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Attached gingiva: Histology and surgical augmentation

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 Periodontics
CDE
2 HOURS
CREDIT

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 stabiliza-
tion 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 patient’s 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

T
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 1–9 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 sug-
gested 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 gin-
giva.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 erup-
tion of teeth. As a result, the width
of keratinized gingiva will continue
to increase unless there is a concur-
rent 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
When to consider increasing
attached gingiva
While the implications of find-
ings from previous studies should
be considered when planning
periodontal treatment that involves
mucogingival surgery, there are
some indications for surgical inter-
vention.4-6 Mucogingival surgical
procedures should be strongly con-
sidered when the patient’s 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 tech-
niques designed to correct the lack
of attached gingiva was the apically
repositioned flap.8,9 This technique
allowed surgeons to increase or pre-
serve 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

www.agd.org General Dentistry July/August 2009 381

Periodontics  Attached gingiva
Fig. 1. A patient with no clinical crown but
adequate keratinized gingiva on tooth No. 6.
(including the keratinized epithe-
lium 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 par-
tial-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 eden-
tulous 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 connec-
tive tissue, without epithelium,
were transplanted from either the
keratinized gingiva or the non-
382 July/August 2009 General Dentistry
Fig. 2. The patient in Figure 1, after the pre-
existing gingival margin was sutured apically.
keratinized alveolar mucosa. The
gingival CTGs were covered with
keratinized epithelium, displaying
the same characteristics as those
found in normal gingival epithe-
lium, while the alveolar mucosa
transplants were covered with non-
keratinized 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 over-
lying 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 pres-
ent with FGGs.
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 adja-
cent interproximal bone loss. Class
III describes recession apical to the
mucogingival junction with mild
to moderate adjacent interproximal
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Fig. 3. The patient in Figure 1 eight weeks
later, upon receiving the final prosthesis.
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 clini-
cal crown-lengthening procedure
on tooth No. 6, which was going
to serve as an abutment for a
four-unit bridge spanning teeth
No. 6–9 (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 gingivec-
tomy 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 kerati-
nized zone.
Using two vertical release inci-
sions, a crevicular incision was made
around the labial surface and a split-
thickness flap was reflected. The pre-
existing 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).
Fig. 4. A patient whose labial frenum extended
into the marginal gingiva of tooth No. 25.
Fig. 7. A patient who had a muscle pulling on
tooth No. 21 and no attached gingiva on tooth
No. 20.
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 hori-
zontal 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,
Fig. 5. The patient in Figure 4, after the donor
tissue was sutured in place.
Fig. 8. The patient in Figure 7, after donor
tissue is secured by suture.
with 1–2 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).
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Fig. 6. A photo of the patient in Figure 4
taken two weeks postoperatively, showing an
increased zone of attached gingiva.
Fig. 9. The patient in Figure 7 three months
later, after the final restoration is placed.
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 muco-
gingival junction. Based on Miller’s
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).
General Dentistry July/August 2009 383
Periodontics  Attached gingiva
Fig. 10. A patient with recession on teeth No.
24 and 25 and a loss of interproximal papillae.
Fig. 12. The patient in Figure 10, after the
donor tissue was stabilized with interrupted
sutures.
Figure 13 shows postoperative heal-
ing after four months. A zone of
attached gingiva (with 2 mm pocket
depths) was created around the labial
side of tooth No. 24.
Discussion
Depending on the patient’s situa-
tion, various techniques can be per-
formed 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 kera-
tinized attached gingiva. Studies
have proven that apically positioned
flap techniques can establish
adequate zones of attached gingiva
without deforming the dentogingi-
val junction.1,10,15,16 Because gingival
384 July/August 2009 General Dentistry
Fig. 11. A radiograph of the patient in Figure
10, showing interproximal bone loss between
teeth No. 23 and 25.
Fig. 13. The patient in Figure 10, four months
after treatment.
recession is the major risk from an
apically positioned flap, this pro-
cedure 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 aug-
mentation, the FGG procedure
has proven to be efficient and
predictable for increasing the apico-
coronal dimension of attached
gingiva.7,15,17 A 2008 retrospective
study reported that FGGs provided
long-term (10–25 years) stability.17
One potential advantage of FGGs is
that postoperative migration of the
gingival marginal tissue in a coro-
nal direction may occur and cover
a previously denuded root surface
partially or even totally; however,
such “creeping attachment” occurs
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unpredictably after the healing
of FGGs.18 Based on the author’s
experience, FGG procedures could
provide better esthetics by avoid-
ing 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 developmen-
tal problems can result in trapped
plaque, root sensitivity, root caries,
and esthetic compromises. Langer
and Langer described a subepithe-
lial CTG technique for root cover-
age 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 Bruno’s 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 obtain-
ing 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
 significant increase in the mean
root coverage between the short-
term 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 signifi-
cant decrease in recession and an
increase in the quantity of kerati-
nized tissue over time, the subepi-
thelial CTG is recommended when
root coverage is attempted.21,25
Summary
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 proce-
dure, case selection and meticulous
surgical technique are the keys to
obtaining the best results.
Acknowledgements
The author thanks Dr. Robert Sachs
for his assistance with writing this
article.
Disclaimer
The author reports no conflicts of
interest related to this study.
View publication stats
Author information
Dr. Oh is an assistant professor,
University of Maryland Dental
School in Baltimore.
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Published with permission by the Academy of
General Dentistry. © Copyright 2008 by the
Academy of General Dentistry. All rights reserved.
July/August 2009 385