Symposium on Periodontics

Diagnosis and Management of

Mucogingival Problems in Children

J. Gary Maynard Jr., D.D.S.*

and Richard D. Wilson, D.D.S.*

The periodontium in the pediatric patient is constantly changing and

adjusting as it matures. Normal jaw growth and development and the
eruption patterns of deciduous and permanent teeth require continual
accommodation on the part of the periodontal tissues. Early restorative
and orthodontic procedures may place additional burdens on the adap­
tive capacities of the periodontium in the pediatric patient. These factors
and how the developing periodontium copes with them influence the
contour and thickness of the periodontium in the adult patient.
The mucogingival complex is the most superhcial and easily seen
component of the periodontium. Observation of this complex by the
family dentist dui ing the Hrst 16 years or so of the patient s life can be
instructive in anticipating soft tissue problems in the adult dentition.
What clues do we look for in the pediatric patient that might forecast
periodontal problems in later years? What causes recession? What role
does the family dentist have in maintaining the health of the developing
periodontium? By answering these and other questions, the authors will
establish some guidelines to aid the practitioner in dealing with the
pediatric periodontium. As the recognition of incipient problems in die
maturing dentition has always been the hallmark of the caring and vigi­
lant dentist, early diagnosis and management of inucogingiial pioblems
in the pediatric patient will be discussed in this article.
Much of the following may appear to be too basic to the clinician in
daily practice. However, a knowledge of normal structures is essential to
useful diagnosis and proper therapy.
There are two basic types of oral mucous membrane that cover the
alveolar process and the cervical portion of the tooth: gingiva (keratiniTxd

*Clinical Professor, Department of Periodontics, Medical College of Virginia School ol

Dentistry, Virginia Commonwealth University, Richmond, Virginia

Dental Clinics of North America—\'ol. 24, No. 4, October 1980 683

684 J. Gary Maynard and Richard D. Wilson

tissue) and alveolar mucosa (Fig. 1).‘® The keratinized tissue is composed of
attached gingiva, free gingiva, and papillary gingiva. Apical to the
keratinized tissue is the alveolar mucosa. The line that separates these two
zones of tissue is called the mucogingival junction.
Gingiva (Keratinized Tissue)
The attached gingiva is that portion of the keratinized tissue that is
bound down to the cementum and underlying bone by means of the
supra-alveolar connective tissue and the lamina propria. This mucous
membrane has a parakeratinized or keratinized epithelial surface. There
are no elastic fibers within this immobile tissue, and its connective tissue
fibers are densely and thickly arranged. The gingiva and the mucosa over
the hard palate are referred to as the masticatory mucosa. Varying widths,
from 0 to 9 mm, of keratinized tissue may be observed on either the
vestibular or the oral aspects of the teeth. Generally, greater amounts
encompass the maxillary teeth than the mandibular teeth.
The free gingiva surrounds the tooth and extends from the gingival
Mlcogingival Probi.kms in Chh.drkn 685
margin to the free gingival groove or the base of the gingival crevice. The
gingival margin is the most coronal portion of the free gingiva surround­
ing the tooth.
Alveolar Mucosa
Alveolar mucosa is loosely attached to the periosteum and is highly
movable. It has a nonkeratinized epithelium and is a darker red than the
adjacent keratinized tissue. It covers the basal portion of the alveolar
process and blends harmoniously into the vestibular fornix. It is a lining
mucosa and is a thin and fragile tissue.
The frenulum is a fold of alveolar mucosa containing hbrous connec­
tive tissue, fatty deposits, and distinct muscle fibers. These muscle fibers
have their origin in the periosteum covering the alveolar process. The
frenulum creates a problem to the dentition only when there is insuf­
ficient attached gingiva separating its insertion from the free gingiva,
thereby increasing tension to the marginal tissue.

DIFFERENTIATION OF ORAL MUCOUS MEMBRANE

Whether the patient is an adult or a child, clinical differentiation of

the two types of mucosa is essential to the practitioner and can be ac­
complished in various ways. Perhaps the most commonly used and the
poorest technique is by visual observation. It is not always possible to
locate the mucogingival junction visually, since in many instances the
tissue may be relatively free of stippling. For example, the keratinized
tissue around an erupting tooth may be so stretched that it has none of the
normal surface characteristics; this tissue would then resemble alveolar
mucosa.
A more reliable method of identifying the mucogingival junction
would be to take the side of a periodontal probe or similar blunt instru­
ment and jiggle the alveolar mucosa in an apicocoronal direction (Fig. 2).'^
Since the alveolar mucosa is mobile, it will roll up ahead of the blunt

Figures. “The jiggling tech-

nique” to identify the mucogingival
junction.
686 J. Gary Maynard and Richard D. Wilson

instrument to the bound-down attached gingival component of the

keratinized tissue. Where this rolled up tissue begins will be the mucogin-
gival junction. All tissue coronal to this will be keratinized tissue.
Another technique used to differentiate the keratinized tissue from
alveolar mucosa is to inject an anesthetic solution into the alveolar mucosa.
Because of the nature of this mobile tissue and its elasticity, it will distend
up to tbe attached gingival border of the keratinized tissue. If the solution
is injected into the attached gingiva, it will immediately blanch the entire
zone of keratinized tissue to the mucogingival junction.
Lang and Loe utilized Schiller’s IKI dye, which stains the keratin but
not the alveolar mucosa.® W'hen this dye is placed on the keratinized
tissue, a quick distinction between the keratinized epithelium surface and
the alveolar mucosa surface can be ascertained.

Why Is Attached Gingiva Significant in the Maintenance of a

Healthy Dentition?

When one explores the literature regarding soft tissue periodontal

surgery, it is apparent that the majority of present surgical techniques
have evolved as a direct result of either attempting to retain as much
keratinized tissue as possible or increasing the dimension of that
keratinized tissue. Periodontists obviously believe that having a certain
quantity of this tissue around a tooth is signihcant. It could be said that the
value of gingiva is measured by our efforts as a prof ession to preserve or
increase it.
Resistance to Products of Inflammation
A tooth that has alveolar mucosa at its margin seems to show clinical
signs of inflammation in the presence of microbial flora more readily than
does a corresponding tooth that has a sufficient band of attached gingiva.
Such marginal tissue appears to be more susceptible to the products of
inflammation that may result in pocket formation or apical migration of
both attachment apparatus and marginal tissue. Kramer has stated that “it
seems logical to assume that dense, closely packed collagen fiber groups
found in zones of attached gingiva are better deterrents to the infiltration
of inflammatory elements than is the loosely arranged fiber milieu of
alveolar mucosa.’’^
Lang and Loe concluded that when a patient presented with less than
2 mm of keratinized tissue, of which only 1 mm was attached gingiva,
inflammation would be present despite the degree of oral hygiene.®
Resistance to Functional Stress
When the marginal tissue is alveolar mucosa, it does not resist the
functional stress of toothbrush trauma imposed on it. Frequently, the
result is apical shifting of the marginal tissue and additional recession.
Mucogingival Problems in Children 687
Keratinized tissue has a more densely organized connective tissue
and is more firmly bound down to the underlying periosteum and bone.
Consequently, it is more resistant to the functional stress placed upon it. It
resembles the epidermis of the soles of the feet or the palms of the hands.
Alveolar mucosa is thin, delicate tissue, poorly attached to bone and
cementum and is not capable of withstanding these same functional
stresses.
Current use of the modified scrub or Bass techniques seems to place
great demands on keratinized tissue. Following periodontal surgery, the
astute clinician more than occasionally observes a minimal width of
keratinized tissue on the radicular surface of certain teeth, particularly
the mandibular premolars. This minimal width is judged to be adequate
and the patient is scheduled for a four or five month recall appointment.
The patient, being conscientious and meticulous with plaque control, will
follow the oral hygiene regimen to the letter. When the patient returns
some months later for recall, the clinician is often embarrassed to find a
reduction in keratinized tissue, apical migration of the attachment ap­
paratus, additional root exposure, and a more sensitive root surface. This
is a result of toothbrush trauma in the presence of insufficient keratinized
tissue. The maintenance of this gingival margin in the position in which it
is placed postoperatively is related to the thickness of marginal bone and
the width of keratinized tissue. More rapid apical shifting will occur when
there is thin or an insufficient apicocoronal dimension of keratinized
tissue and excessively thin alveolar process on the oral or the vestibular
surface.
Resistance to Tensional Stress
Attached gingiva serves as a buffer between the mobile free gingival
margin and mobile alveolar mucosa. There are skeletal muscle fibers
within the alveolar mucosa that exert a force in an apical direction on the
attached gingiva. This force is dissipated by bound down keratinized
tissue. When there is an insufficient apicocoronal dimension of attached
gingiva present, the tensional stress exerted by the muscles of facial
expression results in movement, retraction, and blanching of the free
gingival margin. Apical migration of the entire attachment apparatus
often occurs and is observed clinically as root exposure, pocket formation,
or both.
If there is a thin underlying radicular bone, a fenestration of dehis­
cence of the bone, migration of the attachment in an apical direction may
be more rapid. Apical migration of the marginal tissue in the presence of
inflammation, an irritant, or trauma will proceed until it reaches a thicker
portion of the alveolar process. If there is thick underlying radicular bone
and insufficient keratinized tissue separating the free gingiva and alveolar
mucosa, the tensional stress and inflammation may result in pocket for­
mation rather than root exposure. The thicker underlying bone seems to
preclude any apical migration of the free gingival margin.
688 J. Gary Maynard and Richard D. Wilson

COMPARISON OF ATTACHED GINGIVA IN PEDIATRIC AND

ADULT PATIENTS

It has been reported that clinical observations in children, aged 4 to

16 years, revealed less variation in the width of keratinized tissue from
individual to individual in deciduous incisors than in the permanent
incisors." Rarely is less than 4 to 5 mm of keratinized tissue observed on
the facial surface of deciduous incisors, whereas the width of keratinized
tissue in the permanent dentition varied from 0 to 6 mm. In general,
sulcular depth in the deciduous dentition was less than in the permanent
dentition. I'hus, the attached gingiva was wider and less variable in the
deciduous dentitions than in the permanent dentitions.
A far greater incidence of marginal gingivitis was observed in per­
manent dentitions than in deciduous dentitions. This may relate to the
more resistant nature of the keratinized tissue. The narrower the zone of
keratinized tissue in the permanent dentition, the more frequently mar­
ginal gingivitis was observed clinically. This is consistent with the hndings
of Lang and Loe.
We have never observed mucogingival problems (inadequate
keratinized tissue, gingival recession, or labial root surface exposure) in
the deciduous dentition, except when caused by some bizarre habit pat­
tern (such as fingernail scratching of the tissue). Mucogingival defects
seem to be a developmental problem of the permanant dentition.
To define what is meant by a mucogingival problem, it is necessary to
turn to the glossary of the periodontal terms published in the Journal of
Pfriodontolngy in January 1977. Although there is no definition of
mucogingival problems, mucogingival surgery is defined as a “plastic
surgical procedure designed to correct or modify defects in the morphol-
ogy, position, and amount of gingiva surrounding the teeth.”'® Ex­
trapolating from this, a definition of a mucogingival problem would be “a
defect in the morphology, position, and amount of gingiva surrounding
the teeth.”
Accepting this working definition of a mucogingival problem, what
does the literature reveal about “the morphology, the position, and the
amount of gingiva surrounding the teeth?”
Amount of Gingiva
Studies by Bowers,* Loe and Ainamo,'® Rose and App,'* and Ainamo
and Talari' tend to suggest that the width of attached gingiva increases
with age. These studies imply that as the patient progresses from the
deciduous dentition to a more permanentor a mature dentition, there will
be an increase in the width of attached gingiva.
Position of Gingiva
Hirschfeld noted that “a lingually malposed tooth presented a thicker
and more coronal alveolar buccal plate than was present against its prop­
Mucogingivai. Pkoblkms in Children 689
erly positioned neighbor. The lingual plate, on the other hand, was
thinner and ended more apically than on the adjacent teeth.Morris
observed that “the position of the gingival margin is partly determined by
the buccal and/or lingual prominence of the tooth surface adjacent to it,
being more apical with greater prominence and more coronal with less
prominence.”’^ Bowers reported, “Teeth that are prominent in the arch,
such as the mandibular cuspid and bicuspid, have a narrow zone of
attached gingiva.”^ Examination of erupting teeth in a patient with mixed
dentition reveals that the position in which the tooth erupts through
the alveolar process and its eventual position in the arch will have
a profound influence on the amount of keratinized tissue around that
particular tooth.
Boyd implies that if a tooth is in labial version, has no attached
gingiva, and is moved lingually, the width of attached gingiva will in­
crease.® Reports by Dorfman assert that with “an initial minimal or
nonexistent width of keratinized tissue, the direction of tooth movement
may greatly influence the final gingival coronal height as well as the
dimension of keratinized gingiva in the mandibular incisor region.”“'
Control of Inflammation in Presence of Insufficient Attached Gingiva
In a more recent investigation, Dorfman, et al. concluded that results
to date support the concept that the control of plaque and inflammation is
sufficient to prevent recession and loss of attachment in spite of an
inadequate dimension of attached gingiva.® Paraphrased, if we keep the
plaque off and control the inflammation, no additional recession will
occur even if we don’t have an adequate width of keratinized tissue.
Therefore, the following conclusions could be drawn from the above
studies:
(1) If there is little or no attached gingiva in the deciduous dentition,
the clinician should not be concerned. As age increases, so does the
amount of attached gingiva.
(2) If a tooth is in a labially prominent position and there is a minimal
amount of keratinized tissue on the labial surface, move the tooth lingual­
ly and the amount of keratinized tissue on the labial surface will in­
crease.
(3) If minimal keratinized tissue is present, keepingthe tooth surface
free of plaque will prevent recession.

DISPARITIES BETWEEN LITERATURE AND CLINICAL

FINDINGS

If each or all of the previously mentioned conclusions are valid, why

do so many of us observe mucogingivai problems or defects in the amount
and position of gingiva? It would appear that some disparities exist
between conclusions drawn from the literature and what the practitioner
690 J- Gary Maynard and Richard D. Wilson

sees in clinical practice. These disparities should be compared and

examined.
Many studies reported in the literature seem to be done on groups of
patients and not on individual patients followed from the deciduous
dentition to the permanent dentition. What may be the case for a group
may not be the case for an individual followed over 10 to 15 years.
Figure SA shows a longitudinal case of a patient during the mixed
dentition age with adequate keratinized tissue on the central incisor and
right deciduous canine. With further loss of teeth and maturation, a
minimum of keratinized tissue over the facial aspects of the right incisor
and canine is observed. There has not been an increase in the width of
keratinized tissue during or after the change from the deciduous to
permanent dentition (Fig. 3B).
Another inconsistency between the literature and clinical observation
relates to the movement of a tooth from a labially prominent position to a
lingual position in order to increase the width of keratinized tissue. Hall
states, “Not a single conclusive case has been presented to document that
an increase of attached gingiva occurs on a tooth which has fully erupted
with an inadequate band of attached gingiva.”**

Fijifure 3. A, A longitudinal
case is shown of a patient during
the mixed dentition age with
adequate keratinized tissue on the
central incisor and right decidu­
ous canine.B, With further lo.ss of
teeth and maturation, a minimal
amount of keratinized tissue over
the facial aspects of the right in­
cisor and canine is observed,
rhere has nul been an increase in
the width of keratinized tissue
during or after the change from
the deciduous to permanent den­
tition.
Muc<)(;inc;ival Problems in Children 691

A case (Fig. 4A) is shown in which there was an insufficient width of

keratinized tissue. The tooth was intentionally moved in a lingual direc­
tion, and supplementary treatment was directed toward further lingual
retraction of the roots (Fig. 4B). An increase in the width of keratinized
tissue over the facial aspects of these teeth was not observed (Fig. 4C).
We can only conclude that a tooth may be erupting in a position in
which the appears to be alveolar mucosa, but which is, in fact, bound
down, attached gingiva. The tension that is on that tissue because it is in a
labially prominent position will make \iappear to be alveolar mucosa (Fig.
5). After the tooth is fully erupted and the tension released from the
tissue, it may become apparent that an adequate dimension of keratinized
tissue is present. Fherefore, orthodontic tooth movement from a labially
prominent to a more normal position may only seem to have increased the
dimension of keratinized tissue. In reality, the tension is removed from
stretched keratinized tissue, which then assumes its more normal clinical
appearance.
Lingual retraction with extrusion of the labially prominent tooth may
well result in an increase in the width of keratinized tissue. However,
lingual retraction alone will not create more attached gingiva.
A recent investigation concludes that if a patient has an inadequate
amount of keratinized tissue and the plaque and inflammation is effec­
tively controlled, there will be no additional recession.^ This statement
could undoubtedly be made regarding prevention of all inflammatory
periodontal diseases. If inflammation could be controlled by plaque con­
trol, there would be no loss of attachment (that is, no pocket formation).
692 J. Gary Maynard and Richard D. Wilson

Figure 5. A, An erupting
canine with tissue that appears to
be alveolar mucosa. B, Upon
complete eruption, the tension is
relaxed. An adequate dimension
of keratinized tissue is now pres­
ent.

Hall states that when inadequate gingiva is present in a patient who

has been doing a poor job of brushing, recession may actually be precipi­
tated by changing to better brushing practices.® Many patients already
have slight recession, marginal inflammation, and plaque accumulation.
If a substantial improvement in plaque control is seen, one frequently
observes additional recession occurring around that particular tooth or
teeth.
O’Leary’s report,in which he has shown that lower plaque and
gingival scores were found in patients with recession, seems to contradict
the reports of Dorfman, Kennedy and Bird. O’Leary’s study implies that
the more thorough care taken, the more recession one experiences.
The hygiene control of the patient in everyday practice is rarely up to
the standards of the hygiene control that is essential in a study such as the
one being di.scussed.® Most patients will not maintain the degree of plaque
control we desire. Those patients with recession and alveolar mucosa as a
tissue margin frequently state that brushing causes discomfort, and there­
fore they are not as diligent or effective in that particular area. Finally, if
recession does not oi cur iii the absenc e of microbial florti, wh\ is it so olten
seen on teeth that are so clean and well scrubbed?
 Mucogingival Problems in Children 693
THE CAUSE OF MUCOGINGIVAL PROBLEMS

In our opinion, mucogingival problems originate in the early denti­

tion and result from developmental aberrations in eruption and deficien­
cies in the thickness of the periodontium. When one of these developmen­
tal aberrations occurs, the stage is set for development of a mucogingival
problem. If there is also inadequate plaque control and the sub.sequent
inflammatory changes in the gingiva or if excessive toothbrushing with its
associated trauma and abuse develop, progression of the mucogingival
problems is often seen.
The family dentist, the pedodontist, and the orthodontist have a
special responsibility to examine, on a continuing basis, the mucogingival
complex in the young dental patient. Eruption patterns and the thickness
of the periodontium should be evaluated, noted on the patient’s chart,
and photographed, if possible, as the child’s dentition develops from
deciduous to permanent.
Eruption Pattern
If a tooth were to erupt in labial version or forced in a labial direction
by tongue pressure, crowded intercanine space, and/or lateral incisor
pressure, we believe that there most likely would be minimal keratinized
tissue on the facial aspect and minimal buccal osseous support. A wide
zone of keratinized tissue and a thick bony plate would then be seen on the
lingual aspect. The gingival margin would be more coronal on the lingual
as compared to the labial aspect. The converse would be true for lingually
positioned teeth. The case illustrated will support this conclusion (Fig. 6).
In our opinion, if a tooth is in a labially prominent position and has no
keratinized tissue, the marginal tissue will not become keratinized tissue
with time. In addition, if a tooth is in a labially prominent position and has
a minimal width of keratinized tissue, there will be no further increase in
the apicocoronal dimension of this tissue.
Similar problems are observed on the rotated incisor in Figure 7.
Correction of this rotated tooth orthodontically without consideration of

Figure 6. The mandibular

left central incisor has erupted in a
labially prominent position, and
there is approximately 1 mm of
keratinized tissue on the labial as-
f)ect. There is obvious marginal
gingivitis. A severe mucogingival
problem already exists in this 7 year
old patient. Further loss of attach­
ment and/or keratinized tissue and
r(K)t exposure are inevitable if the
problem were to be ignored.
694 J. Gary Maynard and Richard D. Wilson

Figure 7. Unrotated mandibu­

lar incisor.

the mucogingival problem may result in further stripping of the facial

attachment.
Thickness of the Periodontium
fhe thickness of the periodontium has a significant effect on
mucogingival problems. There are four possibilities;
The Normal or “Ideal” Dimension of Keratinized Tissue with Normal
or Ideal Labiolingual Width of the Alveolar Process. Diagrammalicallv
(Fig. 8/i), there is demonstrated a good band of keratinized tissue and an
adequate or ideal thickness of the bone over the labial surface of the lower
incisor teeth. Clinically (Fig. 8f}), the width of keratinized tissue is 3 to 5
mm and palpation reveals a relatively thick periodontium. A sufficient
dimension of attached gingiva separates the mobile free gingival margin
from the mobile alveolar mucosa.
The Second Type of Periodontium Has a Thinner Dimension of
Keratinized Tissue with Normal Labiolingual Width of the Alveolar Pro­
cess. Diagrammatically (Fig. 9/i), it can be demonstrated as a reduced

Figure 8. A, Diagram relating

ideal dimensions of keratinized tissue
and bone. KT = keratinized tissue;
AM = alveolar mucosa, li, Clinical
representation of ideal dimension of
keratinized tissue and bone.
Mucogingival Problkms in Children 695

Figure 9. A, Diagram repre­

senting thin keratinized tissue over
normal labiolingual width of the al­
veolar process. KT = keratinized tis­
sue;/fiVi = alveolar mucosa. Clini­
cal representation of thin keratinized
tissue over normal labiolingual w'idth
of the alveolar process.

width of keratinized tissue over the facial aspects of the teeth; the bone
thickness is basically the same as in the ideal. The clinical appearance
(Fig. 9B) shows a minimal amount (less than 2 mm) of keratinized tissue
over the facial of the teeth. The bone underneath, when palpated, seems
reasonable thic k.
The Third Type of Periodontium Occurs Where a Normal or Ideal
Dimension of Keratinized Tissue Is Present with Thin, Labiolingual Width
of the Alveolar Process (Fig. lOA). This is observed clinically (Fig. lOfi) as
normal keratinized tissue width, but the bone underneath is thin and the
roots can be |)alpated with the hngers.
The Fourth Type of Periodontium Occurs Where the Dimension of
Keratinized Tissue Is Thin (Less Than 2 mm) and the Labiolingual Dimen-

Figure 10. A, Diagram repre­

senting a normal or ideal dimension
of keratinized tissue over thin labio­
lingual width of the alveolar process.
KT = keratinized tissue;/1AÍ = alveo­
lar mucosa. B, Clinical representa-
696 J. Gary Maynard and Richard D. Wilson

Figure 11. A, Diagram demolisti ating the presene e ol a lililí diinensioii of keratini/ed
tissue and a thin dimension of labiolingual bone. KT = keratinized tissue; AM = alveolar
mucosa. B, Clinical representation.

sion of the Underlying Bone Also Is Thin (Fig. 1 lA). This tissue situation
(Fig. Il/J) has the poteiuitil to letede in tlic presence oi poor plac]ue
control and trauma as the patient matures.
The ideal periodontium may well endure. The second possibility
likewise may survive. The third one frequently may mislead the family
dentist, and the orthodontist must be especially perceptive because labial
tooth movement may result in attachment loss. The fourth type should
generate the most concern to the practitioner.

WHEN IS A MUCOGINGIVAL PROBLEM IN A CHILD A

PROBLEM?

Recognition of a problem is the first step in maintaining health. The

following instances are examples of mucogingival problems which we
believe may progress with age. Therefore, treatment with the autogenous
gingival graft is recommended.

Figure 12. The marginal tis­

sue is alveolar mucosa and is located
at the cemento-enamel junction.
There is demonslrable stress from
the frenuluiii on dial margin.
Mucogingival Problems in Children 697

Figure 13. Exposed root sur­

face, less than 2 min of keratinized
tissue, and no attac hed gingiva.

When the Marginal Tissue Is Alveolar Mucosa and Is Located at the

Cementoenamel Junction and There Is Demonstrable Stress from the Fren­
ulum on that Margin (Fig. 12). The marginal tissue can be moved when
tension is applied by frenulum movement. There is inadequate
keratinized tissue an inadequate attached gingiva component of that
keratinized tissue.
When the Root Surface Is Exposed and Minimal Keratinized Tissue
(Less Than 2 mm) and No Attached Gingiva Are Present (Fig. 13). This is a
problem of root exposure, no attached gingiva, and minimal or no
keratinized tissue.
When an Incisor Erupts Labial to the Adjacent Incisor and There Is
Minimal Keratinized Tissue, No Attached Gingiva, and No Lingual Bodily
Movement of the Incisions is Planned (Fig. 14). A discussion of the reasons
why the teeth cannot be moved lingually is in order.
(a) The patient may be unable to undergo orthodontic treatment for
economic reasons.
(b) Occasionally, the orthodontist has a case where there are labially promi­
nent incisors, where the molar relationship is relatively normal, and where the
facial profile of that particular patient is satisfactory. To correct the position of the
incisors and move those teeth lingually may create more of a problem for the
patient than if the problem were left as it presents.

Figure 14. An incisor erupt­

ing labially m an adjacent incisor.
There is minimal keratinized tissue
and no attached gingiva, and lin­
gual bodily movement of the inci­
sors is not possible.
698 J. Gary Maynard and Richard D. Wilson

Figure 15. A, Preoperativc case showing a very ihin perioclontiuin. Labial tipping
resulting in labial movement of root with attendant recession.

Figure 16. A, Class 111 malocclusion and a thin periodontium on the facial aspect of
the mandibular incisors. B, Recession occurred as the lower incisors were tipped lingually.
Mucogingival Problems in Children 699
When either of these problems exists, we prefer to treat the mucogin-
gival defect rather than neglect both the orthodontic and periodontal
problem.
When an Incisor Erupts in a Rotated Position and There Is Minimal
Keratinized Tissue on the Labial Surface (see Fig. 7). If the incisor is suffi­
ciently retracted lingually prior to correcting the rotation, it may tolerate
the movement. However, most frequently the retraction does not occur
and the tooth is rotated completely out of the keratinized tissue and labial
bony plate.
When There Is a Relatively Thin Periodontium (Type 4) and any Labial
Movement of the Mandibular Incisior Is Anticipated. A discussion of the
mechanics of tooth movement with orthodontists leads one to become
more tolerant and aware of their problems regarding the preciseness of
tooth movement. Orthodontic movement of a tooth in the exact direction
and into a precise position may not always be possible. Unintentional
labial movement may occur more often than most orthodontists care to
admit. Although this labial movement may be only slight, it could still be
excessive for tbe Type 4 periodontium.
What are some instances when labial movement may occur with
attendant recession in the Type 4 periodontium?
(1) Occasionally the orthodontist will tip the incisal edge labially or
lingually. In a very thin periodontium, this labial tipping will move the
cervical portion of the root labially enough to cause recession (Fig. 15).
(2) Orthodontic correction of Class III malocclusion may be attemp­
ted by tipping the maxillary incisors labially and the mandibular incisors
lingually. In tbin periodontium, tbis may create enough labial movement
of the roots of mandibular inci.sors to compromise further an already
fragile periodontium. Recession commonly occurs (Fig. 16).
(3) In finishing up a Class II case, the orthodontist may utilize Class
II elastics, which tend to move the entire lower arch anteriorly. Such
movement will cause the lower incisors to move labially and, in the thin
periodontium (Type 4), often will result in recession of the tissue on the
vestibular surface.
When Root Exposure Occurs During Orthodontic Movement. In any
type of periodontium, labial movement of the lower incisors or any tooth
may be beytind the tolerance of the periodontium and result in recession.
This mucogingival problem may not necessarily be diagnosed before
orthodontic treatment, but its potential for occurring must be understood
by the therapist. Maintaining the integrity of the periodontium must be
included among the objectives of orthodontic therapy. If the lower in­
cisors have “stripped out” during treatment, success in treatment has not
been accomplished in spite of what might be a good functional and
cosmetic orthodontic result (Fig. 17). Evaluation of the periodontium
throughout the entire period of therapy must be an integral part of the
responsibility of the family dentist and the orthodontist.
700 J. Gary Maynard and Richard D. Wilson

Figure 17. In any type perio­

dontium, labial movement of the
lower incisors may be beyond the
tolerance of the periodontium and
recession may result.

When the Maxillary Incisor Overbite Destroys the Existing Keratinized

Tissue on the Mandibular Incisors (¥'ig. 18). These problems are not seen
iretiuently but cause severe mucogiugival problems when they do occur.
When Any of the Above Are Present and There Is a Question in the
Clinician’s Mind as to Whether There Is a Potential Problem in the Case
Being Examined, Evaluate the Sibling or the Parent. If a mucogingival
problem is present in either, then the possibility of a problem developing
in the child in question must be considered. Documentation of numerous
cases has been collected by one of the authors (JGM) wfherein advanced
marginal tissue recession was observed in the child as well as in one of the
parents or in a sibling (Fig. 19).

AUTOGENOUS GINGIVAL GRAFT

Our experience suggests that the use of the autogenous gingival graft
is a dependable method of preventing recession. This procedure results
in conversion of a mobile, nonkeratinized alveolar mucosa into dense,
bound down connective tissue with overlying keratinized tissue. It ap­
pears to be the most predictable periodontal surgical procedure available

Figure 18. Maxillary incisor overbite (A) that has destroyed the existing keratinized
tissue on the mandibitltir incisors (B).
Mucogingival Problems in Children 701

Figure 19. Advanced marginal tissue recession in patients who are father (A) and
daughter (B).

for increasing the dimension of keratinized tissue. The autogenous gingi-

V2i] graft has been used on numerous patients of 6 to 15 years of age to
increase the relative thickness of the periodontium and make it more
resistant to further recesssion.
The case illustrated was selected from one of the many treated over
the past 12 years (Fig. 20). It demonstrates how the mucogingival problem
has been corrected in the pediatric patient and that further recession has
been prevented through the use of the autogenous gingival graft. The
consistent findings in all cases treated in this manner over the years are:
(1) tissue margins become even with the adjacent tissue, (2) no pockets
traverse the mucogingival junction, (3) no additional recession occurs,
and (4) the graft maintains the gingival margin at or near the cemento-
enamel junction.
One long term documented case has been selected to demonstrate
how the graft responds to orthodontic therapy (Fig. 21). It appears
clinically that even in the presence of some labial movement, the graft
may be more resistant to recession than is the normal attached gingiva
present over the labial aspect of the tooth.
702 J. Gary Maynard and Ric hard D. Wh.son

Figure 21. A, Labially prominent incisors with inadequate keratinized tissue. B, Bed
prepared for autogenous gingival graft. Note retenticjn of keratinized tissue on patient s
right central incisor. C, Two years after surgery; compare width of keratinized tissue graft
on patient’s left central incisor with lesser amount on right central incisor. During (D) and
seven years after completion ot'(E) tooth movement. Compare the reduction of keratinized
tissue over lateral incisor, loss of keratinized tissue (over right ittcisor) which was retained at
time of bed preparation, and the stability of the autogenous gingival graft.

Most periodontists would agree that success in covering a denuded

root is difficult and not predictable. Evaluation of cases treated over the
past decade would lead us to conclude that recession in the permanent
dentition can be prevented when managed with an autogenous gingival
graft in the pediatric patient. This would appear to be better than waiting
until recession occurs and then attempting treatment that may fail. If
orthodontic tooth movement is anticipated in the presence of any of the
mucogingival problems listed by the authors, we recommend that the
autogenous gingival graft be performed prior to orthodontic treatment.

REFERENCES

1. Ainamo, J., and Talari, A.: The increase with age of the width of attached gingiva. J.
Periodont. Res., 77:182, 1976.
Mucogingival Problems in Children 703
2. Bowers, G. M.: A study of the width of the attached gingiva. J. Periodontol., I9(i3.
3. Boyd, R. L.: Mucogingival considerations and their relationship to Orthodontics. [.
Pei iodontol.,-/9:67, 197H.
4. Dorfman, H. S.: Mucogingival changes resulting from mandibular incisor tooth move­
ment. .\m. J. Orthodont., 74:286, 1978.
5. Dorfman, H..S., Kennedy, J., and Bird,W.: Longitudinal evaluation of free autogenous
gingival grafts. J. Dent. Res. (Special Issue A), 57:100, 1978.
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7. Hirschfeld, I.: A study of skulls in the .American Museum of Natural History in relation
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(eds.): Periodontal Therapy, F.dition 5. St. Louis, C. V. Mosby Co., 1973, chapter 14.
9. Lang, N. P., and Loe, H.: The relationship Ixitween the width of keratinized gingiva and
gingival health. J. Periodontol., 45:623, 1972.
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scopic study of the free and attached gingiva. J. Periodontol., 57:,'). 1966.
11. Maynard, J. G., and Ochsenbein, C.: .Mucogingival problems, prevalence and therapy in
children. J. Periodontol., 4(5:543, 1975.
12. Morris, M. L.: The |x)sition of the margin of gingiva. Oral Surg., //:969. 1958.
13. Ochsenbein, C., and Maynard, J. G.: The problem of attached gingiva in children I
Dent. Child., 41:263, 1974.
14. OT-eary, I. J., Drake, R. B., Crump, P. P., et al.: The incidence of recession in young
males: A furthei study. J. Periodontol., 42:264, 1971.
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Practice. Philadelphia, W. B. Saunders Co,, 1979, chapter 9.
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Periodontol., 4//: 17, 1977.
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