The Relationship Between the

Width of Keratinized Gingiva

and Gingival Health
by
NIKLAUS P. LANG*
HARALD L E * *
INTRODUCTION
IN M AN THE KERATINIZ ED gingiva includes the free and
the attached gingiva and extends from the gingival mar-
gin to the mucogingival junction.
1
The width of the
keratinized gingiva may vary between 1 and 9 mm.
2 , 3
The characteristics of the gingiva on the facial aspect
have been described by several authors.
17
However,
only one recent study has reported on the width of the
lingual keratinized gingiva of the mandible.
7
Although not substantiated, it is generally believed
that an adequate width of keratinized gingiva is im-
portant for maintaining gingival health. This has resulted
in the introduction of numerous surgical procedures to
increase the width of gingiva.
8 3 0
However, the question
of how much gingiva is "adequate" has not been inves-
tigated.
The purpose of the present investigation was to ex-
amine the width of the facial and lingual keratinized
gingiva and to determine how much keratinized gingiva
is adequate for the maintenance of gingival health.
M ATERI AL AND M ETHODS
Thirty-two dental students between 19-29 years of
age with no pathologic pockets performed supervised
oral hygiene (daily supervision with the Plak-Lite dis-
closing system)
31
for 6 weeks. Following this period,
the gingiva of all buccal and lingual tooth surfaces was
assessed using the Gingival Index system.
32
Oral hy-
giene was scored on all surfaces according to the criteria
of the Plaque Index system.
33
The identification of the
mucogingival junction was facilitated by staining with
Schiller's IKI solution.
34
Using this method, the epithe-
lium of the alveolar mucosa yielded an iodine-positive
reaction while the keratinized gingiva was iodine-nega-
t i ve,
3 4 3 6
(Figure 1 a,b). After application of the Schiller
solution, the width of keratinized gingiva was measured
FIGURE 1. Clinical photographs showing the mucogingival
junction a) without stain b) after application of the Schiller
IKI solution.
to the nearest 0.5 mm from the gingival margin to the
mucogingival junction using a specially graded perio-
dontal probe. The depth of the gingival crevices was
also measured. In order to compare the results of the
present study to results from previous studies the width
of attached gingiva was determined by subtracting the
crevicular depth from the width of keratinized gingiva.
Gingival exudate was assessed
37
on all (116) buccal
and lingual surfaces which had 2 mm or less of kera-
tinized gingiva. In addition, the amount of gingival exu-
date from 118 tooth surfaces randomly selected from
a total of 371 which had 2.5 to 3.0 mm gingiva was
measured. Only plaque free surfaces were scored.
RESULTS
After the six weeks of controlled oral hygiene the
mean individual Plaque Index (PI I) was 0.22 (range
0.00-0.57). The mean individual Gingival Index (GI)
was 0.09 (range 0.04-0.25). The crevicular depth aver-
aged 1.0 mm (range 0.5-1.5 mm).
From a total of 1406 tooth surfaces, 1168 were com-
pletely plaque free.
*Research Associate, Department of Periodontology, Royal
Dental College, Aarhus, Denmark.
**Professor and Chairman, Department of Periodontology,
Royal Dental College, Aarhus, Denmark.
623
624 Lang and Le
J . Periodontol.
October, 1972
MEAN WIDTH OF KERATINIZED GINGIVA
FIGURE 2. Pattern of variation in the mean widthof keratinized gingiva in 32 individuals
(19-29 years of age) with excellent oral hygiene and healthy gingiva.
The facial keratinized gingiva was widest in the area
of upper and lower incisors and narrowest adjacent to
the maxillary and mandibular canines and first pre-
molars (Figure 2). The lingual gingiva of the lower
jaw exhibited its greatest width in the area of the pre-
molars and molars. The incisors showed the narrowest
lingual gingiva (Figure 2). In the maxilla the facial
gingiva was generally 0.5-1 mm wider than in the
mandible (Figure 2).
Most surfaces ( > 80%) with 2.0 mm or more kera-
tinized gingiva were clinically healthy, (Figure 3) and
76% of these same surfaces failed to show gingival
exudation (Figure 4). On the other hand, all surfaces
PERCENTAGE OF SURFACES
FIGURE 3. Proportion of Gingival Index score 0 to 1to 2 in surfaces of varying widthof
keratinized gingiva (1.0-25.0 mm) of 1168 plaque free teeth.
625
Keratinized Gingiva and Gingiva Health
Volume 43
Number 10
PERCENTAGE OF SURFACES
FI GURE 4. Proportion of gingival exudate measurements 0 to 03-0.5 to 0.6-1.0 to
greater than 1.0 mmin surfaces of varying width of keratinized gingiva (1.0-3.0 mm) of
234 plaque free teeth.
with less than 2.0 mm of keratinized gingiva exhibited
clinical inflammation and varying amounts of gingival
exudate (Figures 3, 4). Generally, the Gingival Index
and gingival exudate scores increased as the width of
the keratinized gingiva decreased (Figures 3, 4). The
maximum score during this examination was GI = 2
(moderate inflammation) which occurred only i n sur-
faces whose width of keratinized gingiva was 2 mm or
less (Figure 4).
Figure 5 compares the distribution of variation of
the width of attached gingiva found in the present study
to that of previous studies.
2
'
3 , 7
The similarity between
these results is apparent.
DI SCU SSI ON AND CONCLU SI ON
The present investigation has shown that the pattern
of variation in the width of the facial keratinized gin-
giva minus the crevicular depth agrees with previous
studies on the width of attached gingiva.
2, 3, 5 , 7
Simi-
larly, it corroborates recent data on the width of the
lingual attached gingiva.
7
In this study the width of
the lingual keratinized gingiva varied between 1 and 8
mm. The smallest width was usually seen in the area
of the anterior teeth, and the widest gingiva was found
adjacent to premolars and molars. This pattern of varia-
tion is almost the reverse of that of the facial gingiva.
The present material has also clearly demonstrated
that although tooth surfaces may be kept free of clin-
ically detectable plaque, areas with less than 2 mm of
keratinized (which means less than 1 mm of attached)
gingiva persisted to remain inflamed. The fact that
inflammation persisted in these areas irrespective of
ATTACHED GINGIVA OF BUCCAL SURFACES
FI GURE 5. Comparison of the pattern of variation in the
mean width of attached gingiva in the present study to
those of previous studies.
626 Lang and Le
J . Periodontol.
October, 1972
the presence or absence of frenum insertions, suggests
that the inflammatory situation in the gingiva is not
a result of only mechanical irritation from these struc-
tures. Rather it is conceivable that a movable gingival
margin would facilitate the introduction of microorgan-
isms into the gingival crevice resulting in a thin sub-
gingival bacterial plaque which would be difficult to
detect and not easily removed by conventional tooth-
brushing.
The regions which consistently showed the narrowest
width of keratinized gingiva were the lingual surface
of the lower anteriors and the buccal surface of the
lower canines and first premolars. However, the study
has shown that these surfaces which averaged nearly 3
mm in width should be adequate to maintain gingival
health. Although not a problem from a preventive point
of view, the narrow keratinized gingiva on the lingual
of the lower anteriors may pose a problem in prostho-
dontic and periodontal treatment. For example, it is
required that if lower partial removable appliances are
to be equipped with a lingual bar, the lingual area should
have a minimum width of 4 mm keratinized gin-
giva.
3 8
'
3 9
This requirement may be difficult to satisfy
in the average patient since the mean width of the lin-
gual gingiva adjacent to the lower anterior teeth is
usually less than 3 mm.
It is apparent in periodontitis that pathologic pockets
may easily extend beyond the mucogingival junction.
Although procedures have been devised for correction
this problem when it occurs on the facial aspect, to
the best of our knowledge, modern periodontal surgery
offers no specific method for increasing the width of
keratinized gingiva on the lingual surface of the lower
incisors.
Furthermore, since it would appear from this study
that less gingiva is needed to maintain health than gen-
erally believed, a critical reappraisal of the indications
for performing anyone of the many surgical procedures
available for increasing the width of gingiva must be
undertaken.
SUM M ARY
The study undertook to examine the width of the
facial and lingual keratinized gingiva and to determine
how much gingiva is "adequate" for the maintenance
of gingival health. After 6 weeks of supervised oral
hygiene the gingival health of 1406 buccal and lingual
surfaces in 32 dental students was assessed according
to the criteria of the Gingival Index system. The width
of keratinized gingiva was measured after the applica-
tion of the Schiller IKI solution. Gingival exudation was
measured on all buccal and lingual surfaces which had
2 mm or less of keratinized gingiva and in a randomly
selected number of tooth surfaces with more than 2
mm gingiva. Only plaque free surfaces were scored.
Previous observations on the width and the pattern of
variation of keratinized gingiva were confirmed. It was
demonstrated that gingival health is compatible with a
very narrow gingiva. However, in areas with less than
2 mm keratinized gingiva inflammation persisted in
spite of effective oral hygiene. It is suggested that 2 mm
of keratinized gingiva (corresponding to 1 mm attached
gingiva in this material) is adequate to maintain gin-
gival health.
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Announcements
CONTINUING EDUCATION COURSES
FALL SEMESTER1972
COLLEGE OF MEDICINE AND DENTISTRY
OF NEW JERSEY
NEW JERSEY DENTAL SCHOOL
201 Cornelison Avenue
Jersey City, N.J. 07304
Course TitleP-l Periodontics for the General Practitioner;
FaculyDr. A. Formicola and Staff; Dates 9-20-72 (Wed.);
Fee$40.*
Course TitleCE-2 Getting Prevention Through To Your
Patients; FacultyDr. J. Mittelman; Dates10-18-72 (Wed.);
Fee$50.
Course TitleCE-3 Principles of Occlusion; FacultyDr. N.
Guichet; Dates 11-13, 14, 72 (Mon. and Tues.); Fee$95
(Dentists) $60 (Aux.).
*No tuition for N.J. dentists. However, a $10. registration fee
is required for each course.
FOR INFORMATION AND APPLICATION, WRITE TO:
Dr. Daniel Isaacson
Director of Continuing Education
New Jersey Dental School
201 Cornelison Avenue
Jersey City, New Jersey 07304
ARMY DENTAL RESEARCH INSTITUTE EARN AWARD
AT ARMY SCIENCE CONFERENCE
On June 21, 1972 the United States Army Institute of Dental
Research team of Brigadier General Surindar N. Bhaskar,
Colonel Arthur Gross and Colonel Duane E. Cutright presented
a study of their work with the pulsating water jet device at
the Army Science Conference at West Point. Their contribu-
tion to Army research and development was judged to be
among the nine most significant in all areas of research.
Scientists from throughout the Army Research and Develop-
ment Command had submitted a total of 497 proposals for
papers to be presented at the conference. Of these, 100 were
selected by a panel of Judges for presentation. Papers selected
represented all areas of Army research, and included such
subjects as communications, computer systems and nuclear
research as well as medical studies.
At the end of the week-long conference, the panel of scien-
tists selected the nine best papers presented. Authors of these
studies received medals, certificates, and cash awards.
The studies conducted at the United States Army Institute
of Dental Research led to the use of the pulsating water jet
devices in the debridement of combat wounds in Vietnam.
These techniques have now been adopted for the management
of wounds in all parts of the body.
This is the first time that dental research has won such an
award at the Army Science Conference.