{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T01:17:22Z","timestamp":1783559842909,"version":"3.55.0"},"reference-count":45,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T00:00:00Z","timestamp":1773014400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Dentistry Journal"],"abstract":"<jats:p>Background: The attached gingiva (AG) is the portion of the gingiva firmly bound to the underlying alveolar bone and root cementum, rendering it immobile during functioning. Its dense connective tissue attachment contributes to resistance against mechanical challenges, stabilization of the gingival margin, and dissipation of forces transmitted from the alveolar mucosa. Histologically, AG is characterized by a keratinized epithelium supported by dense collagen fiber bundles, which provide structural integrity to the dento\u2013gingival unit. Clinically, the buccal and lingual width of AG is estimated by subtracting sulcus depth from the total width of keratinized tissue. Although periodontal health may be maintained with minimal AG under optimal plaque control, substantial evidence supports its role in preserving gingival architecture and resisting mechanical trauma. Practical Application: From a clinical perspective, an adequate width of attached gingiva has traditionally been considered necessary to protect the periodontium; however, clinical situations may exist in which its dimension is reduced or absent. Available evidence suggests that a minimal width of approximately 1 mm of attached gingiva may be sufficient to maintain periodontal health under conditions of effective plaque control and absence of inflammation. Nevertheless, when only this minimal dimension is present, the attachment is predominantly derived from the junctional epithelium, which may offer limited mechanical protection to the dento\u2013gingival unit. Within the limits of current evidence, a keratinized tissue width of approximately 3 mm appears to represent a functional threshold associated with increased connective tissue fiber density and enhanced resistance to mechanical trauma. Methods: A narrative review of classical and contemporary literature was conducted to evaluate the morphology, histology, function, and clinical relevance of the attached gingiva. Results: Evidence indicates that when AG width is minimal, reliance on junctional epithelial attachment alone provides limited resistance to mechanical challenges. In contrast, a greater width of AG incorporating connective tissue fiber attachment is associated with improved gingival margin stability, enhanced mechanical protection, and periodontal tissue resilience. Based on this synthesis, a tissue-based clinical categorization of AG is proposed. Conclusions: This review integrates current biological and clinical concepts regarding the functional dimensions of attached gingiva. The proposed categorization offers a practical framework to support clinical decision-making and to identify conditions in which surgical augmentation may be indicated for the management of mucogingival deficiencies.<\/jats:p>","DOI":"10.3390\/dj14030156","type":"journal-article","created":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T13:27:18Z","timestamp":1773062838000},"page":"156","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["The Clinical Significance of Attached Gingiva in the Natural Dentition"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1509-9790","authenticated-orcid":false,"given":"Jo\u00e3o","family":"Carnio","sequence":"first","affiliation":[{"name":"Private Practice, Adhemar Pereira de Barros 131, Londrina 86050-190, PR, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jo\u00e3o Kreling","family":"Carnio","sequence":"additional","affiliation":[{"name":"School of Dentistry, University of Cesumar (UniCesumar), Londrina 86027-810, PR, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paulo M.","family":"Camargo","sequence":"additional","affiliation":[{"name":"Section of Periodontics, UCLA School of Dentistry, Los Angeles UCLA, Los Angeles, CA 90024, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,9]]},"reference":[{"key":"ref_1","unstructured":"American Academy of Periodontology (2001). Glossary of Periodontal Terms 2001, American Academy of Periodontology. [4th ed.]."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1034\/j.1600-0757.2000.2240102.x","article-title":"Development and general structure of the periodontium","volume":"24","author":"Cho","year":"2000","journal-title":"Periodontol. 2000"},{"key":"ref_3","unstructured":"Newman, M.G., Takei, H.H., Klokkevold, P.R., and Carranza, F.A. (2019). Carranza\u2019s Clinical Periodontology, Elsevier. [13th ed.]."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1902\/jop.1963.34.3.201","article-title":"A study of the width of attached gingiva","volume":"34","author":"Bowers","year":"1963","journal-title":"J. Periodontol."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Huang, Z., Lin, Y., Wen, S., Yuan, X., Long, H., and Lai, W. (2024). Evaluation of the width of attached gingiva: A systematic review and meta-analysis. Res. Sq. Prepr.","DOI":"10.21203\/rs.3.rs-4944197\/v1"},{"key":"ref_6","first-page":"1703","article-title":"The Width of the Attached Gingiva and Its Variability in People with Healthy Periodontal Status","volume":"33","year":"2025","journal-title":"Acta Stomatol. Naissi"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Mishra, A. (2025). Attached Gingiva: A Review through the History. Oral Health Maxillofac. Res.","DOI":"10.61577\/ohmr.2024.1000017"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1825","DOI":"10.1902\/jop.2007.060414","article-title":"Increasing the apico-coronal dimension of attached gingiva using the modified Apically repositioned flap technique: A case series with a 6-month follow-up","volume":"78","author":"Carnio","year":"2007","journal-title":"J. Periodontol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1111\/j.1600-051X.1981.tb02041.x","article-title":"Role of keratinized gingiva for gingival health. Clinical and histologic study of normal and regenerated gingival tissue in dogs","volume":"8","author":"Wennstrom","year":"1981","journal-title":"J. Clin. Periodontol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1111\/j.1600-051X.1984.tb00837.x","article-title":"Recession in sites with inadequate width of keratinized gingiva","volume":"11","author":"Ericsson","year":"1984","journal-title":"J. Clin. Periodontol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1902\/annals.1996.1.1.671","article-title":"Mucogingival therapy","volume":"1","author":"Wennstrom","year":"1996","journal-title":"Ann. Periodontol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1902\/annals.1999.4.1.98","article-title":"Mucogingival deformities","volume":"4","year":"1999","journal-title":"Ann. Periodontol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1902\/jop.1979.50.4.170","article-title":"Physiologic dimension of the periodontium significant to the restorative dentist","volume":"50","author":"Maynard","year":"1979","journal-title":"J. Periodontol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1902\/jop.1987.58.10.696","article-title":"Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations","volume":"58","author":"Stetler","year":"1987","journal-title":"J. Periodontol."},{"key":"ref_15","first-page":"9","article-title":"Attached gingiva\u2013Mucogingival therapy and restorative dentistry","volume":"6","author":"Nevins","year":"1986","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1902\/jop.1972.43.10.623","article-title":"The relationship between the width of keratinized gingiva and gingival health","volume":"43","author":"Lang","year":"1972","journal-title":"J. Periodontol."},{"key":"ref_17","first-page":"S73","article-title":"Periodontal soft tissue non-root coverage procedures: A concensus report from the AAP Regeneration Workshop","volume":"86","author":"Sheyer","year":"2015","journal-title":"J. Periodontol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1111\/j.1600-051X.1987.tb00964.x","article-title":"Lack of association between width of attached gingiva and development of soft tissue recession: A 5-year longitudinal study","volume":"14","year":"1987","journal-title":"J. Clin. Periodontol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/S0011-8532(22)02000-6","article-title":"Mucogingival surgery","volume":"8","author":"Friedman","year":"1964","journal-title":"Dent. Clin. N. Am."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1111\/jcpe.12078","article-title":"Biologic width dimensions\u2014A systematic review","volume":"40","author":"Schmidt","year":"2013","journal-title":"J. Clin. Periodontol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1902\/jop.1961.32.3.261","article-title":"Dimensions and relations of the dentogingival junctions in humans","volume":"32","author":"Gargiulo","year":"1961","journal-title":"J. Periodontol."},{"key":"ref_22","unstructured":"Passanezi, E., Sant\u2019Ana, A.C.P., Rezende, M.L.R., Greghi, S.L.A., and Janson, W.A. (2011). Distancias Biologicas Periodontais: Principios para a Reconstrucao Periodontal, Estetica e Protetica, Artes Medicas. [1st ed.]."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1007\/s00784-024-06143-x","article-title":"Evaluation of Gingival Phenotype: The Role of Gingival Thickness Measurements from Different Vertical Gingival Levels","volume":"29","author":"Lutfioglu","year":"2025","journal-title":"Clin. Oral Investig."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1111\/j.1600-051X.1983.tb01282.x","article-title":"A long junctional epithelium\u2014A locus minoris resistentiae in plaque infection?","volume":"10","author":"Magnusson","year":"1983","journal-title":"J. Clin. Periodontol."},{"key":"ref_25","first-page":"1","article-title":"Fine structure of the developing epithelial attachment of human teeth","volume":"2","author":"Schroeder","year":"1971","journal-title":"Monogr. Dev. Biol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1111\/j.1600-0757.1997.tb00097.x","article-title":"The gingival tissues: The architecture for periodontal protection","volume":"13","author":"Schroeder","year":"1997","journal-title":"Periodontol. 2000"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1111\/j.1600-051X.1983.tb01275.x","article-title":"Plaque-induced gingival inflammation in the absence of attached gingiva in dogs","volume":"10","author":"Wennstrom","year":"1983","journal-title":"J. Clin. Periodontol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1111\/j.1600-051X.1977.tb02273.x","article-title":"Gingival condition in areas of minimal and appreciable width of keratinized gingiva","volume":"4","author":"Miyasato","year":"1977","journal-title":"J. Clin. Periodontol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1111\/j.1600-051X.1985.tb00938.x","article-title":"A longitudinal evaluation of varying widths of attached gingiva","volume":"12","author":"Kennedy","year":"1985","journal-title":"J. Clin. Periodontol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1111\/j.1600-051X.1981.tb02354.x","article-title":"Healing of dento-epithelial junction following the use of dental floss","volume":"8","author":"Waerhaug","year":"1981","journal-title":"J. Clin. Periodontol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1111\/j.1600-0757.1996.tb00078.x","article-title":"Manual periodontal probing in supportive periodontal treatment","volume":"12","author":"Armitage","year":"1996","journal-title":"Periodontol. 2000"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"35","DOI":"10.4103\/0972-124X.65436","article-title":"Effect of retraction materials on gingival health: A histopathological study","volume":"14","author":"Phatale","year":"2010","journal-title":"J. Indian Soc. Periodontol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1111\/j.1600-051X.1982.tb02536.x","article-title":"A clinical study comparing the width of attached gingiva and the prevalence of gingival recessions","volume":"9","author":"Tanenbaum","year":"1982","journal-title":"J. Clin. Periodontal."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Schroeder, H.E. (1986). The Periodontium, Springer. Handbook of Microscopic Anatomy.","DOI":"10.1007\/978-3-642-71261-6"},{"key":"ref_35","unstructured":"Lindhe, J., Lang, N.P., and Karring, T. (2015). Clinical Periodontology and Implant Dentistry, Wiley Blackwell. [6th ed.]."},{"key":"ref_36","first-page":"S237","article-title":"Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions","volume":"89","author":"Jepsen","year":"2018","journal-title":"J. Periodontol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"647","DOI":"10.14219\/jada.archive.2010.0252","article-title":"Contemporary crown-lengthening therapy: A review","volume":"141","author":"Hempton","year":"2010","journal-title":"J. Am. Dent. Assoc."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1111\/prd.12208","article-title":"Crown lengthening and restorative procedures in esthetic zone","volume":"77","author":"Marzadori","year":"2018","journal-title":"Periodontol. 2000"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1111\/j.1600-0757.1993.tb00230.x","article-title":"Tissues and cells of the periodontium","volume":"3","author":"Hassel","year":"1993","journal-title":"Periodontol. 2000"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1902\/jop.1981.52.9.569","article-title":"The current status of mucogingival problems and their therapy","volume":"52","author":"Hall","year":"1981","journal-title":"J. Periodontol."},{"key":"ref_41","first-page":"204","article-title":"Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations","volume":"89","author":"Cortellini","year":"2018","journal-title":"J. Periodontol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1902\/jop.2008.070414","article-title":"Free gingival grafts to increase keratinized tissue: A retrospective long-term evaluation (10\u201325 years) of outcomes","volume":"79","author":"Agudio","year":"2008","journal-title":"J. Periodontol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"519","DOI":"10.11607\/prd.3028","article-title":"The Modified Apically Repositioned Flap technique: A long-term (4\u201316 years) retrospective study","volume":"38","author":"Carnio","year":"2018","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"571","DOI":"10.11607\/prd.2386","article-title":"Surgical techniques to increase the apicocoronal dimension of the Attached Gingiva: A 1-year comparison between the Free Gingival Graft and the Modified Apically Repositioned Flap","volume":"35","author":"Carnio","year":"2015","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_45","first-page":"56","article-title":"Periodontal soft tissue non-root coverage procedures: A systematic review from AAP Regeneration Workshop","volume":"86","author":"Kim","year":"2015","journal-title":"J. Periodontol."}],"container-title":["Dentistry Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/3\/156\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T13:55:37Z","timestamp":1773064537000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/3\/156"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,9]]},"references-count":45,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["dj14030156"],"URL":"https:\/\/doi.org\/10.3390\/dj14030156","relation":{},"ISSN":["2304-6767"],"issn-type":[{"value":"2304-6767","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,9]]}}}