ATTACHED GINGIVA SIGNIFICANCE,RATIONALE AUGMENTATION

Introduction Gingiva Macroscopic & Microscopic structure Attached Gingiva: Functions, Width & Assessment Tissue barrier concept Thickness of attached gingiva Importance of attached gingiva in the maintainence of periodontal health Increased width of attached gingiva with age and supraerupted tooth Width of attached gingiva and orthodontic treatment Importance of AG in prosthetic treatment Clinical Significance Reduced or absent attached gingiva may be due to several factors: Objectives accomplished by widening of attachedgingiva Techniques for increasing attached gingiva Conclusion and References

INTRODUCTION:

 Gingiva :
Gingiva is the part of the oral mucosa that covers the alveolar processes of the jaws and surrounds the necks of the teeth. Carranza 10th ed

The fibrous investing tissue, covered by keratinized epithelium, which immediately surrounds a tooth and is contiguous with its periodontal ligament and with the mucosal tissues of the mouth. A A P 1992

MACROSCOPY OF GINGIVA
Anatomically Free or Marginal Gingiva. Attached Gingiva. Interdental Gingiva.

Functionally Part facing oral cavity. Part facing the tooth.

Microscopic structure of gingiva

Gingiva consists of two parts : Epithelium (stratified squamous epithelium) Connective tissue.

GINGIVAL EPITHELIUM :
Morphologic and functional points of view can be divided into : Oral / outer Epithelium - faces the oral cavity Sulcular Epithelium - faces the tooth without being in contact with it. Junctional Epithelium - provides the contact between the tooth and gingiva.

The outer surface of the free & attached gingiva is covered by a keratinizing stratified squamous epithelium. The principal cell type of the gingival epithelium, as well as of other stratified squamous is keratinocyte. Keratinizing oral epithelium has four cell layers: Basal -Stratum basale, Spinous - Stratum spinosum Granular - Stratum granulosum and Cornified -Stratum corneum

Gingival connective tissue

The connective tissue of the gingiva is known as the lamina propria and consists of : Papillary layer - papillary projections between the epithelial rete pegs.

Reticular layer - contiguous with the periosteum of the alveolar bone.

Cellular Exrtra compartment

Fibroblasts Mast cells cellular compartment Macrophages Inflammatory cells

Exrtra cellular compartment

Ground substance Nerves & vessels Fibres

Attached gingiva:
The portion of the gingiva extending from the base of the gingival crevice to the mucogingival line. It is firm, dense, stippled and tightly bound down to the underlining periosteum, tooth and bone. (American academy of peridontology)
It is firm, resilient and tightly bound to the underlying periosteum of alveolar bone and by the gingival collagen fibers to the supra alveolar cementum, resulting in its characteristic immobility. (Carranza,10 th edition)

Attached gingiva is continuous with the marginal gingiva. The facial aspect of the attached gingiva extends to the relatively loose and movable alveolar mucosa, from which it is demarcated by the MGJ. Clinically the width of the attached gingiva is determined as the distance between the gingival margin and the MGJ reduced with the probing depth. The tissue is subjected to the masticated food that is shed from the sluiceways of the occlusal surface of the teeth. Normal attached gingiva is salmon pink and may have a rough stippled texture

EFFECTIVE BARRIER Tissue barrier concept

(Goldman & Cohen 1979)

WITHSTAND THE FORCES OF MASTICATION

Adequate width of Attached gingiva

RESISTS INJURY DUE TO PHYSICAL THERMAL CHEMICAL AGENTS

RESISTEANCE TO MUSCLE INDUCED GINGIVAL STRIPPING & RECESSION

Width of attached gingiva:

It is the distance between the MGJ and the projection on the external surface of the bottom of the gingival sulcus or the PPD

The width of the all ranges from 1-9mm and varies widely between different teeth and jaws (Ainamo and Loe 1966).

It is generally greatest in the incisor region 3.5 to 4.5mm in the maxilla 3.3-3.9mm in the mandible

The least width of the AG in the first premolar 1.9mm in maxilla 1.8mm in the mandible.

Ainamo & Loe 1966

 There was a greater over all width of AG in maxilla than in the mandible. (Bowers et al 1963). Changes in the width of the attached gingiva are due to modifications in the position of its coronal end. The width of attached gingiva increases with age and in supra erupted teeth. On the lingual aspect of mandible, the AG terminates at the junction with the lingual alveolar mucosa, which is continuous with the mucous membrane lining the floor of the mouth. The palatal surface of the AG in the maxilla blends imperceptibility with the equally firm, resilient palatal mucosa.

Assessment of width of attached gingiva:

Subtracting method: The width of the AG is determined by subtracting the sulcus or pocket depth from the total width of the gingiva (gingival margin to mucogingival line)

 Staining method: The MGJ is revealed by staining it is vivo with schillers iodine solution (Schiller 1928) which stains the glycogen in the superficial layer of the nonkeratinized mucosa dark brown. The keratinized surface layer of healthy AG contains no glycogen and deep not stain with the iodine solution (Farrke and Morgenroth 1958). The demarcation line between the light brown AG and the dark brown alveolar mucosa may their early be seen.

OPG assessment of the width of AG (Talari and Ainamo 1976):

The mucogingival junction was marked mid facially at each tooth with a short piece of metal wire (diameter 0.45mm) attached to the tooth and gingival with a rectangular piece of dental bandage. An OPG was than taken with an angulation of -5 degree between the X-ray beam and the horizontally placed occlular level. The anatomical width of the AG i.e., the distance between the MGJ and CEJ was measured to the nearest mm, separately for each tooth.

A straight line was drawn between the mesial and distal CEJ to allow mid facial measurements.

Width of radiologically defined AG over deciduous teeth (Saario M, Ainomo A et al 1995 )

The authors found a significant increase in width of Radiologically defined AG from 6 to 10 years of age It has also been reported that an inadequate width of attached gingiva will correct by itself from 6 to 12 years of age without interference by means of periodontal surgery.

Tissue barrier concept

Goldman &Cohen (1979)

They postulated that a dense collagenous band of connective tissue retards or obstructs the spread of inflammation better than does the losse fiber arrangement of the alveolar mucosa .

They recommended increasing the the zone of keratinized attached tissue to achieve an adequate tissue barrier (THICK TISSUE) , thus limiting recession as a result of inflammation .

Thickness of attached gingiva:

Gingival thickness play an important role in development of gingival recession,wound healing, flap management during regenerative surgeries & is also a significant predictor of the clinical outcome of root coverage procedures.

Dr.VandanaKL& Savitha B(2005) reported that the mean thickness of gingiva

Younger age Gingival thickness Mid buccal Interdental area Older age Gingival thickness Mid buccal Maxilla(mm) 0.97 Mandible(mm) 1.03 Maxilla(mm) 1.63 1.59 Mandible(mm) 1.73 1.78

Interdental area

0.93

1.07

 This study concludes, gingiva is significantly thicker in younger age than older age. Females have thinner gingiva than males. Gingiva is thicker in mandible as compared to maxilla.

Importance of attached gingiva in the maintenance of periodontal health

The importance and even the need for AG is controversial.

It has been suggested that the presence of a band of AG represents the most significant diagnostic clue in estimating the prognosis for periodontal treatment as the alveolar mucosa will not withstand the rigors of mastication or oral physiotherapy (clenching, grinding)

Bowers 1963, suggested that less than 1mm of attached gingiva is sufficient to maintain clinical health of the gingiva.

The keratinized gingiva on the facial aspect of teeth extend from gingival margin to MGJ. It is often claimed that presence of zone of atleast 2mm of keratinized gingiva is necessary for the maintainance of gingival health

suggests that there is no requirement for minimal widthprovided accumalation of plaque is inhibited

 According to Corn 1962, a minimum of 3mm of AG with adequate vestibular depth is ideal. Wennstroms reported that in patients maintaining proper plaque control, the lack of an adequate zone of AG does not result in an increased incidence of soft tissue recessions .

Gingival health can be maintained independent of its width. Evidence from both experimental and clinical studies that, in the presence of plaque, areas with a narrow zone of gingiva possess the same resistance to continuous attachment loss as teeth with a wide zone of gingiva. Hence, the need of an adequate width of gingiva, for prevention of attachment loss is not significantly supported.

Increase in width of attached gingiva with age (Ainamo J, Talari A 1976)

Results of their study showed that the measured anatomical width of attached gingiva does not differ between sexes but also that it increases significantly with age. It was concluded that the MGJ remains at a probably genetically predetermined location while the teeth move in an occlusal direction through adult life. In the absence of concurrent retraction of the gingival margin this results in an increases of the width of attached gingiva with advancing age

Increase in width of attached gingiva on supra erupted teeth (Ainamo and Ainamo 1977):

The anatomical width of attached gingiva i.e., the distance from the MGJ to CEJ in humans is, directly proportional to the amount of past tooth eruption.

The result of their study indicate that even during pronounced supra eruptiorn the teeth tend to erupt with their investing tissues while the location of MGJ remains constant.

Width of attached gingiva and orthodontic treatment:

Alternations occurring in gingival dimensions and marginal tissue position in conjunction with orthodontic therapy are related to the direction of tooth measurement. Facial movement results in reduced facial gingival dimensions, while on increase is observed following lingual movement. (Coatoam et al 1981).

Importance of AG for prosthetic treatment:

It has been reported that if adequate width & thickness of attached gingiva is present than temporary damage to the gingival tissues following prosthetic & restorative treatment will resolve quickly with little chance of progression.

Clinical Significance of attached gingiva:

An adequate zone of keratinized and attached gingiva was considered critical for the maintenance of gingival health and for the prevention of continuous loss of connective tissue attachment. The concept this prevailed that a narrow zone of gingiva was insufficient to protect the periodontium from injury caused by friction forces encountered during mastication. to dissipate the pull on the gingival margin created by the muscles of the adjacent alveolar mucosa (Friedman 1957, Ochsenbein 1960, Friedman and Levine 1964 )

It was believed that an inadequate zone of gingiva would:

Facilitate sub gingival plaque formation because of improper pocket closure resulting from the movability of the marginal tissue (Friedman 1962).

Favor attachment loss and soft tissue recession because of less tissue resistance to apical spread of plaque associated gingival lesions (stern 1976, Ruben 1979).

It was also believed that a narrow gingiva and a shallow vestibular fornix might favor. 1. 2. The accumulation of food particles during mastication. And Impedes proper oral hygiene measures (Gotlsengen 1954, Rosenberg 1960, Corn 1962)

Different opinions have been expressed concerning what could be regarding as being an adequate dimension of the gingiva. 1. 2. Bowers (1963) suggested that less than 1mm of AG is sufficient. Corn (1962) claimed that the width of KG thought to exceed 3mm.

A third category of authors have stated that an adequate amount of gingiva is any width of gingiva which 1. 2. Prevents retraction of gingival margin during movements of the alveolar mucosa or Is compatible with gingival health (Friedman 1962, DeTrey and Bernimoulin 1980). Maynard and Wilson (1979), proposed that in segments of the dentitioninvolved in restorative therapy there is particular demand of AG.The authors claimed that at such sites 3mm of AG i.e., about 4-5mm of KG is required to maintain periodontal health.

The opinions expressed regarding the requirement of sufficient width of AG and KG for the maintenance of the integrity of the periodontium were based on clinical experience rather than scientific evidence.

Clinicians has the impression that sites with a narrow zone of gingiva were often inflamed while the wide zone of the gingiva found at neighboring teeth remained healthy.

It was claimed that a narrow zone of gingiva found apical to a localized soft tissue defect was a contributing factor in the development of recession (Hall 1981).

Reduced or absent attached gingiva may be due to several factors:

The base of the periodontal pocket being apical or close to the mucogingival line. In these cases, some attached gingiva must be created to separate the healed gingival sulcus from the alveolar mucosa and to prevent pockets from recurring.

Frenal and muscle attachments that encroach on periodontal pockets and pull them away from the tooth surface.

.Recession causing denudation of root surfaces and creating a functional as well as an esthetic problem.

The tension test should also be used incases of progressive gingival recession to check the effect of soft tissue tension on the gingival margin. Clinical examination and probing will reveal these areas of root denudation

Objectives accomplished by widening of attachedgingiva:

Enhances plaque removal around the gingival margin Improves esthetics Reduces inflammation around restored teeth

TECHNIQUES FOR INCREASING ATTACHED GINGIVA: Gingival augmentation apical to recession:

Free gingival autograft

I. Accordion technique II. Strip technique

III. Combination technique Free connective tissue autograft The apically positioned flap Other techniques

Gingival augmentation coronal to recession: Free gingival autograft Free connective tissue autograft Pedicle autograft laterally positioned flap coronally positioned flap ; semilunar pedicle Sub-epithelial connective tissue graft(Langer ) GTR Pouch & tunnel technique

References:
cohen- Atlas of cosmetic and reconstructive periodontal surgery) 2nd edition The width of the attached gingivaMuch ado about nothing?Payal Mehta a, Lim Lum Peng j o u r n a l of de n t i s t ry 3 8 ( 2 0 1 0 ) 51 7 52 5 Clinical peridontology 10th edition Carranza F.A., Michael G. Newman. Clinical Periodontology and Implant Dentistry Jan Lindhe, 4th edition Oral Histology, Development, structure and function A.R. Tencate, 5th

edition
Vandana .K.L and S avitha.B- Thickness of gingiva in association with age, gender and dental arch location. J.C.P 2005; 32; 828-830

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