THE NORMAL PERIODONTIUM

Instructor:Dr.Dida B(DMD)
April,2015
 Objectives of the lesson
• After learning this topic students are able to;
1,define the periodontium
2,understand the development ,micro-structural
anatomy and biology of periodontal tissue
3,know the defensive mechanisms in the oral cavity.
 The gingiva
• The gingiva is the part the oral mucosa that covers
the alveolar processes of the jaws and surrounds the
necks of the teeth. It has the following features;
1, clinical features 2, microscopic features
- marginal gingiva -gingival epithelium
- gingival sulcus -gingival connective

- attached gingiva tissue

- interdental gingiva
 Introduction
• The periodontium consists of the investing and supporting
tissues of the tooth: gingiva ,periodontal ligament,
cementum, and alveolar bone.
• It has been divided into two parts: gingiva and attachment
apparatus
• Function of gingiva is protecting the underlying tissue.
• The attachment apparatus composed of the periodontal
ligament, cementum, and alveolar bone.
• The cementum is considered a part the periodontuim
because, with the bone, it serves as the support for the fibers
of the periodontal ligament.
 The gingiva
• The oral mucosa consists of three zones:
1, The masticatory mucosa
2, The specialized mucosa
3, The oral mucous membrane lining
the remainder of the oral cavity.
 1,Clinical features
• The gingiva is divided anatomically into marginal,
attached, and interdental areas.
• all types of gingiva are specifically structured to
function appropriately against mechanical and
microbial damage.
• The specific structure of different gingiva reflects its
effectiveness as a barrier to the penetration by
microbes noxious agents into the deeper tissue.
 1.1,Marginal gingiva
• The marginal or unattached gingiva is the terminal
edge or border of the gingiva that surrounds the
teeth.
• It is demarcated from the adjacent attached gingiva
by the free gingival groove( usually 1mm wide) in
50% of cases.
• The marginal gingiva forms the soft tissue wall of
the gingival sulcus.
 1.2,Gingival sulcus
• Is V-shaped shallow crevice or space around the
tooth.
• It is bounded by the surface of the tooth on one side
and epithelium lining free gingiva on the other side.
• The depth of gingival sulcus is important diagnostic
parameter.
• Under absolutely normal conditions the depth
gingival sulcus is 0mm or closer to 0mm.
 Cont..
• A sulcus of some depth can be found in clinically
healthy gingiva.
• The histological depth is 1.8mm, with variations from
0 to 6mm.
• Probing depth of a clinically normal gingival sulcus in
humans is 2-3 mm.
 1.3,Attached gingiva
• It is continuous with the marginal gingiva.
• It is firm, resilient, and tightly bound to the underlying
periosteum of alveolar bone.
• The facial aspect of the attached gingiva extends to the
relatively loose and movable alveolar mucosa and is
demarcated by mucogingival junction.
• The Width of attached gingiva is the distance b/n the
mucogingival junction and external bottom of
periodontal pocket.
• It is important clinical parameter.
 1.4,Interdental Gingiva
• It occupies the gingival embrasure.
• Gingival embrasure is the interproximal space
beneath the area of tooth contact.
• It is either pyramidal or “col”shaped( “col” presents
valley like depression connects facial and lingual
surface).
• The shape depends on the contact point between
the two adjoining tooth and presence or absence of
some degree of recession.
 Microspic features
• Microscopic examination reveals that gingiva is composed of
the overlying stratified squamous epithelium and the
underlying central core of connective tissue.
• Gingival epithelium: the epithelium participates actively in
responding to infection, in signaling further host reaction ,
and in integrating innate and acquired, immune responses.
• Epithelial cells may respond to bacteria by increased
proliferation, alteration of cell signaling events, changes in
differentiation and cell death, and ultimately, alteration of
tissue tissue homeostasis.
 Cont..
• The gingival epithelium consists of;
-continuous lining of stratified squamous
epithelium
-the oral or outer epithelium
-sulcular epithelium,
-junctional epithelium
• The principal cell type of the gingival epithelium is
the keratinocyte.
 Cont..
• The other cells found in gingival epithelium are the
clear cells or nonkeratinocytes, which include the
langerhans cells, merkel cells, and melanocytes.
• Functions: mechanical, chemical, water, and
microbial barrier as well as signaling functions.
• The main function of the gingival epithelium is to
protect the deep structures, while allowing a
selective interchange with the oral environment. This
is achieved by proliferation and differentiation of the
keratinocytes.
 Structural and metabolic characteristics of
different areas of gingival epithelium
• The regional morphologic variations reflects tissue
adaptation to the tooth and alveolar bone. This
variations include the oral epithelium, sulcular
epithelium, and junctional epithelium.
• The oral epithelium and sulcular epithelium are largely
protective in function whereas the junctional epithelium
serves many more roles and is of considerable
importance in regulating tissue health.
• In gingival tissues epithelial cells are metabolically active
and capable of reacting to external stimuli( how??)
 Cont…
• Oral(outer) epithelium: it covers the crest and the outer
surface of the marginal gingiva and the surface of the
attached gingiva.
• Average thickness is 0.2 to 0.3mm.
• It is keratinized or parakeratinized or combination of this
condition.
• The prevalent surface is parakeratinized.
• The degree of gingival keratinization diminishes with age and
the onset of menopause but is not necessarily related to the
different phases of the menstrual cycle.
 Cont..
• Keratinization of the oral mucosa varies in different areas in
the following order: palate(most keratinized), gingiva, ventral
aspect of the tongue, and cheek(least keratinized).
• Sulcular epithelium: it lines the gingival sulcus. It is a thin,
non-keratinized stratified squamuos epithelium.
• The sulcular epithelium extends from the coronal limit of the
junctional epithelium to the crest of the gingival margin.
• The sulcular epithelium has potential to keratinize if;
1, it is reflected and exposed to the oral cavity.
2, the bacterial flora of the sulcus is totally eliminated.
 Cont..
• Conversely, the outer epithelium loses its keratinization when
it is placed in contact with the tooth. These finding suggest
that local irritation of the sulcus prevents sulcular
keratinization.
• The SE is extremely important as it act as a semi permeable
membrane through which injurious bacterial products pass
into the gingival and tissue fluid from gingiva seeps into the
sulcus.
• Unlike junctional epithelium, however, the sulcular epithelium
is not heavily infiltrated by polymorph nuclear neutrophil
leukocytes(PMNs), it appears to be less permeable.
 Cont..
• Junctional Epithelium. It consists of a collar like band of
stratified squamous non-keratinizing epithelium.
• It is three to four layers thick in early life, but the number of
layers increases with age to 10 or even 20 layers.
• JE tapers from its coronal end which may be 10 to 29 cells
wide to one or two cells at its apical termination, located at
the cementoenamel junction in healthy tissue.
• These cells can be grouped into two strata: the basal layer
facing the connective tissue and suprabasal layer extending to
the tooth surface.
• The length of JE ranges from 0.25 to 1.35mm.
 Cont…
• The JE is formed by the confluence of the oral epithelium and the
reduced enamel epithelium during tooth eruption.
• The JE is completely restored after pocket instrumentation or
surgery, and it forms around an implant.
• Gingival fluid(sulcular fluid): the value of GF is that it can be
represented as either transudates or an exudates.
• GF contains biochemical factors offering potential use as a
diagnostic or prognostic biomarker of the biologic state of the
periodontium.
• GF contains components of connective tissue, epithelium,
inflammatory cells, serum, and microbial flora inhabiting the
gingival margin or the sulcus(pocket).
 Cont…
• The amount gingival fluid is very small in healthy sulcus.
• Gingival fluid flow increases during inflammation and its
composition start to resemble that of an inflammatory
exudates.
• Gingival fluid is believed to:
1,cleanse material from the sulcus
2,contain plasma proteins that may improve adhesion of the
epithelium to the tooth.
3, posses antimicrobial properties
4, exert antibody activity to defend the gingiva.
 Cont…
• Gingival connective tissue: the major components of GCT are
collagen fibers( about 60%), fibroblast(5%), vessels, nerves and
matrix(35%).
• GCT is known as the lamina propria and consists of two layers;
1, papillary layer
2, reticular layer
• connective tissue has a cellular and extracellular compartment
composed of fibers and ground substance, thus GCT is largely
fibrous connective tissue that has elements originating directly
from the oral mucosal connective tissue as well as some
fibers(dentogingival) that originate from the developing dental
follicle.
 Cont…
• The ground substance fills the space between fibers and cells, is
amorphous, and has high content of water.
• It is composed of proteoglycans.
• Gingival fiber :the connective tissue of marginal gingiva is densely
collage nous, containing a prominent system of collagen fiber
bundles called the gingival fibers. They consists of type I collagen
• Functions of GF: 1, to brace marginal gingiva firmly against
tooth
2, to provide rigidity to withstand forces of
mastication
3, to unite free marginal gingiva with cementum of
the root and the adjacent attached gingiva.
 Cont…
• The gingival fibers are arranged in three groups
1, gingivodental group: are those on the facial, lingual and
interproximal surfaces.
2, circular group: encircle tooth in ring like fashion.
3, transceptal group: located interproximally and form
horizontal bundles.
• READING ASSIGNMENT(BLOOD SUPPLY, LYMPHATICS AND
NERVES OF GINGIVA)
 Correlation of clinical and microscopic
features
• Color: the color of attached and marginal gingiva is generally
described as “coral pink” and is produced by the vascular supply,
the thickness and degree of keratinization of epithelium, and the
presence of pigment containing cells.
• The color of alveolar mucosa is red, smooth, and shiny.
• Size: is the sum total of the bulk cellular and intracellular
elements and their vascular supply.
• Contour: depends on the shape of the tooth and their alignment
within the arch, the location and size of the area of proximal
contact.
• Consistency: gingiva is firm and resilient with exception of the
free movable gingiva.
 Cont..
• Surface texture: similar to orange peel and referred to as
stippled which is best viewed by drying gingiva.
• The attached gingiva is stippled and marginal gingiva is not.
• Stippling is the form of adaptive specialization or
reinforcement for function. It is the feature of healthy gingiva.
• Reduction or loss of stippling is the sign of gingival disease.
• Stippling varies with age. It is absent in infancy, appears in
some children at about 5 years of age, increases until
adulthood, and frequently begins to disappear in old age.
 Cont…
• Shape: the shape of interdental gingiva is governed by the
contour of the proximal tooth surfaces and the location and
the shape of gingival embrasures.
• Position: it refers to the level at which the gingival margin is
attached to the tooth.
 The tooth supporting structures
• All of the tooth supporting structures function as single unit
despite distinct location and composition.
• Periodontal Ligament: is composed of a complex vascular and
highly cellular connective tissue that surrounds the tooth root
and connects it to the inner wall of the alveolar bone.
• PL is continuous with connective tissue of gingiva and
communicates with marrow spaces through vascular channels
in bone.
• Average width of periodontal ligament space is about 0.2mm
with considerable variation.
 Cont..
• The most important elements of the periodontal ligaments
are principal fibers.
• The terminal portion of principal fibers that are inserted into
cementum and bone are termed sharpey’s fibers.
• The principal fibers of PL are arranged in six groups that
develop sequentially as follows.
• Transseptal group: extend interproximally over the alveolar
bone crest and are embedded in the cementum of adjacent
teeth. It may be considered as belonging to gingiva because
they do not have osseous attachment.
 Cont..
• Alveolar crest group: extend obliquely from the cementum just
beneath the junctional epithelium to the alveolar crest and also run
from the cementum over the alveolar crest and to the fibrous layer
of the periosteum covering alveolar bone.
• Horizontal group: extend at right angles to the long axis of the tooth
from the cementum to the alveolar bone.
• Oblique group: the largest group in the PL, extend from cementum in
a coronal direction obliquely to the bone. Bear the burnt of vertical
masticatory stresses and transform into tension on the alveolar bone.
• Apical group: radiate in irregular manner from the cementum to the
bone at the apical region of the socket. They do not occur on
incompletely formed roots.
 Cont…
• Interradicular group: fan out from the cementum to the
tooth in the furcation areas of multirooted teeth.
• Four types of cells are identified in the periodontal ligament;
1, connective tissue cells
2, epithelial rest cells
3, immune system cells
4, cells associated with neurovascular elements.
Functions of periodontal ligaments
• Categorized into physical, formative and remodeling,
nutritional, and sensory.
• Physical functions;
 to protect the vessels and nerves from injury by mechanical
forces.
 Transmission of occlusal forces to the bone.
 Attachment of the teeth to the bone.
 Maintenance of the gingival tissues in their proper
relationship to the teeth.
 Resistance to the impact of occlusal forces(shock absorption).
 Cont..
• Formative and remodeling function: cells of the periodontal
ligament participate in the formation and resorption of
cementum and bone.
• Nutritional and sensory function: the PL supplies nutrients to
the cementum, bone, and gingiva by the way of blood vessels
and also provide lymphatic drainage. PL is abundantly
supplied by sensory nerve fibers capable of transmitting
tactile, pressure and pain sensations by trigeminal pathways.
 cementum
• Is the calcified a vascular mesenchymal tissue that forms the
outer covering of the anatomic root.
• The two main types of cementum are acellular(primary) and
cellular(secondary) cementum.
 Alveolar process
• Is the portion of maxilla and mandible that forms and
supports the tooth sockets. It forms when the tooth erupts to
provide osseous attachment to the forming periodontal
ligament; it disappear gradually after the tooth is lost.
• READING ASSIGNMENT(DEVELOPMENT
OF ATTACHMENT APPARATUS)
 AGING AND THE PERIODONTIUM
• Thinning and decreased keratinization of gingival epithelium.
• Gingival recession due to apical migration of junctional
epithelium.
• Change in periodontal ligament due to decreased number of
fibroblasts.
• Increase in cemental width 5 to 10 times.
• Irregular periodontal surface of alveolar bone and less
insertion of fibers.
• Dentogingival plaque accumulation increase with age.
THANKS