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Journal of Dental School 2013; 31(4):216-223 Original Article

Attached gingival width and gingival sulcus depth in three dentition systems
*1Mohammad-Reza Abrishami 2Alireza Akbarzadeh

*1Assistant Professor, Dept. of Periodontics, School of Dentistry, Shahid Beheshti University of


Medical Sciences, Tehran, Iran. E-mail: abrishami@sbmu.ac.ir
2
Associate Professor, Dept. of Basic Sciences, School of Rehabilitation, Shahid Beheshti University
of Medical Sciences, Tehran, Iran.  

Abstract
Objectives: Attached gingival width (AGW) is an important marker for diagnosis of periodontal
disease and normal gingival sulcus depth (GSD) is a sign of healthy periodontium. The aim of this
study was to determine the AGW and GSD in3-15 year-olds with three dentition systems in Isfahan
in 2001.
Methods: A total of 360 students (120 students in each system) eligible for this cross sectional study
were randomly chosen from 30 schools and examined clinically. Data were registered in a
questionnaire by two professional examiners. The GSD (the distance from the free gingival margin
to the deepest part of the pocket) was measured by a probe. Keratinized gingiva (the distance
between the attached gingiva and mucogingival junction) was measured by a vernier caliper or probe
and the AGW was measured by subtracting the two amounts in primary and permanent dentition
systems. These amounts were registered in a questionnaire and compared using ANOVA and
Tukey’s test.
Results: The AGW in the primary, mixed and permanent dentition systems was 2.60 (7.02), 2.56
(7.23) and 2.73 (1.3) mm, respectively. The lingual surface of the posterior mandible had the greatest
amount of attached gingiva in the three dentition systems. Also, the GSD in permanent dentition
system in the anterior, middle and posterior areas of both jaws and in the buccal, lingual and palatal
surfaces was more than in the primary dentition system.
Conclusion: Based on the results, the AGW in permanent dentition was more than in primary and
mixed dentition systems. The AGW increases with age and is not affected by gender. Also, the
AGW was less in the lower jaw compared to the upper jaw and was more in lingual surface than in
buccal surface.
Key words: Attached gingival width, Dentition system, Gingival sulcus depth.
Please cite this article as follows:
AbrishamiMR, Akbarzadeh A. The attachment gingival width and gingival sulcus depth in three
dentition systems. Beheshti Univ Dent J 2013;31(4):216-223.
Received: 29.01.2013 Final Revision: 29.05.2013 Accepted: 03.07.2013

Introduction: Adequate AGW plays an important role in healthy


periodontium (1, 3). Gingival sulcus is a narrow,
Gingiva is part of masticatory oral mucosa. It covers shallow cleft between the tooth surface and free
the cervical area of teeth and alveolar process of the gingiva that circles the tooth crown.
lower and upper jaws and acts as a strong barrier AGW varies between 1 to 9 mm in different
against the penetration of irritants into the people at different ages. Controversy exists
periodontal tissue (1). Moreover, adequate attached regarding the amount of attached gingiva (4-6).
gingiva helps prevent apical migration of tooth In a previous study, the minimum amount of
surrounding tissue and root exposure with or attached gingiva was variable in different people
without periodontal pocket formation (2). The and had a stable pattern of change (2). The
adequate amount of attached gingiva is still a topic minimum amount of attached gingival in clinical
of discussion. Due to having dense collagen fibers, and microscopic observations belonged to the
it can withstand friction and muscle tensions. muscle attachment sites and frenums in the oral

 
Abrishami &Akbarzadeh 217
 
cavity (3). AGW in facial surfaces in the maxilla pattern of change was the same in both jaws;
was 0.5to 1 mm more than in mandibular facial there were no differences between the two
surfaces. In another study, it was concluded that genders. The highest amounts were seen in the
surfaces with less than 2 mm of attached gingival maxillary lateral incisor site and the lowest
had clinical signs of inflammation and variable level belonged to the mandibular first premolar area.
of secretions (7). Moreover, researchers showed that Increase in the gingival width by aging was
the AGW was not different between the two reported as well. Also, measuring the sulcus
genders, but elderly people had more attached depth showed a reduction in this amount by
gingiva (8). Also, AGW varies in different ages aging (17). Sayrafi et al. (1999) in their study on
from tooth to tooth (9). AGW and sulcus depth in facial surfaces of
The perfect depth of gingival sulcus is zero, but upper and lower jaws of 280 subjects (3-16 yrs.)
an amount of 1.8 mm depth has been reported in in three dentition systems, showed that in all
healthy gingiva. This depth was 1 mm or less in groups the AGW of the upper jaw was more
deciduous teeth and more in permanent teeth. than that in the lower jaw and the pattern of
Also, the gingival depth in some studies has change in both jaws was the same. Also, there
reported to be 0.25 to 3 mm (10-12). were no differences in gingival width between
Saario et al. (1995) measured the AGW in 6 the left and right quadrants of the jaw and
year-old (primary dentition) and 10 year-old between the two genders. In permanent
(permanent dentition) children and found a dentition, the greatest gingival width was seen in
significant increase in AGW in both groups (13). the upper lateral region and the lowest in the
Another study assessed AGW among 123 mandibular first premolar site. The greatest
children aged 6, 10 and 12 yrs. And found sulcus depth was seen in mixed dentition system
statistically significant differences in AGW (18).
around first molars, central and lateral incisors in Although adequate AGW plays an important role in
6 and 10, 6 and 12 and 10 and 12 year olds (14). healthy periodontium, controversy still exists in this
No such difference was seen in upper central respect. Moreover, investigating the specific pattern
incisors in 10 and 12 year olds. Their study of change of AGW and sulcus depth in an Iranian
showed that the inadequate AGW would be population is important. This study sought to assess
compensated over time. Srivastava et al. (1990) the AGW and GSD in permanent, mixed and
also evaluated AGW and sulcus depth in three primary dentition systems in 3-15 year-olds in
dentition systems among 382 subjects aged 4-15 Isfahan.
years and noticed shallow gingival sulcus in
primary dentition compared with permanent Methods:
dentition system (15). AGW was the greatest in
upper and lower incisors and the least in upper This cross sectional study was performed on 360
and lower primary molars. Increase in AGW by subjects (120 in each dentition system) with
aging was justified by the decrease in GSD. In a equal gender ratio. The sample size for
study by Tenenbaum and Tenenbaum (1986) the estimating the mean AGW was calculated
mean AGW did not increase by the transition considering the 95% CI, 0.1 mm absolute error
from primary to permanent dentition (16). and ½ sample design effect in each age group.
Iramloo and Nowroozi (2002) evaluated the Using a table of random numbers, 6 pre-
AGW in children aged12 to 14 years and elementary, elementary and middle schools (one
showed that in all age groups AGW in the upper girls and one boy’s school at each level) were
jaw was more than in the lower jaw and the randomly chosen from each educational district

 
Gingival width and gingival sulcus depth 218
 
of Isfahan using cluster-sampling method. A using a periodontal probe and dental mirror.
total of 30 schools were chosen and 120 students Keratinized gingiva was measured in the buccal
with each of the understudy dentition systems surface of anterior region and lingual surface of
were included in the study (total of 360). The premolar teeth, which did not allow adequate access
inclusion criteria were as follows: no systemic and in order to achieve adequate accuracy the
disease, good oral hygiene, no calculus, having measurement was done by a vernier caliper and a
all the index teeth, no gingival inflammation, probe. The amount of sulcus depth was measured
noperiodontal pocket or gingival recession, no from the free gingival margin to the deepest point of
fracture, decay or large fillings beyond the free the pocket. The distance between the free gingival
gingival margin, no history of oral surgery, no margin and the mucogingival junction (MGJ)
tooth mobility or malposition, no orthodontic indicated the keratinized gingival and was only
appliances or removable prosthesis and eruption measured in the middle zone of facial surface. By
of at least 50% of the index teeth. subtracting the amount of keratinized gingiva from
The anterior region in the primary and permanent the sulcus depth, the AGW was calculated in
dentition systems was considered to be the central millimeters. The MGJ was also determined by
region. Also, the middle region was considered to retracting the alveolar mucosa and demarking with a
be the permanent first premolar site in permanent probe.
dentition, first deciduous molar in primary dentition The examination was performed by two trained
and first deciduous molar (if existed)or the first examiners under the supervision of periodontists. To
permanent premolar (over 50% erupted)in the assess the reliability of findings and matching the
mixed dentition system. The posterior region was two examiners, 20 patients were randomly chosen
considered to be the permanent molar area in and the amounts of keratinized gingiva and sulcus
permanent dentition, the deciduous molar area in depth in them were examined again by two other
primary dentition and the second deciduous molar(if professionals. The intra-class correlation coefficient
existed) or the first permanent molar (over 50% (ICC) for the two measurements by two different
erupted)in the mixed dentition system. For clinical individuals was 95% and 97%; which were
exanimation, a dental mirror, periodontal probe acceptable. Also, to ensure the accuracy of
(Aesculap DB 775 AE) with 0.5 mm accuracy, a measurements made by a probe and caliper, the
vernier caliper (Mitutoyo, Japan) and a bite block KGW in the middle third of the buccal surface was
were used. The instruments were disinfected measured twice by two different examiners with a
using10% Micro10 solution for 15 minutes. probe and vernier caliper. Comparison of results
For examination of primary dentition in showed an acceptable rate of 97%.
preschoolers, the first and second molars and Data were analyzed using SPSS version 13
deciduous incisors, and for examination of mixed software. Normal distribution of data was
dentition in elementary schoolers first molars, confirmed using Shapiro-Wilk test. Considering the
deciduous incisors of the successor permanent teeth, normal distribution of data, one-way ANOVA was
first deciduous molar and the first permanent molar used for the comparison of mean values and
if existed (over 50% erupted) were examined. For Tukey’s test was applied as the post hoc test for pair
examination of permanent dentition in middle wise comparison of groups. In addition, independent
schoolers, the permanent teeth in each quadrant samples t- test was applied to compare the mean
were examined. values between males and females. Type I error was
The GSD was measured in three areas of mesial, considered 0.05 and p<0.05 were considered
middle and distal in the buccal surface and only in significant. The statistician was blinded to the study
the middle third in the lingual or the palatal surface design and group allocations.

 
Abrishami &Akbarzadeh 219
 

Results: were significant (p<0.001) except for the


anterior and posterior maxilla in permanent
Totally, 360 subjects (120 with each dentition dentition (p=0.38) and anterior and posterior
system) from 30 schools in Isfahan were studied mandible in mixed and permanent dentition
(equal number of boys and girls). systems (p=0.08 and p=0.1), which were not
The AGW was 2.60 (1.02) in primary dentition, significantly different. The comparison of AGW
2.56 (1.23) in mixed dentition and 2.73 (1.35) in in lingual surfaces of the mandible showed
permanent dentition. The AGW in buccal significant differences except for the middle and
surfaces of upper and lower teeth in three posterior regions in the primary dentition
dentition systems is shown in Table1. Statistical (p=0.5).
comparisons by ANOVA and Tukey’s test In other cases, significant differences were
showed that the differences among the three found in terms of the site and dentition system
dentition systems in the three examined sites (p<0001) (Table 2).

Table 1- AGW in buccal surfaces of upper and lower jaws in three dentition systems
Upper jaw Lower jaw
Region
Primary Mixed Permanent Primary Mixed Permanent

Anterior 3.31 (0.74) 3.11 (0.94) 3.59 (1.07) 2.55 (0.60) 2.15 (0.94) 2.25 (0.86)

Middle 1.75 (0.75) 2.01 (1.02) 1.92 (0.91) 1.53 (0.53) 1.38 (0.85) 1.16 (0.72)

Posterior 2.08 (0.75) 2.74 (1.08) 3.01 (0.85) 2.16 (0.43) 1.97 (0.65) 2.08 (0.75)

Table 2-AGW of lingual surfaces of lower jaw in three dentition systems


Region Primary Mixed Permanent
Anterior 2.35 (0.50) 1.98 (0.68) 2.29 (0.67)
Middle 3.85 (0.57) 3.57 (1.05) 3.70 (1.00)
Posterior 3.80 (0.59) 4.11 (0.86) 4.60 (1.11)

The AGW was 2.08 (0.67) in buccal surfaces of lower teeth in the three dentition systems is
teeth in the primary dentition system, 1.83 (0.88) shown in Table 4. The t-test showed no
in mixed dentition and 1.83±0.91in permanent significant differences in primary dentition and
dentition. These values for lingual surfaces of primary teeth of the mixed dentition in the
teeth in the three dentition systems were 3.33 anterior, middle and posterior zones of the upper
(0.89), 3.22 (1.26) and 3.53 (1.34), respectively. and lower jaws. These amounts for permanent
The tests showed that the differences between teeth in mixed and permanent dentition systems
the AGW in buccal and lingual surfaces of three in the three zones of both jaws showed
dentition systems were significant (p<0.001 for significant differences as well. In other words,
all). The AGW in the three dentition systems permanent teeth in the mixed dentition system
based on gender is shown in Table 3. The tests had different sulcus depths compared to the
did not show any significant differences between permanent dentition (p=0.011 for the anterior
the two genders in the upper jaw or buccal and region of the lower jaw, p=0.04 for the middle
palatal surfaces of the lower jaw. region and p<0.001 for other sites).
The GSD in the buccal surfaces of upper and

 
Gingival width and gingival sulcus depth 220
 
Table 3- The AGW in the three dentition systems based on gender
-Primary Dentition System
Upper jaw Lower jaw(buccal surface) Lower jaw(palatal surface)
Gender
Anterior Middle Posterior Anterior Middle Posterior Anterior Middle posterior

Male 3.43 (0.77) 1.63 (0.87) 2.11 (0.86) 2.56 (0.61) 1.45 (0.50) 2.16 (0.42) 2.29 (0.44) 3.79 (0.65) 3.82 (0.65)

Female 3.18 (0.67) 1.87 (0.58) 2.04 (0.63) 2.53 (0.59) 1.60 (0.54) 2.16 (0.44) 2.41 (0.54) 3.91 (0.46) 3.76 (0.53)

-Mixed Dentition System


Upper jaw Lower jaw(buccal surface) Lower jaw(palatal surface)
Gender
Anterior Middle Posterior Anterior Middle Posterior Anterior Middle posterior

Male 3.10 (1.05) 1.98 (1.08) 2.86 (1.13) 2.22 (1.08) 1.41 (0.86) 2.06 (0.67) 2.01 (0.78) 3.62 (0.97) 4.11 (0.82)

Female 3.12 (0.81) 2.03 (0.95) 2.62 (1.01) 2.07 (0.75) 1.34 (0.82) 1.86 (0.60) 1.94 (0.56) 3.52 (1.12) 4.09 (0.90)

-Permanent Dentition System


Upper jaw Lower jaw(buccal surface) Lower jaw(palatal surface)
Gender Anterior Middle Posterior Anterior Middle Posterior Anterior Middle Posterior
Male 3.49 (1.03) 1.80 (0.86) 2.88 (0.85) 2.17 (0.71) 1.10 (0.69) 2.16 (0.80) 2.31 (0.66) 3.73 (0.87) 4.57 (1.14)

Female 3.62 (1.07) 2.02 (0.94) 3.14 (0.83) 2.33 (0.98) 1.20 (0.75) 2.0 (0.67) 2.26 (0.86) 3.66 (1.12) 4.62 (1.08)

Table 4- Gingival sulcus depth in buccal surfaces of upper and lower teeth in the three dentition systems
Upper jaw Lower jaw
Dentition system
Anterior Middle Posterior Anterior Middle
1.16 (0.27) 1.21 (0.26) 1.64 (0.34) 0.99 (0.21) 1.18 (0.22) 1.29 (0.32)
Primary dentition
1.32 (0.71) 1.21 (0.35) 1.54 (0.45) 1.17 (0.30) 1.25 (0.28) 1.25 (0.27)
Primary teeth of mixed dentition
2.03 (0.75) 2 (0.51) 2.14 (0.49) 1.43 (0.46) 1.70 (0.38) 2.10 (0.50)
Permanent teeth of mixed dentition
1.59 (0.43) 1.6 (0.35) 1.94 (0.37) 1.30 (0.31) 1.53 (0.32) 1.84 (0.38)
Permanent dentition

The GSD values in the palatal surfaces of the teeth are shown in Table 5.
upper teeth and lingual surfaces of the lower

Table 5- Gingival sulcus depth in palatal surfaces of upper teeth and lingual surfaces of lower teeth in the
three dentition systems
Palatal surfaces of upper teeth Lingual surfaces of lower teeth
Dentition system Anterior Middle Posterior Anterior Middle Posterior
Primary dentition .87 (0.29) 1.38 (0.38) 1.40 (0.40) .79 (0.25) 1.16 (0.29) 1.52 (0.36)
Primary teeth of mixed .96 (0.56) 1.46 (0.40) 1.45 (0.45) 0.82 (0.19) 1.28 (0.51) 1.68 (0.48)
dentition
Permanent teeth of mixed 2.00 (0.73) 2.18 (0.63) 1.88 (0.58) 1.21 (0.48) 1.70 (0.55) 1.92 (0.56)
dentition
Permanent dentition 1.44 (0.39) 1.80 (0.53) 1.66 (0.052) 1.01 (0.19) 1.57 (0.48) 2.00 (0.48)

Comparison of results showed no significant differences in permanent teeth of mixed


differences in GSD in palatal surfaces of upper dentition and permanent dentition in the three
teeth in primary dentition and primary teeth in zones were significant (p=0.007 for all). For the
mixed dentition in the three zones. These lower teeth, the difference in GSD in permanent

 
Abrishami &Akbarzadeh 221
 
teeth of mixed dentition and permanent dentition GSDs in primary and permanent dentition
in the middle region (p<0.001), primary systems in the three areas and in buccal and
dentition and primary teeth of mixed dentition in palatal surfaces of upper and lower teeth are
both middle and posterior zones were significant shown in Table 6. The t-test showed that these
(p=0.006, p=0.03). No other statistically values had statistically significant differences.
significant differences were found. Also, the

Table 6-Gingivalsulcusdepth in the threezones in buccal and palatal surfaces of upper and lower teethin
primary and mixed dentition systems
-Upper Jaw
Dentition Buccal surface Palatal surface
system Anterior Middle Posterior Anterior Middle Posterior
Primary 1.16 (0.27) 1.2 (0.26) 1.64 (0.34) .87 (0.29) 1.39 (0.38) 1.40 (0.40)
Permanent 1.59 (0.43) 1.6 (0.35) 1.94 (0.37) 1.44 (0.39) 1.8 (0.53) 1.66 (0.52)

-Lower Jaw
Dentition Buccal surface Palatal surface
system Anterior Middle Posterior Anterior Middle Posterior
Primary .99 (0.21) 1.18 (0.22) 1.29 (0.32) .79 (0.25) 1.16 (0.29) 1.52 (0.36)
Permanent 1.30 (0.31) 1.63 (0.32) 1.84 (0.38) 1.01 (0.19) 1.57 (0.48) 2.00 (0.48)

Discussion: less than 50% eruption were not included in this


study which resulted in an increase in the
This study aimed to measure the AGW and the measurement of AGW in the mixed dentition
GSD in the three dentition systems. The primary system compared to the study by Rose and App
dentition was assessed in preschoolers (3-6 year (1973) (20). This was done because of the variable
olds), the mixed dentition in elementary students (6- eruption pace of the tooth crown and quick eruption
12 year olds) and the permanent dentition in middle of the upper half of the crown and also to prevent
schoolers (12-15 year olds). The mean AGW was depreciation of the clinical value of the study (15,
2.60in primary dentition and 2.73in permanent 20).
dentition. This study showed that the AGW in fully The mean AGW in the permanent dentition system
erupted permanent and primary teeth increases by was more than in the other two systems (15, 20).
aging but decreases in the mixed dentition system; Although the mean gingival width in the primary
but the GSD increased by age. This result has been dentition was more than in mixed dentition, this
reported in several previous studies (9, 13-16, 17, difference was not significant. Decreased AGW in
19).However, some studies found no significant the mixed dentition system can be due to the deep
increase in AGW after puberty and termination of gingival sulcus and labial movement of newly
tooth eruption period (3, 16). The most important erupted teeth (9). Also, accumulation of
reason for increased AGW is the constant eruption microorganisms in this period is one explanation for
of teeth throughout one’s lifespan to compensate the periodontal tissue destruction in juvenile
occlusal surface attrition leading to the coronal periodontitis. In local juvenile periodontitis, central
migration of CEJ, while the mucogingival junction incisors and first molars are involved (16).
remains unchanged (8). However, there was no AGW in the buccal surface in the three systems
significant difference between the AGW in primary decreased from anterior to middle and increased
and mixed dentition systems. Permanent teeth with from middle to posterior regions. Also, in lingual

 
Gingival width and gingival sulcus depth 222
 
surfaces of lower teeth, the AGW increased from keratinized gingival width in permanent teeth
anterior to posterior zones. The greatest AGW in the was more significant compared to primary and
buccal surface of both jaws in the three dentition newly erupted teeth. The greatest values
systems belonged to the anterior region of upper belonged to primary canines and permanent
teeth and the greatest AGW of the lingual surface incisors. In addition, there were no significant
belonged to the posterior region. The lingual surface differences between the primary canines, molars
of posterior region of lower jaw showed the greatest and permanent incisors in the amount of KGW
AGW in the three dentition systems. These amounts in subjects aged 6 to 11 yrs. (22).
in different regions of the lower jaw in the three There was an increase in AGW of permanent
systems were less than in the upper jaw and in the teeth by transition from primary dentition to
lingual surfaces were greater than in buccal surfaces mixed dentition. A gradual increase in KGW
(15, 16). The lowest amount of gingival width in was also noted but the gingival sulcus depth
different dentition systems in the buccal surface decreased (23).
belonged to the middle region of lower jaw. This
study found no significant difference between males Conclusion:
and females in gingival width which is in accord
with the findings of studies by Iramloo and Our study showed that the AGW in permanent
Nowroozi (2002) (17) and Sayrafi et al. (1999) (18). dentition was greater than in primary and mixed
The GSD of permanent teeth in the three regions dentitions. Also, the gingival sulcus depth in
and the three surfaces (buccal, lingual, palatal) was permanent teeth was greater than in primary teeth
more than in primary teeth; which is in accord with and less than in teeth in the mixed dentition system.
some studies (5, 15, 18). Some researchers believe The AGW increased by age and was not
that primary teeth have deeper gingival sulcus significantly different between males and females.
than permanent teeth (4, 21). Also, GSD in The AGW in the lower jaw was less than in the
permanent teeth of mixed dentition system was upper jaw and in the lingual surface was greater
greater than in permanent dentition but this than in the buccal surface.
difference was not significant for the primary
teeth in mixed and primary dentition systems. Conflict of Interest: “None Declared”
Bosnjak et al. (2002) claimed that decrease in

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