Jounuil of Clinical Periodonlology I9S3: 10: 266-276

Key words: Attached i;ingive! - deiuiil ploquc - giii^ivitt.-,.

Accepted for publication )a\y I, iyS3

Plaque-induced gingival inflammation in

the absence of attached gingiva in dogs
JAN WENNSTROM •\ND JAN LINDI-IT

DepartmenI of Periodonlology, School of Dentistry, University of Goihenburg, Gothenburg. Sweden

Abstraei. The purpose of this experiment was to evaluate the effect of plaque iniection on gingival uniis
(1) with or without support of attached gingiva and (2) with different hcighl of the aiiachment
apparatus. 7 beagle dogs were used. Prior to the initiation of the study 4 different types of
"dentogingival" units had been established in each dog by the use of e\cis.ional andgraltingprocedures,
namely (!) normal non-operated free gingival units supported by a wide zone of attached gingiva and
normal height of the attachment apparatus. {2) regenerated free gingival units supported by looseiy
attached alveolar mucosa and normal height of the attachment appaiatu.s, (3) regenerated free gingival
units supported by loosely attached alveolar mucosa and reduced height ofthe attachment apparatus
and |4) regenerated free gingival units supported by a wide zone of attached gingiva and reduced height
ofthe supporting apparatus. A baseline examination involved assessments of plaque, gingivitis, gingiva!
exudate, probing depth, clinical attachment level, position of the "soft tissue margin" and width of
attached gingiva. Following this examination 2 of the dogs were .scheduled for biopsy and sacrificed. The
remaining 5 dogs were for 40 days placed on a diet regimen which allowed plaque accumulation. The
elinica! examination was repeated and biopsies sampled at the end of this period. F^ollowing preparation
the biopsy material was subjected lo hisiometric and morphometric analysis. The results showed that the
free gingiva which regenerated following surgical excision of the entire gingiva or foiiowing soft tissue
grafting, was in most respects, clinically as well as hi.stologically, simiiar to the "normal" free gingiva.
The data obtained after 40 days oi' plaque accumulation did not reveal any differences between the
various "dentogingival" uniis regarding size and apicai extension of the infiltrated portion of the
connective tissue. It was concluded that a free gingivat unit which is supported by loosely attached
alveolar mucosa is not more susceptible to inflammation than a tree gingival unit which is supported by a
wide zone of attached gingiva.

Much attention has been focused on the ques-
tion whether a free gingival unit supported by a
zone of at tched gingiva serves a.s a more effective
barrier against plaque infection Ihan a unit
supported by loosely attached alveolar mucosa.
In 1972, Lang & Loe presented data fronn a
clincial examination of a group of dental stu-
dents who had been subjected to supervised
piaquecontroi measuresfor aperlodof 6weeks.
The results showed that in areas with less than 1
mm ofatJachedgingiva, inflammation persisted
despite optima] plaque control. The authors
suggested that "a movable gingival margin
would facilitate the introduction of microor-
ganisms into the gingiva! crevice resulting in a
thin subgingival bacterial plaque". On the other
hand, experiments in humans by Miya.satoet al.
(1977) and Dorfman & Kennedy (i98i), in
which no tooth cleaning measures were exer-
cised for 21-25 days, showed that nosignificant
differences were observed with respect to devel-
opment of clinical signs of inflammation
between areas with presence or absence oi'
attached gingiva. The exclusive tise, however, of
clinical parameters to determine the degree of
inflammatory response in the marginal soft
 ATTACHED GINGIVA - GINGIVITIS
tissue to plaque may not be sufficient since
severai studies have shown that clinical and
histologica! parameters describing degree of
gingivitis do not always agree (e.g. Zaehrisson
1968, Listgarten & Ellegaard 1973, Schroeder et
al. 1973, Lindhe et al. 1978). Furthermore,
difficulties inherent in the interpretation of data
obtained from clinical assessment of inllamma-
tion in areas with different width of the zone ol'
keratinizecl gingiva were recently demonstrated
by Wennstrom et al, (1982). In a clinical and
histological study in beagle dogs it was shown
that free gingival units in areas with dilTerent
width of keratinized gingiva responded to
plaque formation by an inflammatory reaction,
the location and extension of which did not
from a histological point of view vary with the
width of the keratinized gingiva. although the
clinical signs of inflammation were more pro-
nounced in areas with a narrow zone of keratin-
ized gingiva.
The purpose of the present experiment was to
evaluate, using both clinical and histological
parameters, the effect of plaque infection on
gingival units with or without support of at-
tached gingiva and with different height of the
attachment apparatus.
Material and Methods
The maxillary and mandibular second, third
and fourth premolars (^UP^^M) ^'""^ ^^^ man-
dibular first molars (iMi) in 7 female beagle
dogs were used. Before the initiation of the
present study, ihe dogs had been subjected to a
42()-day preparatory period in order to establish
"dentogingival" units with different clinical
characteristics,. Hence, in the right side of the
faws (experimental side), a 6-month period of
periodontal tissue breakdown was fallowed by
surgical excision of the entire zone of the
gingiva. After 4 months of healing with daily
piaque control, a gingival graft was inserted in
one quadrant of the experimental side to regain
a zone of attached gingiva while the other
quadrant of the experimental side was left
ungrafted. In the left side of the Jaws (control
side), the teeth were subjected to daily me-
ticulous plaque control during the entire pre-
paratory period. In one of these "normal" jaw
quadrants the entire zone of the keratinized and
attached gingiva was excised at an interval
coinciding with grafting in the experimental
side, while the gingiva in the remaining "nor-
mal" jaw quadrant was left unoperated. A
clinical examination performed after 4 months
of healing, during which meticulous plaque
control measures had been exercised in aH jaw
quadrants, revealed the presence of 4 different
types of "dentogingival" units in each dog,
namely:
Type I: Normal, non-operated gingival units
with wide zones of keratinized and attached
gingiva and with normal height of the sup-
porting apparatus [N-Control), i,c. the jaw
quadrant in the control side where the gingiva
was left unoperated,
Tvpc 2: Regenerated gingival units with a
narrow zone of keratinized gingiva, but without
attached gingiva, and with normal height of the
supporting apparatus (N-Excised), i,e, the jaw
quadrant in the control side where the entire
zone of keratinized and attached gingiva had
been excised,
7ype 3: Regenerated gingivai units with a
narrow zone of keratinized gingiva, but without
attached gingiva, and with reduced height of the
supporting apparatus {PB-Fxeised}. i.e. the un-
grafted jaw quadrant of the experimental side.
Type 4: Regenerated gingival units with wide
zones of keratinized and attached gingiva, and
with reduced height of the supporting appara-
tus {FB-Grafted), i.e. the grafted jaw quadrant
of the experimental side,
A detailed presentation of the design of the
experiment and surgical procedures used has
been reported previously (Wennstrom &
Lindhe 1983),
At the end of this preparatory period (in the
268 WENNSTROM AND LINDHE
present report denoted Day 0), a clinica! exam>
ination comprising the following parameters
was carried out:
1. Plaque Index (Pll) - according to Silness &.
Loe {!964}.
2. Gingivai Index (GI) - according to Loe &
Silness (1963) and Loe (1967),
3. Gingivai Exudate (GE) - according to the
orifice technique described by Loe & Holm-
Pedersen (i965).
4. Probing depth (PD) - using a periodontal
probe with a diameter of 0.4 mm at the tip
and with 1 mm gradings,
5. Clinical attachment leve! (AL) - i.e, the
probing depth measured from the apical
border of an amalgam filling placed in the
buccal tooth surface,
6. Position of the gingival margin (GM) - i, e,
the distance between the apical border of the
amalgam filling and the "soft tissue margin",
7. Width of the attached gingiva (AG)-I.e, the
distance between the "soft tissue margin"
and the mucogingival junction - measured
after staining the alveolar mucosa with
Schiller's iodine solution (Easske & Mor-
genroth 1958) - minus the probing depth.
All assessments were confined to the mid-
buccal part of the buccal roots of the maxillary
and mandibular second, third and fourth pre-
molars and the mandibular first molars. Im-
mediately following the clinical examination, 2
of the 7 dogs, chosen at random, were scheduled
for biopsy and sacrificed. Tissue samples (see
below) were obtained from ail teelh used in the
study.
EoUowing the clinical examination on Day 0
all tooth cleaning measures were abolished in
the remaining 5 dogs.
After 20 and 40 days of plaque accumulation
the clinical examination was repeated. At the
end of the study (Day 40), biopsies were ob-
tained from al! experimental teeth of the 5 dogs
according to the technique originally described
by Schroeder et al. (1973). The tissue samples,
which included the buccal part of the tooth and
its adjacent marginal periodontal tissues, were
fixed in a mixture of 5% glutaraldehyde and 4%
paraformaldehyde buffered to pH 7.2 with
sodium cacodyiate (Karnovsky !965) and de-
calcified in a mixture of 49?' glutaraldehyde, 0.!
M EDTA and 0,2 M sucrose (Warshawsky &
Moore 1965), After decalcification, the speci-
mens were trimmed and divided into four 1 mm
thick blocks and further processed for em-
bedding in Epon. Sections were cut at 2-3/;m in
the bucco-lingual direction and stained with
PAS and toluidine-blue (Schroeder 1973), 2
sections from the central portion of each block
were chosen for detailed microscopic examina-
tion.
Al! bistological examinations were carried
out in the light microscope and by an individual
wbo was not aware of tbe design and the aim of
the experiment. In the histometric analysis the
following distances (Fig. i) were measured (obj,
X20, ocular XIO):
!. The height of the free gingiva (HEG); the
vertical distance between the gingival mar-
gin and the apical border of the junctional
epithelium (JE).
2. The suicus depth (SD); the distance between
the gingival margin and the most coronal
border of the junctional epithelium,
3. The width of the free gingiva at its base
(WEG); the distance between JE and the
surface of the oral epithelium (Tb).
4. The length of the supracrestal connective
tissue attachment (CTA); the distance be-
tween JE and the crest of the alveolar bone.
5. The apical extension of the infiltrated con-
nective tissue (alCT); the distance between
the gingival margin and the apical border of
the infiltrated connective tissue.
The thickness of the keratin layer of the oral
epithelium was assessed (obj. XlOO, ocular
X iO) at 3 different location points along the free
gingiva (Tgn,, T™ and Tb, Fig. 1).
All histometric assessments were expressed in
microns (jum),
A morphometric point-counting procedure
(Weibel 1969, Schroeder & Munzel-Pedrazzoli
1973) was employed (Level I; obj, X20, Grid
 ATTACHED GINGIVA - GINGIVITIS

Percentage distribution of Plaque and Gin-

gival Index scores 0, 1, 2 and 3 was calculated
for each type of "dentogingival" unit and dog.
Individual mean values representing each jaw

alCT
HFG
PLAQUE INDEX SCORES

CTA

Eig, 1. Schematic drawing iilusirating the various

linear distances mea.sured in ihe histologicai sections.
SD —sulcu.s depth. alCT—apicai extension oi' the
infiltrated connective tissue, HFG —height of thefree GINGIVAL INDEX SCORES
gingiva, WFG = width of the free gitigiva, CTA =
length of the supracrestal connective tissue attach-
ment. Tgm, Tm and Tb represent the location points

•I
where the thickness ofthe keratin layer was assessed
and .!E = lhe apicai border of the junctional epi-
thelium.
Schematische Zeiehnung. die die verschiedenen linea-
ren Abstande veranschaulicht. die in den histologischen
Sehnitten vermessen wurden. SD'=SulkusUefe, alCT
= apikale Extension des infilirierten Bindegewebes,
HEG = H6he der freien Gingiva. WEG^Breite der
freien Gingiva, CTA = Hohe des bindegewebiichen At-
tachments iiber der aiveoiaren Knochenleisie. T^n,. 7™
und 7"b veranschaulichen die Beobachiungspunkle an I J Scoic 0 s?* Score I M Score 2
denen die Dicke der Keratinsehieht bestimmt wurde und Eig. 2. Mean percentage of buccal tooth surfaces with
JE=die apikale Grenze des Epiihelansalzes. Plaque Index scores 0, 1 and 2 and gingival units with
Representation sehematique illustrant les differentes Gingival Index scores 0, I and 2 on Days 0, 20 and 40
distances lineaires mesurees sur les coupes histolo- for the N-Control, N-Excised, PB-Excised and PB-
giques. SD—profondeur du siilon, aICT=elendue du Grafted units.
tis.su conjonelif infilire en direction apieale, HFG —
Miitierer prozentualer Anteil bukkaler Zahnobrrfld-
hauieur de la geneive iibre. WEG=largeurde la geneive
citen mit den Plaqueindcx-Scores 0, 1 und 2 und
tibre. CTA=longueur de l'attaehe de tissu conjonctif
gingivale Einheiten mit den Gingivalindex-Scores 0, 1
au-dessus de la erete osseuse. T^m. ?'m et Tb represented
und 2 an den Tagen 0. 20 und 40 fUr N-KontroU, N-
les points de repere ou on enregislrait I'epaisseur dc la
exzidierie, PB-exzidierte und PB-iransplantierte Ein-
eouehe de keraiine et .IE= limiie apieale de l'epithelium
heiten.
de Jonciion.
Poureentage moyen des faces deniaires vestibulaires
ayant les seores 0, I ei 2 pour l'lndiee de Plaque et des
P42} to determine the percentage composition sites gingivaux ayant les scores 0. 1 et 2 pour l'indice
Gingivat aux Jours 0. 20 et 40: sites normaux temoins
of the free gingiva in terms of oral epithelium
(N-Controi). sites normaux avec exeision (N-Excised),
(OE), junctional epithelium (JE), non-infil- sites de destruetion parodonlale avec excision (PB-
trated connective tissue (NCT).and connective Exeised) et sites de destruetion parodontale avee greffe
tissue infiltrated with inflammatory cells (ICT). (PB-Grafted).
270 WENNSTROM AND LINDHE

quadrant were calculated for all other para- The results from the assessments of plaque
meters studied. Statistical analysis of the data (Plaque Index) and the gingivai conditions
was performed using Student's t-test and anal- (Gingival Index and Gingival Exudate) are
ysis of variance. presented in Fig. 2 and Table 1. At the start of
the study (Day 0) all buccal tooth surfaces
Results studied were free from bacterial deposits (Pil
Clinical parameters 0 = 100%). Almost all soft tissue units (98%) in
At the start of the study (Day 0) the mean width the 4 different jaw quadrants were free from
of the attached gingiva in the 4 groups of clinicai signs of inflammation. In addition, only
gingival units was: N-Control 2,7 mm (±8.8; negligible amounts of Gingival Exudate could
s.d.), N-Excised 0.2 mm (±0.2), PB-Excised 0.1 be collected (Table 1).
mm (±0.2) and PB-Grafted 3.0 mm (±1,0). The cessation of regular looth cleaning on
During the 40-day period of plaque accumula- Day 0 resulted in the accumulation of dental
tion the width of the attached gingiva did not piaque and in the development of intiaiiimation
change. in the marginal soft tissue. The amount of
plaque formed was similar in all jaw quadrants.
On Day 40 around 70-80% of the tooth sur-
Table L Amount of Gingival Exudate sampled on faces harbored visible amotints of dentai de-
Days 0, 20 and 40, Mean value (mm) and standard
deviation posits (Pll score 2, Fig. 2), The clinical signs of
Die Menge gingivalen Exsudates das cm den Tagen 0, inflammation in the marginal soft tissue, how-
20 und 40 gemessen worden ist. Mittelwert fmnij und ever, varied between the 4 groups of soft tissue
Standardabweichung units. Thus, in the 3 jaw quadrants in which the
Quantite d'ex.'iudat gingival recueilli aux Joiir.\ ft 20 marginal soft tissue had regenerated following
et 40, Valeur moyenne (mm) et ecart-type surgery there was a higher frequency of units
Units Day 0 Day 2« Dav 40 exhibiting a GI score of 2 than in the remaining
2.0 ±0.9
jaw quadrant. Around 58% of the marginal soft
N-Control 0.2±0,2
N-Excised 0,3±0,2 3,1 ±1, 2.7±I.O tissue units which lacked attached gingiva (N-
PB-Excised 0,1 ±0.2 2.7±0-7 Excised and PB-Excised) and 44% of the PB-
PB-Grafted 0.2±0.2 2.9±0,8 3.3 ±1,3 Grafted sites showed pronounced clinical signs
N-Control (N-Kontrolleinheiten. normaux temoins), of inflammation (GI score 2, Fig. 2). The
fB-Excissd (PB-exzidiertc Einheiten. destruction paro- corresponding figure for the non-operated con-
dontale avec excision), PB-Grafted (FB-transplantierle trol units (N-Control) was 24%, No statistically
Einheiten. destruction parodontale avec greffe).

Table 2. Probing depth and alterations of the position of the ".soft tissue margin" at the buccal tooth surfaces.
Mean value (mm) and standard deviation
Sondierungstiefe und Verdnderungen der Lage der" Grenze des Weichgewebes" an den bukkalen Zahnoberflachen,
Mittelwert (mm) und Standardabweichung
Profondeur de sondage et modifications de la position du ''rebord de ti.ssu mou" au niveau des faces dentaires
vestibulaires, Moyenne (mm) et ecart-type
Alterations of the position of
Probing depth the soft tissue margin
Units Day 0 Day 20 Day 40 Day 20 Day 40

N'Control !.6±0.2 1.8 ±0.3 1,9 ±0.4 -H 0,1 ±0.3 ±0.3 ±0.3
N-Excised I.3±0,2 l,7±0,3 1.7±0.2 -f 0,5 ±0.5 ±0.6 ±0.4
PB-Excised 1,7 ±0.2 2.0 ±0.1 I,9±0,l + 0.2±0,3 ±0,2±0,2
PB-Grafted 1.9±0,2 2,3 ±0,2 2,4 ±0.4 -|-O,3±0.3 ±0.5±0.3
 ATTACHED GJNGIVA - GINGIVITIS

significant differences were observed regarding
the amount of Gingival Exudate between the 4
groups of "dentogingival" units at the various
examination intervals (Table 1). On Day 40 the
mean amount of Gingival Exudate collected in
the 4 groups varied between 2.0-3,3 mm.
The mean probing depth and the alterations
of the position of the "soft tissue margin" are
presented in Table 2. As a result of the develop-
ment of inflammation (1) the position of the
"soft tissue margin" shifted slightly in coronal
direction (mean values 0,2-0,6 mm; Table 2),
and (2) a small increase of the probing depth
was observed in all 4 groups of units (Table 2).
No alteration of the attachment ievel was noted
for any of the 4 groups.
Histological analysis
The results obtained from the histometric as-
sessments of the biopsy materiai are presented
in Table 3. The free gingiva of the non-operated
control units (N-Control) was found on Day 0
to have an average height (HEG) of 1390//ra
and a width (WEG) of 1090 fxm. The gingivai
sulcus (SD) was on the average 102/^m deep. In
all sections the apical cells of the junctional
epithelium were located at or close to the
cemento-enamel junction and at a distance

Table 3. Results (in/jm) from the histometric assessmenis of the gingival tissue on Days 0 and 40, Mean value
and standard deviatioti, HFG = hcight of the free gmgiva; SD-sulcus depth; W F G - w i d t h of the tree gingiva
at its base; CTA = length of the supracresial connective tissue attachment: alCT —apical extension oi the infil-
trated connective ti.ssue, T,,™, Tm and Tb represent the location points along the oral epithelium of the free gingiva
where the thickness of ihc keratin layer was assessed
Resultate der htstometrischen Verntessungen der Gingiva an den Tagen 0 und 40 (in ftmj. Mittelweri und Stan-
datdabweichung, HIXl — Hohe der freicn Gingiva: SD = Sulkustiefe: WFG — Breite der freien Gingiva an ihrer
Basis; CTA = Hohe des bindegeweblichen Attachments iiber der alveolaren Ktiochenlei.ue: alCT—apikale
Extension des inftltrierten Bindegewebes. T^^. Tm und 7], veran.sehaulichetj die Beobachtungspunkte am oralen
Epithel der freien Gingiva. an denen die Dicke der Keratimchicht bestimmi wurde
Resultats (en fini) des mesures histometriques du tissu gingival aux .lours 0 et 40. Valeur moyenne et ecart-type.
HFG^hauteur de la gencive libte; SD=profomieur du sillon; WFG-largeur de la geneive libre a sa base:
CTA = longueur de l'attache de tissu eonjonetif au-dessus de la erete osseuse: aICT=etendue en direction
apicale du ti.-<su eonjonetif injiltre. T^^. T,n et Tt,. places le long de I'cpithcUum bueeal de la gencive libre.
representent les points de repere uii I'epai.fseur de la couehe de keratine a ete mesuree.
N-Control N-Exciscd PB-Excised PB-Grafted

Day 0
HFG 139O± 94 1078 ± 1 1 0 1417±94 1544± 83
102± 51 !22± 10 183±35 134± 68
1090±198 723± 63 780 ±87 1176±392
CTA 83!± 61 687 ± ! 46 SJ8±85 688 ±156
Keratin layer
7.3±4.5 3,5 ±0.3 3,7 ±2.3 3.9 ±2.8
T™ 17.5±4.0 1O.7±L1 11,5±1.3 18,3±L2
T. ! 9,9 ±3.8 n.6±0,3 9,8±I,1 20.8 ±5.0
Day 40
HFG !533±172 1359 ±132* 1523 ±290 1644±il8
SD 230 ±154 372 ±244 300± 78 270± 62
WFG n08±200 831± 99 738±I45 1390±2!8
CTA 834±182 768±I81 705 ±197 771±19I
arCT 760 ±38] 852 ±309 748 ±244 778± 50
alCT/HFG 0,48 ±0,20 0,62±0,]S O.51±0.17 0.47 ±0,05
significantly different from Day 0 (/'<0,05)
272 WENNSTROM AND LINDHE

from the alveolar bone crest of on the average
831 /um (—the length of the supracrestai con-
nective tissue attachment, CTA). In most re-
spects the dimensions ofthe free gingiva, which
had regenerated foiiowing the excisional or
grafting procedures (i.e. N-Excision, PB-Exci-
sion and PB-Grafted units) were similar to
those ofthe non-operated controls (N-Contro!
units). The 2 jaw quadrants which had been
subjected to the excisional procedure (N-Ex-
cised and PB-Excised) had soft tissue units,
however, which were somewhat thinner in
bucco-Hngual direction (WFG) than the cor-
responding units ofthe N-Controi and the PB-
Grafted quadrants (around 750 //m vs around
1100/^m).
The thickness of the keratin layer of the oral
epithelium of the Day 0 biopsies is presented in
Table 3. The keratin layer of the N-Control and
the PB-Grafted units was comparatively thick
(=«20 ^m), except at the gingival margin (Tgm)
where this layer was only between 4-7/im thick.
The N-Excised and the PB-Excised units had a
comparatively thin keratin layer, (4-11
The measures describing the height ofthe free
gingival unit (HFG) and the depth ofthe sulcus
(SD) were in all 4 categories of gingival units
(Table 3) larger in the Day-40 than in the Day-0
biopsies. The increase of the HFG between
Days 0 and 40 was, however, statistically sig-
nificant only for the N-Excised units (F<0.05).
No significant alterations were observed re-
garding the width of the free gingiva or the
length of the supracrestal connective tissue
attachment in any of the 4 categories of units.
The data obtained from the assessments ofthe
extension, in apical direction, ofthe infiltrated
connective tissue portion (alCT) are aiso pre-
sented in Table 3. The apical border ofthe ICT
was located at a distance from the gingival
margin of, on the average, 760 ftm (N-Control),
852 fim (N-Excised), 748/im (PB-Excised) and
778//m (PB-Grafted). Calcuiated in relation to
the height of the free gingiva (HFG) the iCT
involved around 'A to % of the height of the free
gingiva (Table 3). There were no statistically
significant differences between the 4 categories
of units regarding alCT.

Table 4. Percentage volume of oral epithelium (OE), junctional epithelium (JE). non-infiltraled conneciive
tissue (NCT) and conneciive tissue infiltrated with inflammatory cells (ICT) calculated from morphomelric
analysis of ihe various gingival units on Days 0 and 40. Mean value and standard deviation
Durch morphomelrisehe Analyse der verschiedenen gingivalen Einheiten an den Versuchstagen 0 und 40 in %
berechnetes Volumen des oralen Epilhels (OE), des Epithelansatzes (JE), eles nieht-infiltrierien (NCT) und des von
Entziindungszellen infiltrierten Bindegewebes (ICT). Mittelweri und Standardabweichung
Poureentage des volumes de I'epiihelium buccal (OE), de l'epithelium de jonction (.IE), du ti.'isu conjonelif non
infilire (NCT) et du ti.isu eonjonetif infilire par les cellules infiammatoires (ICT). Le ealcul a He fait a pariir de
l'analyse morphomelrique des differents sites gingivaux aux Jours 0 et 40. Vaieur moyenne et eeart-type
Units OE JE NCT iCT No. of points counted
Day 0
N-ControJ 30.9±().3 8.3 ±2.3 60.8 ±2.7 O.]±O.] 286 ±50
N-Excised 34.7 ±7.6 9.4±0.6 55.9±8.2 0 ±0 155±34
PB-Excised 25.4 ±!,1 9.7±0.9 64.9 ±0.4 O.]±O.i 22J±33
PB-Grafted 28.8 ±2.4 7.6±].5 63.5 ±3.9 0.1 ±0.1 295 ±97
Day 40
N-Control 32.8±4.! 7.0 ±0.7 51,8 ±5.4 8.6 ±2.1 329±61 ^
N-Excised 34.4±2.3 8.4±3.0 45.2±5.2 12.0±2.6 211 ±44
PB-Excised 30.2±2.8 7.8±1.0 48.2 ±5,9 i3.8±3.5 260±72 ^^
PB-Grafted 27.6 ±4.8 6.8±1.6 54.2±6.5 n.4±2.8 419±48
» significantly different {P<0.05)
** significantly different {P<0.01)
 ATTACHED GINGIVA - GINGIVITIS
Tabie 4 describes the percetitage composition
of the Tree gingiva with regard to orai epithe-
lium (OE), junctional epithelium (JE). non-
infiltrated connective tissue (NCT) and con-
nective tissue infiltrated by inflammatory cells
(ICT). The data obtained from the morpho-
metric analysis of the Day 0 biopsies revealed
that all 4 categories of "dentogingival" units had
a similar composition. Thus, the free gingiva
was composed of, on the average, 25-35% OE,
8-10% JE, 56-65% NCT and only minute
amounts of ICT. After 40 days of plaque
accumulation all units had developed an ICT
which occupied between 9-14% of the volume
of the various types of gingival units. No
statistically significant differences were ob-
served in the size of ICT when comparing
gingival units with and without attached gin-
giva or when comparing sites with normal and
reduced height of the supporting tissues. Only
minor and statistically insignificant alterations
were noted in the proportions oi' OE and JE
between Days 0 and 40, The size of the free
gingiva, determined as the number of points
counted at Level 1, was on Day 40 significantly
smaller in the 2 categories of units which were
devoid of attached gingiva (N-Excised and PB-
Excised) than in the 2 types of units where
attached gingiva was present (N-Contro! and
PB-Grafted) (Table 4),
Discussion
The results of the present study indicate that the
capacity of a gingival unit to respond to bac-
terial plaque accumulation by inflammation is
related neither to the presence or absence of
attached gingiva (AG) nor to the height of the
supporting attachment apparatus.
In a preparatory experiment 4 different types
of "dentogingival" units were established,
namely (1) normal, non-operated free gingivai
units supported by a wide zone of AG and
normal height of the attachment apparatus (N-
Control), (2) regenerated Tree gingival units
supported by loosely attached alveoiar mucosa
273
and normal height of the attachment apparatus
(N-Excised), (3) regenerated free gingival units
supported by loosely attached alveolar mucosa
and reduced height of the attachment apparatus
(PB-Excised) and (4) regenerated free gingival
units supported by a wide zone of AG and
reduced height of the attachment apparatus
(PB-Grafted), The clinical examination per-
formed at the start of the present study revealed
that almost all of the 4 categories of "dento-
gingival" units were classified as being clinically
healthy (GI score 0; Eig. 2), Only minute
amounts of Gingival Exudate could be sampled
(Table I), Furthermore, the histologic analysis
of the biopsy material disclosed that the free
gmgiva of the 4 different types of "dento-
gingival" units was either devoid of or con-
tained only minute areas of inflammatory cell
infiltration (Table 4), The histometric assess-
ments showed that in most respects the dimen-
sions of the free gingiva, which had regenerated
following the excisional or grafting procedures,
were similar to those of the non-opprated
control units (Table 3). However, the free
gingiva of the 2 types of "dentogingival" units
which had regenerated following excision of the
gingiva (N-Excised and PB-Excised) and which
were supported by loosely attached alveolar
mucosa were somewhat thinner in bucco-
lingual direction (WFG) than those of ihe
normal control and the grafted units. In addi-
tion, the oral epithelium of the free gingiva of
these units had a comparatively thin layer of
keratin. These findings corroborate and extend
observations presented by e.g. Ramfjord et a!.
(1966), Karring et al. (1975), Freeman (S981),
Wennstrom et al, (i981) and reveal that fol-
lowing different surgical treatment - such as
gingivectomy, flap and grafting procedures - a
free gingiva will reform, which in most respects,
clinically as well as histologically, is similar to
that of a "normal" non-operated "dentogingi-
val" unit.
The 40 days of plaque accumulation resulted
in development of an inflammatory lesion in all
gingiva! units. While the amounts of plaque
XJA WENNSTROM AND LINDHE
formed were similar in all jaw quadrants, the
elinical signs of infiammation varied between
the 4 categories of "dentogingival" units (Fig.
2). Thus, the frequency of sites with marked
clinica! signs of gingivitis (GI score 2) was
higher for the 2 types of utiits which lacked
attached gingiva (=58%) than for units which
were supported by such gingiva (N-Control:
24%, PB-Grafted: 44%). This observation may
be interpreted to indicate that a gingival unit
supported by a zone of attached gingiva serves
as a more effective barrier against bacterial
plaque infection than a gingival unit supported
by loosely attached alveolar mucosa. However,
neither the gingival exudate measurements
(Table 1) nor the histological analysis of size
and apical extension of the infiltrated portion of
the connective tissue (Tables 3, 4) revealed any
differences between the various "dentogingival"
units. The higher frequency oi GI score 2 in
units without attached gingiva than in units
supported by such a tissue must, therefore, be
explained by differences regarding the size and
composition of the free gingiva. Thus, com-
pared to the gingival units supported by a zone
ofattached gingiva (N-Control and PB-Grafted)
the free gingiva of the excised units (N-Excised
and PB-Excised) was thinner in bucco-lingual
direction and had a thinner keratin layer of the
oral epithelium.
Although the plaque accumulation period
was limited to 40 days the results of the present
study indicate that a free gingival unit sup-
ported by loosely attached alveolar mucosa is
not more susceptible to inflammation than a
free gingival unit supported by a wide zone of
attached gingiva. In this respect the present
findings corroborate clinical observations re-
ported from similar experiments in humans
(Miyasato et al. 1977, Dorfman & Kennedy
1981). In view of these observations the use of
soft tissue grafts or other periodontal surgical
procedures with the main purpose of establish-
ing a proper zone of attached gingiva may be
questioned.
Zusammeniassung
Durch Plaque induzierte Entziindung des Zahnflei.schcs
beim Eehlen fester Gingiva bcim Hundc
Es wurde beabsichtigt, mil diesem Experiment die
Wirkung der Flaqueinfcklion an gingivalen Einlieiien
(tj mit oder ohne Ergiinziing durch festcGingivaund
(2) bei vcrschiedener Hohe des Attachments zu beob-
achten. Da.'; Experiment wurde an 7 Beagles Hiinden
vorgenommen. Vor dem Beginn die.ser Studie wurden
bei jedem Hiinde durch Exzisions- und Tran.splania-
tionseingriffe "dcntogingivale" Einheilcn von 4 ver-
Bchiedenen Typen geschaffen, niimlich (I) normale,
nicht operierle ireie gingivale Einheiten, die, bei nor-
maler Hohe des Attachments, durch eine breileZone
fester Gingiva erganzi wurden, (2) regcncrierte freie
gingivale Einheiten, die, bei normaler Hohe des
Attachments, durch lockere Gingiva erganzt wurden,
(3) regenerierte freic gingivale Einheilcn, die, bei
reduzierter Atlachmenthohe. durch eine breite Zone
lockerer Gingiva erganzi wurden und (4) regenerierte
freie gingivale Einheiten. die, bei reduziertcm Auf-
hangeapparat. durch eine breite Zone fesler Gingiva
erganzt wurden. Eine Ausgangsuntersuchung bein-
haltete die Beurteilung der Plaqueanlagerung, der
Gingivitis, des gingivalen Exsudatea, der Sondier-
ungstiefe. des klinischen Attachmentniveaus. der La-
ge der Grenze "lockeren Weichgewebes" und der
Breite fester Gingiva, Nach dieser Unlersuchung
wurden 2 Hiinde zur Entnahme von Biopsien ausge-
wahlt und geopfert. An die verbleibenden 5 Hundc
wurde 40 Tage lang eine Diat verfuuert, die Plaque-
ansammlung zuiiess. Die klinisehe Untersuchung
wurde wiederhoil und Stichproben der Biopsien am
Ende dieser Periode untersucht, Nach der Prapara-
lion wurde das Biopsiematerial histometrisch und
morphometrisch analysierl. Die Resultate zeigten,
dass die nach chirurgischer Exzision der Gesamt-
gingiva oder nach Wcichgewebstransplantation re-
generierte Gingiva klinisch sowie histologisch in
vieler Hinsicht der "normalen" freien Gingiva ahnel-
te. Die Daten nach 4D-tagiger Plaqueanlagerung
zeigten hinsichtlich der Ausdehnung und der apikalen
Au.sbreitung des infizierten Anteiles des Bindegewe-
bcs keine Unierschiede zwischen den verschiedenen
"dentogitigivalcn" Einheiten, Es wurde gefolgeri, dass
eine freie gingivale Einheit mit lockerer alveolarer
Mukosa nicht entzundungsanfaiiiger ist a!s eine freie
gingivale Einheit, die durch eine breite Zone fester
Gingiva erganzl wird.
Resume
Inflammation gingivale causee par la plaque chez le
chien en I'absence de gencive attachee
La presente etude experimeniaie a ete entreprise dans
le but d'cvaluer I'action de rinfection par la piaque
 ATTACHED GINGIVA - GINGIVITIS
sur des sites gingivaux (!) avec ou sans souticn de
gencive attaches et (2) avec diiferentes hauteurs
d'atiache, L'etude a ete realisee sur 7 chiens briquets,
Avant le debut de Tetude, on avait produi! 4 cate-
gories differentes de sites "gingivo-dentaircs^" clie2
chaeun des chiens en pratiquant des excisions et.des
greffes. Ces categories etaient: (!) sites non operes
avec gencive libre normale soutenue par une large
zone de gencive uttachee et une attache de hauteur
normale, (2) site.s avec gencive libre regeneree sou-
tenue par une muqueuse alveolaire mobile et par une
attache de hauteur normale, (3) sites avec gencive
libre regeneree souienue par unc muqueuse alveolaire
mobile et par une attache de hauteur reduite et (4)
sites avec gencive libre regeneree soutenue par une
large zone de gencive attachee et par une attache de
liauteur reduite, Dans un examen initial, on a enre-
gistre la plaque, la gingivite, I'exsudat gingival, la
profondeur de sondage, le niveau clinique de Tat-
taehc, la position du "rebord de tissu mou" el la
largeur de la zone de gencive attachee, Apres cet
examen, 2 des chiens ont ete designes pour les biopsies
et sacrifies, Les 5 autres chiens ont rei;ii pendant 40
jours un regime permettant I'accumulation de plaque,
L'examen clinique a ete repctc et des biopsies ont ete
executees a la fin de cette pcriode, Apres preparation
des prelevements, les biopsies ont ete soumiscs a une
analyse histometrique et morphometrique. Les re-
sultats ont montre que la gencive libre se regenerant
apres i'excision chirurgicale de la totalitede la gencive
et apres greffe de tissu mou etait a presque tous les
points de vue, tant cliniques qu'histologiques, sem-
blabie a la gencive libre "normale", Les donnees
obtenues apres 40 jours d'accumuiation de plaque ue
mettaient pas en evidence de difference enire les
categories de sites gingivo-dentaircs en ce qui con-
cernait ia taille et I'etendue en direction apicale dc la
portion infiltree du tissu eonjonetif. En conclusion,
un site avec gencive libre soutenue par une muqueuse
alveolaire mobile n'est pas plus sujet a devenir
cnfiamme qu'un site avec gencive libre soutenue par
une large zone de gencive attachee.
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