Anatomical Characteristics of Gingiva

A Clinical and Microscopic Study of the Free and

Attached Gingiva

by JUKKA AINA.V.O and HARALD LÖE,** aarhus, Denmark

THE GINGIVA EXTENDS from the gingival margin to the muco-gingival

junction. It is divided into the free gingiva and the attached gingiva, the line
of demarcation between the two parts being the free gingival groove (Orban
1948).° The free gingival groove is defined as a shallow V-shaped groove
which runs parallel to the margin of the gingiva at a distance of 0.5-1.5 mm
(Orban 1948). It is thought to develop at the level of, or somewhat apical to
the top of the epithelial attachment due to functional impacts on the free
gingiva (Orban 1953).7 When the free gingival groove is not visible on the
surface (Fehr & Mühlemann 1955)2 it may be seen in histologic sections as
a heavy epithelial ridge (Orban 1953). The width of the attached gingiva
ranges between 1 mm and 9 mm and appears to exhibit a consistent pattern
of variation throughout the dentition (Bowers 1963).1

principal objectives of this investigation were:

The
1. To study the frequency of occurrence of the gingival groove in normal
and mildly inflamed gingiva, its anatomical relationships and underlying
structural arrangement;
2. To study the width of the attached gingiva in teeth showing different
coronal levels of the free gingival margin.

MATERIAL AND METHODS

A. The facial of 1497 teeth in 20 children (3-10 years) 20 dental

gingiva
students (21-27 years) and 52 patients (29-72) who had or had not
received periodontal therapy were examined. Among the children and the
students, males and females were evenly represented, whilst the treated
The Department of Periodontology, The Royal Dental College, Aaarhus, Denmark.
-
Research Associate and Clinical Instructor.
"Professor and Chairman.

Page 5
Page 6 AlNAMO AND LÖE

Table 1
Number of Teeth Studied
Children Students Older patients
Tooth 3-10 years 21-27 years 29-72 years Total
Max. Mand. Max. Mand. Max. Mand.
Ii, ii 33 24 40 40 49 70 256
I2,12 34 35 40 40 44 77 270
Ci, c 40 40 40 40 49 69 278
Pi, mi 37 35 37 39 27 63 238
P2,m2 34 30 38 37 29 47 215
Mi 38 34 21 15 108
M2 37 37 27 31 132
Total 178 164 270 267 246 372 1,497

adult patients (20) consisted of females
only, and the non-treated adult patients
(32) were all males. This distribution is
shown in Table 1. The state of the facial
gingiva was scored for the Gingival
Index (Löe & Silness 1963)4 and only
gingiva scoring 0 or 1 was included in
the study. The location of the gingival
margin on the enamel or on the cemen-
tum was recorded. A gingival groove
was considered present when a distinct
groove could be observed on part of or
on the entire facial gingiva of the tooth.
The following measurements were made
to the nearest millimeter by means of a
graduated pocket probe:
(a) gingival margin to the
gingival junction
(b) gingival margin to the
groove
(c) gingival margin to the bottom of
the gingival crevice.
the gingival crevice from the distance
between gingival margin and the muco-
gingival junction (Bowers 1963). In the
case of frenum and muscle attachment
the width of the gingiva was measured
from the gingival margin to the most
coronal part of the insertion.
B. Twenty-five permanent teeth of students
and 23 teeth of the non-treated male
adults which exhibited a gingival groove
were subjected to a closer examination.
The distance from the gingival margin
to the gingival groove was measured
with calipers, the opening of which
could be controlled by a threaded screw.
The distance from the gingival margin
muco- to the bottom of the gingival crevice was
determined by inserting a 0.05 mm thick
and 1.0 mm wide contoured celluloid
gingival strip to a point where definite resistance
was met. A sharp probe was used to
mark the level of the gingival margin on
the strip. Both measurements were re-
corded to the nearest 0.1 mm by means
of a micrometer.

Only teeth showing a gingival crevice of
2mm or less were included in the study.
The width of the attached gingiva was
calculated by subtracting the depth of
C. The gingival groove was also studied
during the development of experimental
gingivitis (Löe, Theilade, Börglum Jen-
sen 1965).5 During this study marginal
inflammation was produced in the nor-
 Gingival Anatomy
Table 2
The Frequency of Occurrence of a Gingival Groove on Different Teeth in the
Deciduous and Permanent Dentitions (in per cent)
i7i2 mi c it ii
Maxilla 38 35 27 32 27
Mandible 23 26 30 49 29
mal gingiva of students by withdrawal of
all active oral hygiene measures. The
effect of clinical inflammation upon the
gingival groove was studied in color
slides picturing the clinical appearance
of the labial gingivae of maxillary and
mandibulary anterior teeth before, dur-
ing and after the experimental period.
D. teeth of dogs, monkeys and
Sixty-two
humans were examined for the struc-
tural arrangement of the marginal perio-
dontium. Decalcified unstained sections
and sections stained by Mallory and Van
Gieson connective tissue stains were
studied in polarized and non-polarized
light. No clinical history of the presence
or absence of a gingival groove was
available. Therefore, two groups of
teeth were studied: one presenting the
histologic evidence of a gingival groove,
and the other showing no such groove.
The histologic study also included ex-
amination of sections from dog teeth
that had been subjected to experimental
gingivectomy and that had an observa-
tion period exceeding 40 days (Löe &
Silness 1961).3
OBSERVATIONS
Thegingival groove. Because no differ-
ence appeared to exist regarding the preva-
lence of a gingival groove on the gingivae
of the left as compared with the right side,
the teeth of the two sides were pooled.
In the primary dentition a gingival groove
was observed on the facial surface of the
gingiva in 111 out of 347 teeth examined.
No difference in frequency of occurrence
was observed between males and females or
between maxillary and mandibular teeth
(Table 2). Mild inflammation (GI score of
Page 7
h It C Pi P2 Mi M%
21 31 31 22 24 24 36
27 37 52 39 31 18 21
1) wasobserved in only 35 teeth and this
did not to influence the frequency of
seem
occurrence of the groove. The groove was
most often seen in the mandibular lateral in-
cisors and the maxillary molars.
Gingiva of permanent teeth showed ap-
proximately the same frequency of occur-
rence of the gingival groove in the two
sexes, and no difference seemed to exist be-
tween teeth when the free gingiva was lo-
cated on the enamel and on the cementum.
Normal gingiva showed the presence of the
gingival groove in 27% of the maxillary and
in 38% of the mandibular teeth. The corre-
sponding figures for mildly inflamed gingiva
were 22% for maxillary and 28% for man-
dibular teeth. Studied as one group the gin-
gival groove was found in 31 % of the per-
manent teeth. The highest incidence of the
gingival groove was on the lower permanent
canine (Table 2).
Examination of color slides from the gin-
giva of the students who took part in the
experimental gingivitis study showed that in
no instance did a gingival groove that was
observed prior to the experiment disappear
during the development of mild marginal
inflammation.
The mean distance from the gingival mar-
gin to the gingival groove in primary teeth
was 1.1 mm for both jaws. Average depth
of the gingival crevice measured 1.0 mm.
The mean distance from the margin to the
groove in the students was 1.2 mm and the
average depth of the gingival crevice was
1.1 mm. In older non-treated patients the
corresponding figures were 1.6 mm and 1.7
mm. Measured with calipers and a microm-
eter the distance from margin to groove
averaged 1.19 mm in students and 1.58 mm
 AlNAMO AND LÖE

Fig. 1. Section of marginal gingiva of monkey stained with Wilder's silver method for reticulin. A gingival
groove (GG) is seen slightly apical to the level of CEJ (left). Corresponding to the notch in the keratinized epi-
thelium is an extension of the epithelial ridge (ep) into the connective tissue (right).

in the older non-treated patients (Table 3). Table 3

The average depth of the gingival crevice as The Distance from the Gingival Margin to the
determined by the celluloid strip method Gingival Groove and the Depth of the Gingival
was 1.43 for students and 1.86 for older Crevice as Measured to the Nearest 0.1 mm
patients. Gingival
margin to Depths of
The microscopic counterpart to the clini- gingival gingival
Patients groove crevice
cal gingival groove is a notch in the keratin-
ized epithelium and, usually, an extension mean range mean range
of the corresponding epithelial ridge into the Students 1.19 0.8-1.8 1.43 0.6-2.2
connective tissue (Fig. 1). The microscopic
Non-treated
examination of the marginal periodontium
older 1.58 0.9-2.1 1.86 1.3-2.7
showed that histologically normal gingiva
patients
did not necessarily exhibit a gingival groove,
and that a distinct gingival groove might be
found in mild gingival inflammation. Where
a gingival groove was present serial sections the bottom of the gingival crevice (the
showed that it could be traced along parts or cemento-enamel junction). In some cases it
along the entire facial or oral surface. The was seen slightly coronal to this level, and in
few teeth that had been subject to experi- others somewhat apical to it.
mental gingivectomy invariably exhibited a
gingival groove 40-50 days after surgery All sections that showed a distinct gingi-
(Fig. 2). The notch in the epithelium was val groove also presented a characteristic ar-
usually located in the area corresponding to rangement of the supraalveolar fibers. One
 Gingival Anatomy
Fig. 2. Section of marginal periodontium of dog
stained with Mallory's method for connective tissue
fibers. Six weeks after gingivectomy had been per-
formed to the bottom of the gingival crevice (notch at
CEJ) and a new free gingiva has formed showing a
gingival groove (GG) slightly coronal to the bottom
crevice.
group of fibers emerging from the supra-
alveolar cementum sweeps outward and up-
ward terminating into the free gingiva.
Another group was seen to emerge from the
same area, but this passes outward beyond
the alveolar crest in an apical direction into
the lamina propria of the attached gingiva.
This fan shaped fiber arrangement could not
be seen easily in the stained sections (Fig.
2), but was readily seen in polarized light
(Fig. 3). Where these fibers were well-
defined the gingival groove was located in
the angle produced by these fiber systems
(Fig. 4).
Attached gingiva. Mean width and maxi-
mum and minimum extension of the at-
tached gingiva is shown in Table 4. Mini-
mum values in most instances refer to areas
of insertion of frena and of muscle attach-
ments.
Page 9
Fig. 3. Section of marginal periodontium of monkey
view in polarized light. Free gingival fibers extending
from the cementum between cemento-enamel junction
(CEJ) and the bony crest (bo). One group of fibers
sweeps outward and upward into the free gingiva. An-
other group emerges from the same area of the cemen-
tum and passes outward beyond the alveolar crest in
an apical direction into the lamina
propria of the
attached gingiva. The gingival groove (GG) is located
below the CEJ.
In deciduous teeth the greatest width of
the attached gingiva was found on the maxil-
lary and mandibular incisors. In both jaws
the width of attached gingiva decreased
towards the molar regions. The narrowest
zone of attached gingiva was observed in
the area of the first deciduous molar.
In permanent teeth with the free gingiva
located on the enamel the widest area of
attached gingiva was also found in relation
to the upper and lower anterior teeth. Both
jaws showed a decrease in the lateral seg-
ments. The narrowest width was measured
in the region of the upper and lower 1st pre-
molars. Teeth on which the gingiva had
been subject to recession or periodontal sur-
gery during which the marginal gingiva had
been reduced by several millimeters the
Page 10 AlNAMO AND LÖE

Table 4
The Width of Attached Gingiva in Deciduous Teeth and in Permanent Teeth with the
Gingival Margin on Enamel and on Cementum (in millimeters)
Maxilla Mandible
Permanent teeth Permanent teeth
Tooth Deciduous GM GM Deciduous GM GM
teeth enamel cementum teeth enamel cementum

mean range mean range mean range mean range mean range mean range

11.11 3.6 0-6 3.5 0-6 4.3 3-6 2.9 0-4 3.3 1-6 2.9 1-5

12.12 3.8 2-7 4.5 2-7 4.3 3-6 2.6 0-4 3.9 1-6 3.6 2-6

C,c 2.1 0-6 2.7 0-6 2.9 0-6 1.9 1-3 2.6 1-5 2.4 0-4

Pi, mi 1.4 0-6 1.9 0-6 2.2 1-4 1.2 0-2 1.8 0-4 1.8 0-6

P2,m2 1.8 1-5 2.7 1-5 2.4 1-5 1.9 1-3 2.1 1-4 1.7 1-4

Mi 3.0 1-6 2.1 0-3 2.4 0-4 2.0 1-4

M2 2.9 0-5 2.3 1-4 1.9 0-3 2.0 1-3

width of the attached gingiva did not appre-

ciably differ from the teeth of young adults
where the gingival margin was still located
on the enamel (Table 4 and Fig. 5).

discussion

This investigation has shown that a gin-

gival groove is present in about one third of
the facial surfaces of normal gingivae. There
seems to be no major difference in the fre-
quency of its occurrence between the sexes
or between deciduous and permanent teeth.
Its presence or absence does not appear to
be influenced by the level of the marginal
gingiva. The gingival groove occurs as fre-
quently on teeth where the gingival margin
is apical to the cemento-enamel junction as
on teeth where the gingival margin is lo-
cated on the enamel. It has also been shown
both clinically and microscopically that a
gingival groove reappears in the course of
healing after surgical excision of the mar-
ginal gingiva. Also, the development of mild
gingival inflammation is not necessarily fol-
lowed by a disappearance of the gingival
groove.

The fact that less than half of all normal
gingivae exhibit a gingival groove, and that
it persists during mild gingival inflammation
indicates that the gingival groove is not di-
Fig. 4. Section of marginal periodontium of monkey.
Well denned fan shaped fiber arrangement emerging
from the cementum between the cemento-enamel junc-
tion (cej) and the alveolar crest (bo). The extended
epithelial ridge corresponding to the gingival groove is
located in the angle produced by the fiber systems
(fi).
 Gingival Anatomy
Mean width of attached gingiva in the
human dentition.
Fig. 5.
rectly related to the health of the free gin-
giva. Consequently, the presence of a gingi-
val groove cannot be used as a clinical
criterion of the normal gingiva.
The measurements show that the gingival
groove is located between 0.8 and 2.1 mm
from the gingival margin and that when a
gingival groove is present it is located ap-
proximately level with the bottom of the
gingival crevice. This relationship would
suggest that the presence or absence of the
gingival groove is dependent on the depth
of the gingival crevice or pocket, and that
its location is in some way determined by the
location of the bottom of the gingival crev-
ice (the base of the epithelial attachment).
However, both clinical measurements and
microscopic examination have shown that
the width of the free gingiva and the depth
of the gingival crevice seldom fully coincide.
Microscopic investigation of the spatial
relationship between the gingival groove and
the structural elements of the marginal peri-
odontium indicates that the presence or
absence, as well as the location of the gin-
Page 11
primary and permanent
Deciduous teeth
Gingival margin on enamel
Permanent
teeth
Gingival margin on cementum
Diagram.
gival groove may be dependent upon a spe-
cial arrangement of the supra alveolar col-
lagen fibers running from the cementum into
the free and attached gingiva. The special
configuration of the fiber systems probably
arises when a certain number of dimen-
sional relationships exist between the differ-
ent anatomical features of the marginal
periodontium (Fig. 6).
In view of the fact that a gingival groove
is found only in one third of the normal gin-
givae it is unreasonable to assume that this
represents the dividing line between free and
attached gingivae. A more suitable demarca-
tion would be an imaginary horizontal plane
which can be drawn from the bottom of the
gingival crevice to the surface at the gingival
groove or in the absence of a groove, at a
level corresponding to the bottom of the
gingival crevice. In this way the free gingiva
may be defined as a three-dimensional con-
cept comprising the surface epithelium of
the marginal gingiva, the gingival margin
and the gingival crevice as well as the inter-
connecting fibrous tissue.
Page 12 AlNAMO AND LÖF,

Attached gingiva. This investigation has

shown that the width of the attached gingiva
varies widely between different teeth and
jaws. The attached gingiva on deciduous
teeth is narrower than that on corresponding
teeth of the adult dentition, but the pattern
of variation is similar in the two. The broad-
est attached gingiva is invariably found in
the frontal regions and decreases from the
cuspid area into the lateral segments. In
both the primary and permanent dentition
the narrowest zone of attached gingiva is
found on the first tooth distal to the cuspid,
i.e., the first deciduous molar or the first
premolar. In any tooth, a narrow zone of
attached gingiva may be found associated
with frenum and muscle attachments.

These latter findings fully agree with those

reported by Bowers (1963). However, a
striking observation was made in the present
investigation on the attached gingiva of the
adult dentition. There appears to be no ma-
jor difference in the width of the attached
gingiva of students with a quantitatively and
qualitatively normal periodontium as com-
pared with healthy gingiva of older patients,
the marginal part of which had been reduced
by several millimeters through recession or
gingivectomy. As no muco-gingival surgery
with the aim of increasing the depth of the
attached gingiva had been performed in
Fig:. 6. Schematic drawing of the marginal perio-
these patients, and as no increase in this dontium showing the special arrangement of the supra-
alveolar fibers running into the free and attached
occurs with age (Bowers 1963) there ap- gingiva. The gingival groove is located in the angle
pears to be no immediate explanation for produced by these fiber systems.
this finding. The possibility exists, however,
that the attached gingiva extends apically 1. A gingival groove was found in one
by some unknown mechanism in the course third of the teeth. It did not disappear
of the re-establishment of healthy periodon- during development of mild gingival in-
tal conditions. This is presently the subject flammation, so that the gingival groove
of further investigation. cannot be used as a criterion of normal
gingiva. The gingival groove is located
SUMMARY AND CONCLUSIONS approximately level with the bottom of
the gingival crevice. Microscopic inves-
The occurrence and the anatomical rela- tigation suggests that its absence or pres-
tionship of the gingival groove and the width ence as well as its location is dependent
of the attached gingiva were studied in nor- on a special arrangement of the supra
mal and mildly inflamed gingivae of 1497 alveolar fibers running from the cemen-
deciduous and permanent teeth. tum into the free and attached gingiva.
 Gingival Anatomy Page 13
2. As the gingival groove shows little regu- 3. The width of the attached gingiva varies
larity both in the frequency of its occur- within large limits but a consistent pat-
rence and in location, the dividing line tern of variation is observed in both

between free and attached gingiva is
suggested to be represented by the pro-
jection of the bottom of the gingival
crevice on to the gingival surface.
primary and permanent dentitions. The
width of the attached gingiva in adults
where the gingival margin was on
enamel did not appreciably vary with
those resting on cementum.

REFERENCES

1. Bowers, G. M.: A study of the width of attached
gingiva. J. Periodont. 34:201-209, 1963.
2. Fehr, Carin and Mühlemann, H. R.: The surface
of the free and attached gingiva studied with the replica
method. Oral Surg. 8:649-655, 1955.
3. Löe, H. and Silness, J.: Tissue reactions to a new
gingivectomy pack. Oral Surg. 14:1305-1314, 1961.
4. Löe, H. and Silness, J.: Periodontal disease in
pregnancy. I. Prevalence and severity. Acta Odont.
Scand. 21:533-551, 1963.
5. LÖe, H., Theilade, Else and Börglum Jensen, S.:
Experimental gingivitis in man. J. Periodont. 36:177-
187, 1965.
6. Orban, B.: Clinical and histologic study of the
surface characteristics of the gingiva. Oral Surg. 1:827-
841, 1948.
7. Orban, B.: Oral histology and embryology. 3rd
ed London, Henry Kimpton, 1953, p. 364.

THE LATE DR. ISADOR HIRSCHFELD HONORED

The late Dr. Isador Hirschfeld was honored recently by The American Academy of Periodontology
with the dedication to his memory of the Dr. John Opie McCall Award. The Award, sponsored by the
pharmaceutical firm of E. R. Squibb & Sons, was presented to Dr. Hirschfeld's son, Dr. Leonard Hirsch-
feld, at a reception during the annual meeting of The American Academy of Periodontology held in
Las Vegas, Nevada for his many contributions in this field.
Shown here is Dr. Leonard Hirschfeld (left) accepting the award from Dr. Frank Beube, president,
The American Academy of Periodontology.