Journal of Periodontology 1972 Oct (623 - 627): The Relationship Between the Width

of Keratinized Gingival and Gingival Health Niklaus P. Lang Harald Löe

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The Relationship Between the Width of Keratinized Gingival and Gingival Health
Niklaus P. Lang
Harald Löe
INTRODUCTION
IN MAN THE KERATINIZED gingiva includes the free and the attached gingiva and
extends from the gingival margin to the mucogingival junction. 1 The width of the
keratinized gingiva may vary between 1 and 9 mm.2,3
The characteristics of the gingiva on the facial aspect have been described by several
authors.1-7 However, only one recent study has reported on the width of the lingual
keratinized gingiva of the mandible.7
Although not substantiated, it is generally believed that an adequate width of keratinized
gingiva is important for maintaining gingival health. This has resulted in the
introduction of numerous surgical procedures to increase the width of gingiva.8-30
However, the question of how much gingiva is "adequate" has not been investigated.
The purpose of the present investigation was to examine the width of the facial and
lingual keratinized gingiva and to determine how much keratinized gingiva is adequate
for the maintenance of gingival health.
MATERIAL AND METHODS
Thirty-two dental students between 19-29 years of age with no pathologic pockets
performed supervised oral hygiene (daily supervision with the Plak-Liteâ disclosing
system)31 for 6 weeks. Following this period, the gingiva of all buccal and lingual tooth
surfaces was assessed using the Gingival Index system.32 Oral hygiene was scored on all
surfaces according to the criteria of the Plaque Index system.33 The identification of the
mucogingival junction was facilitated by staining with Schiller's IKI solution.34 Using
this method, the epithelium of the alveolar mucosa yielded an iodine-positive reaction
while the keratinized gingiva was iodine-negative,34-36 (Figure 1 a,b). After application
of the Schiller solution, the width of keratinized gingiva was measured to the nearest 0.5
mm from the gingival margin to the mucogingival junction using a specially graded
periodontal probe. The depth of the gingival crevices was also measured. In order to
compare the results of the present study to results from previous studies the width of
attached gingiva was determined by subtracting the crevicular depth from the width of
keratinized gingiva.
Gingival exudate was assessed37 on all (116) buccal and lingual surfaces which had 2
mm or less of keratinized gingiva. In addition, the amount of gingival exudate from 118
tooth surfaces randomly selected from a total of 371 which had 2.5 to 3.0 mm gingiva
was measured. Only plaque free surfaces were scored.
RESULTS
After the six weeks of controlled oral hygiene the mean individual Plaque Index (P1 I)
was 0.22 (range 0.00-0.57). The mean individual Gingival Index (GI) was 0.09 (range
0.04-0.25). The crevicular depth averaged 1.0 mm (range 0.5-1.5 mm).
From a total of 1406 tooth surfaces, 1168 were completely plaque free.
The facial keratinized gingiva was widest in the area of upper and lower incisors and
narrowest adjacent to the maxillary and mandibular canines and first premolars (Figure
2 ) . The lingual gingiva of the lower jaw exhibited its greatest width in the area of the
premolars and molars. The incisors showed the narrowest lingual gingiva (Figure 2 ) In
the maxilla the facial gingiva was generally 0.5-1 mm wider than in the mandible
(Figure 2).
Most surfaces (> 80% ) with 2.0 mm or more keratinized gingiva were clinically
healthy, (Figure 3) and 76% of these same surfaces failed to show gingival exudation
(Figure 4). On the other hand, all surfaces with less than 2.0 mm of keratinized gingiva
exhibited clinical inflammation and varying amounts of gingival exudate (Figures 3, 4).
Generally, the Gingival Index and gingival exudate scores increased as the width of the
keratinized gingiva decreased (Figures 3, 4). The maximum score during this
examination was GI = 2 (moderate inflammation) which occurred only in surfaces
whose width of keratinized gingiva was 2 mm or less (Figure 4).
Figure 5 compares the distribution of variation of the width of attached gingiva found in
the present study to that of previous studies.2,3,7 The similarity between these results is
apparent.
DISCUSSION AND CONCLUSION
The present investigation has shown that the pattern of variation in the width of the
facial keratinized gingiva minus the crevicular depth agrees with previous studies on the
width of attached gingiva.2,3,5,7 Similarly, it corroborates recent data on the width of the
lingual attached gingiva.7 In this study the width of the lingual keratinized gingiva
varied between 1 and 8 mm. The smallest width was usually seen in the area of the
anterior teeth, and the widest gingiva was found adjacent to premolars and molars. This
pattern of variation is almost the reverse of that of the facial gingiva.
The present material has also clearly demonstrated that although tooth surfaces may be
kept free of clinically detectable plaque, areas with less than 2 mm of keratinized
(which means less than 1 mm of attached) gingiva persisted to remain inflamed. The
fact that inflammation persisted in these areas irrespective of the presence or absence of
frenum insertions, suggests that the inflammatory situation in the gingiva is not a result
of only mechanical irritation from these structures. Rather it is conceivable that a
movable gingival margin would facilitate the introduction of microorganisms into the
gingival crevice resulting in a thin subgingival bacterial plaque which would be difficult
to detect and not easily removed by conventional toothbrushing.
The regions which consistently showed the narrowest width of keratinized gingiva were
the lingual surface of the lower anteriors and the buccal surface of the lower canines and
first premolars. However, the study has shown that these surfaces which averaged
nearly 3 mm in width should be adequate to maintain gingival health. Although not a
problem from a preventive point of view, the narrow keratinized gingiva on the lingual
of the lower anteriors may pose a problem in prosthodontic and periodontal treatment.
For example, it is required that if lower partial removable appliances are to be equipped
with a lingual bar, the lingual area should have a minimum width of 4 mm keratinized
gingiva.38,39 This requirement may be difficult to satisfy in the average patient since the
mean width of the lingual gingiva adjacent to the lower anterior teeth is usually less
than 3 mm.
It is apparent in periodontitis that pathologic pockets may easily extend beyond the
mucogingival junction. Although procedures have been devised for correction this
problem when it occurs on the facial aspect, to the best of our knowledge, modern
periodontal surgery offers no specific method for increasing the width of keratinized
gingiva on the lingual surface of the lower incisors.
Furthermore, since it would appear from this study that less gingiva is needed to
maintain health than generally believed, a critical reappraisal of the indications for
performing anyone of the many surgical procedures available for increasing the width of
gingiva must be undertaken.
SUMMARY
The study undertook to examine the width of the facial and lingual keratinized gingiva
and to determine how much gingiva is "adequate" for the maintenance of gingival
health. After 6 weeks of supervised oral hygiene the gingival health of 1406 buccal and
lingual surfaces in 32 dental students was assessed according to the criteria of the
Gingival Index system. The width of keratinized gingiva was measured after the
application of the Schiller IKI solution. Gingival exudation was measured on all buccal
and lingual surfaces which had 2 mm or less of keratinized gingiva and in a randomly
selected number of tooth surfaces with more than 2 mm gingiva. Only plaque free
surfaces were scored. Previous observations on the width and the pattern of variation of
keratinized gingiva were confirmed. It was demonstrated that gingival health is
compatible with a very narrow gingiva. However, in areas with less than 2 mm
keratinized gingiva inflammation persisted in spite of effective oral hygiene. It is
suggested that 2 mm of keratinized gingiva (corresponding to 1 mm attached gingiva in
this material) is adequate to maintain gingival health.

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