|Year : 2017 | Volume
| Issue : 2 | Page : 42-49
Assessment of gingival sulcus depth, width of attached gingiva, and gingival thickness in primary, mixed, and permanent dentition
KL Vandana1, Singh Shivani1, B Savitha2, HP Vivek3
1 Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Periodontics, Consultant and Practiotioner, Davangere, Karnataka, India
3 Department of Community Dentistry, College of Dental Sciences, Davangere, Karnataka, India
|Date of Web Publication||10-Oct-2017|
K L Vandana
Department of Periodontics, College of Dental Sciences, Davangere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
Aim and Objective: The objective of this in vivo study was to evaluate sulcus depth width and thickness of facial attached gingiva in primary, mixed, and permanent dentition. Materials and Methods: The study included 40 subjects (22 males and 18 females) with 480 sites of an age range 4–25 years. Subjects were divided into three groups: the primary dentition (4–6 years), mixed dentition (7–13 years), and adult dentition (16–25 years). All the parameters were measured in the upper and lower anterior segments. Results: Gingival sulcus depth (GSD), attached gingiva width (AGW), and gingival thickness (GT) were measured archwise and toothwise in different dentition and overall dentition wise without differentiating archwise and toothwise. GSD was significantly higher in maxillary mixed dentition (1.75 ± 0.75), followed by permanent and primary dentition. AGW was significantly higher in maxillary permanent dentition (3.4 ± 0.36) followed by maxillary mixed and permanent dentition. GT was significantly higher (P = 0.001) in mixed dentition midbuccally (1.3 ± 0.46) and interdentally (2.31 ± 0.71) in both the arches. In all the dentition, maxillary central incisor showed significant GSD. AGW was significantly higher in permanent maxillary canine (3.5 ± 0.5). GT (midbuccal) was significantly higher in primary dentition (1.4 ± 0.5), and GT (ID) was significant in mixed dentition (2.6 ± 0.7). Conclusion: The sulcus depth and GT increases from primary to mixed dentition and significantly higher in maxilla. The width of attached gingiva was less in mixed dentition than primary with maxillary sites exhibiting higher values than mandibular.
Keywords: Gingival sulcus depth, gingival thickness, mixed dentition, permanent dentition, primary dentition, width of attached gingiva
|How to cite this article:|
Vandana K L, Shivani S, Savitha B, Vivek H P. Assessment of gingival sulcus depth, width of attached gingiva, and gingival thickness in primary, mixed, and permanent dentition. J Dent Res Rev 2017;4:42-9
|How to cite this URL:|
Vandana K L, Shivani S, Savitha B, Vivek H P. Assessment of gingival sulcus depth, width of attached gingiva, and gingival thickness in primary, mixed, and permanent dentition. J Dent Res Rev [serial online] 2017 [cited 2020 Dec 1];4:42-9. Available from: https://www.jdrr.org/text.asp?2017/4/2/42/216420
| Introduction|| |
The gingival unit is subject to morphological changes due to normal pattern of oral development. It has long been known that this clinical appearance of marginal periodontium differs from subject to subject and even among different tooth types. Many features are genetically determined, others seem to be influenced by tooth size, shape, and position, and biological phenomenon such as gender, growth, and age. With age, changes may occur in each of the tissues while some of these changes are caused by inflammation, others are the result of aging. The severity of gingivitis is less intense in children than in adults with similar amount of plaque. There is so much lower prevalence of destructive periodontal disease in children than in adults, but diagnosis in children is more difficult; however, early diagnosis is important for successful treatment. Thus, it is imperative that children receive a periodontal examination as a part of their routine dental visits. The three anatomical aspects of gingiva such as gingival sulcus depth (GSD), attached gingiva width (AGW), and gingival thickness (GT) are addressed scantity.
The GSD is an important clinical tool for diagnosing periodontal disease and evaluating therapy. One of the important characteristics of this sulcus is its depth; hence, the operator must become concerned and informed about the changes which occur in the sulcus during life. However, it has some limitations because it does not detect current disease activity, but merely demonstrates the past destruction pattern.
The importance of attached keratinized tissue around natural teeth is a controversial topic. Since historically, an adequate band of keratinized tissue was viewed as important to prevent future recession. Lang and Löe suggested that a minimum of 2 mm of keratinized tissue, 1 mm of which was attached was necessary. Few authors have reported that the tissue could remain clinically healthy with <1 mm of attached gingiva.,,, Certain types of adult periodontal diseases may be anticipated by observations made during childhood and adolescence, thus more attention should be given to the zone of attached gingiva and its relationship to the deciduous, transitional, and permanent dentition.
In recent years, the dimensions of different parts of masticatory mucosa, especially GT has become a subject of considerable interest in periodontics, both from a epidemiologic and a therapeutic point of view. The assessment of facial GT and its correlation with the age, gender, and dental arch in the anterior segment is scanty. Vandana and Savita in 2005 reported thicker gingiva in younger age group than that of the older age group. The GT plays a vital role in the development of mucogingival problems and in success of treatment for recession  and wound healing, hence, assessment of GT is relevant.
We searched electronic databases and hand-searched bibliographies of already identified reports, as well as online sites with reports accepted for publication ahead of print for the most relevant scientific journals. We limit our study in Humans and English language. Medline search using keywords sulcus depth, AGW, and GT revealed few studies in primary, mixed, and permanent dentition. Thus, this study was conducted to evaluate the GSD, AGW, and GT in primary, mixed, and permanent dentitions.
| Materials and Methods|| |
The present study was conducted in the Department of Periodontics and Pedodontics, College of Dental Sciences, Davangere. Anterior teeth (12 teeth) with 480 sites in 40 systematically healthy controls (22 males and 18 females, age range 4–25 years) were analyzed in the study. The study protocol was approved by institutional IRB (Ref. No. CODS/1977/2015-2016) fulfilling the criteria of RGUHS, India. The primary dentition age group (4–6 years) consisted of 10 subjects; mixed dentition age group (7–13 years) also consisted of 15 subjects and the adult dentition age group (16–25 years) consisted of 15 subjects. The inclusion criteria included the presence of all anterior teeth in both upper and lower jaw, good oral hygiene, clinically healthy periodontal tissues with no loss of attachment. The exclusion criteria included gingival recession in anterior teeth, known systemic disease, use of any medications possibly affecting the periodontal tissue such as phenytoin and cyclosporine A, extensive restorations.
After collecting the information about this study such as the objectives, expected outcomes, and the degree of discomfort that might occur, the subjects gave their informed consent. The selected volunteers were divided into three groups: Group A – Primary dentition, Group B – mixed dentition, and Group C – permanent dentition.
In the first visit, plaque index  and gingival bleeding index  were recorded followed by scaling and polishing. The measurements were done using UNC-15 periodontal probe (Hu-friedy USA) 1-week postscaling.
Measurement of gingival sulcus depth
The width of keratinized gingiva was measured in midfacial area for six anterior teeth in the maxillary and mandibular regions from the gingival margin to the mucogingival junction using UNC-15 periodontal probe [Figure 1]. The probe was inserted parallel to the long axis to the tooth and walked along the tooth. The probing depth was measured from the free gingival margin to the deepest penetration of periodontal probe. The readings were recorded and rounded to the nearest millimeter.
|Figure 1: (a and b) Measurement of gingival sulcus depth in maxilla and mandible|
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Measurement of attached gingiva width
The width of keratinized gingiva was measured in midfacial area for six anterior teeth in the maxillary and mandibular regions from the gingival margin to the mucogingival junction using UNC-15 periodontal probe [Figure 2]. The mucogingival junction was determined using a jiggle method because of movable the alveolar mucosa and firmly attached gingiva. A blunt instrument was used to jiggle the alveolar mucosa in an apicocoronal fashion and thus delineating the mucogingival junction. The width of attached gingiva was obtained by subtracting the probing sulcus depth from the width of keratinized gingiva at the midbuccal aspect of each tooth.
|Figure 2: (a and b) Measurement of attached gingiva width in maxilla and mandible|
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AGW = Width of keratinized gingiva − probing sulcus depth.
Measurement of gingival thickness
The GT was assessed in subjects using transgingival probing, midfacially in the attached gingiva, half way between the mucogingival junction, and free gingival groove and at the base of interdental papilla [Figure 3]. The GT was assessed by anesthetizing the facial gingiva with xylonor spray (lignocaine 15 g) and if required filtration was conducted using 2% lignocaine HCL with 1:80,000 adrenaline injection. GT was assessed after 20 min of injection using UNC-15 probe. Measurements were not rounded off to the nearest millimeter.
The measurements recorded were subjected to statistical analysis. Mean values and standard deviations were calculated. The analysis of variance and post hoc test was used to compare the transgingival probing measurements, midbuccally, and at the interdental papillary region.
| Results|| |
Each parameter was studied in anterior teeth with 480 sites in 40 subjects (22 males and 18 females) of age group range between 4 and 25 years. GSD was significantly higher (P = 0.001) in the maxillary mixed dentition (1.75 ± 0.75) followed by maxillary permanent and primary dentition. The mandibular GSD was similar in all the dentitions. On comparing both the jaws, mixed and permanent dentition showed significantly higher GSD in maxilla (1.75 ± 0.75) and (1.33 ± 0.14), respectively, than mandible whereas, primary dentition showed no significant difference [Table 1]. In all the three dentitions, in maxilla, GSD was significantly higher in central incisors (CIs), followed by lateral incisors (LI), and canine (C). On interdentition comparison, maxillary mixed CI (2.2 ± 0.8) showed significantly higher (P = 0.001) GSD followed by permanent CI (1.4 ± 0.1) and primary CI (1.3 ± 0.4). In mandible, among all the dentitions, only in permanent dentition, CI (1.3 ± 0.3) showed significantly higher GSD followed by permanent LI and canine (1.2 ± 0.1) and (1.1 ± 0.4), respectively [Graph 1 [Additional file 1]]. In mixed dentition, maxillary CI (2.2 mm), LI (1.6 mm) and in permanent dentition, maxillary LI (1.3 mm) showed significantly higher GSD than mandibular teeth [Table 2]. AGW was significantly higher (P = 0.001) in maxilla than mandible in all 3 dentitions. Maxillary permanent dentition (3.4 ± 0.36) showed significantly higher AGW than primary (2.17 ± 0.71) and maxillary mixed (2.11 ± 0.71) [Table 3]. On toothwise comparison, AGW was highly significant (P = 0.001) in maxillary canine (3.5 ± 0.5) of permanent dentition, followed by maxillary permanent CI (3.3 ± 0.3), and LI (2.5 ± 70.6) whereas primary and mixed dentition showed nonsignificant difference. Similarly, in mandible permanent canine (02 ± 0.4) showed higher AGW but the difference was nonsignificant (P = 0.01). Significant difference was found in mandibular permanent CI (1.9 ± 0.1) [Graph 2 [Additional file 2]]. In all the dentition maxillary teeth showed higher GW except in mixed dentition where mandibular LI showed significantly higher AGW. In permanent dentition, maxillary CI (3.3 mm), LI (2.5 mm), and canine (3.5 mm) showed significantly higher AGW than mandibular teeth [Table 4]. GT was significantly higher (P = 0.001) in mixed dentition both midbuccally (1.3 ± 0.46) and interdentally (2.31 ± 0.71) than primary and permanent dentition. On comparison between the arches within the dentition, primary dentition showed significantly higher (P = 0.001) midbuccal GT (MBGT) in maxillary (1.2 ± 0.4) than mandibular (1.06 ± 0.25) arch. In mixed dentition, similar midbuccal and interdental GT (IDGT) were seen similar in both the arches. In permanent dentition, mandible (1.74 ± 0.69) showed significantly higher GT than maxilla (0.93 ± 0.3) [Table 5]. In all the 3 dentitions, in maxilla, MBGT was higher in CI followed by LI and canine but the difference was significant in primary dentition. On interdentition comparison, CI of maxillary primary and mixed dentition (1.4 ± 0.5) was significantly higher than permanent CI (1.0 ± 0.2) whereas in mandible, mixed dentition, CI (1.4 ± 0.5) showed significantly higher MBGT than primary and permanent dentition. Within a dentition, mandibular canine (1.2 ± 0.4) of primary dentition, and CI (1.4 ± 0.5) of mixed dentition, showed significantly higher MBGT than other two teeth in mandibular arch [Graph 3 [Additional file 3]]. IDGT was significantly higher (P = 0.001) in CI, LI, and canine of mixed dentition followed by primary and permanent dentition. Interdentally maxillary mixed CI (2.6 ± 0.7) showed significantly higher (P = 0.001) IDGT followed by maxillary mixed LI (2.3 ± 0.6) and canine (2.0 ± 0.6). In mandible significant, IDGT (P = 0.001) was found in mixed dentition CI (2.6 ± 0.7) [Graph 4 [Additional file 4]]. On comparing maxillary and mandibular anterior teeth of three dentitions, only maxillary CI (1.4 mm) of primary dentition showed significantly higher MBGT than mandibular CI and interdentally, mandibular canine (2.3 mm) of primary dentition showed significantly higher IDGT [Table 6]. The overall presentation of GSD, AGW, and GT (MB and ID) without differentiating of archwise and toothwise showed that GSD (1.4 mm), GT both midbuccally (1.3 mm), and interdentally (0.3 mm) was significantly higher in mixed dentition. The second in the line was primary dentition for GT in midbuccal (1.1 ± 0.3) and interdental (1.7 ± 0.6). Gingival width was highly significant in the permanent dentition (2.5 ± 0.7) followed by mixed and primary dentition [Table 7].
|Table 1: Sulcus depth in primary, mixed, and permanent dentition (mm) of maxilla and mandible|
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|Table 2: Maxillary versus mandibular determination of gingival sulcus depth of each tooth|
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|Table 3: Attached gingiva width in primary, mixed, and permanent dentition (mm) of maxilla and mandible|
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|Table 4: Maxillary versus mandibular determination of attached gingiva width of each tooth attached gingiva width|
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|Table 5: Gingival thickness in primary, mixed and permanent dentition (mm) of maxilla and mandible|
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|Table 6: Maxillary versus mandibular determination of gingival thickness-mid bucally and interdentally of each tooth|
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| Discussion|| |
In several clinical situations, information on thickness of masticatory mucosa is highly desirable. A thin and delicate gingiva might be prone to developing gingival recessions after traumatic surgical or inflammatory injuries likewise orthodontic tooth movement may also have detrimental influence on the mucogingival complex, especially at sites where keratinized tissue and underlying bone appear to be thin.
In the present study, the three gingiva parameters such as GSD, AGW, and GT at midbucally (MBGT) and interdentally (IDGT) were measured. The GSD of maxillary mixed dentition (1.75 mm) was significantly higher than primary and permanent dentition, whereas in mandibular arch, it was similar in all the dentitions. Studies conducted by Srivastava et al. and Kim  also confirmed the increased sulcus depth around newly erupted permanent teeth of mixed dentition with narrower width of attached gingiva. It is probably due to the reasons such as lagging of active eruption behind the passive, the lesser quality of the “primary attachment apparatus” which offers less resistance to probing  and “eruption gingivitis” which allows for deeper probe penetration beyond the histological sulcus. A study showed that GSD of anterior teeth in mixed dentition ranged between 1.48 and 2.75 mm while in childhood and adolescence, it ranged between 1.06 and 1.96 mm.
In the present study, in general, the CIs showed higher sulcus depth followed by LIs and canines. Among different dentition, maxillary mixed CI showed significantly higher GSD followed by permanent and primary dentition whereas mandible showed similar GSD in CI, LI, and canine in all the dentition. Bimstein and Eidelman also reported higher GSD maxillary permanent CI (2.7 mm) of mixed dentition than primary CI (1.7 mm).
In the present study, the AGW was significantly higher in permanent dentition followed by mixed and primary dentition. Between the arches, the AGW of all the maxillary dentition was significantly higher than mandibular. The reasons for increased AGW with age are concomitant reduction in sulcus depth  and there is constant eruption of teeth throughout one's lifespan to compensate the occlusal surface attrition leading to the coronal migration of CEJ while the mucogingival junction remains unchanged. Maxillary showed higher values than mandibular. In maxillary and mandible, permanent CI, LI and canine (C) showed higher AGW followed by mixed and primary dentition. The AGW was found to be similar in CI, LI, and C of primary and mixed dentition. A study reported the mean value of AGW between 1.36 and 3.85 mm except in the newly erupted permanent anterior teeth where the mean ranged from 1.12 to 2.53 mm. With the eruption of the permanent tooth, there is an increase in the alveolar bone, but at the same time, there is no increase in the width of the keratinized and/or attached gingiva due to the more buccal position of the erupting permanent tooth as compared to its predecessor., Study conducted by Bowers in 1963 on four age groups 3–5, 15–25, 25–35, and over 35 years reported increased mean width of attached gingiva from the deciduous dentition to the adult dentition and it became extremely narrow in the cuspid and first bicuspid region. AGW increases with age having the greatest width in maxillary incisors and mandibular premolars the least width  whereas Shaju and Zade  and Chandulal et al. reported least width in mandibular molars.
In the current study, MBGT and IDGT were highly significant in mixed dentition followed by primary and permanent dentition in both the arches. In the primary dentition, maxilla showed significantly higher MBGT than mandible. However, in mixed and permanent dentition, MBGT was found to be similar in both the arches. Contrary to the MBGT, IDGT was higher in the mandible. In maxilla and mandible, MBGT of CI, LI, and canine was found to be similar in all the 3 dentitions. However, the MBGT was found to be highly significant in CI of mixed dentition. Thickness mainly depends on tooth type and is correlated with width of gingiva. A study conducted on 200 subjects on three age groups (20–25, 40–45, and 55–60 years) to showed that in the maxilla, mean GT varied between 0.9 mm (canines and first molars), and 1.3 mm (second molars) and in the mandible, GT ranged between 0.8 mm (canines) and 1.5 mm (second molars). GT varies with age, gender, and dental arch location. Vandana and Savita in 2005 in their study on 32 subjects of age group 16–38 years determined the thickness of facial gingiva through transgingival probing in the maxillary and mandibular anteriors. The younger age group of 16–24 years demonstrated significantly thicker gingiva (1.63 and 1.73 mm midbuccally and 1.59 and 1.78 mm interdentally) than that of the older age group of 25–38 years, (0.97 and 1.03 mm midbuccally and 0.93 and 1.07 mm interdentally). Younger age group had significantly thicker gingiva than that of the older age group, it might be because of changes in the oral epithelium caused by age, related to thinning of the epithelium and diminished keratinization. There may be other confounding factors that influence GT such as racial and genetic factors. The gingiva was found to be thinner in females than males and in the mandibular arch than the maxilla. Palatal mucosa may be thin in subjects with a thin and narrow gingiva and a slender shape of upper front teeth. A study performed in younger (14–21 years) and older age group (30–59 years) reported thinner palatal mucosa 2.8 ± 3.0 mm in younger age group than older age group 3.1 ± 3.0 mm.
The assessment and comparison of GSD and AGW has been attempted by few authors.,,, However, GT has been attempted for the first time in primary and mixed dentition. Archwise and toothwise measurement of GSD and GT in all the three dentition also has been attempted for the first time.
To summarize the current study, the archwise and toothwise assessment of GSD, AGW, and GT were done. The overall presentation includes measurements of all the teeth in maxilla and mandible to ease the clinical presentation of data in general. If any specific consideration is required, individual tooth archwise data are presented in the current study which is extensive and clinically not feasible.
The GSD of the current study demonstrated the highest sulcus depth in maxillary mixed dentition (1.75 mm) and least in mandibular mixed dentition (1.16 mm). In maxilla, the maximum GSD was observed in CI of mixed dentition (2 mm) and least in the primary canine tooth (1 mm). In mandible, the maximum GSD was observed in the primary and permanent CI (1.3 mm) and least in LI of primary and mixed dentition and canine of permanent dentition (1.1 mm). In primary dentition CI, LI, and Canine showed almost similar GSD in both jaws. In mixed and permanent dentition, maxillary CI, LI, and canine showed higher GSD than mandible.
The AGW of the current study demonstrated that among all the dentitions, AGW was maximum in maxillary permanent dentition (3.42 mm) and least in mandibular primary dentition (1.62 mm). In interdentition comparison of maxilla, maximum AGW was found in CI of permanent dentition (3.3 mm) and minimum width was in LI of mixed and primary dentition (1.8 mm). In mandible, the maximum AGW was found in canine of permanent dentition (2.0 mm) and least in CI of primary dentition (1.4 mm). In all the dentitions, canine showed maximum width in maxillary (3.5 ± 0.5) and mandible (2.0 ± 0.4).
The GT of the current study demonstrated that among all the dentitions, the greatest GT was found in maxillary mixed dentition both midbucally (MBGT 1.3 mm) and interdentally (IDGT 2.3 mm). The least GT was found in maxillary permanent dentition both midbucally (1 mm) and interdentally (0.93 mm). In maxilla, MBGT was maximum in CI (1.4 mm) of mixed dentition. Minimum GT was found in canine (0.9 mm) of permanent dentition. In mandible, the MBGT was maximum in CI (1.4 mm) of mixed dentition. Minimum MBGT was found in LI (0.9 mm) of permanent dentition. In maxilla, IDGT was maximum in CI (2.6 mm) of mixed dentition. Minimum GT was found in CI and canine (0.9 mm) of permanent dentition. In mandible, the IDGT was maximum in CI (2.6 mm) of mixed dentition. Minimum IDGT was found in CI (1.5 mm) of primary dentition.
Clinical transfer of the study
The mixed dentition period is a transient phase. Hence, any measurements of sulcus depth, AGW, and GT should never be attempted for therapeutic correction. GT and gingival width are important from the point of periesthetics and restotarive esthetics. The due consideration for GT and AGW measured should be kept in mind to minimize post esthetic consequences.
| Conclusion|| |
GSD is higher in mixed dentition (1.4 mm), followed by permanent (1.2 mm) and primary dentition (1.2 mm). AGW is higher in permanent dentition (2.5 mm) followed by mixed (1.9 mm) and primary dentition (1.8 mm). GT is higher in mixed dentition both mesiobucally (1.3 mm) and interdentally (2.3 mm) followed by primary (1.1 mm MB and 1.7 mm, ID) and permanent dentition (1.0 mm, MB and 1.3 mm, ID). The archwise and anterior tooth wise data presentation is useful in these clinical issues to delineate healthy and disease status of gingiva.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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