Evaluation of the width of attached gingiva: A systematic review and meta-analysis

doi:10.21203/rs.3.rs-4944197/v1

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Systematic Review

Evaluation of the width of attached gingiva: A systematic review and meta-analysis

https://doi.org/10.21203/rs.3.rs-4944197/v1

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Aims

To conduct a systematic review and meta-analysis of studies that evaluated the width of attached gingiva.

Methods

An electronic search was performed in PubMed, Embase, Web of Science, and CNKI with no language restrictions. Eligible study selection, data extraction, and evaluation of risk of bias were conducted by two authors independently and in duplicate. Any disagreement was solved by discussion or judged by a third reviewer.

Results

Six studies were finally included. Upper incisors and upper canines had pooled Means of 4.48 mm and 3.80 mm, while lower incisors and lower canines had pooled Means of 3.23 mm and 2.40 mm, respectively. Upper premolar and lower premolars had pooled Means of 3.13 mm and 2.16 mm, respectively. Upper molars had a pooled Mean of 3.38 mm, while lower molars had a pooled Mean of 2.40 mm.

Conclusion

The maxillary attached gingiva is always wider than the corresponding mandibular attached gingiva in the same region. In the four quadrants, the attached gingiva from wide to narrow are incisors, canines, molars, and premolars, respectively. Future studies are necessary to evaluate the width of attached gingiva among different gingival phenotypes and age groups.

Dentistry

Width of attached gingiva

Mini-implant

Systematic review

Meta-analysis

Attached gingiva is an anatomic structure of the periodontium continuous with the free gingiva and lies between the free gingival groove and the mucogingival junction.¹ Histologically, the attached gingival epithelium is comprised of keratin as well as thin, prominent epithelial ridges and a thick lamina propria and the connective tissue contains no elastic fibers.² All these features highlight the importance and contribution of the attached gingiva to the health and stability of the periodontium, including the provision of increased resistance to external injury, stabilization of the gingival margin, and dissipating physiological forces exerted by the muscular fibers of the alveolar mucosa on the gingival tissue.³ Especially in the field of orthodontics, the insertion of mini-implants at the mucogingival junction is a common practice. If the mini-implants are positioned too close to the alveolar ridge, they may become unstable and prone to loosening, ultimately resulting in treatment failure. Meanwhile, insertion into the alveolar mucosa could cause inflammation and subsequent failure.⁴ Cheng et al., in a prospective clinical study involving 140 mini-implants, found that the absence of keratinized mucosa around mini-implants significantly increased the risk of infection and failure.⁵ These scenarios highlight the clinical importance of a healthy attached gingiva with an appropriate width in orthodontic treatments.

To date, numerous studies have investigated the width of attached gingiva; however, comprehensive measurements are limited. Padmini et al. measured the width of attached gingiva and vestibular depth of 165 young Malaysian adults, but only included six anterior teeth, from cuspid to cuspid.⁶ Sreeja et al. investigated the association between the width of attached gingiva and its impact on dental hygiene care. It is regrettable that they only provided the mean width of the attached gingiva of the gross maxillary and mandibular(3.00mm and 2.01mm,respectively), failing to provide the widths of all sites including incisors, cuspid, premolars and molars.⁷ Surprisingly, no scholar has conducted a systematic review of the existing literature on this topic. In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we conducted a systematic review to bridge this gap. Our objective was to determine the average widths of attached gingiva in various oral sites, compare and offer valuable insights for future studies.

This study aimed to systematically review and meta-analyze the attached gingival width in different oral sites respectively. By providing the mean attached gingival width and comparing them between regions, our results could assist the clinicians in periodontal and orthodontic treatment.

Protocol and Registration

The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; http://www.crd.york.ac.uk/prospero; registration number CRD42024568391).

Information Sources, Search Strategy, and Study Selection

The databases searched included those of PubMed, Embase, Web of Science, and CNKI. Specifically, the online search parameters were articles from time of database inception to August 28, 2023, without language restrictions. A search for published, peer reviewed articles was conducted using keywords “attached gingiva”, “width” and their synonyms. Titles and abstracts were assessed according to the eligibility criteria. The selected articles were evaluated after reading full texts, and a final selection was determined. Searching and assessment of studies was performed independently by two reviewers (Z.H. and Y.L.) separately. The final decisions on inclusion were made after consulting with a third reviewer (H.L.) (Figure 1).

Eligibility criteria

Owing to the research question of interest, patients with good general health, healthy gingival tissues (no loss of attachment) were included. Both randomized controlled trials (RCTs) and non-randomized studies of the effects of interventions (NRSIs) were eligible.

The following exclusion criteria were adopted: patients with systemic illnesses, pregnant or lactating women, patients on medications that could influence the width of the gingiva such as calcium channel blockers, moderate to severe gingival inflammation, presence of gingival recession, and presence of clinical attachment loss were excluded.

Data Extraction

After conducting full-text reviews of the articles, we organized the data into a standardized table, which included study design, demographic data (age, sample size, grouping, and width of attached gingiva), detailed description (interventions, treatment duration, and comparator), and outcomes. Any discrepancies in the extracted data were resolved through discussion among all three reviewers.

Risk of Bias and Quality Assessment

The evaluation of risk of bias for the included studies was performed independently and separately by two reviewers (Z.H. and Y.L.) according to the Cochrane tool for assessing risk of bias in nonrandomized trials (ROBINS-I tool).⁸ For each bias domain, a judgment score was given following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0. Any disagreement was solved by discussion or judged by a third reviewer (H.L.).

Meta-analysis

Original data were subject to statistical pooling through random effect models. Significance analysis was conducted using GraphPad Prism 9 software to evaluate the significance of outcomes between different groups (Figure 2). Heterogeneity across studies was assessed through the I² statistic, and an I² statistic greater than 50% was considered as substantial heterogeneity. If substantial heterogeneity existed, a subgroup analysis on different study designs and periodontal health condition would be executed to explore the potential heterogeneity. In addition, sensitivity analysis for studies with small sample sizes was conducted to evaluate the robustness of the pooled results in the meta-analysis. The Egger test and Begg test were used to assess publication bias. All the meta-analyses were performed in Comprehensive Meta-Analysis (version 2.2.064, Biostat, Englewood, NJ).

Description of Studies

Initially, 736 articles from the database were identified and 723 were excluded as irrelevant. The remaining thirteen articles were further assessed for eligibility, and six studies were finally included in this systematic review.^3,9-13 The procedures of online searching and selection are shown in Figure 1. Sample size ranges from 45 to 356 in different groups (Table 1).

Table 1. Characteristics of the Included Studies

Study

Design

No. of patients

Age Range

Attached Gingival Width of Incisors

Attached Gingival Width of Canines

Attached Gingival Width of Premolars

Attached Gingival Width of Molars

Adesola et al. 2018

Cross-sectional Study

n = 73

(19males, 54females)

18~34

Upper: 4.59 ± 1.79

Lower: 3.27 ± 1.17

Upper: 3.73 ± 1.51

Lower: 2.51 ± 1.17

Upper: 3.28 ± 1.51

Lower: 2.43 ± 1.07

Upper: 3.44 ± 1.69

Lower: 3.16 ± 1.03

Tenenbaum et al. 1982

Cross-sectional Study

n = 100

(68males, 32females)

19~26

Upper: 3.50 ± 1.02

Lower: 2.38 ± 0.96

Upper: 2.40 ± 1.15

Lower: 1.40 ± 0.80

Upper: 2.65 ± 1.08

Lower: 1.63 ± 0.85

Upper: 3.20 ± 1.15

Lower: 2.00 ± 0.89

Bhatia et al. 2015

Before-after Study

n = 45

15~60

Upper: 3.71 ± 0.81

Lower: 3.21 ± 0.83

Upper: 3.13 ± 1.05

Lower: 2.10 ± 0.87

Upper: 2.19 ± 0.68

Lower: 1.60 ± 0.47

Upper: 2.45 ± 0.63

Lower: 1.86 ± 0.53

Yang et al. 2017

Cross-sectional Study

n = 144

(72males, 72females)

20~30

Upper: 4.98 ± 1.20

Lower: 4.05 ± 1.00

Upper: 4.35 ± 1.20

Lower: 2.90 ± 0.90

Upper: 3.37 ± 1.01

Lower: 2.25 ± 0 .97

Upper: 3.93 ± 1.30

Lower: 2.60 ± 1.05

Wang et al. 1990

Cross-sectional Study

n = 356

(173males, 183females)

15~20

Upper: 5.05 ± 2.09

Lower: 3.00 ± 1.00

Upper: 4.70 ± 1.90

Lower: 2.80 ± 1.20

Upper: 3.85 ± 1.50

Lower: 2.74 ± 1.37

Upper: 4.00 ± 1.36

Lower: 2.65 ± 1.22

Liu et al. 2021

Case-control Study

n = 66

(18males, 48females)

20~51

Upper: 5.10 ± 1.61

Lower: 3.45 ± 1.05

Upper: 4.50 ± 1.50

Lower: 2.70 ± 1.20

Upper: 3.45 ± 1.24

Lower: 2.30 ± 0.90

Upper: 3.25 ± 1.21

Lower: 2.15 ± 0.92

Description of Outcomes

Among the proposed study outcomes, all outcomes were investigated in the included studies. Outcomes from patients with good general health, healthy gingival tissues were studied in this meta-analysis. The average width of attached gingiva for different types of teeth ranges from 4.48 mm (upper incisors) to 2.16 mm (lower premolars). Generally, maxillary teeth exhibit wider attached gingiva than mandibular teeth. The incisors possess the widest attached gingiva while the premolars show the narrowest. Widths of attached gingiva for canines and molars lie between incisors and premolars. Every analysis has a two-sided p <0.0001 except for the analysis between lower canines and lower molars.

Risk of Bias and Quality Assessment

Quality assessment for the included studies was calculated using ROBINS-I tool. Out of the six articles, four^3,10-12 were rated low in overall risk of bias and two^9,13 were rated medium. Quality assessment is presented in Table 2.

Table 3. Risk of bias

Reference	Confounding	Selection bias	Bias in the classification of interventions	Bias due to deviations from intended interventions	Bias due to missing data	Bias in measurements of outcomes	Bias in selection of the reported result	Overall
Adesola et al. 2018	Low	Low	Low	Low	Low	Low	Low	Low
Tenenbaum et al. 1982	Mod	Mod	Low	Low	Low	Low	Mod	Mod
Bhatia et al. 2015	Low	Low	Low	Low	Low	Low	Low	Low
Yang et al. 2017	Low	Low	Low	Low	Low	Low	Low	Low
Wang et al. 1990	Low	Low	Low	Low	Low	Low	Low	Low
Liu et al. 2021	Mod	Low	Low	Low	Low	Low	Low	Mod

Meta-analysis

Six studies^3,9-13 investigated the width of attached gingiva for upper incisors and upper canines, which had pooled Means of 4.48 mm (95% confidence interval [CI]: 3.86, 5.12), 3.80 mm (95% CI: 3.01, 4.59), while lower incisors and lower canines had pooled Means of 3.23 mm (95% CI: 2.76, 3.70) and 2.40 mm (95% CI: 1.87, 2.93), respectively (Figure 3).

For posterior teeth, six studies^3,9-13 investigated the width of attached gingiva for upper and lower premolars, which had pooled Means of 3.13 mm (95% CI: 2.59, 3.67) and 2.16 mm (95% CI: 1.75, 2.56), respectively (Figure 3). Six studies^3,9-13 investigated the width of attached gingiva for upper molars, which had a pooled Mean of 3.38 mm (95% CI: 2.82, 3.93), while lower molars had a pooled Mean of 2.40 mm (95% CI: 2.04, 2.76) (Figure 3).

Sensitivity Analysis

To conduct a sensitivity analysis, one study was excluded from the meta-analysis. However, the results of the meta-analysis remained unchanged, indicating the robustness of the findings in this study (Figure 4).

Assessment of Publication Bias

The assessment of publication bias is not performed due to insufficient numbers of included studies.

To date, no scholar has conducted a systematic review of the existing literature on the attached gingival width in different oral sites. In this systematic review, the average attached gingival widths of each type of teeth were examined. We aimed to conduct a comprehensive analysis of these studies and identify any enlightenment that may be addressed in future research.

The mean attached gingival widths of each type of teeth ranged from 2.16 mm (lower premolars) to 4.48 mm (upper incisors). Patients with attached gingiva wider than the average are more suitable to choose mini-implants during orthodontic treatment. Also, the width of the maxillary attached gingiva is always greater than that of the corresponding mandibular teeth, and there is greater overall width of attached gingiva in the maxilla than in the mandible. This is because the maxillary alveolar process is higher than that of the mandibular alveolar process, while the width of which is roughly the same.¹⁴

Whether in the maxilla or mandible, the width of the anterior attached gingiva is generally greater than that of the posterior region. This is probably because the height of the alveolar process in the anterior teeth is obviously higher than that of the posterior teeth.¹⁵ This is consistent with their physiological function——posterior teeth bear more masticatory force, requiring lower and tougher alveolar process.¹⁶

According to our research, premolars possess the narrowest attached gingiva in both arches, probably due to the buccal frena attachment. Specifically, maxillary buccal frena are generally more prominent than mandibular buccal frena, rendering the mean difference in the widths of attached gingiva between maxillary premolars and other maxillary teeth greater than that of the mandibular ones (Figure 5). Bowers et al. investigated the width of attached gingiva in both healthy volunteers and patients with high frenum attachments, finding that higher frenum attachments are usually associated with narrower attached gingiva.¹⁷ Later he demonstrated that labio- or buccoversion teeth have a narrower zone of attached gingiva, and on the contrary teeth in linguoversion have a broader zone of attached gingiva.¹⁷ Normally, only the mandibular posterior teeth show lingual inclination, while all other teeth exhibit labial or buccal inclination. As a result, the width of the attached gingiva in the mandibular posterior teeth is higher than that of the maxillary posterior teeth (Figure 5).

During the past decade, mini-implants have been widely used in the orthodontic treatment. However, mini-implants are also associated with various complications, one of which is the insufficient space between the dental roots and mini-implants.¹⁸ Hu et al. analyzed twenty human mandibles and maxillae, finding that the inter-root distance increased from anterior to posterior teeth and from the cervical line to the root apex in both the maxilla and the mandible.¹⁹ Therefore, the farther mini-screws are from the gingival margin, the less likely they are to cause complications such as root damage, and the distance between the mini-implants and the gingival margin is determined by the width of attached gingiva. Antonio Manni et al. studied 300 mini-screws inserted in the attached gingiva (103 mini-screws), free gingiva (121 mini-screws), and mucogingival line (76 mini-screws). They found that success rates of mini-screws inserted in the attached gingiva and the mucogingival junction did not show statistically significant differences (85.4% and 84.2%，respectively), but the success rate of mini-screws located in the free gingiva was significantly lower (75.2%), which indicates that a healthy attached gingiva with an appropriate width is of great importance in orthodontic treatments.²⁰ According to our outcomes, there is more sufficient space to insert a mini-screw in maxillary and anterior regions, which might lead to higher success rate and lower incidence of orthodontic complications in these regions. This is consistent with the research by D. Wiechmann et al., which revealed that the cumulative survival rate of mini-implants was significantly higher in the maxilla than those in the mandible.²¹ This may be attributed to the wider attached gingiva in the upper arch.

When inserting mini-implants in narrowed attached gingiva region, one of the approaches is to augment the insertion angle or the insertion height to gain more inter-radicular space. In premolar regions, extra vigilance should be maintained and oblique insertion is often preferred, since these regions have the narrowest attached gingiva.²² However, when the insertion height is increased, the head of the mini-implant should still be placed in the safe zone of the width of the attached gingiva so as to avoid mucositis and improve its stability.^5,23

In addition to providing guidance on the insertion of mini-implants, the width of the attached gingiva itself also indicates periodontal status and gingival health.²⁴ Sreeja et al. assessed the width of attached gingiva in six front teeth and clinical metrics comprising Oral hygiene index and modified gingival index, finding that the association between the attached gingival width and its impact on dental hygiene care was statistically significant.⁷ Our results can serve as a reference for normal attached gingival width values, assisting in judgement of gingival recession and whether or not stronger dental hygiene care is indicated.

Limitations

Despite the strengths of this investigation, our meta-analysis presented some limitations of the current literature. Bhatia et al. found that the width of attached gingiva increases with age.¹² In this meta-analysis, the age of patients varies in each study, which might lead to unreliable results. Unfortunately, we failed to obtain the average attached gingival width for people of different age groups due to the insufficient data available. Therefore, our outcomes might not be referable for all age groups.

Nowadays, we can roughly distinguish between three types of gingival phenotype: thin scalloped, thick flat, and moderate.²⁵ The systematic review conducted by Vlachodimou et al. suggested that patients with different types of gingival phenotype ought to process different widths of attached gingiva.²⁶ All six studies^3,9-13 included in our review did not distinguish the gingival phenotype of patients, which means our results are applicable for the general public, but failed to describe the attached gingival width of different gingival phenotypes.

Alkan et al. found that orthodontic treatment can affect the width of the attached gingiva.²⁷ Whereas, there is no information on whether the patient has received orthodontic treatment in the articles included in this review, which might have a marginal influence on the results of the outcomes.

Besides, different methods were adopted to assess attached gingival width in these studies, such as visual and histochemical methods. But according to the research by Bhatia et al., there was no substantial, consistent variance in the methods of assessing the attached gingival width, which indicates that methods may not significantly influence the final outcomes.¹² Therefore, results of this meta-analysis are still significant.

This systematic review evaluates the average width of attached gingiva in different oral sites. According to our study, the maxillary attached gingiva is always wider than the corresponding mandibular attached gingiva in the same region. In the four quadrants, the attached gingiva from wide to narrow are incisors, canines, molars, and premolars, respectively. Our study may assist the clinicians in periodontal and orthodontic treatment, such as assisting in judgement of gingival recession and determining mini-implants insertion sites.

Implications for clinical practice

The success rate of the mini-implant insertion might be higher in maxilla and anterior regions, because the attached gingiva is relatively wider in these sites.

When inserting mini-implants, extra vigilance should be maintained and oblique insertion is often preferred in premolar regions, since these regions have the narrowest attached gingiva.

Differences between patient’s attached gingival width and the average indicates periodontal status and gingival health.

Implications for research

Width of attached gingiva should be considered in future researches concerning mini-implants.

The success rate and complications of mini-implants insertion is probably related to the width of the attached gingiva

DECLARATION OF COMPETING INTEREST

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

ACKNOWLEDGEMENTS

This study was supported by National Natural Science Foundation of China (No. 82071147), Sichuan Science and Technology Program (Nos. 2018JY0558, 2018SZ0232 and 2021YJ0428), Research Grant of Health Commission of Sichuan Province (Nos. 19PJ233 and 20PJ090), CSA Clinical Research Fund (CSA-02020-02), and Research and Develop Program, West China Hospital of Stomatology, Sichuan University (No. LCYJ2020-TD-2 and WCHS-201704).

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The authors declare no competing interests.

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Evaluation of the width of attached gingiva: A systematic review and meta-analysis

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