by Dr. Manthan Desai
According to the glossary of periodontal terminology, attached gingiva is a portion of the gingiva that is firm, dense, stippled, and tightly bound to the underlying periosteum, tooth, and bone.
Keratinized gingiva provides stabilization of the gingival margin, contributes to the dissipation of forces from muscle fibers, mastication, and obviates damage from external insult.
Drs. Niklaus Lang and Harald Loe concluded that 2mm of keratinized gingiva, with less than 1mm of attached gingiva, is adequate to maintain gingival health.1 Dr. Jan Wennström and others concluded that the attached gingiva and its width have minimal impact on maintaining periodontal health.2
Dr. Mehdi Adibrad and others concluded that the absence of adequate keratinized mucosa around implants supporting overdentures was associated with higher plaque accumulation, gingival inflammation, bleeding on probing, and mucosal recession.3
According to Dr. Ingvar Ericcson, an adequate band of attached gingiva could be defined as that amount which is sufficient to prevent recession based upon the assessment of individual practitioners.4
The importance of keratinized gingiva still remains a topic of controversy in the literature.
The use of free gingival grafts, apically repositioned flaps and free connective tissue grafts are commonly used therapeutic techniques to augment the volume of attached gingiva.
The two cases presented demonstrate the use of free gingival grafts to augment attached gingiva.
Case report #1
A 26-year-old healthy male patient presented with a chief complaint of sensitivity, and receding gums associated with the lower anterior teeth.
Examination revealed rotations of teeth #'s 24 and 25, gingival recession and an inadequate zone of attached gingiva with aberrant frenal attachment (Fig.1).
Intra-oral periapical radiographs showed no significant bone loss. The patient wished to prevent further recession. The treatment plan consisted of augmenting the keratinized gingiva using a free gingival graft. After obtaining adequate anesthesia, the recipient site was prepared using a #15C scalpel blade (Hu-Friedy). A graft was then harvested from the right hard palate (Fig.2).
Palatal hemostasis was achieved by 3-0 silk sutures (Fig.3). A protective vacuum formed soft template was also provided for patient comfort. The graft was stabilized at the recipient site using 5-0 monofilament sutures (Fig.4).
The recipient area was covered with a periodontal dressing. After two weeks the donor as well the recipient site showed a positive healing trend (Fig.5). A degree of creeping reattachment was noted. The patient was advised to seek orthodontic treatment to prevent a reoccurrence of recession. Unfortunately, the patient did not consent to pursue this treatment option.
Case report #2
A 55-year-old female patient presented with a chief complaint of receding gums associated with the lower anterior teeth.
Examination revealed inadequate attached gingiva, gingival recession, horizontal bone loss and a grade I mobility of the lower anteriors. (Fig.6)
The patient wished to preserve her natural teeth. The treatment plan proposed included splinting the lower anteriors and augmentation of the keratinized gingiva using a free gingival graft.
After obtaining adequate anesthesia, the recipient site was prepared using a #15c scalpel blade (Fig.7). Care was taken to preserve a good periosteal bed to ensure a rich nutrient supply for the graft. A graft of necessary dimensions was harvested from the right hard palate (Fig.8). Palatal hemostasis was achieved using Surgicel and 3-0 silk sutures (Fig.9). The graft was stabilized at the recipient site using 4-0 monofilament sutures (Fig.10).
The recipient area was covered with a periodontal dressing. After two weeks the donor (Fig.11) as well the recipient site (Fig.12) showed a positive healing trend. The patient is enrolled in a regular recare program.
Augmenting attached gingiva should be a primary consideration in patients with compromised plaque control. Augmentation of keratinized gingiva prevents increased recession and also induces regeneration of keratinized gingiva via creeping attachment. The newly formed keratinized gingiva can be sustained provided all negative vectors are eradicated and the patient adheres to suitable maintenance care.
- Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Perio October 1972:43(10);623-627
- Wennström JL, Dahlén G, Gröndahl K, Heijl L Periodic subgingival antimicrobial irrigation of periodontal pockets. II Microbiological and radiographic observations. J Clin Perio November 1987;14(10):573-580
- Adibrad M, Shahabuei M, Sahabi M. Significance of the Width of Keratinized Mucosa on the Health Status of the Supporting Tissue Around Implants Supporting Overdentures. J Oral Implant October 2009;35(5):232-238
- Ericsson I. Recession in sites with inadequate width of the keratinized gingival An experimental study in the dog. J Clin Perio February 1984;11(2):95-103
Dr. Manthan Desai has been practicing for five years in Mumbai, India. He received his MDS in periodontics from the Rajiv Gandhi University of Health Sciences in 2011. Desai is a member of the Indian Society of Periodontology, the Indian Society of Oral Implantology, and the Indian Dental Association.