Dimensional alterations of the gingiva related to changes of facial/lingual tooth position in permanent anterior teeth of children

Abstract Maxillary and mandibular anterior permanent teeth in 38 children aged 7–12 years were examined 2 × with an interval of 2 years to determine whether spontaneous facial/lingual tooth position changes were related to alterations of the widths of keratinized and attached gingiva and the clinical crown height. Measurements included dental plaque, gingival inflammation, probing depth, and width of keratinized and attached gingiva. In addition, study casts from the baseline and 2-year examinations were used to measure clinical crown height and tooth position. The results showed that significant alterations in the widths of the keratinized and attached gingiva took place when the teeth changed positions in facial or lingual directions. The changes in gingival widths could to some extent be coupled to changes in clinical crown height. In teeth moving lingually, the gingival widths increased and the clinical crown height decreased. In teeth moving facially, the gingival widths decreased, and the facial gingiva sometimes receded. These gingival alterations call for examination of the facial gingiva as part of the monitoring of the development of the permanent dentition.     

A clinical study of the width of the attached gingiva in the deciduous, transitional and permanent dentitions

This study involved 331 individuals who were without clinical evidence of gingival inflammation. The width of the keratinized gingiva and the depth of the gingival sulcus were measured on the mid-facial aspect of all teeth in each patient, using a calibrated, flat periodontal probe. The mean width of the attached gingiva did not show an increase from the deciduous to the permanent dentition. However, the width of the attached gingiva in the case of newly erupted permanent teeth was narrower than in the corresponding primary teeth. The widest zone of attached gingiva was found over the central and lateral incisors. The width of the attached gingiva decreased over the canine and the first premolar (and first primary molar). It then increased over the second premolar (and second primary molar) and the first molar. These variations were approximately the same in both the maxilla and the mandible, although there was a greater over-all width of attached gingiva in the maxilla than in the mandible. The tendency, in the permanent dentition, for the attached gingiva to increase in width with age was related to a concomitant decrease in sulcus depth.     

The width of clinically-defined keratinized gingiva in the mixed dentition

Some authors have noticed a clear decrease of the width of keratinized gingiva when they compared the width over deciduous and newly erupted permanent teeth. The aim of this cross-sectional study was to assess the width of keratinized gingiva over permanent and deciduous teeth present in 6 to 11-year old children in an urban environment. The greatest width of keratinized gingiva was found over deciduous canines and permanent incisors. When comparing the width of keratinized gingiva over deciduous canines and molars and permanent first incisors and first molars, statistically significant differences were found only between 6- and 11-year-old groups. The findings do not seem to support previously published data, but do suggest that periodontal mucogingival surgery is not needed before the patient reaches the adult age, since there is a tendency of an increase of the width of keratinized gingiva.     

Morphological changes in the attached and keratinized gingiva and gingival sulcus in the mixed dentition period

Abstract A longitudinal study was undertaken to examine the changes in the sulcus probing depth, keratinized and attached gingiva during the mixed dentition period. 54 children aged 7 to 9 years at the first examination were examined twice, with an interval of 5 years. Sulcus probing depth and keratinized gingiva were examined at the buccal aspect of the incisors, and either right or left cuspids and posterior areas. The width of the attached gingiva was obtained by substracting the probing depth from the width of the keratinized gingiva. When compared to primary predecessors, the permanent teeth had a deeper probing depth, narrower attached gingiva and at the maxillary teeth, a wider keratinized gingiva. When a pennanent tooth was present at both examinations, there was a significant increase in width of the attached gingiva with a corresponding decrease in probing depth, and a slight beginning of an increase in the width of keratinized gingiva. Previous and the present findings indicate that during the early years after eruption of the permanent tooth, an increase in width of the attached gingiva takes place, without occlusal migration of the marginal gingiva whereas, at later stages, this coronal migration takes place, concomitant to tooth eruption.     

Role of attached gingiva for maintenance of periodontal health

The present study was undertaken to analyze the role of attached gingiva for the maintenance of periodontal health in sites with normal and reduced height of the supporting apparatus. Furthermore, the effect of excision and grafting of gingiva on some parameters describing dimensions and location of the periodontal tissues was evaluated. 7 beagle dogs were used. A baseline examination comprised assessments of dental plaque, gingival conditions, attachment level, position of the gingival margin and width of the keratinized and the attached gingiva. In the right side of the jaws (experimental side) a 6-month period of periodontal tissue breakdown was followed by surgical excision of the entire zone of the gingiva. After another 4-month period of healing with daily plaque control, a gingival graft was inserted in one quadrant of the experimental side to regain a zone of attached gingiva while the other quadrant of the experimental side was left ungrafted. In the left side of the jaws (control side), the teeth were subjected to daily meticulous plaque control during the entire study. In one of the control quadrants the entire zone of the keratinized and attached gingiva was excised at a time point corresponding to the grafting procedure in the experimental side, while the gingiva in the remaining control jaw quadrant was left unoperated. Clinical examinations of all control and experimental tooth units were repeated at certain time intervals during the course of the study. The final examination was carried out 4 months after grafting. The results of the experiment showed that in sites exposed to careful plaque control measures gingival health could be established and maintained without sign of recession of the gingival margin or loss of attachment, independent of (1) presence or absence of attached gingiva, (2) width of keratinized gingiva or (3) height of the supporting attachment apparatus. Following surgical excision of the entire gingiva, all buccal sites regained a zone of keratinized gingiva, but most sites were lacking attached gingiva. Furthermore, grafting of gingival tissue significantly increased the width of the keratinized and the attached gingiva but had no obvious effect on the position of the gingival margin or the level of the attachment.     

A clinical and histologic evaluation of gingival fibroblasts seeding on a chitosan-based scaffold and its effect on the width of keratinized gingiva in dogs

Background: Finding biocompatible matrix materials capable of enhancing the procedures of gingival augmentation is a major concern in periodontal research. This has prompted the investigation of a safe grafting technique by means of synthetic or natural polymers. The objective of this study is to examine the effect of a gingival fibroblast cultured on a naturally derived (i.e., chitosan‐based) scaffold on the width of keratinized gingiva in dogs. Methods: Gingival fibroblasts were cultured from a small portion of hard palates of five dogs. A bilayered chitosan scaffold was seeded with the gingival fibroblasts and transferred to dogs. Surgery was performed bilaterally, and the regions were randomly divided into two groups: chitosan only (control site) and chitosan + fibroblast (test site). Periodontal parameters, including probing depth and width of keratinized and attached gingiva, were measured at baseline and 3 months after surgery. A histologic evaluation was also performed on the healed grafted sites. Results: Comparison of width of keratinized and attached gingiva in control and test sites showed that the mean width of keratinized and attached gingiva increased in each group after surgery. However, the difference between control and test groups was not statistically significant. Concerning the existence of the keratinized epithelium, exocytosis, and epithelium thickness, no significant difference was observed in test and control sites. The difference was significant in relation to rete ridge formation. Conclusion: The tissue‐engineered graft consisting of chitosan + fibroblast was applied to gingival augmentation procedures and generated keratinized tissue without any complications usually associated with donor‐site surgery.     

3-year observations on gingival recession in mandibular incisors in children

28 children aged 6-13 years, with gingival recession localized to mandibular incisors, were monitored longitudinally to evaluate any changes of the labial periodontal tissues. Measurements included dental plaque, gingival inflammation, gingival recession, probing depth, probing attachment level, keratinized and attached gingiva. Following baseline examination, the incisors were observed at yearly intervals over 3 years. The results showed that a high level of oral hygiene was maintained and that gingival inflammation occurred only to a minor degree throughout the observation period. Gradual reductions in the amount of gingival recession and probing attachment levels took place in all children except for 1 of the subjects with 1 severely malpositioned tooth. Probing depths and widths of keratinized and attached gingiva remained relatively unchanged. The finding that gingival recession in mandibular incisors in young children often improves over time suggests that preventive or reparative treatment in this part of the developing dentition may not be necessary. Decisions about such treatment should be postponed until any spontaneous improvement has taken place.     

Longitudinal observation of "unattached," mobile gingival areas

Facial gingival surfaces over cuspids and bicuspids in 20 patients were monitored for 5 years to evaluate the importance of attached gingiva in the maintenance of a stable periodontium. 43 surfaces "at risk" were compared to 36 "non-risk" surfaces within these patients. Surfaces "at risk" had to meet the following 3 criteria as established by both of 2 independent examiners: width of keratinized gingiva less than or equal to 1.0 mm; absence of attached gingiva; mobility of the gingival margin. During the 5 years of observation, "non-risk" surfaces showed a trend toward decrease in mean width of keratinized gingiva, while this measurement remained unchanged for the surfaces "at risk" Probing depths remained unaltered for both groups. A trend toward gingival recession and loss of probing attachment was observed for both "risk" and "non-risk" surfaces. Thus, this study failed to demonstrate that "unattached" and mobile facial gingival surfaces are more susceptible to periodontal breakdown than "attached" surfaces.     

120名汉族青年前段牙弓唇侧角化龈宽度的测量

目的 通过测量获取前段牙弓唇侧角化龈和附着龈宽度的相关数据,以期为牙周解剖和牙周手术提供参考.方法 选择20～30岁牙龈健康的汉族青年120人,分别测量前段牙弓唇侧龈缘高点处角化龈宽度及龈沟深度、邻间牙龈乳头尖端处冠根向角化龈宽度,并对数据进行统计学分析.结果 龈缘高点相应处角化龈宽度在上颌前段牙弓最宽可达(5.6±1.3)mm,在下颌前段牙弓最宽可达(4.5±1.1)mm,且以切牙区最宽,尖牙、第一前磨牙其宽度逐渐变窄,第二前磨牙开始增宽;上、下颌前段牙弓邻间牙龈乳头尖端相应处冠根向角化龈宽度范围分别为(6.2±1.3)～(8.9±1.4)mm及(5.8±1.0)～(7.6±0.9)mm.结论 本组汉族青年前段牙弓唇侧龈缘高点相应处角化龈宽度和附着龈宽度因人和牙位而异;由于唇系带的附着,两中切牙邻间牙龈乳头尖端相应处冠根向角化龈宽度最窄.     

Cross-sectional study to evaluate variations in attached gingiva and gingival sulcus in the three periods of dentition

The dimensional differences of the attached gingiva and gingival sulcus in the primary, mixed and permanent dentition were studied clinically in normal gingivae of 382 children, aged 4-15 years. The depth of the gingival sulcus and the width of keratinized gingiva were also measured. Shallow gingival sulcus was observed in the primary dentition as compared to that in permanent dentition. However, in the mixed dentition deeper sulcus was observed around the newly erupted teeth. This was attributed to deeper penetration of the instrument, at the time of eruption. The widest zone of attached gingiva was observed in maxillary and mandibular incisors, decreasing gradually over the cuspids and first premolars (first primary molars), and again attached gingiva increased in second premolars (second primary molars) and first and second permanent molars. The width of attached gingiva in case of newly erupted permanent teeth (mixed dentition) was narrower in the corresponding primary teeth. This was due to an increase in the gingival sulcus depth. The attached gingiva increased in width with age. This was related to a concomitant reduction in sulcus depth.     

Role of keratinized gingiva for gingival health

Abstract The present study was carried out in the Beagle dog in order to determine if variations of the width of the zone of keratinized gingiva occur in the canine dentition, if the width alters during the development of destructive periodontitis and if, subsequent to surgical excision of the periodontal lesion, the regenerated gingival margin differs from that of a normal, noninflamed gingiva. Five dogs were used. A baseline examination comprised assessments of dental plaque, gingival conditions and width of the zone of keratinized gingiva. Cotton floss ligatures were placed around the teeth on the right side of the jaws and plaque was allowed to accumulate in order to induce periodontal tissue breakdown. After 150 days the inflamed periodontal tissues around the experimental teeth were removed surgically using a “gingivectomy” or a flap procedure. In the “gingivectomy” procedure the entire zone of the keratinized gingiva was excised whereas the main part of the keratinized tissue was maintained with the flap procedure. During a healing period of 120 days plaque control was carried out daily. On the left side of the jaws (control side) a careful toothcleaning program was performed during the entire observation period of 270 days. Clinical examinations of all control and experimental tooth units were repeated on days 150 and 270. Biopsies were sampled from both sides of the jaws on day 270. In histological sections the free gingival tissue was subjected to histometric assessments and a stereologic analysis based on a standardized morphometric point-counting procedure. In addition, the number of leukocytes residing within the junctional epithelium was determined. The results showed that in Beagle dogs the width of the keratinized gingiva (WKG), on the facial aspect of premolars and molars, varies between 2 and 6 mm. During a period of 270 days of careful plaque control, the WKG was maintained unaltered. In comparison, a phase of experimental periodontitis resulted in a substantial decrease of the WKG. Subsequent to the excision of the inflamed periodontal tissues, which in some cases included the entire zone of the keratinized gingiva, a new free gingival unit developed. In most respects the structural composition of this regenerated gingival unit was similar to that of a normal control unit. Furthermore, in the absence of plaque, the regenerated soft tissue was free from signs of inflammation independent of presence or absence or width of the keratinized zone.     

根向复位瓣在附着龈宽度不足患牙的牙冠延长术中的应用

目的：：评价根向复位瓣在附着龈宽度不足的患牙牙冠延长术中的应用效果。方法：纳入需行牙冠延长术但附着龈宽度不足的患牙17颗,术中采用根向复位瓣法对牙龈瓣进行复位,记录手术前和术后6个月龈缘到牙体断端的距离、附着龈的宽度等指标并进行比较和评价。结果：术前17颗患牙牙体缺损边缘均位于龈下,术后6个月16例(94.11%)缺损边缘均暴露在龈缘冠方,龈缘根向位移距离(3.88±0.49) mm;17颗患牙附着龈宽度术前为(2.35±0.61) mm,术后6个月为(2.65±0.49) mm(P>0.05)。结论：牙冠延长术可以有效暴露牙体缺损边缘,为牙体缺损创造修复条件,避免切除过多角化龈导致附着龈宽度变窄。     

Lack of association between width of attached gingiva and development of soft tissue recession

The purpose of this study was to longitudinally monitor changes in the position of the soft tissue margin at 26 buccal sites surgically deprived of all gingival tissue. A baseline examination carried out 6 months after treatment revealed that the sites to be monitored were lacking or had only a minimal zone (less than 1 mm) of regenerated attached gingiva. 12 control sites with an "adequate" width of attached gingiva (greater than 1 mm) were also examined. Assessments of oral hygiene and gingival conditions, probing pocket depths, probing attachment levels, position of the soft tissue margin, and gingival width were carried out at baseline and after 5 years. The results revealed that in the test sites, a slight increase of the width of the gingiva occurred during the observation period. 7 out of the 26 areas showed a coronal regrowth of the soft tissue margin, while 2 sites showed a further apical displacement of the soft tissue margin. In the control areas, 3 sites developed recession accompanied by a reduction in the width of the gingiva. Hence, it appears that in patients maintaining a proper plaque control, the lack of an "adequate" zone of attached gingiva does not result in an increased incidence of soft tissue recessions.     

Gingival condition in areas of minimal and appreciable width of keratinized gingival

Sixteen dental, dental hygiene, and dental assisting students and dental faculty members who had contralateral or unilateral areas of minimal (less than or equal to 1.0 mm) and appreciable (greater than or equal to 2.0 mm) widths of keratinized gingiva on mid-buccal plaque-free surfaces of mandibular bicuspids were examined. Gingival exudate amounts and clinical inflammation based on color change and/or swelling and bleeding on probing were evaluated. The results showed that gingiva with "appreciable" width as well as gingiva with "minimal" width of keratinized tissue exhibited only minute amounts of gingival exudate. Also, there were generally no clinical signs of inflammation for both types of tissue. From the groups of 16, six subjects were selected who had contralateral pairs of minimal and appreciable keratinized gingiva. They were instructed to cease oral hygiene in the lower bicuspid area for 25 days. At day 0, 4, 7, 11, 14, 18, 21, and 25, plaque, gingival exudate, and clinical gingival inflammation were evaluated. Results revealed increases in plaque, gingival exudate scores and clinical gingival inflammation over the 25-day period with no apparent difference between the areas with minimal and appreciable width of keratinized gingiva.     

Culture of human gingival fibroblasts on a biodegradable scaffold and evaluation of its effect on attached gingiva: a randomized, controlled pilot study

BACKGROUND: An adequate width of attached gingiva is necessary to maintain healthy periodontium, especially in orthodontics or restorative treatments in periodontics. The purpose of this study was to evaluate the width of attached gingiva after clinical application of a cultured gingival graft compared to a periosteal fenestration technique. METHODS: This study was conducted on nine patients (18 sites) with insufficient attached gingiva adjacent to at least two teeth in contralateral quadrants of the same jaw. A small portion (approximately 3 x 2 x 1 mm) of attached gingiva (epithelial + connective tissue) was removed with a surgical blade. After culture of gingival fibroblasts, 2 x 10(5) cells in 250 microl nutritional medium were added to 250 microl collagen gel. One tooth in each patient was randomized to receive a periosteal fenestration technique for gingival augmentation (control) or a tissue-engineered mucosal graft (test). Clinical parameters measured at baseline and 3 months included width of keratinized tissue, probing depth, and width of attached gingiva. RESULTS: An increased amount of keratinized tissue was seen at all treated sites after 3 months. The mean increased amount of attached gingiva was 2.8 mm at test sites and 2 mm at control sites; this difference was significant (P < 0.05). CONCLUSION: Based on the results of this investigation, the tissue-engineered mucosal graft is safe and capable of generating keratinized tissue.     

Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment. I. A 7-year longitudinal study

BACKGROUND: Mucogingival interceptive therapy in patients with buccally erupting teeth is performed to prevent the ectopic permanent tooth from developing periodontal lesions. The keratinized tissue entrapped between the erupting tooth and the deciduous tooth is retained to maintain a satisfactory width of the gingiva for the permanent tooth. The aim of the present study on buccally-erupted premolars scheduled for orthodontics was to evaluate the keratinized tissue width 3 months, 2 years, and 7 years subsequent to mucogingival interceptive therapy and orthodontic treatment. METHODS: Twenty-nine patients participated. Three different surgical techniques were used according to specific indications. Eight patients were treated with double pedicle flaps (DPF), 10 patients with apically positioned flaps (APF), and 11 with free gingival grafts (FGG). RESULTS: The amount of keratinized tissue on the treated (test) sites was not significantly less than on the control (untreated) sites showing normally erupting premolars at all observation periods. All 3 surgical procedures appeared to be effective in saving the keratinized tissue for the permanent tooth. Preoperative periodontal parameters such as gingival width, probing depth, and bleeding on probing significantly influenced the outcome 3 months after surgery (P <0.01). CONCLUSIONS: Mucogingival interceptive surgery is an effective approach to conserve the keratinized buccal gingiva of ectopically erupting premolars.     

Influence of free gingival grafts on the health of the marginal gingiva

Abstract In order to evaluate the effect of increasing the width of inadequate attached gingiva on the health of the marginal gingiva, 12 free gingival grafts were performed on 12 patients with less than 1.0 mm of attached gingiva on homologous contralateral pairs of mandibular teeth. A baseline examination, which included measurements of plaque, gingival exudate, sulcus bleeding, sulcus probing depth and width of attached gingiva, was done before surgery. One week after surgery, plaque was eliminated mechanically on the test and control sides. All measurements were repeated 7 and 14 weeks after surgery. During the week following the first postsurgical examination, individual oral hygiene instruction was given until the patient could show plaque-free test and control sites. The width of the attached gingiva increased significantly on the side where the grafting was performed (test side). The only other significant changes observed during the experiment were a decrease of the mid-buccal plaque index on the test side during the first 7 weeks following surgery and a decrease of the buccoproximal plaque index on the test and control sides during the total experimental period (14 weeks). None of the other clinical parameters measured showed significant differences when test and control sites were compared or when the same sites were compared longitudinally.     

Relationship among gender, race, age, gingival width, and probing depth in primary teeth

BACKGROUND: Limited information is available regarding the attached keratinized tissue, probing depth, and sociodemographic characteristics of primary teeth. This study was carried out to evaluate the relationship among age, gender, race, gingival width, and probing depth in each primary tooth type. METHODS: The study population consisted of 300 children, aged 4 to 6 years, with clinically healthy gingiva, who were enrolled in an oral health program. Gingival width and probing depth were measured with a standard Williams periodontal probe in the middle of the keratinized gingiva and at six gingival sites (mesio-buccal, mid-buccal, disto-buccal, mesio-lingual, mid-lingual, and disto-lingual), respectively. Schiller's solution was used to establish the limits of keratinized gingiva. RESULTS: The gingival width (mean +/- SD) on the buccal surfaces decreased from anterior to posterior positions in both arches; in the lower lingual surfaces, the inverse was observed. The gingival width (mean +/- SD) ranged from 2.95 +/- 0.15 mm to 6.16 +/- 0.20 mm and the probing depth from 1.03 +/- 0.91 mm to 2.08 +/- 0.07 mm. There was a tendency toward increased probing depth as age increased from 4 to 6 years. There was also an increase in the probing depth from anterior to posterior teeth. CONCLUSIONS: In the majority of observations, it was concluded that there was a relationship among age, gingival width, and probing depth, but generally not among race and gender and these measurements, respectively. Furthermore, there is no relation between gender and gingival width and race and probing depth.     

A longitudinal evaluation of varying widths of attached gingiva

32 patients with bilateral areas of inadequate attached gingiva on the facial surface of homologous contralateral teeth have been followed for 6 years. Treatment consisted of scaling, root planing, oral hygiene and maintenance at 3- to 6-month intervals or as needed to control inflammation. A free gingival graft was placed on one side (experimental), while the other side served as the unoperated control. Areas of inadequate attached gingiva on control sides, to include those with recession and no attached gingiva, did not demonstrate additional recession or further loss of attachment. Gingival inflammation and plaque were significantly reduced. On experimental sides, the dimension of keratinized and attached gingiva increased and was stable over 6 years. Areas which began with recession and no attached gingiva exhibited a reduction in recession and gain in clinical attachment following the placement of a gingival graft. Examination of patients who had discontinued participation in the study for a period of 5 years revealed a re-establishment of gingival inflammation on the control sides associated with additional recession. Similar changes were not observed in areas treated by a free graft. The findings demonstrate that it is possible to maintain periodontal health and attachment through control of gingival inflammation despite the absence of attached gingiva.     

Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment. II. Surgically treated versus nonsurgically treated cases

BACKGROUND: The aim of this 2-year longitudinal study was to compare the width of keratinized gingiva after orthodontic therapy for buccally erupting premolars that had been pretreated by extraction of deciduous teeth alone versus interceptive mucogingival surgery. METHODS: In 8 patients (aged 9 to 12 years) who presented with bilateral buccal eruption of homologous teeth (premolars), one side was randomly treated with extraction of the deciduous molar and mucogingival surgery (test site), while the other side was treated only by extraction of the deciduous molar (control site). All of the subjects underwent orthodontic treatment with fixed appliances. RESULTS: At the baseline visit prior to any treatment, there was no significant difference between the mean amount of keratinized gingiva at test sites (3.06 mm) and control sites (2.93 mm). Two years later, upon completion of orthodontic treatment, there was a significant difference between test (2.93 mm) and control (1.37 mm) sites in the mean width of keratinized tissue. In the control (untreated) group, 2 sites exhibited 1 mm of gingival recession after orthodontic treatment. CONCLUSIONS: Mucogingival interceptive surgery is an effective technique to maintain keratinized tissue in correspondence with buccally-erupted teeth.