The Relationship Between the

Width of Keratinized Gingiva

and Gingival Health

by
Niklaus P. Lang*
Harald Löe**

Introduction
In man the keratinized gingiva includes the free and
the attached gingiva and extends from the gingival mar-
gin to the mucogingival junction.1 The width of the
keratinized gingiva may vary between 1 and 9 mm.2, 3
The characteristics of the gingiva on the facial aspect
have been described by several authors.1"7 However,
only one recent study has reported on the width of the
lingual keratinized gingiva of the mandible.7
Although not substantiated, it is generally believed
that an adequate width of keratinized gingiva is im-
portant for maintaining gingival health. This has resulted
in the introduction of numerous surgical procedures to
increase the width of gingiva.8 30 However, the question
of how much gingiva is "adequate" has not been inves- Figure 1. Clinical photographs showing the mucogingival
junction a) without stain b) after application of the Schiller
tigated. IKI solution.
The purpose of the present investigation was to ex-
amine the width of the facial and lingual keratinized to the nearest 0.5 mm from the gingival margin to the
gingiva and to determine how much keratinized gingiva mucogingival junction using a specially graded perio-
is adequate for the maintenance of gingival health. dontal probe. The depth of the gingival crevices was
also measured. In order to compare the results of the
Material and Methods present study to results from previous studies the width
of attached gingiva was determined by subtracting the
Thirty-two dental students between 19-29 years of crevicular depth from the width of keratinized gingiva.
age with no pathologic pockets performed supervised
oral hygiene (daily supervision with the Plak-Lite® dis- Gingival exudate was assessed37 on all (116) buccal
and lingual surfaces which had 2 mm or less of kera-
closing system)31 for 6 weeks. Following this period, tinized gingiva. In addition, the amount of gingival exu-
the gingiva of all buccal and lingual tooth surfaces was
date from 118 tooth surfaces randomly selected from
assessed using the Gingival Index system.32 Oral hy-
a total of 371 which had 2.5 to 3.0 mm gingiva was
giene was scored on all surfaces according to the criteria measured. Only plaque free surfaces were scored.
of the Plaque Index system.33 The identification of the
mucogingival junction was facilitated by staining with
Schiller's IKI solution.34 Using this method, the epithe- Results
lium of the alveolar mucosa yielded an iodine-positive
reaction while the keratinized gingiva was iodine-nega- After the six weeks of controlled oral hygiene the
mean individual Plaque Index (PI I) was 0.22 (range
tive,3430 (Figure 1 a,b). After application of the Schiller 0.00-0.57). The mean individual Gingival Index (GI)
solution, the width of keratinized gingiva was measured
was 0.09 (range 0.04-0.25). The crevicular depth aver-
^'Research Associate, Department of Periodontology, Royal aged 1.0 mm (range 0.5-1.5 mm).
Dental College, Aarhus, Denmark.
**Professor and Chairman, Department of Periodontology, From atotal of 1406 tooth surfaces, 1168 were com-
Royal Dental College, Aarhus, Denmark. pletely plaque free.
623
624 Lang and Löe J. Periodontol.
October, 1972

MEAN WIDTH OF KERATINIZED GINGIVA

1 1-.-.-,-,-. TOOTH
h l2 C P, P2 M1 M2 M3
Figure 2. Pattern of variation in the mean width of keratinized gingiva in 32 individuals
(19-29 years of age) with excellent oral hygiene and healthy gingiva.

The facial keratinized gingiva was widest in the area gingiva was generally 0.5-1 mm wider than in the
of upper and lower incisors and narrowest adjacent to mandible (Figure 2).
the maxillary and mandibular canines and first pre-
molars (Figure 2). The lingual gingiva of the lower Most surfaces (> 80%) with 2.0 mm or more kera-
jaw exhibited its greatest width in the area of the pre- tinized gingiva were clinically healthy, (Figure 3) and
molars and molars. The incisors showed the narrowest 76% of these same surfaces failed to show gingival
lingual gingiva (Figure 2). In the maxilla the facial exudation (Figure 4). On the other hand, all surfaces

PERCENTAGE OF SURFACES
Volume 43
Number 10 Keratinized Gingiva and Gingiva Health 625

PERCENTAGE OF SURFACES GINGIVAL EXUDATE

IN MM
100

80
| 0.3-0.5
60
0.6 -1.0
40
>1.0
20

1.0 1.5 2.0 23 >3.0 MM

KERATINIZED
GINGIVA
Figure 4. Proportion of gingival exudate measurements 0 to 0.3-0.5 to 0.6-1.0 to
greater than 1.0 mm in surfaces of varying width of keratinized gingiva (1.0-3.0 mm) of
234 plaque free teeth.

with less than 2.0 mm of keratinized gingiva exhibited ATTACHED GINGIVA OF BUCCAL SURFACES
clinical inflammation and varying amounts of gingival I MM
exudate (Figures 3, 4). Generally, the Gingival Index 5
and gingival exudate scores increased as the width of 4
the keratinized gingiva decreased (Figures 3, 4). The
3
maximum score during this examination was GI = 2
2
(moderate inflammation) which occurred only in sur- <
faces whose width of keratinized gingiva was 2 mm or 5
1
less (Figure 4). Mi
O -TOOTH

Figure 5 compares the distribution of variation of 1

the width of attached gingiva found in the present study 2
LU
_l
m
to that of previous studies.2'3' 7 The similarity between 3 o
these results is apparent. z
<
4
5

Discussion and Conclusion ATTACHED GINGIVA OF LINGUAL SURFACES.

The present investigation has shown that the pattern I MM
of variation in the width of the facial keratinized gin-
giva minus the crevicular depth agrees with previous
studies on the width of attached gingiva.2'8- 7 Simi- CO
a
larly, it corroborates recent data on the width of the
lingual attached gingiva.7 In this study the width of
the lingual keratinized gingiva varied between 1 and 8
mm. The smallest width was usually seen in the area -TOOTH
L, l2 C R, P2 M,
of the anterior teeth, and the widest gingiva was found
adjacent to premolars and molars. This pattern of varia- &—a BOWERS 1963
tion is almost the reverse of that of the facial gingiva.
o-o AINAMO AND LÖE 1966
The present material has also clearly demonstrated
d— COPPES 1972
that although tooth surfaces may be kept free of clin-
ically detectable plaque, with less than 2 mm of
areas •—• LANG AND LOE 1972
keratinized (which less than 1 mm of attached)
means
Figure 5. Comparison of the pattern of variation in the
gingiva persisted to remain inflamed. The fact that mean width of attached gingiva in the present study to
inflammation persisted in these areas irrespective of those of previous studies.
626 Lang and Löe
the presence or absence of frenum insertions, suggests
that the inflammatory situation in the gingiva is not
a result of only mechanical irritation from these struc-
tures. Rather it is conceivable that a movable gingival
margin would facilitate the introduction of microorgan-
isms into the gingival crevice resulting in a thin sub-
gingival bacterial plaque which would be difficult to
detect and not easily removed by conventional tooth-
brushing.
The regions which consistently showed the narrowest
width of keratinized gingiva were the lingual surface
of the lower anteriors and the buccal surface of the
lower canines and first premolars. However, the study
has shown that these surfaces which averaged nearly 3
mm in width should be adequate to maintain gingival
health. Although not a problem from a preventive point
of view, the narrow keratinized gingiva on the lingual
of the lower anteriors may pose a problem in prostho-
dontic and periodontal treatment. For example, it is
required that if lower partial removable appliances are
to be equipped with a lingual bar, the lingual area should
have a minimum width of 4 mm keratinized gin-
giva.38- 39 This requirement may be difficult to satisfy
in the average patient since the mean width of the lin-
gual gingiva adjacent to the lower anterior teeth is
usually less than 3 mm.
It is apparent in
Periodontitis that pathologic pockets
may easily extend beyond the mucogingival junction.
Although procedures have been devised for correction
this problem when it occurs on the facial aspect, to
the best of our knowledge, modern periodontal surgery
offers no specific method for increasing the width of
keratinized gingiva on the lingual surface of the lower
incisors.
Furthermore, since it would appear from this study
is needed to maintain health than gen-
that less gingiva
erally believed, critical reappraisal of the indications
a
for performing anyone of the many surgical procedures
available for increasing the width of gingiva must be
undertaken.
Summary
The study undertook to examine the width of the
facial and lingual keratinized gingiva and to determine
how much gingiva is "adequate" for the maintenance
of gingival health. After 6 weeks of supervised oral
hygiene the gingival health of 1406 buccal and lingual
surfaces in 32 dental students was assessed according
to the criteria of the Gingival Index system. The width
of keratinized gingiva was measured after the applica-
tion of the Schiller IKI solution. Gingival exudation was
measured on all buccal and lingual surfaces which had
2 mm or less of keratinized gingiva and in a randomly
selected number of tooth surfaces with more than 2
J. Periodontol.
October, 1972
mm gingiva. Only plaque free surfaces were scored.
Previous observations on the width and the pattern of
variation of keratinized gingiva were confirmed. It was
demonstrated that gingival health is compatible with a
very narrow gingiva. However, in areas with less than
2 mm keratinized gingiva inflammation persisted in
spite of effective oral hygiene. It is suggested that 2 mm
of keratinized gingiva (corresponding to 1 mm attached
gingiva in this material) is adequate to maintain gin-
gival health.
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Number 10 Keratinized Gingiva and Gingiva Health 627

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Announcements
CONTINUING EDUCATION COURSES ARMY DENTAL RESEARCH INSTITUTE EARN AWARD
FALL SEMESTER—1972 AT ARMY SCIENCE CONFERENCE
COLLEGE OF MEDICINE AND DENTISTRY On June 21, 1972 the United States Army Institute of Dental
OF NEW JERSEY Research team of Brigadier General Surindar N. Bhaskar,
NEW JERSEY DENTAL SCHOOL Colonel Arthur Gross and Colonel Duane E. Cutright presented
201 Cornelison Avenue a study of their work with the pulsating water jet device at
Jersey City, N.J. 07304 the Army Science Conference at West Point. Their contribu-
tion to Army research and development was judged to be
Course Title—P-l Periodontics for the General Practitioner;
A. Formicola and Staff; Dates 9-20-72 (Wed.); among the nine most significant in all areas of research.
Faculy—Dr.
Fee—$40.* Scientists from throughout the Army Research and Develop-
ment Command had submitted a total of 497 proposals for
Course Title—CE-2 Getting Prevention Through To Your papers to be presented at the conference. Of these, 100 were
Patients; Faculty—Dr. J. Mittelman; Dates—10-18-72 (Wed.); selected by a panel of Judges for presentation. Papers selected
Fee—$50. represented all areas of Army research, and included such
Course Title—CE-3 Principles of Occlusion; Faculty—Dr. N. subjects as communications, computer systems and nuclear
research as well as medical studies.
Guichet; Dates— 11-13, 14, 72 (Mon. and Tues.); Fee—$95
(Dentists) $60 (Aux.). At the end of the week-long conference, the panel of scien-
*No tuition for N.J. dentists. However, a $10. registration fee tists selected the nine best papers presented. Authors of these
is required for each course. studies received medals, certificates, and cash awards.
The studies conducted at the United States Army Institute
FOR INFORMATION AND APPLICATION, WRITE TO: of Dental Research led to the use of the pulsating water jet
devices in the debridement of combat wounds in Vietnam.
Dr. Daniel Isaacson
These techniques have now been adopted for the management
Director of Continuing Education
of wounds in all parts of the body.
New Jersey Dental School
201 Cornelison Avenue This is the first time that dental research has won such an
Jersey City, New Jersey 07304 award at the Army Science Conference.