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Attached gingiva: Histology and surgical augmentation

Se-Lim Oh, DMD, MS
The keratinized attached gingiva provides the periodontium with increased resistance to external injury, contributes to the stabilization of the gingival margin, and aids in dissipating physiological forces exerted by the muscular fibers of the alveolar mucosa on the gingival tissues.1 Increasing attached gingiva should be strongly considered in cases where the patients plaque control is compromised. The apically positioned flap, free gingival graft, and subepithelial connective tissue graft are the most common surgical procedures used for augmenting the zone of attached gingiva effectively and predictably. The newly obtained keratinized gingiva can be maintained for a long period; in addition, these periodontal procedures halt the progression of gingival recession and could lead to gaining more keratinized gingiva from creeping attachment after the surgery. This article reviews the biology of attached gingiva and presents cases related to the functional role of periodontal plastic surgery. Received: July 14, 2008 Accepted: August 11, 2008

he keratinized gingiva includes both free and attached gingiva and extends from the gingival margin to the mucogingival junction. Histologically, the attached gingiva is better suited than nonkeratinized mucosa to withstand mechanical irritations.2 The epithelium of attached gingiva is keratinized and has thin, prominent epithelial ridges. The connective tissue contains no elastic fibers. These characteristics are exactly the opposite of the histology of alveolar mucosa. The width of the keratinized gingiva may vary from 19 mm.3 A 1972 study by Lang and Loe reported that even when tooth surfaces are kept free of clinically detectable plaque, areas with less than 2 mm of keratinized gingiva (which means less than 1 mm of attached gingiva) remained inflamed.3 Such persistent inflammation did not correlate with muscle pulling from frenum insertions. Lang and Loe strongly suggested that an adequate width of keratinized gingiva is important for maintaining gingival health and

rationalized the introduction of numerous surgical procedures to increase the width of attached gingiva.3 However, more recent studies have challenged this notion.4-6 As people age, the width of the band of anatomical attached gingiva continues to increase due to the continuous compensatory eruption of teeth. As a result, the width of keratinized gingiva will continue to increase unless there is a concurrent reduction in height of the gingival tissue due to periodontal breakdown.4,5 According to Wennstrom, the lack of a minimal amount of attached gingiva does not necessarily result in soft tissue recession.6 The narrow attached gingiva apical to a localized recession is a result of the recession rather than a cause.6 Proper plaque control technique prevents soft tissue recession, even without an adequate zone of attached gingiva.6

periodontal treatment that involves mucogingival surgery, there are some indications for surgical intervention.4-6 Mucogingival surgical procedures should be strongly considered when the patients plaque control is compromised. For teeth with little or no attached gingiva that require prosthetic restorations or orthodontic treatment or have an abnormal frenal attachment, the zone of the attached gingiva must be increased.7 Attached gingiva also needs additional width when the pocket depth extends beyond the alveolar mucosa.

Surgical procedures to increase attached gingiva

One of the earliest surgical techniques designed to correct the lack of attached gingiva was the apically repositioned flap.8,9 This technique allowed surgeons to increase or preserve the existing attached gingiva by moving the tissue apically or by exposing a variable band of crestal bone, depending on how much attached gingiva was desired.10 A free gingival graft (FGG) refers to grafting of a piece of gingiva
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When to consider increasing attached gingiva

While the implications of findings from previous studies should be considered when planning

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Periodontics Attached gingiva

Fig. 1. A patient with no clinical crown but adequate keratinized gingiva on tooth No. 6.

Fig. 2. The patient in Figure 1, after the preexisting gingival margin was sutured apically.

Fig. 3. The patient in Figure 1 eight weeks later, upon receiving the final prosthesis.

(including the keratinized epithelium and periodontal connective tissue) to the recipient site after it has been detached completely from the donor site.11 Prior to the re-establishment of vascularization, the FGG survives by consuming nutrients from the cut blood vessels of the recipient site into the graft. By the second day, the blood supply is re-established in the graft through anastamosis; it continues to mature for the next 28 days.11 The subepithelial connective tissue graft (CTG) refers to submerging gingival connective tissue (without covering epithelium) under a partial-thickness flap or in a prepared gingival pouch. This procedure can be used to treat isolated or multiple root exposures (in combination with minimal attached gingiva) and recession adjacent to an edentulous area that also requires ridge augmentation.12 Gingival connective tissue is capable of inducing the formation of keratinized gingival epithelium.13 A 1975 study by Karring et al investigated the role of gingival connective tissue in determining the differentiation of the overlying epithelium. Free grafts of connective tissue, without epithelium, were transplanted from either the keratinized gingiva or the non382 July/August 2009

keratinized alveolar mucosa. The gingival CTGs were covered with keratinized epithelium, displaying the same characteristics as those found in normal gingival epithelium, while the alveolar mucosa transplants were covered with nonkeratinized epithelium.13 The success of subepithelial CTGs has been attributed to the double blood supply at the recipient site from the underlying connective tissue base and the overlying recipient flap.12 Compared to an FGG, a subepithelial CTG offers minimal palatal denudation (and thus smoother postoperative healing) and a closer color blend of the graft with adjacent tissue, avoiding the keloid healing present with FGGs.

bone loss. Class IV refers to severe recession with accompanying severe bone loss. Interdental bone loss, soft tissue loss, and tooth extrusion can prevent placement of a gingival graft at the cementoenamel junction (CEJ) and thus make complete root coverage nearly impossible.

Case report No. 1

A 37-year-old man needed a clinical crown-lengthening procedure on tooth No. 6, which was going to serve as an abutment for a four-unit bridge spanning teeth No. 69 (Fig. 1). Tooth No. 6 had 3 mm pocket depth. Upon bone sounding, the tooth required only soft tissue reduction and not an ostectomy; however, a gingivectomy would leave the tooth with little or no attached gingiva. Since tooth No. 6 had enough attached gingiva, an apically positioned flap was chosen to preserve the keratinized zone. Using two vertical release incisions, a crevicular incision was made around the labial surface and a splitthickness flap was reflected. The preexisting gingival margin was sutured apically (Fig. 2). After eight weeks, the patient had an optimal zone of attached gingiva with 2 mm pocket depth and the final prosthesis was made (Fig. 3).

Recession beyond the mucogingival junction

According to Miller, marginal tissue recessions can be divided into four classifications.14 Class I refers to recession that is coronal to the mucogingival junction with no interproximal bone loss. Class II refers to recession apical to the mucogingival junction with no adjacent interproximal bone loss. Class III describes recession apical to the mucogingival junction with mild to moderate adjacent interproximal

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Fig. 4. A patient whose labial frenum extended into the marginal gingiva of tooth No. 25.

Fig. 5. The patient in Figure 4, after the donor tissue was sutured in place.

Fig. 6. A photo of the patient in Figure 4 taken two weeks postoperatively, showing an increased zone of attached gingiva.

Fig. 7. A patient who had a muscle pulling on tooth No. 21 and no attached gingiva on tooth No. 20.

Fig. 8. The patient in Figure 7, after donor tissue is secured by suture.

Fig. 9. The patient in Figure 7 three months later, after the final restoration is placed.

Case report No. 2

A 44-year-old woman had a labial frenum extending into the marginal gingiva of tooth No. 25 with 1 mm pocket depth (Fig. 4). The recipient site was prepared by making a horizontal split-thickness incision just above the mucogingival junction. The horizontal incision was sufficient to remove all muscle insertion from the frenum. The palatal gingiva was used as the donor site and the graft was sutured in place (Fig. 5). This FGG increased the width of attached gingiva and prevented further recession from the abnormal frenum attachment (Fig. 6).

Case report No. 3

A 40-year-old woman had a muscle pulling on tooth No. 21 and no attached gingiva on tooth No. 20,

with 12 mm pocket depths on both teeth (Fig. 7). In addition, tooth No. 20 needed clinical crown lengthening. The initial crevicular incisions were made on the buccal and lingual sides. A split-thickness flap was reflected on the buccal side to receive an FGG and a full-thickness flap was reflected on the lingual side for the clinical crown-lengthening procedure. The ostectomy was completed on the lingual side and the donor tissue from the palate was secured on the buccal side (Fig. 8). The final restoration was placed three months later. Since the incision design removed the entire zone of attached gingiva, there was no keloid healing line between the previously existing attached gingiva and the new graft tissue (Fig. 9).

Case report No. 4

A 51-year-old woman had 5 mm of recession on tooth No. 24 and 2 mm of recession on tooth No. 25, with the loss of interproximal papillae (Fig. 10). A radiograph showed interproximal bone loss between teeth No. 23, 24, and 25 (Fig. 11). The recession on tooth No. 24 was apical to the mucogingival junction. Based on Millers classification, only partial root coverage could be expected. A horizontal incision was made at the level of interproximal bone (from the distal of tooth No. 22 to the distal of tooth No. 27) and sharp dissection was performed to create a partial-thickness flap. The donor tissue taken from the palate was covered by the flap and stabilized with interrupted sutures (Fig. 12).
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Periodontics Attached gingiva

Fig. 10. A patient with recession on teeth No. 24 and 25 and a loss of interproximal papillae.

Fig. 11. A radiograph of the patient in Figure 10, showing interproximal bone loss between teeth No. 23 and 25.

Fig. 12. The patient in Figure 10, after the donor tissue was stabilized with interrupted sutures.

Fig. 13. The patient in Figure 10, four months after treatment.

Figure 13 shows postoperative healing after four months. A zone of attached gingiva (with 2 mm pocket depths) was created around the labial side of tooth No. 24.

Depending on the patients situation, various techniques can be performed to increase attached gingiva effectively. An apically positioned flap should be the first choice when attached gingiva is available. The apically positioned flap has been used for gingival pocket reduction while preserving or increasing keratinized attached gingiva. Studies have proven that apically positioned flap techniques can establish adequate zones of attached gingiva without deforming the dentogingival junction.1,10,15,16 Because gingival
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recession is the major risk from an apically positioned flap, this procedure is recommended primarily when pocket depth exists or when a gingivectomy could remove all or most of the attached gingiva. One of the most common approaches for gingival augmentation, the FGG procedure has proven to be efficient and predictable for increasing the apicocoronal dimension of attached gingiva.7,15,17 A 2008 retrospective study reported that FGGs provided long-term (1025 years) stability.17 One potential advantage of FGGs is that postoperative migration of the gingival marginal tissue in a coronal direction may occur and cover a previously denuded root surface partially or even totally; however, such creeping attachment occurs

unpredictably after the healing of FGGs.18 Based on the authors experience, FGG procedures could provide better esthetics by avoiding the keloid line between the previous gingiva and the new graft tissue (Fig. 9). Despite these positive aspects, attempts to cover areas of deep, wide gingival recession with FGG procedures were unpredictable for many years.19 A 1983 study by Holbrook and Ochsenbein reported that FGG provided complete root coverage in 22 of 50 cases (44%).20 Ten years later, Jahnke et al reported a mean root coverage of 43% following FGG.21 Although Miller demonstrated that successful root coverage was possible for Class I and Class II recessions, root coverage was not the immediate and primary goal of FGG procedures.14,19,22 Gingival recession related to periodontal disease or developmental problems can result in trapped plaque, root sensitivity, root caries, and esthetic compromises. Langer and Langer described a subepithelial CTG technique for root coverage in which a partial-thickness flap with two vertical incisions was used to prepare the recipient site.12 In the cases presented here, the subepithelial connective tissue procedure was performed according to Brunos technique, in which only a horizontal incision is made to prevent cicatricial lines and avoid compromising the blood supply.19 Several studies have shown that the subepithelial CTG is a predictable procedure for obtaining esthetic root coverage.23,24 A 2002 study reported that the root coverage (measured by reduction of gingival recession) gained from a subepithelial CTG was maintained for a long period (mean 27.5 months). There was a statistically

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significant increase in the mean root coverage between the shortterm follow-up (97.1%) and the long-term follow-up (98.4%).25 The fact that the mean root coverage improved with time supports the concept of creeping attachment when autogenous soft tissue grafts are used.25 Based on the significant decrease in recession and an increase in the quantity of keratinized tissue over time, the subepithelial CTG is recommended when root coverage is attempted.21,25

Author information
Dr. Oh is an assistant professor, University of Maryland Dental School in Baltimore.


It is important that dentists who plan to perform periodontal plastic surgery understand the biology of attached gingiva. The case reports in this article presented situations in which the apically positioned flap, FGG, and CTG procedures were necessary. As with any procedure, case selection and meticulous surgical technique are the keys to obtaining the best results.

The author thanks Dr. Robert Sachs for his assistance with writing this article.

The author reports no conflicts of interest related to this study.

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13. Karring T, Lang NP, Loe H. The role of gingival connective tissue in determining epithelial differentiation. J Periodontal Res 1975;10(1):1-11. 14. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5(2):8-13. 15. Fagan F. Clinical comparison of the free soft tissue autograft and partial thickness apically positioned flapPreoperative gingival or mucosal margins. J Periodontol 1975;46(10):586-595. 16. Dordick B, Coslet JG, Seibert JS. Clinical evaluation of free autogenous gingival grafts placed on alveolar bone. Part II. Coverage of nonpathologic dehiscences and fenestrations. J Periodontol 1976;47(10):568-573. 17. Agudio G, Nieri M, Rotundo R, Cortellini P, Pini Prato G. Free gingival grafts to increase keratinized tissue: A retrospective long-term evaluation (10 to 25 years) of outcomes. J Periodontol 2008;79(4):587-594. 18. Matter J. Creeping attachment of free gingival grafts. A five-year follow-up study. J Periodontol 1980;51(12):681-685. 19. Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994;14(2):126-137. 20. Holbrook T, Ochsenbein C. Complete coverage of the denuded root surface with a one-stage gingival graft. Int J Periodontics Restorative Dent 1983;3(3):8-27. 21. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC. Thick free gingival and connective tissue autografts for root coverage. J Periodontol 1993;64(4):315-322. 22. Miller PD Jr. Root coverage with the free gingival graft. factors associated with incomplete coverage. J Periodontol 1987;58(10):674-681. 23. Wennstrom JL. Mucogingival therapy. Ann Periodontol 1996;1(1):671-701. 24. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Root coverage revisited. Periodontol 2000 2001;27:97-120. 25. Harris RJ. Root coverage with connective tissue grafts: An evaluation of short- and long-term results. J Periodontol 2002;73(9):1054-1059. Published with permission by the Academy of General Dentistry. Copyright 2008 by the Academy of General Dentistry. All rights reserved.

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