The Relationship Between the

Width of Keratinized Gingiva

and Gingival Health

by
NIKLAUS P. L A N G *

HARALD L Ö E * *

INTRODUCTION

IN MAN T H E KERATINIZED gingiva includes the free and

the attached gingiva and extends from the gingival mar­
1
gin to the mucogingival junction. The width of the
2, 3
keratinized gingiva may vary between 1 and 9 mm.

The characteristics of the gingiva on the facial aspect

17
have been described by several authors. However,
only one recent study has reported on the width of the
7
lingual keratinized gingiva of the mandible.

Although not substantiated, it is generally believed

that an adequate width of keratinized gingiva is i m ­
portant for maintaining gingival health. This has resulted
in the introduction of numerous surgical procedures to
830
increase the width of g i n g i v a . However, the question
FIGURE 1. Clinical photographs showing the mucogingival
of how much gingiva is "adequate" has not been inves­ junction a) without stain b) after application of the Schiller
tigated. IKI solution.
The purpose of the present investigation was to ex­
amine the width of the facial and lingual keratinized to the nearest 0.5 mm from the gingival margin to the
gingiva and to determine how much keratinized gingiva mucogingival junction using a specially graded perio­
is adequate for the maintenance of gingival health. 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
M A T E R I A L AND METHODS
of attached gingiva was determined by subtracting the
Thirty-two dental students between 19-29 years of crevicular depth from the width of keratinized gingiva.
age with no pathologic pockets performed supervised 37
Gingival exudate was assessed on all (116) buccal
oral hygiene (daily supervision with the Plak-Lite® dis­
31
and lingual surfaces which had 2 mm or less of kera­
closing system) for 6 weeks. Following this period,
tinized gingiva. In addition, the amount of gingival exu­
the gingiva of all buccal and lingual tooth surfaces was
32
date from 118 tooth surfaces randomly selected from
assessed using the Gingival Index system. Oral hy­
a total of 371 which had 2.5 to 3.0 mm gingiva was
giene was scored on all surfaces according to the criteria
33
measured. Only plaque free surfaces were scored.
of the Plaque Index system. The identification of the
mucogingival junction was facilitated by staining with
34
Schiller's I K I solution. Using this method, the epithe­ RESULTS
lium of the alveolar mucosa yielded an iodine-positive
After the six weeks of controlled oral hygiene the
reaction while the keratinized gingiva was iodine-nega­
3436 mean individual Plaque Index (PI I) was 0.22 (range
tive, (Figure 1 a,b). After application of the Schiller
0.00-0.57). The mean individual Gingival Index ( G I )
solution, the width of keratinized gingiva was measured
was 0.09 (range 0.04-0.25). The crevicular depth aver­
*Research Associate, Department of Periodontology, Royal aged 1.0 mm (range 0.5-1.5 m m ) .
Dental College, Aarhus, Denmark.
**Professor and Chairman, Department of Periodontology, From a total of 1406 tooth surfaces, 1168 were com­
Royal Dental College, Aarhus, Denmark. pletely plaque free.

623
624 Lang and Löe J. Periodontol.
October, 1972

MEAN WIDTH OF KERATINIZED GINGIVA

FIGURE 2. Pattern of variation in the mean width of 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 ( > 8 0 % ) 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 ) . O n the other hand, all surfaces

PERCENTAGE OF SURFACES

FIGURE 3. Proportion of Gingival Index score 0 to 1 to 2 in surfaces of varying width of

keratinized gingiva (1.0-25.0 mm) of 1168 plaque free teeth.
Volume 43
Number 10
Keratinized Gingiva and Gingiva Health625

PERCENTAGE OF SURFACES

FIGURE 4. Proportion of gingival exudate measurements 0 to 03-0.5 to 0.6-1.0 to

greater than 1.0 mm in 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 ATTACHED GINGIVA OF BUCCAL SURFACES
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 G I = 2
(moderate inflammation) which occurred only in 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
2 3 , 7
to that of previous studies. ' The similarity between
these results is apparent.

DISCUSSION AND CONCLUSION

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
2, 3, 5 , 7
studies on the width of attached gingiva. Simi­
larly, it corroborates recent data on the width of the
7
lingual attached gingiva. 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)
FIGURE 5. Comparison of the pattern of variation in the
gingiva persisted to remain inflamed. The fact that
mean width of attached gingiva in the present study to
inflammation persisted in these areas irrespective of those of previous studies.
626 Lang and Löe
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
38 3 9
giva. ' 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.
SUMMARY
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 I K I 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
J. Periodontol.
October, 1972
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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Number 10
dizierte Vertiefung des unteren Mundvorhofes. Parodon-
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Announcements
CONTINUING EDUCATION COURSES
FALL SEMESTER—1972
COLLEGE OF MEDICINE AND DENTISTRY
OF NEW JERSEY
NEW JERSEY DENTAL SCHOOL
201 Cornelison Avenue
Jersey City, N.J. 07304
Course Title—P-l Periodontics for the General Practitioner;
Faculy—Dr. A. Formicola and Staff; Dates 9-20-72 (Wed.);
Fee—$40.*
Course Title—CE-2 Getting Prevention Through To Your
Patients; Faculty—Dr. J. Mittelman; Dates—10-18-72 (Wed.);
Fee—$50.
Course Title—CE-3 Principles of Occlusion; Faculty—Dr. 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
Keratinized Gingiva and Gingiva Health 627
30. Hilming, E. and Jerv0e, P.: Surgical extension of
vestibular depth. Tandlaegebladet 74:329-343, 1970.
31. Lang, N. P., 0stergaard, E. and Löe, H.: A fluor-
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1972.
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nancy. I. Prevalence and severity. Acta odont. scand. 27:
533-551, 1963.
33. Silness, J. and Löe, H.: Periodontal disease in preg-
nancy. II. Correlation between oral hygiene and periodontal
condition. Acta odont. scand. 22:121-135, 1964.
34. Fasske, T. and Morgenroth, K.: Comparative
stomatoscopic and histochemical studies of the marginal
gingiva in man. Parodontologie 72:151-160, 1958.
35. Zabinska, O.: Die Anwendung der Schillerschen
Jodprobe als Index der Zahnfleisch — Entziindungsinten-
sität im Verlauf der Parodontopathien. Parodontologie 22:
65-73, 1968.
36. Mutschelknauss, R.: Indikation und Operations-
methoden der mucogingivalen Chirurgie. Dtsch. zahnärztl.
Z. 26:541-556, 1971.
37. Löe, H. and Holm-Pedersen, P.: Absence and pres-
ence of gingival fluid in normal and inflamed gingivae.
Periodontics. 5:171-177, 1965.
38. Tryde, G. and Brantenberg, F.: The sublingual bar.
Tandlægbladet 69:873-885, 1965.
39. Derry, A. and Bertram, U.: A clinical survey of
removable partial dentures after 2 years usage. Acta odont.
scand. 25:581-598, 1970.
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.