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ORIGINAL ARTICLE
Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 157-161

Assessment of width of attached gingiva in primary, mixed, and permanent dentition: Part - 2


Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Kharidhi Laxman Vandana
Department of Periodontics, College of Dental Sciences, Davangere - 577 004, Karnataka
India
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DOI: 10.4103/srmjrds.srmjrds_44_17

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  Abstract 


Aim and Objective: The objective of this study was the arch and toothwise evaluation of attached gingiva width in primary, mixed, and permanent dentition. Materials and Methods: The study included 40 participants (22 males and 18 females) with 480 sites of an age range 4–25 years. Participants were divided into three groups – the primary dentition (4–6 years) mixed dentition (7–13 years) and adult dentition (16–25 years). The width of the attached gingiva was measured on the midfacial aspect of anterior teeth using calibrated University of North Carolina 15 periodontal probe. Results: Attached gingiva width (AGW) was measured archwise and toothwise in different dentition and overall data wise without differentiating archwise and toothwise. Gingival width increased with age and significantly higher in maxillary permanent dentition (3.4 ± 0.36). In maxilla, permanent central incisor (3.3 ± 0.3) and canine (3.5 ± 0.5) showed significantly higher gingival width than lateral incisor (2.5 ± 0.6) whereas other dentition showed nonsignificant difference. In all the dentition, variations were approximately similar in central incisor and canine. Conclusion: There was a greater overall width of attached gingiva in the maxilla than in the mandible. The AGW increases with age. It is greater in permanent dentition than primary and mixed dentition.

Keywords: Attached gingiva width, mixed dentition, permanent dentition, primary dentition


How to cite this article:
Singh S, Vandana KL. Assessment of width of attached gingiva in primary, mixed, and permanent dentition: Part - 2. SRM J Res Dent Sci 2017;8:157-61

How to cite this URL:
Singh S, Vandana KL. Assessment of width of attached gingiva in primary, mixed, and permanent dentition: Part - 2. SRM J Res Dent Sci [serial online] 2017 [cited 2018 Jul 15];8:157-61. Available from: http://www.srmjrds.in/text.asp?2017/8/4/157/220807




  Introduction Top


Oral mucosa consists of three zones, namely, the gingiva and hard palate, termed the masticatory mucosa; the dorsum of the tongue (specialized mucosa) and the oral mucous membrane (lining mucosa). Macroscopically, the gingiva is divided into marginal, attached, and interdental areas.[1] The importance of attached keratinized tissue around natural teeth is a controversial topic.[2] Orban [3] first described the term attached gingiva as that part of the gingiva that is firmly attached to the underlying tooth and bone and is stippled on the surface.[3] The role of the attached gingiva width (AGW) in maintaining periodontal health has been investigated in adults. It has been observed that in the absence, or following the removal, of the attached gingiva the remaining tissue (alveolar mucosa) will curl and will not respond to treatment.[4] In addition, alveolar mucosa will not withstand the rigors of mastication or oral physiotherapy.[5] Lang and Loe suggested that a minimum of 2 mm of keratinized tissue, 1 mm of which was attached was necessary.[6] Few authors have reported that the tissue could remain clinically healthy with <1 mm of attached gingiva.[7],[8],[9],[10]

Certain types of adult periodontal diseases occur during childhood and adolescence thus more attention should be given to the zone of attached gingiva and its relationship to the deciduous, mixed, and permanent dentition.[11] However, the evaluation of gingival width in primary teeth has not been thoroughly investigated. Despite the fact that epidemiological data may not be applicable for an individual case, these cases should take into consideration before deciding to perform mucogingival surgical procedures, with the purpose of establishing an adequate band of attached gingiva in children.[12]

We searched electronic databases and hand searched bibliographies of already identified reports, as well as online sites with reports accepted for publication ahead of print for the most relevant scientific journals. We limit our search on human studies in English language. Medline search using keywords AGW, primary, mixed, and permanent dentition revealed few studies. This study protocol comprises of recording of gingival sulcus depth, AGW, and gingival thickness in primary, mixed, and permanent dentition. Due to the word limit, the current work is distributed in three parts. The measurement of gingival sulcus depth (in three dentitions is presented in part 1).[13] The part 2 deals with the AGW measurement.


  Materials and Methods Top


The present study was conducted in the Department of Periodontics and Pedodontics, College of Dental Sciences, Davangere. Anterior teeth (12 teeth) with 480 sites in 40 systematically healthy controls (22 males and 18 females, age range 4–25 years) were analyzed in the study. The study protocol was approved by institutional IRB (Ref. No. CODS/1977/2015-2016) fulfilling the criteria of RGUHS, India. Informed consent was obtained from the parents of children and participants involved in the study. The primary dentition age group (4–6 years) consisted of 10 participants; mixed dentition age group (7–13 years) also consists of 15 participants; and the adult dentition age group (16–25 years) consisted of 15 participants. The inclusion criteria included the presence of all anterior teeth in both upper and lower jaw, good oral hygiene, clinically healthy periodontal tissues with no loss of attachment. The exclusion criteria included, gingival recession in anterior teeth, known systemic disease, use of any medications possibly affecting the periodontal tissue such as phenytoin and cyclosporine A, extensive restorations (as mentioned in part 1 paper).[13]

After collecting the information about this study such as the objectives, expected outcomes, and the degree of discomfort that might occur, the participants gave their informed consent. The selected volunteers were divided into three groups – Group A - Primary dentition, Group B - mixed dentition, and Group C - permanent dentition.

In the first visit, plaque index [14] and gingival bleeding index [15] were recorded followed by scaling and polishing. The measurements were done using University of North Carolina (UNC) 15 periodontal probe (Hu-Friedy USA) 1 week post scaling. The six anterior teeth in both maxillary and mandibular arches were included in this study.

The width of keratinized gingiva was measured in midfacial area for six anterior teeth in the maxillary and mandibular regions from the gingival margin to the mucogingival junction using UNC-15 periodontal probe [16] [Figure 1]a and [Figure 1]b. The mucogingival junction was determined using a jiggle method, because of movable the alveolar mucosa and firmly attached gingiva. A blunt instrument was used to jiggle the alveolar mucosa in an apico-coronal fashion and thus delineating the mucogingival junction.[17] The width of attached gingiva was obtained by subtracting the probing sulcus depth from the width of keratinized gingiva at the midfacial aspect of each tooth.
Figure 1: (a) Measurement of attached gingiva width in maxillary teeth. (b) Measurement of attached gingiva width in mandibular teeth

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AGW = Width of keratinized gingiva − probing sulcus depth.[18]

Statistics

The measurements recorded were subjected to statistical analysis. Mean values and standard deviations were calculated. The ANOVA, Student's t-test, and post hoc test were used.


  Results Top


Each parameter was studied in anterior teeth with 480 sites in 40 participants (22 males and 18 females) of the age group range between 4 and 25 years [Table 1]. AGW was significantly higher (P = 0.001) in maxilla than mandible in all 3 dentitions. Maxillary permanent dentition (3.4 ± 0.36) showed significantly higher AGW than primary (2.17 ± 0.71) and mixed (2.11 ± 0.71) [Table 2]. On tooth-wise comparison, AGW was highly significant (P = 0.001) in maxillary canine (3.5 ± 0.5) of permanent dentition, followed by maxillary permanent central incisor (3.3 ± 0.3) and lateral incisor (2.5 ± 70.6) whereas primary and mixed dentition showed non significant difference. In all the dentition, variations were approximately same in central incisor and canine. Similarly, in mandible permanent canine (2 ± 0.4) showed higher AGW but the difference was nonsignificant (P = 0.01). Significant difference was found in mandibular permanent central incisor (1.9 ± 0.1) [Table 3], [Table 4] and [Graph 1]. In all the dentition, maxillary teeth showed higher AGW. On arch-wise comparison, maxillary primary central incisor (2.00 ± 0.6); maxillary mixed central incisor (2.1 ± 0.8); and maxillary mixed canine (2.1 ± 0.4) and in permanent dentition, maxillary CI (3.3 mm), LI (2.5 mm), and canine (3.5 mm) showed significantly higher AGW than mandibular teeth [Table 5]. The overall presentation of AGW without differentiating of archwise and toothwise showed highly significant values in the permanent dentition (2.5 mm) followed by mixed (1.9 mm) and primary dentition (1.8 mm) [Graph 2].
Table 1: Demographic data

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Table 2: Attached gingiva width in primary, mixed, and permanent dentition (mm) of maxilla and mandible

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Table 3: Tooth-wise width of attached gingiva dentition-wise comparison (mm) in maxilla

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Table 4: Tooth-wise width of attached gingiva dentition-wise comparison (mm) in mandible

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Table 5: Maxillary versus mandibular determination of attached gingiva width of each tooth

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  Discussion Top


Since historically, an adequate band of keratinized tissue was viewed as important to prevent future recession. An attempt was made in this study to gain information with regard to the clinical widths of attached gingiva in primary, mixed, and permanent dentition. In the present study, maxilla showed higher gingival width (AGW) than mandible. In maxillary arch, AGW was significantly higher in permanent dentition followed by primary and mixed dentition whereas in mandible permanent dentition followed by mixed and primary dentition. The reasons for increased AGW with age are a concomitant reduction in sulcus depth [19] and there is a constant eruption of teeth throughout one's lifespan to compensate the occlusal surface attrition leading to the coronal migration of cementoenamel junction, while the mucogingival junction remains unchanged.[20]

In the current study, AGW was maximum in maxillary permanent dentition (3.42 mm) and least in mandibular primary dentition (1.62 mm). In all the dentitions, canine showed maximum width in maxilla (3.5 ± 0.5) and mandible (2.0 ± 0.4). In interdentition comparison of maxilla, maximum AGW was found in CI of permanent dentition (3.3 mm) and minimum width was in lateral incisor of mixed and primary dentition (1.8 mm). In mandible, the maximum attached gingival width was found in canine of permanent dentition (2.0 mm) and least in central incisor of primary dentition (1.4 mm). The width of attached gingiva also varies for each tooth. In both the arches, permanent anterior teeth (CI, LI, and canine) showed higher AGW whereas it was found to be similar in primary and mixed dentition. In all the dentitions, central incisor and canine showed higher AGW than the lateral incisor.

There are other few studies related to the same work.[7],[16],[21],[22],[23],[24],[25] Bhatia in 2015 showed the mean value of AGW of 2.05 mm in <14 years and 3.11 mm in 45–60 years age in maxillary teeth. In the mandibular teeth, the mean in <14 years was 1.57 mm and 2.31 mm in the age group of 45–60 years. There was no significant difference in the width of attached gingiva in both maxillary and mandibular teeth in the age group of <14 years irrespective of the method used for its assessment.[21] Bowers in 1963 conducted a study on four age groups 3–5, 15–25, 25–35, and above 35 years and reported increased mean width of attached gingiva from the deciduous dentition to the adult dentition and it became extremely narrow in the cuspid and first bicuspid region.[7] AGW increases with age having the greatest width in maxillary incisors and least in mandibular premolars.[22],[23] whereas Shaju and Zade [16] and Chandulal et al.[24] reported least width in mandibular molars. During the development of the jaws and dentition, the morphology of the mucogingival complex undergoes certain changes. These changes are associated also with the position of teeth in alveolus. Rose and App [25] as well as Bowers [7] observed that the position of the tooth in the arch impacts the width of attached gingiva. The movement of both deciduous and permanent teeth during growth in the lingual or vestibular direction causes changes in the width of attached gingiva.[26]

It has been previously reported that the sulcus of erupting permanent teeth is deeper than that of corresponding deciduous teeth, but later it becomes shallower.[17],[25] These differences may result from initially weaker periodontal attachment, which is less resistant to probing [27] as well as from the occurrence of false pockets and temporary inflammation during gingival phase of teeth eruption. These two factors cause higher probing depth recordings.[28],[29] The width of the attached gingiva of newly erupted permanent teeth is, therefore, lesser than in the case of deciduous teeth. However, the width of attached gingiva increases while permanent teeth erupt.[28]

Rose and App reported the mean value of attachéd gingiva width as 1.36–3.85 mm except in the newly erupted permanent anterior teeth where the mean ranged from 1.12 to 2.53 mm.[25] With the eruption of the permanent tooth, there is an increase in the alveolar bone, but at the same time, there is no increase in the width of the keratinized and/or attached gingiva due to the more buccal position of the erupting permanent tooth as compared to its predecessor.[22],[30]

The present study results are not comparable with above studies due to the difference in age groups, dentitions and arches studied.

To summarize the current study, the arch- and tooth-wise assessment of gingival AGW was done. The overall presentation includes measurements of all the teeth in maxilla and mandible to ease the clinical presentation of data in general. If any specific consideration is required, individual tooth arch-wise data are presented in the current study which is extensive and clinically exhaustive.

Clinical transfer of the study

The mixed dentition period is a transient phase. Hence, any measurements of AGW should never be attempted for therapeutic correction. Considering a surgical procedure one should take into account the fact that during the mixed dentition the width of attached gingiva decreases only temporarily.[17],[22],[31] When permanent teeth erupted completely, a gradual increase in the width of gingiva occurs.[32] A decrease in the width of gingiva in mixed dentition may be caused by greater sulcus depth and by vestibular movement of newly erupted teeth [17],[33] In this period, an increased accumulation of bacterial plaque resulting in gingivitis may also occur.[30] If oral hygiene is maintained the risk of recession is significantly limited.[34] The absence of gingival margin inflammation is the most important, in reducing or eliminating gingival recessions.


  Conclusion Top


The width of attached gingiva is significantly higher in permanent dentition (2.5 mm) whereas mixed (1.9 mm) and primary dentition (1.8 mm) showed almost similar values. The presence of the band of attached gingiva represents the most significant diagnostic clue in estimating the prognosis for periodontal treatment. In case of an inadequate band of attached gingiva, proper home treatment is needed to avoid inflammation and gingival recession.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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