures histometriques des tissus gingivaux aux Jours 0 el 40. Valeur moyenne et erreur-type.
HFG~ hauteur de la geneive librc; SD=profondeur du siUon gingival: WFG ~ largeur de la gencive lihre a sabasc:
CTA~ longueur de Caltachement de tissu conjonctif au dessus de la crete osseuse: alCT~ etendue du tissu
conjonctif infiltre en direction apieale
Change Change alCI
Units HFG Days 0-40 SD Days 0-40 WFG CTA alCT HFO
Non-operated
DayO 1316± 42 264± 76 , ^,, 1106±36 720 ± 78 ND* 0,66
+ 312t
Day 40 1628± 96 480 ± 82 ^'^'^ 1132±54 740 ± 78 1068 ±72
Regenerated
a) "Flap"
Day 0 1622± 58 82 ± l!90±54 794±114 ND
Day 40 1946±148 388 ±120 '•'""' I28O±96 724±48 1278±140 0,6f
b) "Gingivectoray"
DayO 1380±I28 232 ± 26 ^ 718±64 814±i00 ND
Day 40 1640± 50 -rZW 640± 62 * 732±52 762 ±126 1232±108 0,7:
• ND = Not done
t PO.05
{ /•<0.001
Change {Verdnderung. changement).
 KERATINIZED GINGIVA - GINGIVITIS 81

Table 4. Percentage volume of oral epithelium (OE), junctional epithelium (JE), non-infiltrated connective
tissue (NCT) and connective tissue infiltrated with inflammatory cells (ICT) calculated from morphometric
analysis of non-operated and regenerated gingiva ("flap*" atid "gingivectomy") on Days 0 and 40. Mean value
and standard error
Prozentuales Votumen des oralen Epithets (OE), des Epithelansatzes (JE), nicht inftltrierten Bindegewebes (NCT)
und des mit Entziindungszetlen infiltrierten Bindegewebes (ICT), durch morphometrische Analyse far nicht-
operierte und regenerierte Gingiva CLappen" und "Gingivektomie') am Tage 0 und 40 errechnet. Mittelwert und
Standarirrtum
Volume (%) de I'epithelium buccal (OE), de I'epithelium de)onction (JE), du tissu conjonctifnon-inftltre (NCT) etdu
tissu conjonctif infihre de cellules inflammatoires (ICT), calcule d'apres 1'analyse morphometrique de la gencive
non-operee et de la gencive regeneree Cflap^ — lambeau et"gingivectomie'') auJour 0 et auJour 40. Valeur moyenne
et erreur-type
No. of points
Units OE JE NCT ICT counted
Non-operated
Day 0 32.2±0.9 7.9 + 0.6 59.4±0.6 0.5±0.3 251 ±10
Day 40 31.0±0.7 7.4±0.2 48.7±1.2 12.9+1.6 368 ± 4 3
Regenerated
a) "Flap"
Day 0 26.9±1.0 9.2±0.6 62.9±1.5 1.0+0.3 357 ±16
Day 40 25.5±1.2 8.7±0.2 48.0±I.5 17.8+2.4 540 ±80
b) "Gingivectomy"
Day 0 30.4±2.7 12.1±1.6 57.2±2.4 0.3±0.3 181±2!
Day 40 28.9±1.7 9.3±1.9 39.5±4.2 22.3 ±4.3 262 ±26
No. ol points counted (Anzahl gezdhlter Punkte. nombre de points comptes).

This increase was statistically significant for
non-operated units (/'<0.05) but not for the
regenerated units. The sulcus depth (SD) in-
creased with 216 fim in non-operated units and
with 306 /im and 408 /jm in "flap" and in
"gingivectomy" units, respectively. This in-
crease was statistically significant for the re-
generated units ("flap": P<0.05, "gingivect-
omy": P<0.0Ol). Only minute and statistically
insignificant alterations were observed between
Days 0 and 40 regarding the width of the free
gingiva (WFG) and the length of the sup-
racrestal connective tissue attachment (CTA) in
the three categories of gingivai units. The
•issessments of the extension of the infiltrated
connective tissue in apical direction (alCT)
revealed that the apical border of the ICT was
located at a distance from the gingival margin
of, on the average, 1068/im, 1278/im and 1232
'm in the non-operated, "flap" and "gingivect-
imy" units, respectively. Thus, the ICT in-
volved around two-thirds to three-fourths of
the height of the free gingiva. This difference in
spread of the infiltrate between the three cate-
gories of units was not statistically significant.
The composition of the free gingiva, i.e the
percentage volume distribution of various tis-
sue structures, is presented in Table 4and Fig. 4.
At the start of the study (Day 0), the overall
composition of the regenerated gingival units
was almost identical to that of the non-operated
gingiva. However, the size (number of points
counted) of the regenerated free gingiva was
significantly smaller following "gingivectomy"
(_P<0.05) and significantly larger following
"flap" surgery (P<0.05) than that of the non-
operated control gingiva (Table 4). The in-
filtrated portion of the connective tissue (ICT)
occupied only around 0.5% (0.3-1.0%) of the
various gingival units. On Day 40, the size of the
ICT, in comparison to the Day 0 value, was
increased in all three categories of units studied.
Furthermore, the size of the ICT in the re-
generated units ("Flap" - 17.8%; "Gingivect-
82 WENNSrROM, LINDHE AND NYMAN
COMPOSITION OF QWGIUIU. TISSUE
Fig. 4. Histogram illustrating the mean percentage
volume of the various gingival tissue components of
non-operated gingiva and regenerated gingiva follow-
ing "gingivectomy" and "flap" procedures on Days 0
and 40. ICT =^ connective tissue infiltrated with in-
flammator>' cells, NCT = non-infiltrated connective
tissue, JE=junctional epithelium and OE = oral epi-
thelium.
Histogramm das das mittlere Volumen (in Prozent) der
verschiedenen Komponenten nicht-operierter und re-
generierter Gingiva nach "Gingivektomie-" und"Lap-
penoperation". an den Versuchstagen 0 und 40 ver-
anschaulicht. lCT=mit Entzundungszellen infittriertes
Bindegewebe. NCT=nicht-infiltriertes Bindegewebe,
JE=Epithelansatz und OE=orales Epithet.
Histogramme illustrant le volume moyen (%} des
differents elements du tissu gingival de la gencive non-
operee et de la gencive regeneree apres "girtgivectomie"
et apres operation a lambeau ("flap^) aux Jours 0 et 40.
ICT— tissu conjonctif infiltre de cellules inflammat-
oires. NCT~ tissu conjonctif non-infiltre. JE~epithe-
lium de Jonction et OE=epithelium buccal.
omy" - 22.3%) tended to be larger than that of
the non-operated control units (12.9%). The
difference was, however, not statistically signif-
icant. There were no marked changes regarding
the percentage distribution of oral epithelium
and junctional epithelium between Day 0 and
Day 40 in the specimens examined.
The number of neutrophilic and mononu-
clear leucocytes present within the junctional
epithelium on Days 0 and 40 are presented in
Table 5. As a rule, the marginal (MA) and
middle (MI) portion of the junctional epi-
thelium harboured a larger number of leuco-
cytes than the apical (AP) portion. Assessments
made in the biopsy materiai from Day 0
revealed that there were no significant dif-
ferences between the three categories of units
regarding number of leucocytes per 100 /Am
length of junctional epithelium. All sections
representing Day 40 of the experiment con-
tained, in comparison to Day 0 sections, a larger
number of junctional leucocytes (5.6 vs 3.6,10.5
vs 4.9, 10.5 vs 4.2). This increase was mainly the
result of an increased density of inflammatory
cells in the marginal (MA) portion of the
junctional epithehum. The number of leuco-
cytes in this particular portion of the junctional
epithelium was significantly larger in regene-
rated units than in the non-operated controls
(P<0.01). Also the total number of leucocytes
residing within the junctiona! epithelium was
significantly larger in regenerated than in non-
operated units (P< 0.001).
Discussion
The present experiment was designed to exam-
ine whether a dento-gingival unit with a wide
zone of keratinized gingiva (KG) provides a
more efficient seal against plaque infection than
a unit with a narrow zone of KG or lack of such
gingiva. Hence, in a preparatory experiment
three categories of gingival units were establish-
ed, namely (1) regenerated gingiva with a wide
zone of KG (healed following a "flap" proce-
dure), (2) regenerated gingiva with an "in-
sufficiently" wide zone of KG (healed following
a "gingivectomy" procedure), and (3) non-
operated control gingiva with a normal zone of
KG. Examinations carried out at the end ofthe
preparatory period revealed that all gingival
units, non-operated as well as regenerated units,
met the criteria of health. Thus, most units
received a GI seore of 0 (Fig. 2) and the exudate
samples consistently showed only traces or
absence of gingival fluid flow (Table 1), The
histological analysis of the biopsy material
furthermore revealed that the noti-operated as
well as the regenerated gingival units were fret
from or contained only mitiute areas of inflam
matory cell infiltration (Table 4) and harbourec
few leucocytes in a junctional epithelium whict
was getierally devoid of rete peg formations
The three categories of healthy gingival units
 KERATINIZED GINGIVA - GINGIVITIS 83

Tabte 5. Number of leucocytes present within the junctional epithelium (Total) and within each of its three
subportions (MA = marginal, MI = middle, AP = apical) on Days 0 and 40, Mean number of leucocytes/100
IJtm of junctional epithelium and standard error
Leut<ozytenanzaht im Epithetansatz (Total) und innerhatb eines jeden seiner drei Unterabteilungen (MA = marginal,
MI=mtttlerer Abschnitt. AP=apikat) an den Tagen 0 und 40. Mittlere Leukozytenanzaht/IOO fim des
Epithelansatzes und Standardirrtum
Nombre de leucocytes presents dans I'epithetium de jonction (Total) et dans chaeune des trois portions de cet
epithetium (MA =marginatc. MI=moyenne. AP=apicale) aux .lours 0 et 40. Nombre moyen de leucocytes/100
fim d'epithelium de jonction et erreur-type
Units Total MA MI AP
Non-operated
DayO 3,6+0.9 4.3 + 0.6 4.6+0,2 2.2±0.3
Day 40 5.6 + 0.8 9.2+1.8 4,6+0,9 3,l±0.2
Regenerated
a) "Flap"
Day 0 4.9 + 0.7 8,2+1,9 4.4±0.8 2.0±0.7
Day 40 10.5 + 1.2' 22,1 ±2.8" 6.7 ±0.5 2.7±0,4
b) "Gingiveetomy"
Day 0 4.2±0.9 4.8 + 0.9 5.3±1,1 2.4±0.8
Day 40 10.5+0.6" 18.7+1.3'' 7.9 ±1,4 4,8±0.8
Regenerated vs non-operated (P<0,001)
Regenerated vs non-operated (/'<0,01)

however, differed markedly not only with re-
spect to the height and the width (Table 3) of the
free gingiva but also with regard to the thickness
of the keratin layer of the marginal oral epi-
thelium (Wennstrom et al. 1981).
After 40 days of plaque accumulation all
gingival units examined showed a varying de-
gree of clinical signs of inflammation. Fre-
quently the free gingiva of non-operated units
and/or regenerated units with a wide zone of
KG showed only slight changes in colour and
texture (GI score 1; Fig. 2) while the free gingiva
of regenerated units with a narrow ("insuf-
ficient") KG in three cases out of four were red,
oedematous and bleeding on gentle probing (GI
score 2), i.e. showed more pronounced clinical
signs of gingivitis. This observation may be
interpreted to indicate that a gingiva with a
narrow KG responds to plaque accumulation
with a more intense inflammatory reaction than
a unit with a wide KG. However, gingival
exudate measurements as well as morphomet-
rical and histometrical measurements of the
relative size and the apical extension of the
inflammatory cell infiltrate (Tables 1, 3 and 4)
in biopsies representing Day 40 of experiment-
ation yielded similar values for the two groups
of regenerated units. The finding that clinical
and histological parameters describing degree
of gingivitis do not always agree is in ac-
cordance with e.g. Zachrisson (1968), List-
garten & Fllegaard (1973), Schroeder et al.
(1973), Lindhe et al. (1978), and illustrates the
difficulties inherent in the interpretation of data
from clinical scorings. In the present com-
parison between clinical and histological
measurements regarding the inflammatory
response of the two categories of regenerated
gingival units certain differences concerning the
size and the structural composition of the free
gingiva of these units must be considered. Thus,
the free gingiva of units with a wide zone of KG
was almost twice as wide - in bucco-lingual
direction - as the free gingiva of units with a
narrow zone of KG (Table 3; 1280 fim vs 732
jim; /'<0.001). Furthermore, since the relative
size and the apical extension of the ICT of the
two types of free gingiva were similar, the
buccal border of the infiltrate must have been
located closer to the oral epithelium in the free
84 WENNSTROM, LINDHE AND NYMAN
gingiva of narrow KG units than in that of wide
KG units. Furthermore, the thickness of the
keratin layer of the marginal oral epithelium of
wide KG units was twice as wide as that of
narrow KG units (Wennstrom et al. 1981).
Taken together, i.e. variations regarding the
location of the inflammatory cell infiltrate in
relation to the oral epithelium and the thickness
of the keratin layer of this epithelium, these
discrepancies between the free gingiva of wide
and narrow KG units may explain the varia-
tions noted regarding clinical symptoms of
gingivitis in the two experimental units.
Biopsy material sampled at the end of the
preparatory period (Day 0) contained a junct-
ional epithelium with comparatively few poly-
morphonuclear and mononuclear leucocytes.
There was no difference between the three
categories of gingival units regarding the num-
ber of leucocytes per 100 fim length of junct-
ional epithelium. Biopsies obtained after 40
days of plaque accumulation contained in com-
parison to Day 0 biopsies a larger number of
junctional leucocytes. This increase, which was
mainly the result of a larger number of leuco-
cytes in the marginal portion of the juctional
epithelium, was more pronounced in regener-
ated than in non-operated control units. The
reason for this difference in reactivity between
regenerated and non-operated units - also
validated by the gingival exudate data (Table 1)
- is presently not understood but may be related
to variations in vascularity within the dento-
gingival connective tissue as suggested by
Lindhe et al. (1978). It should be observed,
however, that the variation in number of leuco-
cytes in the junctional epithelium of regenerated
units was unrelated to the width of the keratin-
ized gingiva.
The results of the present investigation de-
scribing the effect on the gingiva of 40 days of
plaque accumulation demonstrated that the
free gingiva of units with wide and narrow zones
of KG responded to microbial colonization by
an inflammatory reaction, the location and
extension of which did not vary with the width
of the keratinized gingiva. Previous studies
(Dorfman et al. 1980, Hangorsky & Bissada
1980, Lindhe & Nyman 1980, Wennstrom et al.
1981) have shown that in the absence of plaque
there seem to be no requirements for presence
or minimal width of keratinized gingiva for the
maintenance of periodontal health. The present
data indicate that, in the presence of plaque, a
dento-gingival unit with a narrow zone of
keratinized gingiva or with lack of such gingiva
has an equal capacity for inflammatory res-
ponse against plaque infection as a unit with a
wide zone of keratinized gingiva.
Acknowledgement
This investigation was supported by the Swed-
ish Medical Research Council, grant No.B 80-
24X-05247-03A.
Zusammenfassung
Die Rollc kcvaiiiti.sicrtcr Gini^iva bei voii I'laquc be-
gkitctcr (Utigiviti.s des Ilunde.s
Der vorliegende Vcrstich wurde konzipicrl tun / u
unlcrsuchen, ob cine dcnto-gingivale liiiilieit mit
einer breiten Zone keratinisierter Gingiva (KG) sich
als wirktmgsvollerc B;irricrc gcgcniibcr der Plaqiie-
inlektion crwcist als eine solclie Einheit mil cngiirer
KG-Zoni; odcr beim volligcii Fchlcn solcher Gingiva.
Funf Beagles Hundc wurdcii ITir dicscn Versuch
angewendet. In einctn Vorvcisuch wtitdcn bci jcdcm
Hunde drci Katcgorien gingivalcr Einhcilcn gcschal-
fcn, namlich (1) rcgenerierte Gitigiva tnit ciiic-r breiten
KG-Zone (Heiluiigsbild nach ciner "Lappcnopeta-
tion"), (2) rcgenerierte Gingiva mit "nicht ausrcichcn-
der" Zonciibrcitc der KG (Heilungsbild nach cinor
"Gingivcktomicoperalion") und (3) nlcht opcriertc
Kontrollgitigiva mil normalcr KG-Zotie. Klinische
und histologischc Untersuchungen am Ende der
Vorversuchszcit zcigten, dass alle gingivalcn Eiti-
heitcn, die nichtopcricrten wie auch die rcgcncriertoti
Einheiten, die Kritcricn gingivaler Gcstiiidlioit cr-
liilllcn. Alle der Zahnrciniguiig dienendcii Ma.s.snah-
mcn wurden dann eiiigeslclll. Nach 40 Tagcn un-
gchindcrter Plaqtieansammlung wutdc die klinische
Untersuchung (Plaqticindex, Giiigivalindcx tind ging-
vale Exsudatc) wiederholt. Ausscrdem wurden
Biopsien entnommcn. Nach ihrer Priipaiation
wtirden sie histometrisch und morpliomclrisch
aiialysieit. Die Resultate zciglen, dass die freie
Gingiva der Einheiten, die wcitc tiiid enge KG-Zonen
hatten, auf die mikrobiologischc Kolonisalion mit
 KERATINIZED GINGIVA - GINGIVITIS
entzundlicher Reaktion antworteten, deren Lokali-
sation und Ausdehnung keine. der Zonenbreite
keratinisierier Gingiva entsprechenden, Variationen
aufwies. Es wurde gefoigert, dass bei Gegenwart von
Plaque, dento-gingivaie Einheiten mit einer engen
Zone Oder ohne keratinisierte Gingiva uber die
gleiche Kapazitat zu entzundlicher Antwort auf
Plaqueinfektion verfiigen, wie Einheiten mit breiter
KG-Zone.
Resume
Role de la gemivc keratinisee dans les gingivitcs dues
a la presence de plaque chez le chien
La presente etude a ete confue dans le but de constater
si les localisations gingivales presentant une large
zone de gencive keratmisee (KG) constituent une
protection plus efficace centre l'infection due a la
plaque baeterienne que lorsque ia zone de KG est
etroite ou en I'absenee de KG, Les experiences ont ete
pratiquees sur cinq chiens briquets. Dans une ex-
perience preparatoire, on etablissait d'abord chez
chacun des chiens trois categories de localisations
gingivales: (I) gencive regeneree avec large zone de
gencive keratinisee (cicatrisation apres une operation
a lambeau = "nap'"), (2) gencive regeneree avec zone
de gencive keratinisee de largeur "insuffisante" (ci-
catrisation apres 'gingiveetomie") et (.''I gencive te-
moin sans intervention chirurgicale, avec une zone
normale de gencive keratinisee. Les examens ciiniques
et hislologiques effectues a la fm de la periode
preparatoire montraient que toutes les localisations,
qu'il s'agisse des locaiisations non operees ou de eelles
avee gencive regeneree, presentaient les caracteres
d'une gencive saine. Tous les soins de nettoyage des
dents ont alors ete interrompus. Apres 40 jours
d'accumulation de la plaque, on a de nouveau
pratique un examen clinique (Indice de Plaque, Indice
Gingival et Exsudat Gingival) et des biopsies ont ete
prelevees. Apres preparation des tissus preleves, on
Ies a soumis a une analyse histometrique et morpho-
nretrique. On a ainsi constate que la gencive libre des
localisations presentant des zones de gencive kera-
tinisee larges ou etroites donnaient, en reponse a la
formation des colonies tnierobiennes. une reaction
inflammatoire dont la situation et l'etendue etaient
independantes de la largeur de la gencive keratinisee.
On pouvait conciure que, en presence de plaque, les
localisations dento-gingivales presentant une zone de
tiencive keratinisee etroite, ou meme absente, avaient
Line aptitude equivaiente a celle des localisations dont
ia zone de KG etait large a donner une reaction
inflammatoire envers l'infection par la plaque.
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Address:
Jan Wennslrom
Department of Periodontotogy
Schoot of Dentistry
University of Goteborg
Box 33070
S-400 33 Goteborg
Sweden