Width of attached gingiva an important consideration for periodontium- A case report and literature review

Reduced width can cause inflammation more frequently leading to recession. Increase in width of attached gingiva can be done by free gingival grafts, connective tissue grafts, guided tissue regeneration or acellular dermal matrix (ADM). Though, ADM has advantage that it doesnot create a donor site but, it is costly and shrinkage is more in comparison to connective tissue graft. The present case report is of female patient with reduced width of attached gingiva which causes blanching and sensitivity of teeth. © This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Gingival recession is the apical shift of the gingival margin leading to exposed root surfaces, resulting in an unaesthetic appearance". 1 The denuded roots become more sensitive, prone to caries and unaesthetic. The two major objectives of gingival augmentation are to cover either the root surfaces or to increase the width of attached gingiva. There are different treatment modalities to increase the width of attached gingiva such as pedicle graft, free gingiva graft (FGG), connective tissue grafts (CTG), guided tissue regeneration, using alloderm membrane etc. but the preferred one is connective tissue graft if compared to other autografts due to double blood supply; one from underlying periosteum and other from the graft from the donor site. Sometimes, shallow palatal vault hinders in the uptake of CTG graft so one has to look for other modalities. The present case report is class III Miller's recession in lower anteriors and complains of sensitivity in teeth and gradual drifting of gingiva apically.

Case Report
The present case report is of female patient 44 years who came to outpatient department of Periodontics with the chief complaint of sensitivity and gradual apical migration of lower central incisors. Clinical attachment loss was 7-8 mm with lower central incisors with 3mm of pocket depth. It was a class III Miller's recession. We had planned soft tissue augmentation with mandibular anteriors apically with the aim of increasing width of attached gingiva but not root coverage.

Treatment protocol
It constituted of scaling and root planing which were performed along with frenectomy at the first sitting. After 4 weeks patient was recalled for gingival augmentation apical to area of recession.
Recipient site was prepared by de-epithelization of overlying buccal gingiva sparing interdental papillae. Measurements of bed were taken with UNC #15 probe and Trap door technique was followed where one horizontal and two vertical incisions were given using blade #15. The graft was procured of uniform thickness of approx. 1mm and the epithelial flap was placed in position and sutured with silk sutures. The connective tissue graft was secured with sling, periosteal and circumferential sutures on the recipient site. The coe-pak dressing was given and recall was done at 2 weeks, 1 month and 1 year. The healing occurred through primary intention on the donor site unlike FGG. Follow up of one year showed increased width of attached gingiva apical to area of recession along with no blanching negative tension depicted in Figure 1.

Discussion
Adequate width of attached gingival is prerequisite for implant site selection in this modern era of implant dentistry. Though there are many different school of thoughts for adequate width of attached gingiva but the two most popular are by Lang and Löe who suggested that 2 mm of gingiva is an essential prerequisite for periodontal health 2 and the other by Miyasato et al. demonstrated that, with proper oral hygiene and absence of bacterial plaque, clinically healthy gingiva can exist in areas with minimal or no attached gingiva. 3 The connective tissue graft (CTG) has gained considerable attention and is considered a gold standard for soft tissue augmentation. The palatal graft tissue has thicker masticatory mucosa which is mostly the site of choice for harvesting the graft. There are few anatomical considerations to be followed to avoid injury to neurovascular bundle (NB). One of most important factor is palatal vault.
Reiser Gary mentioned that the retrieval of donor tissue from the premolar region in the high and average palate offers a greater margin at safety than retrieval from the shallow (flat) palatal vault." 4 The Table 1 classifies the palatal vault by measuring the Distance between the CEJ and the neurovascular bundle (NB). The other consideration is thickness of graft. The graft should not be thinner than 0.75 mm and not thicker than 1.5mm. The thickest tissue can be procured from in the area from mesial line angle of the palatal root of the first molar till distal line angle of the canine. In the present case CTG was preferred over FGG and alloderm membrane for soft tissue augmentation because of following advantages better healing postoperatively, dual blood supply, colour matching, less shrinkage of tissue and hence more width of Keratinized tissue (KT) can be achieved.
In accordance to our case there are supportive studies by Harris (1988) 5 and Wei (2007). 6 In both the clincal trials increase in keratinized tissue from CT grafts was more than alloderm membrane group.

Conclusion
The connective graft is the gold standard for increasing the attached gingiva in both high and average vault conditions. Inspite, of knowing the significance of adequate width of attached gingiva the acceptance of increasing width is less in implant dentistry which might be due to issues of improper diagnosis and deficiency in time. So, it is of supreme significance in era of implant dentistry and full mouth rehabilitation cases. As the prevalence of periimplantitis and peri mucositis is tremendously increasing day by day. Hence, every clinician placing implants should be aware and give a referral call for a periodontist or oral surgeon before implant placement.

Source of Funding
None.

Conflict of Interest
The authors declare no conflict of interest.