The Importance of Keratinized Gingiva Surrounding Dental

Implants

By

Anita Desai

Juniata College, 2008

Howard University College of Dentistry, 2012

University of Pittsburgh School of Dental Medicine Department of Periodontics, 2015

Submitted to the Graduate Faculty of

University of Pittsburgh School of Dental Medicine in partial fulfillment

of the requirements for the degree of

Masters of Dental Science

University of Pittsburgh

2015

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 U N IV E R S IT Y O F P IT T S B U R G H
S C H O O L O F D E N T A L M E D IC IN E

This thesis was presented

by

Anita Desai

It w a s d e f e n d e d o n
M a y1 2 , 2 0 1 5
and approved by
A l i S e ye d a i n , D M D , M D S , A s s i s t a n t P r o f e s s o r , D i r e c t o r o f
Undergraduate Periodontics, Department of
Periodontics and Preventative Dentistry
Edward Heinrichs, DDS, Assistant Professor Periodontics Department
Thesis Director: Pouran Famili, DMD, MDS, MPH, PHD, Professor,
Department of Periodontics and Prevent ive Dentistry

ii
Copyright © by Anita Desai
2015

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 T h e I mp o r t a n c e o f K e r a t i n i z e d G i n g i v a S u r r o u n d i n g D e n t a l
I mp l a n t s
Anita Desai, DDS, MDS
U n i v e r s i t y o f P i t t s b u r gh , 2 0 1 5

Pu r p o s e : T h e p u r p o s e o f t h i s s t u d y w a s t o d e t e r m i n e i f k e r a t i n i z e d

gi n gi v a h a s a n e f f e c t o n t h e s u c c e s s o f i m p l a n t s .

M a t e r i a l s a n d M e t h o d s : S i x t y- n i n e i m p l a n t s w e r e u s e d i n t h i s s t u d y.

T h e a m o u n t o f k e r a t i n i z e d gi n gi v a w a s m e a s u r e d a n d d i v i d e d i n t o t w o

groups; less than 2mm and greater than 2mm. The amount of

k e r a t i n i z e d g i n gi v a w a s c o m p a r e d t o c l i n i c a l p a r a m e t e r s s u c h a s

b l e e d i n g u p o n p r o b i n g, r e d n e s s , a n d p o c k e t d e p t h s t o d e t e r m i n e

whether implant success was related to the amount of keratinized

gi n gi v a .

R e s u l t s : C h i s q u a r e a n d r e g r e s s i o n a n a l ys i s w e r e u s e d t o a n a l yz e t h e

data. All implants survived independent of the amount of keratinized

gi n gi v a . P a t i e n t s w i t h l e s s t h a n 2 m m o f k e r a t i n i z e d gi n gi v a d i s p l a ye d

increased bleeding upon probing and redness , which was statistically

significant (p=0.023), indicating increased inflammation due to lack

o f k e r a t i n i z e d g i n gi v a .

C o n c l u s i o n : A m o u n t o f k e r a t i n i z e d gi n gi v a d i d n o t a f f e c t t h e s u c c e s s

rate of implants. However, implants with less than 2mm of

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k e r a t i n i z e d g i n gi v a e x h i b i t e d i n c r e a s e d b l e e d i n g u p o n p r o b i n g,

redness, and inflammation, which may contribute to later failure.

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 TABLE OF CONTENTS

1 . 0 I N T R O D U C T I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 . 0 R E V I E W O F T H E L I T E R A T U R E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 3

2.1 SURGICAL TECHNIQUES ........................................................... 3

2.2 NEED FOR MINIMAL AMOUNT OF KERATINIZED GINGIVA .. 4

2.3 DENTAL IMPLANT ANATOMY ................................................... 5

2.4 IMPLANT-MUCOSA INTERFACE ............................................... 7

2.5 IMPLANT SUPPORTED RESTORATIONS ................................... 8

2.6 HYPOTHESIS AND PURPOSE ..................................................... 9

3 . 0 M A T E R I A L S A N D M E T H O D S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 1 0

4 . 0 R E S U L T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 1 2

5 . 0 D I S C U S S I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9

6 . 0 C O N C L U S I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1

7 . 0 B I B L I O G R A P H Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2

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 LIST OF TABLES

TABLE 1. KERATINIZED GINGIVA RESEARCH CASE REPORT ..... 15

TABLE 2. POCKETING VS KERATINIZED GINGIVA ..................... 16

TABLE 3. BLEEDING VS KERATINIZED GINGIVA ........................ 17

TABLE 4. REGRESSION FINAL MODEL ........................................ 18

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 1.0 INTRODUCTION

The periodontium is composed of four structures, the cementum,

a l v e o l a r b o n e , p e r i o d o n t a l l i g a m e n t , a n d t h e gi n g i v a . It i s c o n s i d e r e d

the supporting structure of the teeth. These structures are derived

from the dental follicle during tooth development. Each of the four

components has a distinct location, composition, architecture, and

function. The periodontium supports the teeth during function and

allows the teeth to withstand considerable forces and insult.

Periodontal disease is an inflammatory disease of the peri odontium

resulting in the progressive destruction of the structures comprising

t h e p e r i o d o n t i u m ( C h u n g, 2 0 0 6 ) .

T h e p r o t e c t i o n a n d m a i n t e n a n c e o f p e r i o d o n t a l h e a l t h i s t h o u gh t

to be related to the presence of an adequate zone of keratinized

gi n gi v a . K e r a t i n i z e d gi n gi v a s u r r o u n d s t h e n e c k s o f t h e t e e t h a n d i s

m e a s u r e d f r o m t h e m u c o gi n gi v a l j u n c t i o n t o t h e f r e e gi n gi v a l m a r g i n .

H i s t o l o g i c c o m p a r i s o n o f k e r a t i n i z e d a t t a c h e d gi n g i v a a n d

n o n k e r a t i n i z e d a l v e o l a r m u c o s a s h o w s t h a t a t t a c h e d gi n gi v a i s

keratinized with thin, prominent epithelial ridges, and is firmly

a t t a c h e d t o t h e u n d e r l yi n g b o n e a n d t o o t h a l l o w i n g i t b e m o r e

protective and making it better able to withstand mechanical irritation

( B o u r i , 2 0 0 8 ) . La n g a n d Lo e i n 1 9 7 2 s t a t e d t h a t t h e r e m u s t b e a t l e a s t

2 m m o f k e r a t i n i z e d gi n gi v a , o f w h i c h 1 m m m u s t b e a t t a c h e d ( La n g

1
a n d Lo e , 1 9 7 2 ) . T h e i r s t u d y s h o w e d 8 0 % o f s i t e s w i t h k e r a t i n i z e d

gi n gi v a 2 m m o r g r e a t e r r e m a i n e d h e a l t h y, w h i l e s i t e s w i t h l e s s t h a n 2

m m o f k e r a t i n i z e d g i n gi v a d e m o n s t r a t e d s i gn s o f c l i n i c a l

i n f l a m m a t i o n ( La n g a n d Lo e , 1 9 7 2 ) . T h e s e f i n d i n g s l e d t o t h e i r

c o n c l u s i o n t h a t a t l e a s t 2 m m o f k e r a t i n i z e d gi n gi v a i s r e q u i r e d f o r

s t a b i l i t y o f t h e p e r i o d o n t i u m ( La n g a n d Lo e , 1 9 7 2 ) . T h i s c o n c l u s i o n

a l s o r a t i o n a l i z e d t h e i n t r o d u c t i o n o f n u m e r o u s s u r gi c a l p r o c e d u r e s t o

i n c r e a s e t h e w i d t h o f k e r a t i n i z e d g i n gi v a i n d e f i c i e n t a r e a s .

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 2.0 REVIEW OF THE LITERATURE

2.1 SURGICAL TECHNIQUES

Two commonly used surgical techniques by which to increase

t h e w i d t h o f k e r a t i n i z e d gi n g i v a a r e t h e f r e e gi n g i v a l g r a f t a n d t h e

subepithelial connective tissue graft (Oh, 2008). Bjorn in 1963 and

A t k i n s i n 1 9 6 8 f i r s t d e s c r i b e d t h e f r e e gi n gi v a l g r a f t p r o c e d u r e . T h i s

g r a f t w a s i n i t i a l l y u s e d t o i n c r e a s e t h e a m o u n t o f k e r a t i n i z e d gi n gi v a ,

b u t l a t e r s t u d i e s h a v e d e m o n s t r a t e d t h e a b i l i t y o f t h i s gr a f t t o a l s o

a t t a i n r o o t c o v e r a g e ( O h , 2 0 0 8 ) . A f r e e gi n gi v a l g r a f t i n v o l v e s

g r a f t i n g a d o n o r p i e c e o f gi n gi v a t o a r e c i p i e n t s i t e . T h e f r e e

gi n gi v a l g r a f t i s a v e r y p r e d i c t a b l e p r o c e d u r e t o i n c r e a s e t h e a m o u n t

o f k e r a t i n i z e d g i n gi v a . E d e l , i n 1 9 7 4 , f i r s t d e s c r i b e d t h e

subepithelial connective tissue graft. A subepithelial connective

t i s s u e gr a f t r e f e r s t o s u b m e r g i n g g i n gi v a l c o n n e c t i v e t i s s u e u n d e r a

p a r t i a l t h i c k n e s s f l a p ( O h , 2 0 0 8 ) . T h e gi n gi v a l c o n n e c t i v e t i s s u e w i l l

i n d u c e t h e f o r m a t i o n o f k e r a t i n i z e d gi n gi v a . T h i s p r o c e d u r e i s n o t a s

p r e d i c t a b l e a s a f r e e gi n g i v a l g r a f t , b u t i s a l s o i n t e n d e d t o i n c r e a s e

t h e a m o u n t o f k e r a t i n i z e d gi n gi v a a n d g a i n r o o t c o v e r a g e .

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 2 . 2 N E E D F O R M I N I M A L A M O U N T O F K E R A T I N I ZE D
GINGIVA

La t e r s t u d i e s c h a l l e n ge d t h i s c o n c e p t o f t h e n e e d f o r a m i n i m a l

a m o u n t o f k e r a t i n i z e d gi n gi v a , a n d h a v e s h o w n t h a t b y c o n t r o l l i n g

i n f l a m m a t i o n w i t h a d e q u a t e o r a l h yg i e n e , p e r i o d o n t a l s t a b i l i t y c a n b e

m a i n t a i n e d w i t h a l m o s t n o k e r a t i n i z e d gi n gi v a . A c c o r d i n g t o

W e n n s t r o m , a m i n i m a l a m o u n t o f k e r a t i n i z e d gi n gi v a d o e s n o t

n e c e s s a r i l y l e a d t o gi n gi v a l r e c e s s i o n a n d i n f l a m m a t i o n ( W e n n s t o m ,

2 0 1 2 ) . H e s t a t e d t h a t t h e n a r r o w z o n e o f k e r a t i n i z e d g i n gi v a l o c a t e d

apically to an area of recession is the result of recession, not the

cause (Wennstom, 2012). Some later studies state that even in areas

o f m i n i m a l k e r a t i n i z e d gi n g i v a , p r o p e r p l a q u e c o n t r o l t e c h n i q u e s c a n

p r e v e n t gi n g i v a l r e c e s s i o n a n d s o f t t i s s u e i n f l a m m a t i o n .

A n e x c e p t i o n t o t h i s w a s i n t e e t h w i t h s u b gi n g i v a l r e s t o r a t i o n s .

T h e r e w a s a s i g n i f i c a n t a s s o c i a t i o n b e t w e e n s u b gi n g i v a l r e s t o r a t i o n s

a n d g i n gi v a l i n f l a m m a t i o n i n a r e a s o f m i n i m a l k e r a t i n i z e d gi n gi v a

( B o u r i , 2 0 0 8 ) . S t e t l e r c o n c l u d e d t h a t s u b gi n gi v a l r e s t o r a t i o n s p l a c e d

o n t e e t h s u r r o u n d e d b y l e s s t h a n 2 m m o f k e r a t i n i z e d g i n gi v a

d e m o n s t r a t e d a n i n c r e a s e d gi n gi v a l i n d e x ( S t e t l e r , 1 9 8 6 ) . A c c o r d i n g

t o S t e l e r i n 1 9 8 6 , g i n gi v a l g r a f t i n g i s r e c o m m e n d e d i n a r e a s w h e r e

s u b gi n g i v a l m a r gi n s w i l l b e p l a c e d i f t h e w i d t h o f k e r a t i n i z e d gi n g i v a

is less than 5 mm (Stetler, 1986). The rationale behind this is that

the keratinized gingiva will provide a protective barrier against

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inflammation and attachment loss (Stetler, 1986). A similar study by

Li n d h e a n d E r i c s s o n d e m o n s t r a t e d a n i n c r e a s e i n p l a q u e a n d b a c t e r i a l

i n f i l t r a t e i n a r e a s w h e r e s u b gi n gi v a l r e s t o r a t i o n s w e r e p l a c e d w i t h

m i n i m a l k e r a t i n i z e d gi n gi v a ( G r e e n s t e i n , 2 0 1 1 ) .

2.3 DENTAL IMPLANT ANATOMY

In 1 9 7 8 , D r . B r a n e m a r k p r e s e n t e d t h e t i t a n i u m r o o t – f o r m

implant (Abraham, 2014). This discovery was made accidently while

s t u d yi n g b l o o d f l o w i n r a b b i t f e m u r s ( A b r a h a m , 2 0 1 4 ) . H e p l a c e d

titanium chambers in their bone and noticed that over time the

titanium became rigidly fixated to the bone and was not able to be

removed (Abraham, 2014). This was later termed by Branemark as

osseointegration, and was defined as a “direct structural and

functional connection between ordered, living bone, and the surface

o f a l o a d c a r r yi n g i m p l a n t ” ( A b r a h a m , 2 0 1 4 ) . S e v e r a l d i f f e r e n t t yp e s

of implants were later introduced and the use of dental implants for

r e p l a c e m e n t o f m i s s i n g t e e t h b e ga n t o d r a m a t i c a l l y i n c r e a s e

(Abraham, 2014). As the use of dental implants replacing natural

d e n t i t i o n b e c o m e s i n c r e a s i n gl y t h e s t a n d a r d o f c a r e , t h e a m o u n t o f

k e r a t i n i z e d g i n gi v a s u r r o u n d i n g d e n t a l i m p l a n t s t o o p t i m i z e gi n g i v a l

health also comes into question . Due to the structural and anatomical

differences between implants and natural teeth, the same concepts

c a n n o t b e a p p l i e d t o i m p l a n t s ( Li n , 2 0 1 3 ) . Im p l a n t s a r e m o r e

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susceptible to the development of inflammation and subsequent bone

loss in the presence of plaque accumulation and bacterial infiltration

d u e t o s e v e r a l f a c t o r s ( Li n , 2 0 1 3 ) . T h e i m p l a n t t o m u c o s a i n t e r f a c e i s

d i f f e r e n t f r o m t h e i n t e r f a c e b e t w e e n n a t u r a l t e e t h a n d m u c o s a ( Li n ,

2013). While the junctional epit helium ends at a similar distance to

t h e b o n e c r e s t i n b o t h t e e t h a n d d e n t a l i m p l a n t s , t h e gi n gi v a l f i b e r

o r i e n t a t i o n i s d i f f e r e n t ( Li n , 2 0 1 3 ) . T h e gi n g i v a l f i b e r s o f n a t u r a l

t e e t h r u n i n a p e r p e n d i c u l a r c o n f i gu r a t i o n , w h e r e a s t h e gi n gi v a l f i b e r s

of implants run in a parallel configuration to the implant and do not

attach to the implant surface creating a much weaker me chanical

a t t a c h m e n t c o m p a r e d t o n a t u r a l t e e t h ( Li n , 2 0 1 3 ) . T h i s w e a k e r

attachment increases the susceptibility to bacterial infiltration

l e a d i n g t o gi n g i v a l i n f l a m m a t i o n a n d b o n e l o s s a r o u n d t h e i m p l a n t . If

the surface of the implant is contaminated by bacteria, an

inflammatory response is triggered in the connective tissue (Paiva,

2 0 1 2 ) . U n l i k e t h e p e r i o d o n t a l l i ga m e n t a r o u n d n a t u r a l t e e t h , t h e b o n e

surrounding the implant cannot organize a defense mechanism against

infection (Paiva, 2012). Therefore the apical extension of the

inflammatory infiltrate around implants seems to result from the

orientation of the supra-alveolar peri-implant fibers (Paiva, 2012).

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 2.4 IMPLANT-MUCOSA INTERFACE

A s s t a t e d b y B o u r i i n 2 0 0 8 n a r r o w z o n e s o f k e r a t i n i z e d g i n gi v a

a r e l e s s r e s i s t a n t t o i n s u l t a l o n g t h e i m p l a n t - m u c o s a i n t e r f a c e . In t h e

presence of an inflammatory response, implants placed in a reas with

n a r r o w z o n e s o f k e r a t i n i z e d gi n g i v a h a v e a n i n c r e a s e d s u s c e p t i b i l i t y

to tissue breakdown and showed earlier loss of attachment (Bouri,

2008). Greenstein, in a literature review, similarly stated that a

n a r r o w z o n e o f k e r a t i n i z e d gi n gi v a , l e s s t h a n 2 m m , w a s a s s o c i a t e d

with increased inflammation, plaque accumulation, and recession of

t h e gi n gi v a , u l t i m a t e l y r e s u l t i n g i n t i s s u e d e s t r u c t i o n ( G r e e n s t e i n ,

2 0 1 1 ) . W i d e r z o n e s o f k e r a t i n i z e d gi n gi v a m a y o f f e r m o r e r e s i s t a n c e

to the forces of masticatio n and frictional contact that occurs during

o r a l h yg i e n e p r o c e d u r e s a n d m a y c r e a t e a n e n v i r o n m e n t t h a t i s l e s s

susceptible to tissue breakdown in the presence of inflammation

(Bouri, 2008).

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 2 . 5 I M P L A N T SU P P O R T E D R E S T O R A T I O N S

Also, the implant-supported restoration is often located

s u b gi n g i v a l l y. A s s t a t e d b y V a l d e r h a u g a n d B i r k e l a n d t h e

s u b gi n g i v a l p l a c e m e n t o f t h e r e s t o r a t i o n w a s a s s o c i a t e d w i t h a

significantly increased rate of inflammation and attachment loss,

e s p e c i a l l y i n a r e a s w i t h m i n i m a l k e r a t i n i z e d gi n gi v a ( C h u n g, 2 0 0 6 ) .

An adequate biologic width is fundamental to the success of implants.

The biologic width around implants ranges from 3 -4 mm (Esper,

2 0 1 2 ) . It i s c o m p o s e d o f j u n c t i o n a l e p i t h e l i u m a n d c o n n e c t i v e t i s s u e .

P r o s t h e t i c r e s t o r a t i o n s e x t e n d i n g s u b gi n gi v a l l y r e q u i r e a w i d t h o f a t

l e a s t 5 m m o f k e r a t i n i z e d gi n gi v a ( E s p e r , 2 0 1 2 ) . T h e s e t y p e s o f

restorations often facilitate the accumulation of plaque bacteria and

gi n gi v a l i n f l a m m a t i o n b y i m p i n gi n g o n b i o l o gi c w i d t h ( E s p e r , 2 0 1 2 ) .

According to Abrahamsson in 1996, a certain width of keratinized

gi n gi v a i s r e q u i r e d t o p r o m o t e a n a d e q u a t e e p i t h e l i a l a n d c o n n e c t i v e

tissue attachment; otherwise bone resorption can occur in an attempt

t o e s t a b l i s h a n a d e q u a t e b i o l o gi c w i d t h a r o u n d d e n t a l i m p l a n t s

(Wennstrom, 2012).

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 2 . 6 H Y P O T H E SI S A N D P U R P O SE

There is a great deal of controversy in the literature about the

i m p o r t a n c e o f k e r a t i n i z e d gi n gi v a a r o u n d d e n t a l i m p l a n t s a n d t h e

a m o u n t , i f a n y, w h i c h i s r e q u i r e d f o r i m p l a n t h e a l t h . S o m e s t u d i e s

concluded that peri-implant health could be maintained even in the

a b s e n c e o f k e r a t i n i z e d gi n g i v a p r o v i d i n g a d e q u a t e o r a l h y gi e n e i s

e m p l o ye d ( C h u n g, 2 0 0 6 ) . O t h e r s t u d i e s s u g g e s t t h a t a r e a s o f m i n i m a l

k e r a t i n i z e d g i n gi v a h a v e d e c r e a s e d t i s s u e r e s i s t a n c e a l l o w i n g p l a q u e

a c c u m u l a t i o n , w h i c h i n c r e a s e s t h e r i s k o f g i n gi v a l i n f l a m m a t i o n ,

m a r g i n a l b o n e l o s s , a n d i n c r e a s e d gi n g i v a l r e c e s s i o n ( C h u n g, 2 0 0 6 ) .

W e h yp o t h e s i z e t h a t i m p l a n t s s u r r o u n d e d b y l e s s t h a n 2 m m o f

k e r a t i n i z e d g i n gi v a a r e m o r e s u s c e p t i b l e t o f a i l u r e d u e t o d e c r e a s e d

resistance of the tissues to bacterial infiltration, leading to increased

tissue breakdown, increased probing depths surrounding the implants,

i n c r e a s e d b l e e d i n g u p o n p r o b i n g, a n d i n c r e a s e d b o n e l o s s . T h e

purpose of this study is to determine whether a minimum width of

2 m m o f k e r a t i n i z e d gi n gi v a a r o u n d d e n t a l i m p l a n t s i s n e c e s s a r y f o r

the health and stability of the surrounding soft and hard tissues of the

periodontium. Knowing this will help clinicians to deter mine whether

o r n o t gi n g i v a l a u g m e n t a t i o n t o i n c r e a s e t h e a m o u n t o f k e r a t i n i z e d

gi n gi v a i s r e q u i r e d p r i o r t o i m p l a n t t h e r a p y.

9
 3.0 MATERIALS AND METHODS

A cross sectional study was done to determine implant

health/success when looking specifically at the amount of keratinized

gi n gi v a s u r r o u n d i n g t h e i m p l a n t . Im p l a n t h e a l t h , a s w e d e t e r m i n e d ,

w a s t h e a b s e n c e o f b l e e d i n g u p o n p r o b i n g, r e d n e s s , i n f l a m m a t i o n ,

s u p p u r a t i o n , m o b i l i t y, p o c k e t d e p t h s l e s s t h a n o r e q u a l t o 3 m m , a n d

n o r a d i o gr a p h i c e v i d e n c e o f p r o g r e s s i v e c r e s t a l b o n e l o s s .

Patients participating in this study were randomly selected from

those who presented to the Graduate Periodontics Clinic or the

Multidisciplinary Implant Center at the University of Pittsburgh

School of Dental Medicine for routine maintenance appointments.

S u b j e c t s i n c l u d e d i n t h i s s t u d y w e r e 2 1 ye a r s o f a g e o r o l d e r a n d h a v e

had an implant supported restoration placed a minimum of six months

prior. Two examiners, one resident and one faculty member in the

G r a d u a t e P e r i o d o n t i c s D e p a r t m e n t , r e c o r d e d d a t a f o r t h i s s t u d y. B o t h

examiners were calibrated and inter and intra -examiner reliability was

evaluated.

The following data was recorded for each implant: The number

a n d s i t e o f t h e i m p l a n t , w i d t h o f k e r a t i n i z e d gi n gi v a , p o c k e t d e p t h ,

presence or absence of bleeding upon probing, presence or absence of

s u p p u r a t i o n , m o b i l i t y o f t h e i m p l a n t , g i n gi v a l c o l o r , r a d i o g r a p h i c

b o n e l e v e l , t i m e s i n c e i m p l a n t p l a c e m e n t , t yp e o f i m p l a n t , s m o k i n g

h i s t o r y i n p a c k s p e r ye a r , a g e , a n d g e n d e r . T h e w i d t h o f k e r a t i n i z e d

10
gi n gi v a w a s m e a s u r e d a t t h e m i d f a c i a l a s p e c t o f e a c h i m p l a n t u s i n g a

M i c h i g a n P r o b e . M e a s u r e m e n t s w e r e t a k e n f r o m t h e m u c o gi n gi v a l

j u n c t i o n t o t h e f r e e gi n gi v a l m a r g i n a n d w e r e m e a s u r e d t o t h e n e a r e s t

millimeter. Pocket depths were measured to the nearest millimeter

using a Michigan Probe at six surfaces of each implant: mesial-

b u c c a l , m i d b u c c a l , d i s t o b u c c a l , m e s i a l - l i n gu a l , m i d l i n g u a l ,

distolingual. Radiographic bone level was measured from a fixed

reference point to the alveolar crest on periapical radiographs. The

periapical radiographs taken at the time of implant placement were

compared to periapical radiographs taken at the current maintenance

appointment to assess crestal bone loss.

W i d t h o f k e r a t i n i z e d gi n gi v a w a s d i v i d e d i n t o t w o g r o u p s u s i n g

2 mm as a cutoff point: Group 1: implants where the width of the

s u r r o u n d i n g k e r a t i n i z e d gi n g i v a w a s 2 m m o r g r e a t e r , G r o u p 2 :

i m p l a n t s w h e r e t h e w i d t h o f t h e s u r r o u n d i n g k e r a t i n i z e d g i n gi v a w a s

less than 2 mm.

11
 4.0 RESULTS

This study included 69 patients . Thirty-six patients (52.2%) of

t h e p a t i e n t s w e r e 2 6 - 5 0 ye a r s o l d a n d 3 3 p a t i e n t s ( 4 7 . 8 % ) r a n g e d i n

a g e f r o m 5 1 - 7 5 ye a r s . F o r t y- n i n e p a t i e n t s ( 7 1 . 0 % ) w e r e m a l e , w h i l e

20 (29.0%) were female. Thirty-four (49.3%) of the patients reported

current use of tobacco products, while 35 (50.7%) of the patients

denied use of tobacco. Eighteen patients (26.1%) had keratinized

gi n gi v a l e s s t h a n 2 m m s u r r o u n d i n g t h e i r i m p l a n t s , c o m p a r e d t o 5 1

p a t i e n t s ( 7 3 . 9 % ) w h o h a d m o r e t h a n 2 m m o f k e r a t i n i z e d gi n gi v a

surrounding their implants. Bleeding upon probing was seen in 17

patients (24.6%) and was absent in 52 patients (75.4%) . Pocket

depths of more than 3mm was noted in 22 patients (31.9%) , compared

to pockets depths less than 3mm noted in 47 patients (68.1%) (Table

1).

The data was analyzed using a Chi Square test to determine if

t h e w i d t h o f k e r a t i n i z e d gi n g i v a s i g n i f i c a n t l y a f f e c t e d p r o b i n g d e p t h s

a n d b l e e d i n g u p o n p r o b i n g. T h e d a t a w a s c o n s i d e r e d s t a t i s t i c a l l y

significant if the p value is less than or equal to 0.05. Also, a

m u l t i v a r i a t e r e gr e s s i o n a n a l ys i s w a s d o n e t o d e t e r m i n e w h e t h e r t h e

w i d t h o f k e r a t i n i z e d gi n gi v a w a s i n d e p e n d e n t l y a s s o c i a t e d w i t h

b l e e d i n g u p o n p r o b i n g. S m o k i n g a n d g e n d e r w e r e a d j u s t e d . A g e w a s

12
n o t d i s t r i b u t e d w e l l e n o u gh t o b e u s e d i n t h e m o d e l . O t h e r v a r i a b l e s

w e r e n o t s i gn i f i c a n t a n d w e r e n o t i n c l u d e d i n t h e f i n a l m o d e l .

C h i S q u a r e a n a l ys i s w a s d o n e t o e v a l u a t e t h e a s s o c i a t i o n

between the amount of keratinized gi n g i v a and pocket depths.

S t a t i s t i c a l a n a l ys i s o f t h e d a t a f o r p o c k e t d e p t h s s h o w s t h a t t h e r e i s

no s i gn i f i c a n t association between pocketing and amount of

k e r a t i n i z e d gi n g i v a ; i n d i c a t i n g t h a t a l a c k o f k e r a t i n i z e d gi n gi v a d o e s

not result in greater pocket depths (p = 0.878) (Table 2).

S t a t i s t i c a l a n a l ys i s o f t h e d a t a f o r b l e e d i n g u p o n p r o b i n g s h o w s

that there is a statistically significant association between the amount

o f k e r a t i n i z e d g i n gi v a a n d b l e e d i n g u p o n p r o b i n g ( p = 0 . 0 2 3 ) .

E i gh t y- t w o p e r c e n t o f t h e i m p l a n t s w i t h l e s s t h a n 2 m m o f k e r a t i n i z e d

gi n gi v a e x p e r i e n c e d b l e e d i n g u p o n p r o b i n g a s c o m p a r e d t o 5 6 % o f t h e

i m p l a n t s w i t h k e r a t i n i z e d gi n gi v a g r e a t e r t h a n 2 m m ( T a b l e 3 ) .

A l o gi s t i c r e gr e s s i o n m o d e l w a s p e r f o r m e d , a n d i t w a s a d j u s t e d

f o r s m o k i n g a n d ge n d e r . S i n c e a g e w a s n o t d i s t r i b u t e d w e l l e n o u gh ,

it was not used in the model. Variables such as, suppuration,

mobility of the implant, timing of implant placement, and width of

t h e i m p l a n t w e r e n o t s i gn i f i c a n t a n d w e r e n o t i n c l u d e d i n t h e f i n a l

model.

Table 4 showed implants with less than 2mm of keratinized

gi n gi v a a r e 6 . 5 t i m e s m o r e l i k e l y t o e x p e r i e n c e b l e e d i n g u p o n p r o b i n g

13
t h a n t h o s e i m p l a n t s w i t h g r e a t e r t h a n 2 m m o f k e r a t i n i z e d g i n gi v a

(OR=6.5). The final model was adjusted for smoking a nd gender.

14
TABLE 1 . KERATINI ZED GI NGIVA RESEARCH CASE
REPO RT

Characteristics N u mb e r o f
Patients
Age
< 2 5 ye a r s 0
2 6 - 5 0 ye a r s 36
5 1 - 7 5 ye a r s 33
> 7 5 ye a r s 0

Gender
Male 49
Female 20

Smoke
Yes 34
No 35

KG levels
< 2mm 18
> 2mm 51

Bleeding
Yes 17
No 52

Redness
Yes 3
No 66

Pocket Depth
> 3mm 22
< 3mm 47

T i mi n g of Implant
< 2 ye a r s 5
2-3 ye a r s 15
> 3 ye a r s 49

15
TABLE 2. POCKETING VS KE RATINI ZE D GI NGIVA

Pocketing > 3mm KG < 2mm Total

Yes No

Yes 6.00 16.00 22.00

27.27 72.73 100.00
33.33 31.37 31.88
No 12.00 35.00 47.00
25.53 74.47 100.00
66.67 68.63 68.12
Total 18.00 51.00 69.00
26.09 73.91 100.00
100.00 100.00 100.00

Chi square = 0.0236 P = 0.878

16
TABLE 3. BLE EDING VS KE RATINI ZED GI NGIVA

Bleeding KG < 2mm Total

Yes No

Yes 8.00 9.00 17.00

47.06 52.94 100.00
44.44 17.65 24.64
No 10.00 42.00 52.00
19.23 80.77 100.00
55.56 82.35 75.36
Total 18.00 51.00 69.00
26.09 73.91 100.00
100.00 100.00 100.00

Chi Square = 5.1455 P = 0.023

17
TABLE 4. REG RESSION FINAL MODE L
Bleeding Odds Standard Z P > |z | 95% CI
Ratio Error
KG < 6.483607 4.868435 2.49 0.013 1.488 28.25
2mm
Gender 2.780876 2.123517 1.34 0.180 0.623 15.42
Smoking 12.19472 9.778232 3.12 0.002 2.533 58.71
_ cons 0.2460288 0.1948526 -1.77 0.077 0.521 1.162

18
 5.0 DISCUSSION

T h e n e e d f o r k e r a t i n i z e d gi n gi v a a r o u n d d e n t a l i m p l a n t s h a s

been a controversial topic. Several studies have suggested that a

m i n i m a l w i d t h o f k e r a t i n i z e d gi n gi v a a r o u n d i m p l a n t s i s n e c e s s a r y f o r

health and stability of the implant, while other studies ha ve failed to

demonstrate the need for minimal width.

The results of this study suggest that implants surrounded by

l e s s t h a n 2 m m o f k e r a t i n i z e d g i n gi v a h a v e a n i n c r e a s e d a m o u n t o f

b l e e d i n g u p o n p r o b i n g. B l e e d i n g u p o n p r o b i n g i s a c l i n i c a l i n d i c a t i o n

o f a c t i v e i n f l a m m a t i o n . P r o l o n ge d i n f l a m m a t i o n a r o u n d d e n t a l

implants can result in subsequent attachment loss and bone loss,

ultimately leading to failure of the implant.

A s s t a t e d b y La n g a n d Lo e , t h e m i n i m u m w i d t h f o r h e a l t h y

k e r a t i n i z e d t i s s u e s u r r o u n d i n g t h e t e e t h i s 2 m m ( La n g a n d Lo e , 1 9 7 2 ) .

This concept has been carried over to peri -implant keratinized tissue.

However, several studies have challenged this concept as it pertains

to teeth and also implants, and have stated that a minimum width of

k e r a t i n i z e d g i n gi v a i s n o t r e q u i r e d p r o v i d e d a d e q u a t e o r a l h yg i e n e i s

m a i n t a i n e d . C o x a n d Za r b i n 1 9 8 7 c o n d u c t e d a s t u d y i n w h i c h t h e y

f o u n d t h a t 8 0 % o f t h e i m p l a n t s e v a l u a t e d h a d n o k e r a t i n i z e d gi n gi v a

b u t h a d h e a l t h y p e r i - i m p l a n t t i s s u e ( C o x a n d Z a r b , 1 9 8 7 ) . S i m i l a r l y,

Esper in 2012 showed no statistically significant difference between

19
bleeding upon probing and plaque control and the width of keratinized

gi n gi v a ( E s p e r , 2 0 1 2 ) .

W h i l e t h e a b s e n c e o f k e r a t i n i z e d gi n gi v a a r o u n d d e n t a l i m p l a n t s

does not necessarily cause peri -implant disease, maintaining

m e t i c u l o u s o r a l h yg i e n e i n a r e a s o f m i n i m a l k e r a t i n i z e d g i n gi v a i s

difficult because mobile mucosa is more susceptible to inflammatory

c h a n g e s ( T e n B r u g g e n c a t e , 1 9 9 1 ) . P r o p e r o r a l h yg i e n e m a y b e b e t t e r

f a c i l i t a t e d i n a r e a s o f a d e q u a t e k e r a t i n i z e d gi n g i v a ( S a l v i a n d La n g ,

2004).

H e a l t h y k e r a t i n i z e d gi n gi v a a r o u n d d e n t a l i m p l a n t s r e s u l t s i n

more predictable success and ma intenance of the implant, and also

r e s u l t s i n a n i m p r o v e d e s t h e t i c o u t c o m e . K e r a t i n i z e d g i n gi v a

provides stabilization to the periodontium, protects the teeth and

implants from masticatory and external trauma, and provides a barrier

to inflammatory infiltrate (Paiva, 2012). While the sample size in

this study is limited, we feel that implants should have a minimum

a m o u n t o f 2 m m o f k e r a t i n i z e d g i n gi v a t o m a i n t a i n h e a l t h . W e b e l i e v e

t h a t r e c o n s t r u c t i o n o f t h e k e r a t i n i z e d g i n gi v a i n d e f i c i e n t a r e a s u s i n g

t e c h n i q u e s s u c h a s t h e f r e e gi n g i v a l g r a f t o r t h e s u b e p i t h e l i a l

c o n n e c t i v e t i s s u e g r a f t s h o u l d b e e m p l o ye d p r i o r t o i m p l a n t

placement.

20
 6.0 CONCLUSION

D e s p i t e l i m i t e d d a t a i n t h i s s t u d y, w e c o n c l u d e d t h a t r e g a r d l e s s

o f t h e a m o u n t o f k e r a t i n i z e d g i n gi v a p r e s e n t , i m p l a n t p l a c e m e n t w a s

successful. However, implants with less than 2mm of keratinized

gi n gi v a e x h i b i t e d i n c r e a s e d b l e e d i n g u p o n p r o b i n g, w h i c h i s a c l i n i c a l

sign of inflammation. Persistent inflammation around an implant may

possibly contribute to later failure. These findings may warrant

gi n gi v a l a u gm e n t a t i o n p r i o r t o i m p l a n t p l a c e m e n t i n a r e a s w h e r e

m i n i m a l k e r a t i n i z e d gi n gi v a e x i s t s t o p r e v e n t f u t u r e f a i l u r e . F u r t h e r

s t u d i e s m a y b e n e e d e d t o c o n f i r m t h e f i n d i n gs f r o m t h i s s t u d y d u e t o

the small sample size.

21
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