COURSE 2.

ANATOMY OF THE MARGINAL PERIODONTIUM

The marginal periodontium is composed of all the tissues that ensure the maintenance and
support of the teeth in the maxillary bones. In vertical plane, the marginal periodontium extends from
an area between the level of the free gingival margin and an indefinite area near the apex.
The upper limit (the gingival limit) of the marginal periodontium is located under normal
circumstances, around the anatomical neck of the tooth, but it can also be located above it, in case of
abnormal gingival overgrowth (hypertrophies, hyperplasia) or below it, in early constitutional and
senescence involutions (alveolar bone atrophies) or in the case of pathological gingival recessions
(underlying bone resorption).
The limit between the marginal and the apical periodontium is not clearly marked by a
particular anatomical element or structure.
The distinction between the two major components - the marginal and the apical periodontium
- is manifested by a different pathology and evolution.
The apical periodontium is usually affected endodontically, beyond the apex, by complications
of dental caries, with acute or chronic clinical manifestations.
The marginal periodontium presents, more frequently, diseases with chronic evolution and with
a starting point most often at the level of the gingiva and gingival sulcus. The evolution of periodontal
disease is mainly desmodontal, with a less obvious subjective symptoms, sometimes even painless.
Over time, inflammatory marginal chronic periodontitis lead to the appearance of periodontal pockets,
gingival recessions, pathological dental mobility, which untreated lead to a major complication- tooth
avulsion.
 Main components of the marginal periodontium

The marginal periodontium has two main components

A. The superficial periodontium consists of:
Gingiva with:

 gingival epithelium;
 connecting tissue;
 supraalveolar ligament (gingival fibers);

B. Deep, supporting or "functional" periodontium, consisting of:

 root cementum;
 periodontal ligament
 the alveolar process
 Marginal superficial periodontium
The oral mucosa consists of the following three zones:
1. The gingiva and the mucosa covering the hard palate (formed by the palatal apophyses of the
maxillary bones and the horizontal lamellae of the palatal bones), also called the masticatory
mucosa.
2. The dorsum of the tongue specialized in receiving stimuli that produce taste sensations-
specialized mucosa
3. The lining of the oral cavity, poorly keratinized and with a well-represented submucosa of loose
connective tissue, is the mucosa of the lips, cheeks, ventral surface of the tongue, buccal floor,
soft palate and uvula, and alveolar mucosa.
The masticatory mucosa at the gingival level is firm and fixed, and from a functional point of view -
resistance to pressure and stress.
The structure of the masticatory mucosa is represented by a thickened epithelium and a dense,
inelastic connective tissue with a very low resilience. The gingival mucosa supports the tooth and the
alveolar bone.
In the edentulous, the gingival mucosa becomes a simple masticatory mucosa.
The masticatory mucosa that covers the palatal arch is also provided with a thick epithelium and a
dense connective tissue, rich in accessory salivary glands. In some areas it has a loose submucosa
towards the bony substratum of the palatine vault, which gives it a greater resilience than the area of
the palatine rugae, the palatine torus and the median area.
Clinical and practical implications. The structural features of the masticatory mucosa lead to a
number of consequences:
o the surgical wounds located in the palatine area have little or no extensible opening
through the incision and therefore difficult to ensure the drainage of an incised marginal
periodontal abscess;
o injection by infiltration of anesthetics (or other solutions such as those used in the
treatment of periodontal bioreactivation) is difficult due to the lack of elastic fibers,
painful and with low efficiency;
o mobile dental prostheses must be designed taking into consideration the different
resilience of the areas of the palatal masticatory mucosa;
o suturing the masticatory mucosa is difficult due to the dense connective tissue, which is
firmly fixed to areas of the periosteum and the underlying bone, but it is a stable suture.
The lining mucosa is thin, dense and elastic; it is a mobile mucosa with a lower degree of keratinization
and a high absorption capacity.
Clinical and practical implications:
 o represents the main place (especially the
alveolar mucosa) for submucosal dental
anesthesia or for infiltration of bioreactivation
medicinal products;
o Surgical incisions and sutures are easily made.
o Inflammatory processes and hemorrhages
spread easily in the areas covered by the lining
mucosa and may be large but evolve with less
pain than in areas covered by the masticatory
mucosa.
The mucosa on the dorsum of the tongue is slightly
mobile, resistant to pressure and frictional forces, has a dense
but elastic structure, has numerous lingual papillae and is
located on the muscular substrate of the tongue.

Gingiva
Represents the visible area of the marginal periodontium and is the area of the masticatory
mucosa that covers the alveolar bone. The gingiva consists of three areas:
a) The free gingival margin is the most coronally area, located between the interdental papillae
of the gingiva and corresponds to the external wall of the gingival sulcus
The thickness of the free gingival margin varies between 0.5 and 2 mm.
Normally, the marginal contour is sharp, smooth, without irregularities or depressions.
The limit between the free gingival margin and the attached gingiva is marked by the free gingival
groove, which can sometimes be erased or missing.
b) The interdental papilla occupies the interdental space (gingival embrasure), being located
immediately below the area of the contact point; when it is missing (primary diastema, dento-alveolar
incongruence with spacing), the interdental papilla has the shape of a plateau or even a saddle, like a
concave depression.
The normal shape in the frontal region is pyramidal. The spatial shape of the interdental papilla
at the posterior lateral teeth was compared with the appearance of a tent, with a depression on the
upper edge
 Between the posterior lateral teeth it has a depressed tip, concave in appearance,
corresponding to the contact area under which it is located. In facial-oral direction, it has a facial and
an oral tip.
The interdental papillae have a vertical depression on the vestibular faces, from the base to the
top, as a vertical groove, more obvious in children.
The shape and volume of the interdental papilla vary in relation to:

 morphology of the underlying alveolar bone.

 age:
- in children and young adults it occupies the interdental space and has a slightly rounded pointy
tip;
-in the elderly, by involution processes, the volume is reduced, and the contour of the papilla
flattens; the trauma from toothbrushing and other secondary means of hygiene, occlusal trauma,
abrasion, and added inflammation also contribute to the volume reduction.
- dento-alveolar incongruences with spacing reduces the volume of the interdental papilla by direct
food impact and it changes its shape from prominence to plateau or even a concave shape;
- dento-alveolar incongruence with crowding reduces the volume of the papilla, which is narrow. It
becomes hypertrophic and hyperplastic, like a pediculate or sessile polyp, with a large implantation
base;
- trauma caused by aggresive use of the toothpick, excessive brushing reduces the volume of
interdental papillae;
- diastema produced by pathological movements of the periodontal teeth produce deformities of
the interdental papillae with irregular appearance and volume from one tooth to another.
c) The attached gingiva firmly adheres to the tooth and the underlying alveolar bone and extends
from the base of the free gingival margin to the alveolar mucosa. It has a vertical height between 1 and
9 mm, depending on the tooth, the location of frenulums and underlying muscle bundles and increases
with age and the vertical development of the alveolar process.
The attached gingiva is generally higher in the jaw than in the mandible, especially in the incisors
and molars of the jaw, on the facial aspect, and lower in the canines and premolars. It is also higher on
the lingual face of the first mandibular molar. It is very narrow in mandibular II and III molars.
In children, the height of the attached gingiva on the facial aspect of permanent teeth is lower in
teeth with a tendency of facial inclination and it increases in those with a tendency of lingual
inclination. This may be an indication of the prospect of teeth movements during the natural evolution
of their position on the arches.
 The attached gingiva represents an area of resistance against the tendencies of recession and
displacement of the free gingival margin, that result from brushing or traction exerted by the alveolar
mucosa and its underlying formations (frenulums, muscle fibers).
The limit between the attached gingiva and the alveolar mucosa is done by the muco-gingival
junction, represented by a demarcation line: the muco-gingival line, visible on the facial aspect of both
jaws. Below this line is the alveolar mucosa, more elastic and mobile than the fixed mucosa located in
the coronally direction.
The muco-gingival junction line is also visible on the lingual aspect of the mandibular alveolar site,
but is missing in the palatine area, where the mucosa of the hard palate is firmly attached to the
underlying bone, well keratinized and continues without a demarcation line with the gingiva.
The alveolar mucosa is weakly keratinized, dark red and mobile compared to the underlying
structure, where transparency shows blood vessels with a well-defined trajectory.

CLINICAL ASPECTS OF THE HEALTHY GINGIVA

The normal color of the gingiva is light pink, but it varies with:
- thickness of the epithelial layer;
- degree of keratinization;
- the degree of vascularization in the connective tissue
- the presence and number of pigment containing cells - melanoblasts - from the basal layer of the
epithelium. The color of the gingiva is paler, even slightly whitish in areas of hyperkeratosis, reacting to
the impact of traumatic food. In some people or populations of color, oriental, Mediterranean, the
color of the gingiva may normally range from dark brown or dark blue to black and is a result of excess
melanin in the gingival epithelium. This pigmentation can be distributed evenly or irregularly over large
areas of the gingiva and is not, in any case, a sign of gingival disease.
 The texture of the gingival surface in the attached gingiva, not on the free gingival margin, is
"stippled" or "orange peel", containing orifices that correspond to areas of deep connective tissue
projections.
These micro-depressions are the effect of the collagen bands that are perpendicular to the surface
of the alveolar bone and which maintain a close contact between the basal lamina of the mucosa and
the underlying periosteum. The appearance is more obvious after the age of 5 years and is more
noticeable in the frontal teeth, diminishes in the anterior lateral areas (premolars) and disappears at
the molars. This aspect is more clearly highlighted on the facial surface, it is accentuated in adults, it
disappears in the elderly. In some people, this aspect is missing throughout life.
The presence of stippled gingiva pattern is a sign of gingival health. Its absence usually indicates
gingival disease, and recurrence after treatment is a clinical indicator of its beneficial effect and signals
healing.
Consistency : the gingiva is firm, especially in the attached gingiva; In relation to this, the free
gingival margin and the tip of the papillae have a looser consistency, and a little distensible when
compressed with a periodontal probe.
The position of the gum in relation to the tooth
The level at which the gingiva attaches to the tooth is usually located around the anatomical neck
of the tooth, so that the free gingival margin is projected on the enamel in its most apical zone.
The position of the gingiva in relation to the tooth depends on:
- tooth eruption;
- constitutional type;
- age;
- dentomaxillary anomalies;
- bacterial inflammation;
- parafunctions and vicious habits;
- direct trauma;
- indirect, occlusal trauma;
- the effect of some circumstances (traumas) of iatrogenic cause;
- the influence of systemic conditions
 HISTOLOGICAL CHARACTERISTICS OF THE GINGIVA
The gingiva consists of connective tissue, covered with an overlaying stratified squamous
epithelium.
Gingival epithelium
It consists of:

 oral or outer epithelium; (OE)

 epithelium of the gingival sulcus, sulcular or internal epithelium; (SE)
 the junctional epithelium (JE)

For a better understanding of the currently accepted terminology, it should be noted that the
junctional epithelium or epithelial junction is the most apical area of the gingival sulcus, where the
reduced adamantine epithelium joined the oral epithelium, now reflected on the inner face of the
gingival sulcus.
Epithelial insertion refers to the cells in the junctional epithelium, located more apically from the
bottom of the gingival sulcus, that come in direct contact with the tooth surface. The more apically
located epithelial cells represent the primary epithelial insertion and the coronally ones, the secondary
epithelial insertion.
 Oral or outer gingival epithelium
The oral epithelium continues towards the oral cavity with the sulcular epithelium. It extends from
the crest of the free gingival margin and the attached gingiva to the mucogingival junction.
The topographic relationship between the oral epithelium and the connective tissue is
characterized by a wavy surface, the result of the penetration of epithelial extensions (rete pegs) that
penetrate the underlying connective tissue. This arrangement enlarges the interface of the epithelium
and the connective tissue and ensures a good nutrition of the non -vascularized epithelium, by
osmosis.
The wavy appearance from the junction between the oral epithelium and connective tissue
decreases to extinction as it approaches the junctional epithelium.
The oral epithelium consists of the following layers (from depth to surface):
- basal or germinal layer;
- prickle cell layer (of cells with BIZZOZZERO spines);
- granular layer;
- cornified layer

Sulcular or internal epithelium

The epithelium that covers the soft wall of the gingival sulcus is poorly keratinized or even non-
keratinized. This histological feature is of essential importance in the pathogenesis, evolution and
treatment of early forms of periodontal disease: chronic gingivitis, but especially chronic superficial
marginal periodontitis. Reduced or no keratinization favors the production of microerosions and
microulcerations followed by bleeding which is controlled in this situation by a particular therapeutic
attitude.

Junctional epithelium
It represents the most significant structure of the dento-gingival junction.
The dento-gingival junction is the only place exposed to an open cavity in the human body where
soft tissue, vulnerable in terms of mechanical strength, attaches organically to a dense,
hypermineralized structure.
 The junctional epithelium extends in the apical direction from the most apical portion of the
gingival sulcus and forms a sleeve around the tooth which, under normal conditions, can be located:
- only on enamel;
- on enamel and cement;
- only on the cement depending on the stage of normal eruption of the tooth or gingival recession
by involution phenomena.
From a structural point of view, the junctional epithelium is the only component of the gingival
epithelium that has two basal laminae, one on each face:
- the outer basal lamina which is constituted as the basal lamina of the sulcular epithelium and
connects with the underlying connective tissue;
- internal basal lamina that fixes the junctional epithelium directly on the tooth surface.
The anatomical features of the junctional epithelium explain its vulnerability to physical and
biological aggression.
At the junctional epithelium, epithelial extensions are missing, and the interface between the
epithelium and the connective tissue is smooth, without rete pegs, suggesting poor nutrition through
osmotic imbibition.

Another element of vulnerability is the reduction or absence of keratinization. Keratin is a

scleroprotein that acts against microbial aggression by acid Ph and mechanically with increased
consistency. The cells in the basal layer, located in the most apical portion of the junctional epithelium,
have hemidesmosomes and through mitosis move in coronal direction without tonofilaments, which
explains the lack of keratinization. In the coronally zone, the junctional epithelium has a non-
keratinized surface. This feature is an adaptation to the condition of adhesion to the tooth surface,
which can not be done through keratin.

Defense elements
 LANGERHANS cells are present in the junctional epithelium, which function like macrophages in
stimulating the tissue-specific immune response. Neutrophils with phagocyte function are also present,
which contribute to the maintenance of antimicrobial defense and gingivo-periodontal clinical health.
Even in the most eloquent states of health, the gingiva has a leukocyte infiltrate consisting of
neutrophils and polymorphonuclear cells, which under the influence of chemotactic bacterial peptides
exert their phagocytic function. Other leukocytes are attracted to the gingival sulcus by cytokines
released by bacteria-destroyed epithelial cells, which they phagocytose. Thus, the presence of
neutrophils in the gingival fluid is explained. Some of them, being overloaded with bacteria,
degranulate and are destroyed in smaller fragments. Additionally, in conditions of microbial aggression
a glycogen load of the affected tissues was noticed, which indicates a defense reaction with repairing
histochemical phenomena.
The junctional epithelium adheres to the tooth directly or through various films or cuticles.

THE GINGIVAL SULCUS

It represents the space between the tooth surface and the sulcular epithelium that lines the gingival
margin from its crest to the junctional epithelium.
The gingival sulcus is delimited by:
- internal, dental wall
- external, gingival wall
- the base of sulcus, the coronal contour of the junctional epithelium.
The depth of the gingival sulcus clinically measured with a periodontal probe, normally varies
between 1 and 3 mm, being on average 1.8 mm
The clinical depth of the gingival groove does not correspond to the histological depth, which is
higher.
 THE CREVICULAR OR SULCULAR FLUID

Normally, it comes in small amounts, continuously, from the venules of the gingival connective
tissue, located under the sulcular epithelium. Experimental animal studies have shown that
intravenous injected fuoroscein is found in the gingival tract after only three minutes (BRILL and
KRASE).

Properties of gingival crevicular fluid:

1. Mechanical removal from the gingival sulcus of fluid material or in the form of foreign particles,
some with antigenic action and aggressive effects;
2. Adhesion of the epithelium to the tooth
3. Complex antimicrobial activity through antibodies, antimicrobial factors, viable leukocytes.
Increases in the volume of gingival fluid are found:
- in the morning;
- during mastication
- by gingival massage;
- by brushing;
- in pregnancy;
- following the use of contraceptives;
- during gingival inflammation;
 - during the healing period after surgical treatment.
The penetration of microbes or small particles of solid substances into the gingival sulcus is
followed by an increase in fluid flow and their elimination starting a few minutes after their insertion.
Dental plaque antigens or particles with a diameter of 1-3 µm, for example carbon, pass through the
intact sulcular epithelium into the connective tissue, in the opposite direction to the normal course of
gingival flow.
Gingival fluid is not a simple exudate but an inflammatory exudate, produced as a result of a local
active defense mechanism and contains:
- cellular elements: polymorphonuclear leukocytes, lymphocytes, monocytes;
- amino acids;
- albumin;
- alpha 1, alpha 2, beta and gamaglobulins with antibody function: type IgA, IgG, IgM :
immunoglobulins
- fibrinogen;
- fibrinolysin;
- protein fractions of complement C3, C4;
- carbohydrates (3-4 times more than in the blood serum the result of the activity of the local
microbial flora and not of a tissue metabolic mechanism);
- lactoperoxidase system with a role in pH correction;
- whole or fragmented neutrophils after overloading with bacteria and degranulation;
- lysosomal enzymes;
- enzymes such as: acid phosphatase, alkaline phosphatase, beta-glucuronidase, cathepsin,
protease, lactic dehydrogenase and lysozyme: this is a glycosidase enzyme and acts by breaking the
bonds between N-acetyl-glucosamine and acetylmuramic acid in the bacterial wall;
- electrolytes: Na, K, Ca, P;
- sometimes, during treatments for general infections and conditions, medicinal substances such as
hydantoin, tetracycline, in a higher concentration than in the blood serum.

Connective tiussue
 It consists of:
- the ground substance, composed of non-fibrous molecular constituents;
- cells;
- collagen and elastin fibers; -
- vessels and nerves.

The ground substance

It is a non-fibrous organic matrix, in which the components of the gingival connective tissue are
incorporated. From a chemical point of view, the ground substance is made up of macromolecules of
proteoglycans and glycoproteins.
Proteoglycans play a major role in maintaining the integrity of the connective tissue.
The supraalveolar ligament system is made up of gingival fibers, especially collagen. The fibers of
the supraalveolar ligament are:
1. The dento-gingival fibers that start from the radicular cementum and are arranged ascending
and laterally in the connective tissue.
2. The dento-dental or transseptal fibers located between adjacent teeth and have an almost
horizontal trajectory.
3. The dento-periosteal fibers start from the tooth, pass over the alveolar edge (the alveolar
Iimbus) and attach to the periosteum.
4. The dento-alveolar fibers start from the tooth and reach the alveolar edge after an almost
horizontal trajectory.
5. The alveolo-gingival fibers have an end attached to the alveolar ridge and end in the connective
tissue
6. The periosteal-gingival fibers fix the gingiva to the bone through the periosteum.
7. The transgingival fibers start with one end on the radicular
cementum of the approximate surfaces and go to the vestibular or oral
surface of the neighboring tooth, where they intertwine with similar
fibers from the opposite direction.
8. The intergingival fibers continuously cross the connective tissue
parallel to the facial and oral surfaces of the roots.
 9. Interpapillary fibers that cross the interdental space in the facial-oral direction at the base of the
papilla.
10. The semicircular fibers start from the approximate surface (mesial or distal) of the root of a
tooth, bypass the facial or oral face and are fixed on the approximately opposite face of the same
tooth.
11. Circular fibers in small numbers completely surround the root of the tooth.
12. The intercircular fibers are located between the circular
fiber rings.

Vascularization and innervation of the gums will be treated

together with the entire marginal periodontium.