Journal of Periodontal Research 1985: 20: 209-211 Short Communication

Marginal soft tissue recessions with and

without attached gingiva
A five year longitudinal study

W . H. SCHOO AND U. VAN DER V E L D E N

Department of Periodontology, Faculty of Dentistry, University of Amsterdam, The Netherlands

Changes in the position of the labial/buccal soft tissue margin of gingival recessions were
investigated. In twenty-five subjects, fifty-two teeth without attached gingiva and fifty-four teeth
with attached gingiva were selected. On the average, changes were minimal over the five year
period in both groups. Statistically significant loss of attachment was found in the group of teeth
with attached gingiva. The validity of the assumption, that the presence of attached gingiva
reduces the risk of further loss of attachment, appears to be questionable.

(Accepted for publication November 12, 1984)

Introduction Material and Methods

It has been suggested that a certain amount
of gingiva, or attached gingiva, is necessary
for the maintenance of the integrity of the
dento-gingival junction. However, it has not
been determined how much gingiva or at-
tached gingiva is necessary to minimize the
occurrence or progression of gingival re-
cessions (cf. Hall 1981, Farnoush & Schon-
feld 1983). Recent longitudinal investiga-
tions in humans have shown that loss of
attachment does not occur frequently in
sites with minimal or no attached gingiva,
provided oral hygiene is carefully controlled
(Dorfman, Kennedy & Bird 1982, Wilson
1983).
In the present longitudinal study, evalu-
ation was made of soft tissue margins bord-
ering teeth which exhibited localized reces-
sion and the presence or absence of attached
gingiva.
Twenty-five patients, ranging in age from
18-67 years, participated in this five-year
study. A total of 106 labial/buccal sites with
locahzed recession and a pocket depth of 3
mm or less were selected. These sites were
located at 73 mandibular and 33 maxillary
teeth; 27 were incisors, 32 were canines, 41
were premolars, and 6 were molars. Pre-
ceeding the base line examination, all pa-
tients received initial treatment consisting of
plaque control and removal of supra- and
subgingival deposits. They were carefully
instructed in an atraumatic brushing tech-
nique using a soft toothbrush. After initial
treatment, oral hygiene control and re-
peated instruction was not performed on a
regular basis in our department, but only
upon the request of the patient.
On a yearly basis recessions, pocket
depths, and gingival widths were assessed.
Recession was defined as the distance from
210 S C H O O A N D V A N DER V E L D E N
the most apical point of the soft tissue
margin to the cemento-enamel junction,
measured parallel to the long axis of the
tooth. The other measurements were per-
formed at the same location. The location of
the mucogingival junction was detennined
on the basis of differences between gingiva
and alveolar mucosa in clinical appearance
(color, surface texture) and tissue mova-
bility. The measurements were made to the
nearest 0.5 mm using a standard periodon-
tal probe (HuFriedy B®).
The width of the attached gingiva was
calculated by subtracting the pocket depth
from the gingival width; the attachment
level was estimated by summation of re-
cession and pocket depth. In addition, after
five years, plaque, redness and swelling of
the gingiva, and bleeding on probing of the
pocket were scored as being present or
absent.
On the basis of the measurements at the
start of the study, the teeth were divided into
a group without attached gingiva (AG = O)
and a group with attached gingiva (AG > 0).
The AG = 0 group consisted of 52 teeth, of
which 5 had no clinically detectable gingival
tissue and 41 had a gingival width of 1 mm
or less. The 54 teeth in the A G > 0 group
had a gingival width of 1 mm or more; 49
teeth had a gingival width of more than 1
mm, and 19 teeth had an attached gingiva of
more than 2 mm.
AG = O
BL CH
R 2.6 (1.1) -0.3
PD 1.5 (0.3)** 0.2
AL 4.1 (1.4)** -0.1
G 1.0 (0.6)** 0.4
Recession (R), pocket depth (PD), attachment level (AL), and gmgival width (G); mean values at base line (BL) and
changes over the five year period (CH) in millimeters, standard deviations in parenthesis. Statistically significant
differences between groups at base line and changes within groups are indicated with * = p<0.01 and
** = p<0.001, respectively.
A decrease or an increase in any of the
measured or calculated parameters was as-
sumed to have occurred when 1) there was a
difference between the first and the last
observation, and 2) a floating sum of three
consecutive observations showed a consis-
tent trend. When both conditions were met,
the amount of change was then calculated
by subtracting the base line measurements
from the recordings at five years. In all other
cases, eventual differences over the years
were scored as zero.
Changes within each group, AG = O or
A G > 0 , were tested using Student's r-test
for matched pairs; differences between both
groups were tested using the /-test for two
independent samples. Values of p<0.01
were considered statistically significant.
Results
The initial mean values with regard to re-
cession, pocket depth, attachment level, and
gingival width in the two groups and the
changes over the five year period are presen-
ted in Table 1. At the start of the investi-
gation, differences existed between the two
groups in pocket depth and loss of attach-
ment. After five years, these differences were
no longer present (p>0.05): in the AG = O
group mean pocket depth was 1.7 mm (SD
0.6) and mean loss of attachment was 4.1
mm (SD 2.5); in the A G > 0 group mean
Table 1
AG>0
BL CH
(0.9) 2.3 (1.0) -0.1 (1.0)
(0.6) 1.0 (0.3)** 0.4 (0.6)**
(0.9) 3.3 (1.1)** 0.4 (0.9)*
(0.8)* 2.2 (0.9)** 0.3 (0.9)
 RECESSIONS AND
pocket depth and loss of attachment were
1.5 mm (SD 0.7) and 3.8 mm (SD 1.8),
respectively.
After five years, some plaque or gingivitis
was present at 49 teeth in the AG = 0 and at
44 teeth in the AG > 0 group. There was no
indication of a relationship between plaque
or gingivitis score and any of the changes in
the other parameters.
Discussion
A so-called creeping attachment following
the use of the gingival grafts to create or
increase a zone of attached gingiva has been
reported in a number of studies (cf. Hall
1981). A more coronal position of the soft
tissue margin and of the attachment level
resulted in grafted sites, as compared to
untreated sites in the study of Dorfman et
al. (1982). However, in some cases even a
relatively atraumatic surgical intervention,
using a gingival graft, apparently resulted in
loss of attachment or further soft tissue
recession (e.g. Soehren et al. 1973, Ber-
nimouhn 1979). Lindhe and Nyman (1980)
investigated patients who had undergone
pocket elimination surgery. They found
that, during a ten-year post-operative
period, some coronal regrowth of the mar-
ginal tissues occurred both at sites originally
with, as well as without a clinically recogniz-
able zone of gingival tissue.
Our findings confirm that when gingival
recessions are present, ehmination of trau-
matic oral hygiene habits will, in general, be
sufficient to prevent further clinically sig-
nificant loss of attachment and recession
irrespective of the width of the gingiva.
Furthermore, a close supervision of oral
hygiene as in the studies of Dorfman et al.
(1982) and Wilson (1983) is apparently not
essential. In the present study, on the aver-
ATTACHED GINGIVA 211
age, a small amount of loss of attachment
was found in the A G > 0 group, but not in
the AG = 0 group. If the object of a surgical
intervention is to prevent further loss of
attachment at teeth with gingival recessions,
it seems impossible to decide that such a
procedure is indicated based merely on the
presence (or absence) of a certain minimum
width of attached gingiva.
References
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Address:
Department of Periodontology
Paculty of Dentistry
University of Amsterdam
Louwesweg 1, 1066 EA Amsterdam
The Netherlands