ATTACHED GINGIVA

ATTACHED GINGIVA

1. 1/7/2018 Attached gingiva 1 Dr Mushahida Anjum JR-1 Deptt . Of Periodontology Dental College Azamgarh ATTACHED GINGIVA

2. Introduction Definition Width of attached gingiva Thickness of attached gingiva Microscopic features Stippling Measurement of width Measurement of thickness Function Methods of increasing attached gingiva CONTENTS 1/7/2018 Attached gingiva 2

3. INTRODUCTION Historically a certain amount of attached gingiva has been considered important to maintain gingival health and prevent gingival recession. M ucogingival surgery or periodontal plastic surgery still remains a valid alternative for increasing the amount of attached gingiva. 1/7/2018 Attached gingiva 3

4. 1/7/2018 Attached gingiva 4 Orban and sicher - oral cavity is lined by three different kind of mucosa. Masticatory mucosa - hard palate and gingiva of alveolar process Lining mucosa - lips, cheeks and vestibular fornix Specialized mucosa covering the dorsum of tongue. Oral mucosa

5. 1/7/2018 Attached gingiva 5 Gingiva is the part of the oral mucosa that covers the alveolar processes of the jaws and surrounds the necks of the teeth - Carranza 10th ed The fibrous investing tissue, covered by keratinized epithelium, which immediately surrounds a tooth and is contiguous with its periodontal ligament and with the mucosal tissues of the mouth. - AAP 1992 GINGIVA

6. 1/7/2018 Attached gingiva 6 Anatomically gingiva is divided into: Free Attached and Interdental gingiva.

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8. ATTACHED GINGIVA Definitions GPT (1972) Attached gingival is that portion of gingiva that extending from base of gingival crevice to the mucogingival junction. Schroder It is combination of epithilium & C.T. defined as a portion of mucous membrane in complete post-eruptive dentition of a healthy young individual, is attached to teeth & alveolar process. 1/7/2018 Attached gingiva 8

9. 1/7/2018 Attached gingiva 9 It is continuous with marginal gingiva. firm, resilient & tightly bound to underlying periosteum of alveolar bone

10. Facial aspect of attached gingiva extends to relatively loose & movable alveolar mucosa & is demarcated by mucogingival junction 1/7/2018 Attached gingiva 10

11. On the lingual aspect of mandible, the attached gingiva terminates at the junction of lingual alveolar mucosa, which is continuous with mucous membrane lining the floor of the mouth. Wide in molar region, narrow in incisor region, varies 1-9mm The palatal surface of attached gingiva in maxilla blends imperceptibly with equally firm and resilient palatal mucosa. 1/7/2018 Attached gingiva 11

12. Classification There are 3 types of attached gingiva Type 1: there is a minimum of 5mm of attached gingiva covering edentulous ridge from lingual & buccal tangent to buccal side of proposed implant site. (flap can be apically positioned to increase zone of keratinized tissue on facial aspect) Type 2: there is keratinized tissue on top of ridge & at lingual / palatal tangent to proposed implant site. 1/7/2018 Attached gingiva 12

13. 1/7/2018 Attached gingiva 13 Divided into two classes class 1; Enough lingual keratinized gingiva at proposed implant site (a free gingival graft is recommended on facial aspect to increase zone of keratinized tissue) class 2; most keratinized tissue will be eliminated on lingual side if gingiva is festooned around implant (A gingival graft is performed on buccal side & apically positioned flap on lingual side to increase zone of keratinized gingiva)

14. Type 3 : keratinized tissue of alveolar ridge is present only on lingual /palatal side of propsed implant side (A free gingival graft is used to increase zone of keratinized tissue) 1/7/2018 Attached gingiva 14

15. WIDTH OF ATTACHED GINGIVA It is distance b/w mucogingival junction & projection on the external surface of bottom of gingival sulcus or periodontal pocket. On facial aspect differs in different areas of mouth Greatest in incisor region- 3.5-4.5mm in maxilla 3.3-3.9mm in mandible Narrowest in posterior region- 1.9mm in maxilla 1.8mm in mandible 1/7/2018 Attached gingiva 15

16. 1/7/2018 Attached gingiva 16 presence of an ‘adequate’ zone of gingiva was considered critical for maintenance of marginal tissue health & for prevention of continuous loss of connective tissue attachment. Inadequate zone of gingiva 1) facilitate subgingival plaque formation because of improper pocket closure resulting from mobility of marginal tissue. [Friedman (1962)] 2) favour attachment loss & soft tissue recession b/c of less tissue resistance to apical spread of plaque-associated gingival lesion. [stern et al(1976)]

17. 1/7/2018 Attached gingiva 17 Adequate or sufficient dimension dimension of gingiva varied Bowers et al 1963 suggested <1mm may be sufficient Corn et al 1962 suggested apico -coronal height of keratinized tissue ought to exceed 3 mm De trey and Bernimoulin 1980,Friedman 1962 suggested Any dimension of gingiva which is compatible with gingival health, prevents retraction of gingival margin during movement of mucosa.

18. 1/7/2018 Attached gingiva 18 Lang & loe 1972 Based on observation 2mm keratinized gingiva is adequate of which 1mm must be attached. On basis of observation it seems justified to assume that the anatomical width of the attached gingiva is in direct proportion to the amount of past tooth eruption.

19. 1/7/2018 Attached gingiva 19 THICKNESS OF THE GINGIVA In 1977 Goslind et al, reported that gingival thickness varied considerably among subjects, within individual thickness varied among areas. The average thickness of the attached gingiva was 1.25mm +/-0.42mm. The thickness increased in the mandible from anterior to posterior and was inversely proportional to the width. The mean thickness was 1.41mm

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21. 1/7/2018 Attached gingiva 21 MICROSCOPIC FEATURES

22. 1/7/2018 Attached gingiva 22 Histologically , the attached gingiva is better suited than non-keratinized mucosa to withstand mechanical irritations. The epithelium of attached gingiva is keratinized, predominantly cellular in nature, & contains prominent epithelial ridges. The connective tissue is less cellular, composed primarily of collagen fibers & ground substance.

23. 1/7/2018 Attached gingiva 23 Epithelium of attached gingiva is lined by four layers. Stratum Basale . Stratum spinosum Stratum granulosm Stratum corneum .

24. 1/7/2018 Attached gingiva 24 Proliferation of keratinocytes takes place by mitosis in basal layer & less frequently in supra basal layers. Differentiation involves process of keratinazation , which consists of progression of biochemical & morphologic events

25. 1/7/2018 Attached gingiva 25 Main morphologic changes are Progressive flattening of cells with increasing prevalence of tonofilaments ( corneum ) Intercellular junction coupled to production of keratohyaline granules.( granulosum ) Disappearance of nucleus ( corneum )

26. 1/7/2018 Attached gingiva 26 There is a basal lamina (300-400Å) below stratum basale divided into Lamina lucida 30-50nm ( glycoprotein laminin ) towards epithelium Lamina densa 30-60nm ( collagen type IV) towards C.T. Lamina lucida connected to stratum basale through hemidesmosome Lamina densa connected to papillary part of connective tissue through anchoring fibers ( type collagen IIV)

27. 1/7/2018 Attached gingiva 27 Connective tissue of gingiva, also known as lamina propria and consists of: Papillary layers subjacent to epithelium consisting of papillary projection between epithelial rete pegs. Reticular layers contiguous with periosteum of alveolar bone.

28. 1/7/2018 Attached gingiva 28 CELLS Principal cell type of gingival epithelium is keratinocytes . Other cells found in epithelium are clear cells or non keratinocytes . include langerhans cells, Merkel cells & melanocytes

29. 1/7/2018 Attached gingiva 29 Feature which are specific to attached gingiva are Deep rete pegs. Thick lamina propria . Abundant collagen with no elastic fibers Indistinct sub mucosa.

30. 1/7/2018 Attached gingiva 30 Attached gingiva is tough, inflexible and resistant to abrasion. Collagenous nature of connective tissue and its adherence to underlying muco-periosteum determine the firmness of attached gingiva. Elongated papilla provides good mechanical attachment and prevents epithelium being striped under shear forces. Thick network of closely packed collagen fibers resist the loading. Thus attached gingiva can bear the compressive and shear forces.

31. 1/7/2018 Attached gingiva 31 SURFACE TEXTURE OF ATTACHED GINGIVA stippling Stippling is a form of adaptive specialization or reinforcement for function. The attached gingiva presents a textured surface like that of an orange peel and is referred to as being stippled. Stippling is best viewed by drying the gingiva in natural light.

32. Surface texture is also related to the presence & degree of epithelial keratinization . Keratinization is considered a protective adaptatation for function. It increase when gingiva is stimulated by tooth brushing 1/7/2018 Attached gingiva 32

33. M icroscopic appearance of stippling Microscopically stippling is produced by the alternate protuberances and depressions in the gingival surface. papillary layer of the connective tissue projects into the elevations and both the elevated and the depressed areas are covered by stratified squamous epithelium. The degree of keratinization and the prominence of stippling appear to be related. 1/7/2018 Attached gingiva 33

34. At low microscopic examination the surface appears rippled, interrupted by irregular depressions 50μm in diameter, at higher magnification cell pits can be seen ( Cleaton -Jones et al 1978). 1/7/2018 Attached gingiva 34 Attached gingiva binds with marginal gingiva by gingival fibers. Anatomically there is variation in color and also the presence of stippling.

35. 1/7/2018 Attached gingiva 35 Measurement of width of attached gingiva; HALL said that the width of attached gingiva is determined by subtracting the sulcus or pocket depth from total width of gingiva.

36. 1/7/2018 Attached gingiva 36 Methods to determine mucogingival junction 1. Visual method. 2. Functional method. 3. Visual methods after histochemistry staining 4. OPG assessment 5. Anaesthesia method

37. 1/7/2018 Attached gingiva 37 I. Mucogingival junction assessed as a scalloped line separating attached gingiva from the alveolar mucosa.

38. 1/7/2018 Attached gingiva 38 Visual method AG = total width of gingiva ­̶ pocket depth This is done by stretching the lip or cheek to demarcate the mucogingival line while pocket is being probed.

39. 1/7/2018 Attached gingiva 39 Roll test / functional method II. Assessed as a borderline between movable and immovable tissue. Tissue mobility waas assessed by running a horizontally positioned probe from the vestibule toward the gingival margin using light force.

40. 1/7/2018 Attached gingiva 40 Assessed visually after staining the mucogingival Junction with potassium iodide solution. Attached gingiva is iodine-negative.

41. 1/7/2018 Attached gingiva 41 If mucogingival junction is distinct this is done by stretching the lip or cheek to demarcate Mucogingival junction while pocket is being probed.

42. 1/7/2018 Attached gingiva 42 If Mucogingival junction is indistinct its position can be gauged by placing a probe horizontally flat against the mucosal surface and sliding it coronally .

43. 1/7/2018 Attached gingiva 43 Methods of measuring thickness of attached gingiva Gosalind et al – Average thickness of attached gingiva is 1.25 ± .42mm. Transgingival probing Earlier method of measuring the thickness of attached gingiva includes traumatic technique like probing and injecting needles.

44. 1/7/2018 Attached gingiva 44 Now a day’s new methods include measuring atraumatically with the help of newer device called “ KRUPP SDM”

45. 1/7/2018 Attached gingiva 45 This device uses pulse echo principle with aids of pulse generator and measurement frequency of 5MHz, a piezoelectric crystal is allowed to oscillate. Ultrasonic pulses are transmitted through the sound permeable gingiva. On reaching bone or teeth surface, it is reflected.

46. 1/7/2018 Attached gingiva 46 A transducer probe of 4mm diameter moistened with saliva is applied to measure site with slight pressure to produce acoustic coupling. By timing received echo with respect to transmission of pulse, thickness is digitally displayed.

47. 1/7/2018 Attached gingiva 47 Eager divided attached gingiva based on periodontal type Shallow thin gingiva with slender crown formation. Wide thick gingiva with quadrant crown formation. Unknown combination Thin gingiva – more recession as compared to pockets Thick gingiva – more pockets as compared to recession

48. 1/7/2018 Attached gingiva 48 Wide thick combination

49. 1/7/2018 Attached gingiva 49 Clinical implication of thickness of attached gingiva Gingiva thickness is genetically determined and associated with tooth form. Therefore surrounding soft tissue should carefully be considered when tooth form or size has to be altered. Successful clinical outcome of both regenerative and periodontal surgical procedures, highly rely on the thickness of attached gingiva covering it. Claffey et al said that in case of thin gingiva, there is increased amount of recession following non-surgical periodontal treatment.

50. 1/7/2018 Attached gingiva 50 Factors Affecting Width Of Attached Gingival High frenum attachment Recurrent inflammation Recession Malpositioned teeth Osseous dehiscence

51. Functions Acts as buffer zone/ neutral zone b/w movable & immovable zone Esthetic Bears trauma from occlusion Reduce plaque b/c of proper margin closure Reduce inflammation around tooth Bears masticatory forces Braces gingiva firmly against tooth Maintain oral hygiene by removing food away from gingival margin Prevent transmission of frenal pull 1/7/2018 Attached gingiva 51

52. 1/7/2018 Attached gingiva 52 Prevent attachment loss & soft tissue recession b/c of more tissue resistance Maintain vestibular depth Prevent root caries, chemical erosion Hygiene aids are more comfortable to use within the keratinized tissue as it’s more resistant to abrasion. Provides tight collar around implants.

53. 1/7/2018 Attached gingiva 53 Dissipating physiological forces exerted by the muscular fibers of the alveolar mucosa on the gingival tissue Increase resistance to external injury and contribute in stabilization of gingival margin. Against frictional forces.

54. 1/7/2018 Attached gingiva 54 1/7/2018 Attached gingiva 54 keratinized attached gingiva around implants: The needs for keratinized gingiva around dental implant are more controversial, the color, contour and texture of soft tissue drape should be similar around implants. Absence of keratinized mucosa increases the suseptibility of peri -implant lesions and plaque induced destruction.

55. 1/7/2018 Attached gingiva 55 Amount of keratinized gingiva did not affect the success rate of implants. However, implants with less than 2mm of keratinized gingiva exhibited increased bleeding upon probing, redness, and inflammation, which may contribute to later failure.

56. 1/7/2018 Attached gingiva 56 C linical significance of attached gingiva The structure of the gingival tissues is the basis for the healthy gingival function. The presence of thick keratinized gingival covering serves as an effective barrier that resists damage from the physical forces of mastication and thermal and chemical stimuli. The integrity of the gingival connective tissue also seems to counteract the forces applied to the gingiva by the muscles of mastication and facial expression and also frenal pull.

57. 1/7/2018 Attached gingiva 57 Patient experiencing discomfort during tooth brushing and chewing – Deep periodontal Pockets. In cases where orthodontic treatment planned and final position is expected to result in recession. Indication to increase width of attached gingiva

58. 1/7/2018 Attached gingiva 58 To improve aesthetic – The coverage of denuded root surface for aesthetic which increase the attached gingiva. For teeth that serve as an abutment for fixed or removable partial denture, as well area in relation to denture.

59. 1/7/2018 Attached gingiva 59 TISSUE BARRIER CONCEPT Goldman and Cohen outlined a “tissue barrier” concept for mucogingival surgery. They postulated that a dense Collagenous band of connective tissue retard or obstruct the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa. They recommended increasing the zone of keratinized tissue to achieve an adequate tissue barrier

60. 1/7/2018 Attached gingiva 60 GENERAL PRINCIPLES FOR MUCOGINGIVAL SURGERY Existing keratinized gingiva should always be maintained. 2. Exposing bone to increasing the zone of keratinized gingiva is contraindicated (wilderman1964). 3. When an adequate zone of keratinized gingiva exists, vestibular depth is not a factor.

61. METHODS OF INCREASING OF ATTACHED GINGIVA Gingiva augmentation apical to recession Free gingival autograft Free C.T. autograft Apically displaced flap Gingival augmentation coronal to recession ( root coverage ) Free gingival autograft Free C.T. autograft pedicle graft 1) horizontally positioned flap 2) coronally positioned flap subepithilial C.T. graft GTR Pouch & tunnel technique 1/7/2018 Attached gingiva 61

62. METHOD OF INCREASING THE WIDTH OF ATTACHED GINGIVA The earliest of these technique are the vestibular extension operations 1. Denudation techniques. ( Ochsenbein 1960, Corn 1962, Wilderman 1964) - Removal of all soft tissue within an area extending from below the the gingival margin to a 3mm apical to the mucogingival junction leaving the alveolar bone completely exposed. 1/7/2018 Attached gingiva 62

63. 1/7/2018 Attached gingiva 63 Stripping of buccal half of the mucoperiosteum by sharp dissection ½ to 1 cm apical to muco-buccal fold bone is covered with periosteum . Insertion of surgical cement. 2. Periosteal retention procedure or Split flap procedure ( Staffileno et al. 1962, 1966, Wilderman 1963, Pfeifer 1965)

64. 1/7/2018 Attached gingiva 64 A mucogingival flap consists of epithelium & a layer of C.T. was reflected & then excised. Gingival fibers attached to tooth were also removed. No exposure of bone & wound was covered by a layer of C.T. of varied thickness. Results showed an average increase in attached gingiva tissue of 2.1mm. MGJ moved apically the same distance

65. 1/7/2018 Attached gingiva 65 3. Free grafts have been used for gingival augmentation ( Nabers 1966, Sullivan & Atkins 1968, Hawley & Staffileno 1970, Edel 1974). If alveolar mucosa separated from periosteum & then stripping the periosteum from bone, called double flap procedure. This same periosteum would be sutured over the bone to act as biological pack

66. 1/7/2018 Attached gingiva 66 The FGGs had been utilized to increase amounts of keratinized tissue and obtain root coverage. This extremely predictable procedure has been used to treat various types of mucogingival defects, Including recession, the aberrant frenum , and the shallow vestibule. However, probably the procedure’s most common use is to increase the amount of keratinized tissue. FREE GINGIVAL GRAFT

67. Technique Prepare the recipient site Obtain the graft from donor site Transfer & immobilized the graft Protect the donor site 1/7/2018 Attached gingiva 67

68. 1/7/2018 Attached gingiva 68 Prepare the recipient site prepare a firm C.T. bed to receive the graft Site can be prepared by incising at existing mucogingival junction with a #15 blade to desired depth, blending the incision on both ends with existing mucogingival line. Periosteum should be left covering the bone.

69. 1/7/2018 Attached gingiva 69 Another technique site consists of outlining the recipient site with two vertical incision from cut gingival margin into alveolar mucosa extend incision approximately twice the desired width of attached gingiva.

70. 1/7/2018 Attached gingiva 70 Obtain the graft from donor site conventional FGG technique consists of transferring a piece of keratinized gingiva approximately size of recipient site. A partial thickness graft is taken from palate.

71. 1/7/2018 Attached gingiva 71 separate graft with blade place the template over the donor site, & make a shallow incision around it with a #15 blade. insert the blade to desired thickness at one edge of the graft

72. 1/7/2018 Attached gingiva 72 Transfer & immobilize the graft Remove the sponge from recipient site Position the graft & adapt it firmly to recipient site b/c dead space impairs vascularization & jeopardize the graft. suturing take place

73. 1/7/2018 Attached gingiva 73 Protect the donor site Cover the donor site with a periodontal pack Sutures may be used in order to stabilize the blood clot during early phases of healing. Fabrication of an acrylic or plastic stent before surgical procedure is most effective.

74. Apically displaced flap An internal bevel incision is made It should be no more than about 1mm from crest of gingiva & directed to crest of the bone. Crevicular incision are made followed by initial elevation of flap, then interdental incision is performed, & wedges of tissue that contains pocket wall is removed. Vertical incisions are made extending beyond mucogingival junction. Full thickness flap is elevated by blunt dissection with periosteal elevator. Split thickness elevated using sharp dissection with BP blade. 1/7/2018 Attached gingiva 74

75. 1/7/2018 Attached gingiva 75 After removal of granulation tissue, scaling & root planing, & osseous surgery if required, flap is displaced apically. Sling suture in full thickness, direct loop in split thickness flap. A dry foil is placed over the flap before covering it with pack.

76. Modified apically repositioned flap (MARF) 1/7/2018 Attached gingiva 76 It is indicated to be used should present with minimal or no inflammation, physiologic sulcus depth, & at least .5 mm of attached gingiva. A horizontal beveled incision is made with a # 15 blade approximately .5mm coronal to MGJ into attached gingiva.

77. 1/7/2018 Attached gingiva 77 Blade makes a contact with periosteum at a point slightly apical to alveolar crest. Incision should be parallel to MGJ so that approx .5mm of attached gingiva remains along the coronal portion. A split thickness flap is elevated, dissection is extended in apical direction as far as deemed necessary. ( 5-6mm usually sufficient )

78. 1/7/2018 Attached gingiva 78 Flap is moved apically & secured to periosteum with inturrepted sutures using 6-0 gut. With a moist gauge, gentle digital pressure is applied for 3-5 minutes to maintain close contact with underlying periosteum .

79. 1/7/2018 Attached gingiva 79 CONCLUSION The adequate width attached gingiva cover the essential component for Maintaining Healthy Periodontium . Adequate keratinized gingiva provides a firm and stable Base for maintaining good oral hygiene, restorative and esthetic procedure. Restoring dentist should be aware of the biology of keratinized Gingiva and methods for increasing the attached gingiva for a successful treatment Outcome.

80. 1/7/2018 Attached gingiva 80 Thank you