Clinical Assessment of Free Gingival Graft Effectiveness

on the Maintenance of Periodontal Health*

Uri Hangorskyf and Nabil F. Bissada4

This investigation was undertaken to evaluate the long term clinical effect of free gingival
grafts onthe periodontal condition. Forty grafts, performed on 34 patients 1 to 8 years ago,
were selected. Plaque and gingival indices were determined in the grafted areas. Direct clinical
measurements from the cementoenamel junction to: a) margin of the gingiva, b) bottom of the
gingival sulcus and c) mucogingival junction were also recorded. Similar examination of
contralateral or adjacent 40 nongrafted areas for each patient was also conducted to serve as
a control. Tissue mobility of the grafted and control areas was then recorded to the nearest
0.001 inch, using a specially developed device, which exerted a standardized tension of 50 gm
perpendicular to the surface of the gingiva. Data was subjected to statistical evaluation to
determine the significance of changes in variables between grafted and nongrafted sites. The
following conclusions were drawn: 1) The zone of keratinized and attached gingiva, though
more apically positioned, is
significantly wider in the grafted sites. 2) There are no significant
differences between grafted and nongrafted sites with regard to plaque index, gingival index
and pocket depth. 3) In both grafted and nongrafted sites, a wider zone of attached
gingiva
corresponds to a shallower pocket depth. 4) There is a significant positive correlation between
mobility of the graft and pocket depth. The present investigation, therefore, indicates that,
while the free gingival graft is an effective means to widen the zone of the attached and
keratinized gingiva, there is no indication that this increase bears direct influence upon
periodontal health.

Free gingival grafts have been studied extensively MATERIALS AND METHODS
during the last two decades regarding their objectives,
Forty free gingival grafts performed on 34 patients
indications, surgical techniques and healing patterns.1"26 were selected from the records of the periodontal clinic
Presently, the significance of graft mobility in relation to at Case Western Reserve University and from
the maintenance of periodontal health has not been private
periodontal offices in the Greater Cleveland area. For
investigated. The present study was conducted to evalu- 34 grafts, the contralateral gingival areas in the same
ate the long term (1-8 years) clinical effects of free
arch served as controls. In the remaining six bilateral
ginfival grafts on the periodontal condition in an attempt grafts, the adjacent gingival areas served as controls. All
jâiPècifically answer the following questions:
of the grafts were performed 1 to 8 years prior to the
examination. No other criteria for patient selection were
f. Is there a significant increase in width of the kera-
used.
tinized and attached gingiva in grafted sites, when
compared to similar nongrafted areas in the same Methods of Evaluation
patient? A. The width of keratinized gingiva was determined
2. Is there a correlation between plaque index, gingi-
in both control (nongrafted) and experimental (grafted)
val index, pocket depth, and the width of the sur-
areas by direct measurement of the distance from the
gically created attached gingiva? mucogingival junction to the gingival margin with a
3. Does the extent of graft mobility away from the
divider.
underlying bone influence the degree of gingival B. Pocket depth was measured with a periodontal
inflammation, recession, and/or pocket depth?
probe§ at midfacial surface of the tooth most centrally
placed in relation to the graft.
C. The width of attached gingiva was calculated (A
*
This project was supported in part by United States Public Health
minus B).
Grant No. RR 05335.
D. Objective measurement of the graft mobility, per-
t Assistant Professor, Department of Periodontics, School of Den-
tistry, Case Western Reserve University, Cleveland, OH 44106. pendicular to the underlying bone, was performed by
Professor and Chairman, Department of Periodontics, School of
Dentistry, Case Western Reserve University, Cleveland, OH 44106. § Amcycle No. 1 American Dental.
Volume 51
Number 5 Free Gingival Graft Effectiveness 275

having the patient seated in an upright position with the

head immobilized in a head apparatus attached to the
dental chair. A standardized plastic disc, 3 mm in di-
ameter, with a 4-0 silk suture, was attached to the center
°f the grafted tissue utilizing a commercial adhesive.*
The other end of the suture was attached to a standard
weight of 50 gm placed over a gauge indicating the
degree of tissue displacement to the nearest 0.001 inch
(Fig. 1 ). This particular weight was chosen from a pilot
study in which the use of heavier weights appeared to
eause some discomfort to the patient. To promote a
uniform application, an initial weight of 10 gm was
applied prior to taking the measurements. Each meas-
urement was repeated three times and the mean was
recorded.
E. Gingival recession and loss of attachment were
evaluated by measuring the distance from the gingival
margin to the cementoenamel junction and from the
sulcular base to the cementoenamel junction respec-
tively. The measurements were taken at the vertical
midline of the tooth surface in both grafted and non-
grafted areas.
F. The amounts of plaque and gingival inflammation
were assessed using Silness and Löe and Loe and Silness
indices respectively27 on the facial surface of the tooth in
both grafted and nongrafted sites.
Data was subjected to statistical analysis.f Pearson's
correlation coefficients were obtained for all variables to Figure 1. Shows method used for quantitative measurement of tissue
displacement perpendicular to the underlying bone, using a standard
determine significant relationships. Student / tests were
weight and a tensionmeter.
Performed to compare differences between paired obser-
vations. In the grafted (experimental) group, there was a neg-
ative correlation between the width of attached gingiva
RESULTS
and pocket depth. The width of attached gingiva was not
The age of the patients who participated in the study related to gingival index, plaque index, loss of attach-
ranged from 17 to 68 years, with a mean of 36.8 years. ment or recession (Table 2 and Fig. 2).
The clinical age of the grafts was distributed as follows:
Si year (13 grafts), <2 years (nine grafts), <3 years Gingival Mobility
The mobility of the
graft, as measured by objectiv e
(eight grafts), and <3 to 8 years (ten grafts).
means, showed a significant direct relationship to pocket
Zone of Attached Gingiva depth only. Gingival mobility (control sample) when
In the experimental group, the average zone of at- measured in the same manner was not related to anv of
tached gingiva was found to be 3.53 mm as opposed to the variables (Table 2 and Fig. 3) ~'
the average width of 1.71 mm in the control group (Table
Plaque Index and Gingival Index
0· This difference is statistically significant (P < 0.01).
There were no significant differences in the gingival
in 14 control and three experimental areas the zone of
attached gingiva was 1 mm or less. The gingival index in and plaque indices between experimental and control
eight such areas in the control group and one area in the groups. The majority of the patients examined main-
tained good oral hygiene. There was only one patient
Sperimentai group was 0.
In the nongrafted (control) group, there was a negative with plaque and gingival indices as high as 3. In all other
never exceeded the score of 2. The
correlation between the width of attached gingiva and patients, these indiceshad
above noted patient the most mobile gingival graft
Pocket depth, gingival recession and loss of attachment.
and was wearing a poorly fitted partial
No correlations existed between the width of attached (0.142 inches)
denture.
gingiva, plaque and gingival indices (Table 2 and Fig. In the experimental group, the gingival index was
related to plaque index, recession and loss of attachment.
The plaque index was related to the gingival index,
*
Histocryl (Butyl cyano acrylate).
t Computer: Univac 1108 batch processing computer, Chi Corpo- pocket depth, recession and loss of attachment. In the
ration, 11000 Cedar Road, Cleveland, OH. control group, the gingival index was directly related to
 i. Periodont«)!-
276 Hangorsky, Bissada May. 1980
Table 1
Mean Values and Standard Deviations of Measured Variables in Grafted and Nongrafted Sites*
Grafted sites Nongrafted sites Significance
Attached gingiva 3.53 + 1.79 1.71 ± 1.42 < 0.01
Keratinized gingiva 4.90 ± 1.67 2.91 ± 1.51 < 0.01
Mobility 36.05 ± 27.23 37.55 ± 17.24 > 0.05
Plaque index 0.4 ±0.63 0.38 ± 0.7 > 0.05
Gingival index 0.58 ± 0.68 0.49 ± 0.72 > 0.05
Pocket depth 1.43 ±0.82 1.39 ± 0.82 > 0.05
Loss of attachment 2.95 ± 1.95 2.31 ± 1.55 < 0.05
Gingival recession_1.48 ± 1.95_0.93 1.63_ ± < 0.05

Mobility expressed in 0.001 inches. Gingival measurements expressed in mm.

*

Table 2
Summary of Pearson's Correlation Coefficients Among Studied Variables in Grafted and Nongrafted Sites
Att. ging. Kerat. ging. Mobility Plaque index Ging, index Pocket depth Lossofatt. Recession
G NG G NG G NG G NG G NG G NG G NG G NG
G-+-
Att. ging. NG- -+ - -

G
Kerat. ging NG

Mobility NG

Plaque index
NQ

G-+ - -
+-+
Ging, index
NG-+ --+-+-+
G
Pocket depth NG
—

G
Loss of att.
NG

Recession
NG-
(+) =
positive correlation; (-) =
negative correlation; G
\
the plaque index, pocket depth, recession and loss of
attachment (Table 2).
DISCUSSION
The present investigation has clearly demonstrated
that gingival grafting results in an increased zone of
keratinized and attached gingiva. Similar results were
recently reported by Dorfman, Kennedy and Bird.5 De-
spite the increased zone of attached and keratinized
gingiva in the grafted group, both the experimental and
control sites had essentially similar plaque and gingival
scores. Furthermore, no relationship was observed be-
tween the width of attached gingiva and the state of
periodontal health. It is of interest that eight nongrafted
sites with 1 mm or less of attached gingiva were free of
clinical inflammation (gingival index 0). These find- =
ings contradict those reported in Lang and Löe's study28
in which all areas with less than 2 mm of keratinized
gingiva were inflamed.
= Graft; NG =
Nongraft sites.
In both the control and experimental
groups, the zone
of attached gingiva was inversely related to
A possible explanation for such
pocket depth-
findings is that an in-
creased zone of attached gingiva acts as a barrier to the
spread of inflammation, thus retarding the destruction
of the periodontal tissue and preventing apical migration
of junctional epithelium.
In the nongrafted sites, a decrease in the zone of
attached gingiva corresponded to an increase in
gingival
recession and loss of attachment. No such relationship
existed in grafted areas. This is understandable because
the increased width of attached gingiva in the
grafted
group occurred in an apical direction, thus shifting the
mucogingival junction more apically. It is evident, there-
fore, that free gingival grafts can be used occasionally to
deepen the vestibule. But, gingival grafts cannot be
expected to cover large areas of denuded roots because
of the lack of sufficient vascularity.
An objective test of graft mobility in primates has
been described by Bissada and Sears.1 In their investi-
Volume 51
Number 5 Free Gingival Graft Effectiveness 277

ATTACHED GINGIVA

AOP OBJ KGIN LOA

Figure 2

OBJECTIVE MOBILITY
+1.0
+0.8
8 Experimental
+0.6
I Control
+0.4

EE Üí +0.2
o o 0
o

O O -0.4
ü -0.2
LU
FT
co ü
rr -0.6
< -0.8
UJ
Q. -1.0
AOG SUB PI AGIN REC
1 _1_

AOP Gl PD KGIN LOA

Figure 3

'gures 2 and 3. Correlation values of width of attached gingiva and objective mobility measurements in relation to other variables studied in both
and nongrafted sites. AOG, Age of graft; AOP, Age of patient; SUB, Subjective mobility; OBJ, Objective mobility; GI, Gingival
index; PI.
Rafted
tlaque index; PD, Pocket depth; AGIN, Attached gingiva; KGIN, Keratinized gingiva; RED, Gingival recession; LOA, Loss of attachment;
Correlation statistically significant. t

êation, the authors determined the amount of weight
needed to displace the gingiva over a constant distance,
^n the present study, this method was modified to mini-
niize the patient's discomfort. Displacement of the gin-
gival tissue, therefore, measured by exerting a pull
was
by means of a standardized weight. The measurement of
niobility in this manner appears to be a more precise
assessment of tissue displacement. It is also expected that
such a displacement would be indicative of the gingival
mobility which is likely to occur during the masticatory
cycle.
Gingival mobility in both control andt experimental
groups was compared using the student test and then
correlated the different parameters used to determine
to
periodontal health. Objective mobility of the control and
the grafted sites was essentially the same (Table 1);
however, an increase in such mobility in the grafted sites
corresponded to an increase in pocket depth. It is possible

278 Hangorsky, Bissada
that a firm attachment of the graft to its underlying bone
and tooth could exert an effective barrier to the spread
of inflammation.
While the mobility of the grafts was not related to the
plaque or gingival indices, it is significant that in both
groups an increase in plaque index corresponded to an
increase in the gingival index, pocket depth, loss of
attachment and gingival recession. This finding reem-
phasizes plaque's role as the main etiological factor in
the destruction of the periodontium.
The gingival recession in both groups was directly
related to the degree of gingival inflammation. Baker
and Seymour29 suggested that gingival recession could
be the result of an inflammatory breakdown of the
underlying connective tissue. Such a breakdown would
cause the proliferation of epithelial cells into the lamina
propria and their eventual subsidence would be mani-
fested as recession. Why the gingival recession was
greater at the grafted site, in view of similar plaque and
gingival indices, can only be hypothesized. It is possible
that the gingival recession was greater at the experimen-
tal sites preoperatively. It is also quite likely that the
surgical procedure itself via the inflammatory process
could have contributed to the gingival recession.
Clinical age of the graft was inversely proportional to
the loss of attachment and the width of the attached
gingiva. Despite the substantial recession, some "creep-
ing attachment," first observed by Goldman9 and later
confirmed by other investigators,6,16 could have taken
place.
The present investigation therefore indicates that,
while the free gingival graft is an effective means to
widen the zone of the attached and keratinized gingiva,
there is no indication that this increase bears direct
influence upon periodontal health. Prevention of plaque
formation and its removal appears to be the most effec-
tive method of maintaining periodontal health.
j '. REFERENCES
1. Bissada, N. F.. and Sears. S. B.: Quantitative assessment of free
gingival grafts with and without periosteum and osseous perforation.
J. Periodoniol 49: 15, 1978.
2.1)rackett, R. S., and Gargiulo, A. W.: Free gingival grafts in
humans. J Periodontol 41:58\, 1970.
3. Dbrdick, B., Coslet, G. J„ and Seibert, J. S.: Clinical evaluation
of free autogenous gingival grafts placed on alveolar bone. Part I.
Clinical predictability. J Periodontol 47: 559, 1976.
4. Dordick, B., Coslet, G. J., and Seibert, J. S.: Clinical evaluation
of free autogenous gingival grafts placed on alveolar bone. Part II. J
Periodontol 48: 568, 1976.
5. Dorfman, H., Kennedy, J., and Bird, W.: Longitudinal evaluation
of free autogenous gingival grafts (abstr. No. 103). J Dent Res 57: 101,
1978.
J. Periodontol.
May, 1980
6. Egli, U., Vollmer, W. H., and Rateitschak, K. H.: Follow-up
studies of free gingival grafts. J Clin Periodontol 2: 98, 1975.
7. Fagan, F.: Clinical comparison of the free soft tissue autografi
and partial thickness apically positioned flap—preoperative gingival or
mucosal margins. J Periodontol 46, 586, 1975.
8. Gargiulo, A. W., and Arrocha, R.: Histo-clinical evaluation of
free gingival grafts. Periodontics 5: 285, 1967.
9. Goldman, H. M., Isenberg, G., and Shuman, .: The gingival
autograft and gingivectomy. J Periodontol 47: 586, 1976.
10. Gordon, H. P., Sullivan, H. C, and Atkins, J. H.: Free autoge-
nous gingival grafts II. Supplemental
findings—Histology of the graft
site. Periodontics 6: 130, 1968.
11. Haggerty, P. C: The use of a free gingival graft to create a
healthy environment for full crown preparation. Case history. Perio-
dontics 4: 329, 1966.
12. Hawley, C. E., and Staffileno, H.: Clinical evaluation of free
gingival grafts in periodontal surgery. J Periodontol, 4: 105, 1970.
13. Janson, W. ., Ruben, M. P., Kramer, G. M., Bloom, .
and Turner, H.: Development of the blood supply to split-thickness
free gingival autografts. J Periodontol 40: 707, 1969.
14. Lange, D. E., and Bernimoulin, J. P.: Exfoliative
cytological
studies in evaluation of free gingival graft healing. J Clin Periodontol
I: 89, 1974.
15. Livingston, H. L.: Total coverage of multiple and adjacent
denuded root surfaces with a free gingival autograft. J Periodontol 46:
209, 1975.
16. Matter, J., and Cimasoni, G.:
Creeping attachments after free
gingival grafts. J Periodontol 47, 574, 1976.
17. Maynard, J. G., and Ochsenbein, C:
Mucogingival problems,
prevalence and therapy in children. J Periodontol 46: 543, 1975.
18. Megarbane, J. M.: A new
approach for gingival grafting. Max-
imizing attached gingiva and minimizing surgical trauma. J Periodontol
46: 217, 1975.
19. Nabers, J. M.: Free gingival grafts. Periodontics 4: 243, 1966.
20. Oliver, R. C, Löe, ., and Karring, T.:
Microscopic evaluation
of the healing and revascularization of free gingival grafts. J Periodont
Res 3: 84, 1968.
21. Sandalli, P.: A new method in
gingival graft. J Periodontol 45:
595, 1974.
22. Soehren, S. E., Allen, A. L., Cutright, D. E., and Seibert, J. S.:
Clinical and histologie studies of donor tissues utilized for free
of masticatory mucosa. J Periodontol 44: 727, 1973.
grafts
23. Stahl, S. S., Slavkin, H. C, Yamada, L., and Levine, S.: Spec-
ulations about gingival repair. J Periodontol 43: 394, 1972.
24. Sugarman, E. F.: A clinical and histologie
tissue to bone and teeth. J Periodontol 40: 381, 1969.
study of the grafted
25. Sullivan, H. C, and Atkins, J. H.: Free autogenous
grafts. I. Principles of successful grafting. Periodontics 6: 5, 1968.
gingival
26. Vandersall, D. C: Management of gingival recession and a
surgical dehiscence with a soft tissue autograft: Four year observation.
J Periodontol 45: 274, 1974.
27. Löe, H.: The gingival Index, the Plaque Index and the Retention
Index systems. J Periodontol 38: 610, 1967.
28. Lang, N. P., and Löe, H.: The relationship between the width
of keratinized gingiva and gingival health. J Periodontol 43: 623, 1972·
29. Baker, D. L., and Seymour, G. J.: The possible
pathogenesis of
gingival recession. J Clin Periodontol 3: 208, 1976.
-
Send reprint requests to: Dr. Nabil F. Bissada, Department of
Periodontics, School of Dentistry, Case Western Reserve University.
Cleveland, OH 44106.