ANATOMY OF

PERIODONTIU
M
Nusreen Jamal.T.P
1st MDS
 The periodontium is a dynamic structure composed
of the tissues supporting and investing the teeth.

 The normal periodontium provides the support

necessary to maintain teeth in function

 Consists of four principal components:

 1) Gingiva- main funtion is protection of the
underlying tissues.
2) Periodontal ligament,
3) Cementum and Attachment apparatus
4) Alveolar bone

 Discusses the structural components of the normal

periodontium; their development, vascularization,
innervation, and functions.
GINGIVA
 Oral mucosa consists of :-
1 )Masticatory mucosa - gingival &
covering of hard
palate
2 )Specialized mucosa - dorsum of tongue
3 )Lining mucosa - remaining part of oral
cavity

 The gingiva is the part of the oral mucosa that

covers the alveolar processes of the jaws and
surrounds the necks of the teeth(CARRANZA)
 MACROSCOPIC ANATOMY
Gingiva divided anatomically into
1.Marginal gingiva
2.Attached gingiva
3.Interdental gingiva
 MARGINAL GINGIVA
 Terminal edge or border of gingiva
surrounding the teeth in collar like
fashion
 In 50% cases, demarcated from

attached gingiva by a shallow linear

depression, free gingival groove.
 Usually 1mm wide, it forms soft

tissue wall of gingival sulcus.

 Gingival sulcus
 Shallow crevice or space
around the tooth
 It is v- shaped & barely

permits the entrance of a

periodontal probe.
 Under absolutely normal or

ideal condition the depth of GS

is 0.
 Histologically reported as

1.8mm
 Clinically healthy gingiva, the

depth is 2 to 3mm
 ATTACHED GINGIVA

 Continuous with marginal

gingiva
 Firm resilient & tightly bound to

the underlying periosteum

 Facial aspect of AG extend to

relatively loose & movable

alveolar(demaracted by
MGJ)mucosa.
 (There is no mucogingival line present in the palate
since the hard palate and maxillary alveolar process
are covered by the same type of masticatory mucosa.)

 Width of AG is distance between MGJ & projection

on external surface of bottom of GS or the periodontal
pocket.

 Greatest in incisor region & less in 1st premolar region.

 MGJ remain stationary throughout adult life

WIDTH OF ATTACHED GINGIVA

 Facial:
• Widest in incisor region
Maxilla: 3.5 – 4.5 mm
Mandible: 3.3 – 3.9 mm
• Most narrow adjacent to premolar
Maxilla: 1.9 mm
Mandible: 1.8 mm
 Lingual:
• Wider in molar region
• Narrow in incisor region
 Increases: by the age of 4 yrs
supraerupted teeth
 INTERDENTAL GINGIVA

 It occupies the gingival embrasure

 Pyramidal or have a col shape

 In former, tip of IG is located

beneath contact point, latter
represent valley like depression
Shape depend upon
 contact point between two adjoining teeth,
 presence or absence of gingival recession,
 the distance between the contact point and the osseous

crest.
 The facial and lingual surfaces are tapered toward the
interproximal contact area, whereas the mesial and
distal surfaces are slightly concave.

 The lateral borders and tips of the interdental papillae

are formed by the marginal gingiva of the adjoining
teeth.
 The intervening portion consists of attached gingiva .

 If a diastema is present, the gingiva is firmly bound

over the interdental bone to form a smooth, rounded
surface without interdental papillae
MICROSCOPIC FEATURES
of gingiva
Gingiva is composed of the

overlying stratified squamous epithelium and the

underlying central core of connective tissue.
GINGIVAL EPITHELIUM – GENERAL ASPECTS :
• Continuous lining of stratified squamous epithelium.
Stratum basale:
• Cells: cylindric or cuboid.

• Found immediately adjacent to the connective tissue

separated by a basement membrane.

• Germinative layer: having the ability to divide.

•Can be considered the progenitor cell compartment of

the epithelium.
 Stratum spinosum:

• Large polyhedral cells with short cytoplasmic processes

•Prickle cell layer.
• Keratinosomes or odland bodies:
 Modified lysosomes.
 Present in the uppermost part of the stratum
spinosum.
 Contain a large amount of acid phosphatase.
 Stratum granulosum:

• Flattened cells, in a plane parallel to the gingival

surface.

• Keratohyaline granules :

• Associated with keratin formation are 1 μm in diameter,

round in shape and appear in the cytoplasm of the cell.
 Stratum corneum:

• Closely packed, flattened cells that have lost nuclei and

most other organelles as they become keratinized.

• The cells are densely packed with tonofilaments.

• Clear, rounded bodies probably representing lipid

droplets appear within the cytoplasm of the cell.
 Function of gingival epithelium:
 Physical barrier to Infection
 Participate actively in responding to infection,
in signaling further host reactions, in integrating Innate
and acquired immune responses.

 The main function of the gingival epithelium is

to protect the deep structures while allowing for a
selective interchange with the oral environment.
via the proliferation and differentiation of
the keratinocytes.
 Proliferation through mitosis occurs in the basal layer
, less frequently in the suprabasal layers.

 Differentiation includes keratinisation

-morphologic changes seen are:
1. Progressive flattening of the cell.
2. Increased prevalence of tonofilaments.
3. Intercellular junctions coupled to the production of
keratohyaline granules.
4. Disappearance of the nucleus
• Three types of surface keratinization can occur in the
gingival epithelium:
1. Orthokeratinization
2. Parakeratinization
3. Nonkeratinization
 ORTHOKERATINIZATION:

• Complete keratinization
superficial horny layer.
• No nuclei in stratum corneal layer.
• Well-defined stratum granulosum.
• Few areas of outer gingival epithelium.
PARAKERATINIZATION:

• Intermediate stage of keratinization.

• Most prevalent surface area of the gingival epithelium.
• Can progress to maturity or dedifferentiate under
different physiologic or pathologic conditions.
• Stratum cornea retains PYKNOTIC NUCLEI.
• Keratohyalin granules are dispersed rather than giving
rise to a stratum granulosum.
NONKERATINIZATION:

• Has neither granulosum nor corneum strata.

• Viable nuclei in superficial layer.
• Layers of nonkeratinized epithelium:
1. Stratum superficiale
2. Stratum intermedia
3. Stratum basale
ULTRASTRUCTURE OF EPITHELIUM:

• Each epithelial type have characteristic pattern of

cytokeratins.
• Keratin proteins are composed of different polypeptide
subunits characterized by their isoelectric points and
molecular weights.
• Basal cells begin synthesis of low mol. Wt. keratins.
Ex.: K19 (40kD).
• High mol. Wt. keratins are expressed when they reach
superficial layers.
Ex.: K1 (68kD).
• K1, K2, K10-12 cytokeratins present are
immunohistochemically expressed with high intensity
in orthokeratinized areas and with less intensity in
parakeratinized areas.
• K6 and K16 , characteristic of highly proliferative
epithelia.
• K5 and K14, are stratification-specific cytokeratins
.
•Parakeratinised areas express K19 which is usually
absent from orthokeratinised normal epithelia.
• Other proteins synthesized during maturation proess:
 Keratolinin
 Involucrin
 Filaggrin
• Corneocyte:
 Most differentiated epithelial cell
 Composed of bundles of keratin tonofilaments in
amorphous matrix of filaggrin, surrounded by a resistant
envelope made of keratolinin and involucrin.
• These histochemical patterns change under normal or
pathologic stimuli, thereby modifying the keratinization
process.
•The degree of gingival keratinization diminishes
with age and the onset of menopause.

•Keratinization of the oral mucosa varies in

different areas in the order:
palate (most keratinized),
gingiva,
ventral aspect of the tongue,
cheek (least keratinized)
 CELLS PRESENT IN GINGIVAL
EPITHELIUM:
 KERATINOCYTES

 NONKERATINOCYTES/CLEAR CELLS:
Langerhans cells
Merkel cells
Melanocytes
Keratinocytes
 Some but not all cells of the stratum basale migrate
through the entire epithelial thickness and eventually
keratinize; these are known as keratinocytes.
 About 1 month are required for the new cell to traverse

the epithelium to reach the stratum corneum.

 SCHROEDER & PAGE have summarized the events
of continuous differentiation, that occur as a new
basal cell derives from a mitotic event in the stratum
basale and makes its way toward the intraoral
epithelial surface.
 Cells lose the ability to multiply by mitotic division;
 Cells produce elevated amounts of protein, and

accumulate keratohyalin granules, keratin filaments

and macromolecular matrix in their cytoplasm;
 Cells lose the cytoplasmic organelles responsible

for protein synthesis and energy production;

 Cells eventually degenerate into a cornified layer

due to the process of intracellular keratinization,

but without loss of cell-cell attachment; and
 cells are finally sloughed away from the epithelial
surface and into the oral cavity as the cell-cell
attachment mechanisms ultimately disintegrate.
Non-keratinocyte
 Cells, other than those of ectodermal origin, may also
be found in the oral epithelium of the gingiva and
include Langerhans cells, melanocytes and Merkel
cells.
 Langerhans cells
 Intraepithelial immunocompetent cells that play an
important role in protective immunity and generally
located in the stratum spinosum.
 Process exogenous antigens and present them to

antigen specific T lymphocytes.

 During inflammation, quantitative and qualitative

changes to the gingival epithelial Langerhans cells may

occur.
 Contain g-specific granules (Birbeck granules), and
they have marked adenosine triphosphatase activity
 Found in the oral epithelium of normal gingiva and in

smaller amounts in the sulcular epithelium;

 Absent from the junctional epithelium of normal

gingiva.
 Melanocytes
 Which originate from neural crest cells , are found in
the stratum basale of the gingival oral epithelium.
 Long dendritic processes that are found interspersed

between the keratinocytes of the epithelium.

 Produce considerable amounts of melanin, which can

produce a brownish pigmentation of the gingiva.

 Merkel cells
 Located in clusters at the tips of rete ridges of gingival
oral epithelium
 Origins from either neural crest cells or epithelial

sources
 Form close associations with intraepithelial nerve

endings, forming the epidermal Merkel cell–neuritis

complexes
 Complexes are involved in mechano perception
 TYPES OF GINGIVAL EPITHELIUM

 Oral or outer epithelium

 Sulcular epithelium
 Junctional epithelium
 ORAL OR OUTER EPITHELIUM

• Covers the crest and outer surface of the marginal

gingiva and the surface of the attached gingiva.

• 0.2 to 0.3 mm in thickness.

• Keratinized or parakeratinized, or it may present

combinations of these conditions.

• The oral epithelium is composed of four layers.

[stratum basale (basal layer), stratum spinosum
(prickle cell layer), stratum granulosum (granular layer), and
stratum corneum (cornified layer).]
 SULCULAR EPITHELIUM

• Lines the gingival sulcus.

• Thin, nonkeratinized stratified
squamous epithelium
• No rete pegs.
• Extends from the coronal limit
of the junctional epithelium to
the crest of the gingival
margin.
Sulcular epithelium….

 Hydropic degeneration of cells.

 Contains K4 and K13, K19.
 Don’t have merkel cells.
 Lacks granulosum and corneum strata
 Sulcular epithelium has the potential to keratinize:

• If it is reflected and exposed to the oral cavity.

• If the bacterial flora of the sulcus is totally eliminated.
 Outer epithelium loses its keratinization:
• When it is placed in contact with the tooth.
 These findings suggest that the local irritation of the sulcus
prevents sulcular keratinization.
 Sulcular epithelium is extremely important because it act as
a semi permeable membrane through which injurious
bacterial products pass into gingival fluid.
-Less permeable than JE.
 JUNCTIONAL EPITHELIUM

• Collar like band of stratified squamous non-keratinizing

epithelium.

• 3 to 4 layers thick in early life, but the number increases with

age to 10 or even 20 layers.

• Tapers from its coronal end to apical termination, located at

the cementoenamel junction in healthy tissue.

• Length: 0.25 to 1.35 mm.

• These cells can be grouped in two strata:
• The basal layer: that faces the connective tissue
(External Basal Lamina)
• the suprabasal layer: that extends to the tooth
surface.– (Internal basal lamina)
THE DENTOGINGIVAL UNIT:
• The attachment of the junctional epithelium to the tooth is
reinforced by the gingival fibers, which brace the marginal gingiva
against the tooth surface.
• For this reason, the junctional epithelium and the gingival fibers
are considered together as a functional unit.
Development of gingival epithelium

 As an erupting tooth approaches the oral epithelium,

the enamel epithelium rapidly proliferates, forming
REE.
 As the crown erupts further, the REE overlying the

enamel fuses with the oral epithelium establishes the

dentogingival junction forming the junctional epithelial
cells.
 The nonkeratinized junctional epithelium originates
from the enamel organ, while the nonkeratinized
sulcular and the keratinized gingival epithelium
originate from the oral mucosa.
Development/Origin of Junctional Epithelium
REE surrounds the crown of tooth from the moment
enamel is properly mineralized till the tooth erupts

Migrating epithelium produces an epithelial

mass between oral epithelium and REE so
When tooth has penetrated in oral cavity that tooth can erupt without bleeding.
large portions immediately apical to incisal
area of enamel are covered by junctional
epithelium containing few layers of cell.

During later phases of tooth eruption all

cells of REE is replaced by JE.
Functions:
• Provides attachment to the tooth.
• Forms an epithelial barrier against the plaque bacteria.
• Rapid turnover
 Hinder bacterial colonization and
 Repair of damaged tissue occurs rapidly.
• Allow GCF:
 From connective tissue into crevice – Gingival fluid
exudates, PMNs,etc.
 From crevice to connective tissue – Foreign material
such as carbon particles,
-protective funtion.
• Produces active antimicrobial substances like defensins,
lysosomal enzymes, calprotectin and cathelicidin.
• Epithelial cells activated by microbial substances secrete
chemokines, e.g. IL-1, IL-6, IL-8 and TNF that attract and
activate professional defense cells such as lymphocytes
and PMNs.
GINGIVAL CREVICULAR FLUID
• Represented as either as transudate or an exudate.
• Diagnostic or prognostic biomarker of the biologic state of the
periodontium in health and disease.
• GCF flow increases during inflammation and resembles that of
inflammatory exudates.
• Gingival fluid diffuses through the basement membranes.
• Functions:

 Cleanse material from the sulcus.

 Contain plasma proteins that may improve adhesion of
epithelium to the tooth
 Possess antimicrobial properties
 Exert antibody activity to defend the gingiva.
BASEMENT MEMBRANE
 Epithelium joined to CT by basal lamina is 300 to
400A thick
 Consist of lamina lucida & lamina densa .
 BL is PAS positive.
 Permeable to fluids but act as barrier to particulate

matter.
 Major constituents are type IV collagen, laminin and
the heparan sulfate proteoglycan perlecan
 other recognized components;

hemidesmosome,anchoring fibrils which contain type

VII collagen;entactin/nidogen, which forms complexes
with laminin; and several poorly characterized
chondroitin sulfate and heparan sulfate proteoglycan
GINGIVAL CONNECTIVE TISSUE
 Major components of gingival CT
are collagen
fiber(60%),fibroblast(5%),vessels,
nerve& matrix(35%)
 CT of gingiva is known as lamina

propria.
 Consist of two layers papillary

layer& reticular layer

 Has cellular & extracellular

compartement
Extracellular compartment
 Ground substances-fill the space between fibers & cells
.composed of proteoglycans,mainly hyaluronic acid &
chondritin sulfate,& glycoprotein mainly fibronectin.
.fibronectin account faint PAS+ve reaction
Cellular compartment
1.Fibroblast
 Preponderant cellular element
 Mesenchymal origin, play major role in gingival CT
 Synthesize collagen& elastic fibers, as well as

glycoprotein & glycosoaminoglycans

 Also regulate collagen degradation
2.Mast cells
 Large spherical or elliptical mononuclear clear cell
 In histologic preparations frequently obscured bcz of

granules
 Granules stain with methylene blue
 Granules contain histamine & heparin
 histamine known to be important in inflammation

process
3.Macrophage
 Under light microscope,the fixed macrophage is
stellate or fusiform cell
 Function-ingest damaged tissue or foreign material in

phagocytic vacuoles
.stimulation of fibroblast proliferation
 In CT of gingiva,two special type seen

1.melanophage
2.siderophage
Inflammatory cell
 Histologically,lymphocyte & plasma cell may observed
in small numbers.
 Type of inflammatory cells depend upon the nature &

duration of injury
 In acute conditions,PMNS
 In chronic condition,lymphocyte,plasma

cell,macrophage & monocyte

FIBERS OF GINGIVAL CONNECTIVE TISSUE

The connective tissue fibers produced by the fibroblasts

and can be divided into
1.collagen fibers
2.reticular fibers
3.elastic fibers
4.oxytalan fibers
1. COLLAGEN FIBER
 are 5 principal fiber bundle groups as well as 6 minor
groups
 The principal groups include dentogingival fibers,

alveologingival fibers, circular fibers, dentoperiosteal

fibers and transseptal fiber
 The secondary or minor collagen fiber bundles are the

periostogingival, interpapillary,transgingival,
intercircular, intergingival and semicircular fibers
According to Carranza,
The gingival fibers are arranged in three
groups:
1. Gingivodental
2. Circular
3. Transseptal
1. Dentogingival fibers
2. Alveologingival fibers 3. Interpapillary fibers 4. Transgingival fibers 5. Circular and
semicircular fibers 6. Dentoperiosteal fibers 7. Transeptal fibers 8. Periostogingival fibers
9. Intercircular fibers 10. Intergingival fibers
 The turnover of collagen in normal gingiva is not as
rapid as exhibited in the periodontal ligament but is
significantly greater than found in other tissues such as
skin, tendon or palate
 half-life of collagen in the gingiva can range from 8.4

days in the transseptal fibers to 25 days in the

dentogingival fibers
2.oxytalan fibers

 They are scare in gingiva but plenty in pdl

 In pdl they run parallel to long axis of tooth
 Their function is yet unknown.

3 . Elastic fibers
In both gingiva and connective tissue of pdl, these fibers
are seen in association with blood vessel
Only, submucossa of alveolar mucosa contain numerous
elastic fibers
4. Reticulin fibers

 argyrophilic staining fibers which are numerous in

tissue adjacent to basement membrane
 occur in large number adjacent to blood vessels
 found at epithelium- connective tissue and the

endothelium- connective tissue interface

Biochemical composition of gingival connective
tissue

 type I collagen is the major collagenous component of

the gingival
 Numerous substrate adhesion molecules have also been
identified in the extracellular matrix, including
fibronectin,laminin,Tenascin &Osteonectin has also
been identified
 proteoglycans of gingival connective tissue are
characterized by at least 3 different species
 The principal proteoglycan is a low-molecular-weight

glycoprotein consisting principally of dermatan sulfate

chains
 chondroitin-4-sulfate and heparan sulfate comprise the

2 remaining gingival proteoglycans

 decorin,primarily in the subepithelial connective tissue,

and versican, sparsely distributed throughout the

connective tissue, have been identified
Development of gingival connective tissue
 Prior to emergence of the crown, the connective tissue
in the future eruption pathway shows alterations
including the degeneration of collagen fibers,cells and
blood vessels. Formation of this eruption pathway
accelerates the rate of tooth eruption.
 Gingival connective tissue fibroblasts originate from

perifollicular mesenchyme, a derivative of the

stomodeal mesoderm
 The collagen matrix of gingival connective tissue is
well organized into fiber bundles, which constitute the
gingival supra-alveolar fiber apparatus.
Blood supply
1. Supraperiosteal arterioles along the facial
and lingual surfaces of the alveolar bone from
which capillaries extend along the sulcular
epithelium and between the rete pegs of the
external gingival surface.
2. Vessels of the periodontal ligament, which
extend into the gingiva and anastomose with
capillaries in the sulcus area.
 3. Arterioles, which emerge from the crest of the
interdental septa and extend parallel to the crest of
the bone to anastomose with vessels of the
periodontal ligament, with capillaries in the gingival
crevicular areas and vessels that run over the alveolar
crest.
 Innervation of gingiva
 innervated by terminal branches
of periodontal nerve fibers and by
branches of the infra orbital and
palatine or lingual, mental and
buccal nerves
 Many of the nerve endings
contain substance P and calcitonin
gene-related peptide
 Unmyelinated nerves are located
in JE; the highest concentration of
free nerve endings are in the
apical portion of the JE and in the
col area
 sympathetic neural activity appears to be must
significant in gingiva leads to vasoconsriction.(alpha
effect)
 Merkel cell neurite complexes (slowly adapting

mechanoreceptors) and encapsulated nerve endings

(rapidly adapting mechanoreceptors. ) are also found in
the GE and its lamina propia.
 Lymphatic circulation
 Lymphatic drainage of gingiva
brings in lymphatics of connective
tissue papilla, it progresses into
the collecting network external to
the periosteum of the alveolar
process and then to the region of
lymph modes particularly,
submaxillary group.
 Lymphatics just beneath JE extend
into the periodontal ligament and
the accompanying blood vessels
 CLINICAL CORRELATIONS OF
MICROSCOPIC FEATURES
1. Colour-
• The colour of attached and marginal gingival is generally -
CORAL PINK
. The alveolar mucosa is red, smooth and shiny rather than pink
and stippled
. Melanin is a non-hemoglobin derived brown pigment,
responsible for normal pigmentation of skin, gingival and oral
mucous membrane
Physiologic
Pigmentation(melanin)
• Melanin (non hemoglobin derived
brown pigment)
• Prominent in blacks, diminished in
albinos
• Distribution of Oral Pigmentations
in blacks:
Gingiva -60%
Hard Palate -61%
Mucous membrane -22%
Tongue -15%
• As a diffuse , deep purplish
discoloration or as irregularly shaped
brown and light brown patches and
may appear as early as 3 hours after
birth.
2. Size

 the sum total of the bulk of

cellular and intercellular
elements and their vascular
supply
 Alteration in size is common

in gingival diseases.
3.Contour
• Marginal gingiva envelops the teeth in
collarlike fashion and follows a
scalloped outline on the facial and
lingual surfaces.
• straight line - along teeth with
relatively flat surfaces.
• accentuated - pronounced mesiodistal
convexity (e.g., maxillary
canines) or teeth in labial version
• horizontal and thickened - in lingual
version.
4.Consistency
 Gingiva is firm and resilient of tightly bound to
underlying bone except free gingiva
 The collagenous nature of lamina propria and its

contiguity with the mucoperiostem of the alveolar bone

determines the firmness of attached gingival
 The gingival fibers contribute to firmness of free

gingiva
5.Surface texture
 Orange peel texture is referred to as stippling which is
best viewed in dryness.
 The attached gingival is stippled; marginal gingival is

not stippled.
 The central portion interdental papilla is usually

stippled
 Microscopically, stippling is produced by alternatively

rounded protubermes and depressions in the gingival

surface of papillary projections of connective tissue
into epithelium.
• Stippling –produced by alternate round protuberance
and
depressions in the gingival surface.
• Low magnification ; a stippled surface,
• Higher magnification; cell micropits
• A form of adaptive specialization or reinforcement
for function
–feature of healthy gingiva
• Reduction of stippling – common sign of Gingival disease.
• Stippling returns when gingiva is restored to health.
• Keratinisation – protective adaptation , increased by tooth
brushing.
• In 40% of adults Gingiva show stippling.
• Generalized absence of stippling is seen in:
Infancy
Diseased conditions like gingival enlargements,
mucocutaneous
lesions affecting gingiva, inflammation etc.,
Changes to the gingival tissues with
onset of inflammation
 Epithelial changes-The gingival epithelium, and in
particular the junctional epithelium, is involved at the
earliest phases of the inflammatory response
 Before the clinical signs of gingivitis develop in

response to plaque accrual, the potential for epithelial

cell activation is high
 Epithelial cells can produce numerous cytokines

including interleukin-1 and interleukin-8, ICAM-

1&EACM-1,PDGF
 Concomitant with this expression, the intercellular
spaces of the junctional epithelium begin to widen and
serve as a primary pathway for the egress of the
inflammatory exudate from the gingiva to the gingival
sulcus.
 Tissue destruction at the epithelium–connective tissue

interface mediated via integrin-a2b1 & a3b1, a6b4

 With continuing plaque accrual, neutrophil migration
and early activation of macrophages and lymphocytes
within the gingival connective tissue, the junctional
epithelium can be seen to commence migration in an
apical direction and result in the earliest formation of a
periodontal pocket
 gingival epithelial cells are also stimulated to produce

collagenase-3,TGF-B, keratinocyte growth factor

Connective tissue matrix changes
 Connective tissue destruction occurs within 3 to 4 days
after plaque accumulation
 The destruction begins at perivascular collagen bundles
 Major inflammatory cells-polymorphonuclear

lymphocytes and macrophages

 Numerous quantitative and qualitative changes occur to

the gingival collagens

 Amount of type V collagen increases and a new

collagen, type I trimer, may appear

 The gingival proteoglycans manifest fewer quantitative
and qualitative changes than do the collagens.
 the amount of dermatan sulfate decreases while the

content of chondroitin sulfate increases.

 In addition, degradation of both proteoglycan core

proteins and hyaluronic acid are characteristic features

of inflamed gingival connective tissues
Clinical considerations
1.Level of gingival attachement plays important role in
restorative dentistry-1st requirement is that restoration
be adapted to mechanical needs
2.Incision in lining mucosa wounds creates gaping
wounds, so require suturing
3.Similiarly infilteration of LA into masticatory mucosa
is difficult & cause pain
4.Healing in oral mucosa is fast & without scar
5.One method of increasing keratinization is by direct
stimulation(massage & brushing)& by minimizing
plaque formation
6.Mechanical irritation of the gingiva from sharp edges
of carious cavities, overhanging filling or crown cause
chronic inflammation
7.Systemic diseases causes changes such as
metal poisoning (lead, bismuth),leukemia, pernicious
anemia,measles,endocrine disturbances, causes
discoloration of gingiva
8.Mutation of gene encoding cytokeratin causes changes
in epithelium. For e.ck4&ck14 causes epidermolysis
bullosa&CK4 &CK13 for white spongy nevus, a
congential keratin D
9.Various gene like P53,P16,P21,bcl-2etc involved in
regulation of epithelial cell proliferation.
GINGIVAL OVERGROWTH
 Fibrotic enlargement of the gingiva occurs as a
hereditary condition known as hereditary gingival
fibromatosis
 In this condition , gingival fibroblasts express and
respond to TGF-3 by increasing the secretion of
extracellular matrix proteins
 Gingival overgrowth, characterized by fibroblast
proliferation, epithelial hyperplasia, increased deposition
of extracellular matrix, and inflammatory cell
infiltration, occurs as an unwanted side effect to several
therapeutic drugs
 Phenytoin has been shown to potentiate the action of
TNF-a in producing IL-1 and prostaglandin E by
gingival fibroblasts'" while cyclosporinA has been
shown to elevate platelet derived growth factor in
gingiva
 Calcium antagonists, such as nifedipine, diltiazem,and

verapamil, block the aldosterone synthesis in the

adrenal cortex
 Recent studies indicate a positive correlation between
the expression of HLA-DR2 antigen ns and gingival
overgrowth
 Gingival overgrowth leads to formation of pseudo-

pockets and accumulation of bacterial plaque that leads

to inflammation.
AGE CHANGES ON GINGIVA.

Epithelial changes

 Thinning and decreased keratinisation of gingiva.

 Increased epithelial permeability to bacterial antigens
 Flattering of rete Pegs and altered cell density.
 Location of JE changes
 Increased width of attached gingival as Of passive

eruption of tooth
Connective tissue changes

 Coarser and more dense connective tissue

 Qualitative and quantitative changes noted
 Increased rate of conversion of soluble to insoluble

increased denaturing temperature.

 Lower rate of collagen synthesis.
 Greater collagen content in older animals
CEMENTUM
Cementum:
•It is a calcified, avascular mesenchymal tissue
that forms the outer covering of the anatomic root

• Main function of cementum is to anchor the

principal collagen fibers of the periodontal
ligament.

•It also has adaptive and resorptive functions.

•Cementum is a non-uniform, mineralized

connective tissue
• Several varieties of cementum are found on human teeth which
differ with respect to location, structure, function, rate of
formation , chemical composition and degree of mineralization

• Cementum does not undergo continuous remodeling like bone,

but continues to grow in thickness throughout life.
DEVELOPMENT :
•The formation of cementum can be subdivided into
a) Prefunctional development
b) Functional development

• Prefunctional portion of cementum is formed

during root development & is extremely long
lasting process

• It is about 3.75 and 7.75 yrs for permanent teeth

• During this period of time the primary distribution

of the main cementum varieties is determined for
each tooth.
• Functional development of cementum commences
when the tooth is about to reach the occlusal level, is
associated with the attachment of the root to the
surrounding bone and continues throughout life.

• It is mainly during functional development that

adaptive and reparative processes are carried out by
the biological responsiveness of cementum.
 CEMENTOGENESIS

Genesis of cementum :

• Formation of cementum
• Types of cementum

•Cells involved
• Cementoblasts
• Cementocytes
 FORMATION OF CEMENTUM:

Cementum is the hard tissue that covers the root surface

The cementum formation usually commences after the

completion of crown formation .

The cells of IEE and OEE form the bilayer of cells

known as Hertwig’s epithelial root sheath.
 Hertwig’s epithelial root sheath
was discovered by Oskar Hertwig
in 1874 in an amphibian.

 This band of cells serves to

separate the cells comprising the
dental papilla and dental follicle.
•IEE induce adjacent cells to
differentiate into odontoblasts
and subsequently deposit dentin.

•Further the Hertwig's root

sheath disintegrate , and does not
cover the predentin.

•The cells from the dental

follicle attach and align onto the
matrix coating of the dentin
surface.
Types of cementum
•Accordingto Schroeder there are mainly two types of
cementum. They are:

•Acellular ( primary ) cementum

•Acellular extrinsic fiber cementum
•Acellular afibrillar cementum.

•Cellular ( secondary) cementum

•Cellular intrinsic fiber cementum
•Cellular mixed stratified cementum

•Intermediate cementum
 CEMENTUM

ACELLULAR Cellular mixed stratified

Cellular intrinsic fiber

Acellular
Acellula extrinsic Interm CELL
r fiber
afibrillar cementum ediate ULAR cementum
ACELLULAR CEMENTUM FORMATION:
•During root formation the first cells that align along the
dentin surface exhibit FIBROBLASTIC characteristics.

•These cells deposit collagen within the unmineralized dentin

matrix so that fibrils from both matrices interdigitate.

•Mineralization of the mantle dentin starts internally and does

not reach the surface until blending of collagen fibrils from
both layers has occurred.
ACELLULAR CEMENTUM
•It
then spreads across into cementum matrix there by
establishing dentin – cementum junction.

•The cells on the root surface continue to deposit

collagen so that the fiber fringe lengthens and thickens.

•Thenon – collagenous proteins fill in the spaces

between the collagen fibers. This activity continues until
about 15 – 20 µm.
•Theintrinsic fiber fringe becomes connected with the
developing periodontal ligament fiber bundles.

•AcellularExtrinsic Fiber cementum formative cells will

be essentially engaged in synthesis of non – collagens
matrix proteins, collagen fibrils that embedded in it will
be formed by periodontal ligament fibroblasts.
 ACELLULAR AFIBRILLAR CEMENTUM

 Found deposited on mature enamel

surfaces.

 It is formed during development, during

eruption or possibly after eruption.

 Contains neither cells nor fibers

 Thickness 1 – 15µm
 Acellular afibrillar cementum classically
appears as cementum spurs( found
around CEJ ) or cementum
islands( cementum deposited on crown
just coronal to CEJ ).

 It has got a little functional significance

because it is not involved in fiber formation
and tooth anchorage.
ACELLULAR EXTRINSIC FIBER CEMENTUM
 Composed of densely packed bundles of sharpey’s
fibers and lack cells.

 Is a product of Fibroblasts and cementoblasts.

 It forms new dentin surface after dissolution of HER’S.

 The fibers are parallel to each other and perpendicular

to the root surface.
 The mineralization of AEFC starts as isolated
patches.

 This type of cementum is located on the

coronal one third of the root surface.
CELLULAR INTRINSIC FIBER CEMENTUM:
•Afterat least half of the root has been formed,
cementoblasts start forming a less mineralized variety
of cementum.

•Its
constituent collagen is produced by cementoblasts
themselves.

•A layer of unmineralized matrix, termed CEMENTOID

is established.

•Cementoid is irregular in shape and is readily

discernible.
•Thecells become entrapped are called
Cementocytes which give cementum a bone
appearance.

•Collagenfibrils are laid down haphazardly and later

become arranged parallel to the root surface.

•Some of the periodontal ligament fibers during

formation are surrounded by cementum and are
mineralized.
CELLULAR MIXED FIBER CEMENTUM

 Contains both collagen fibers and calcified matrix

and appears to be synthesized solely by
cementoblasts.

 This type of cementum contains mixture of collagen

fibers that is extrinsic ( sharpey’s) and intrinsic
fibers.

 CIFC frequently appears as the first layer of CMSC.

It forms first on newly produced dentin when the
advancing root edge reaches the apical region.
 It mainly appears primarily in the apical third
of the roots and in furcation areas.

 The thickness ranges from 100 to 1000µm.

 CELLULAR INTRINSIC FIBER CEMENTUM

 Contains cells but no extrinsic collagen fibers.

 Considered to be a form of reparative cementum.

 It is commonly associated with the repair of

resorptive defects and healing of roots fractures.

 Principle cells involved are cementoblasts and

does not demonstrate any evidence of extrinsic
fiber insertion in the form sharpey’s fibers.
 INTERMEDIATE CEMENTUM

 It is a poorly defined zone near the cemento -

dentinal junction of certain teeth.

 Contains cellular elements of HER’s

embedded in calcified ground substance.
Cementoblasts:

•Are primary source of cementum formation

during both development and later post –
eruption function.( Schroeder 1992, Bosshardt
and Schroeder 1996)

•These cells are located in close apposition to

the cementum surface.
Cementocytes:

•Located
with in the mineralized matrix of
cementum.

•These are the cells entrapped during the structural

organisation of matrix.
COMPOSITION
COMPONENTS
ORGANIC COMPONENTS:
•COLLAGEN – TYPE I
TYPE II

INORGANIC COMPONENTS:
•Hydroxyapetite
•Non – collagenous proteins
ORGANIC COMPONENT
COLLAGEN :
•Is a protein

•Composed of different amino acids –

Glycine
Proline
Hydroxylysine
Hydroxyproline

•The amount of collagen in a tissue can be

determined by its hydroxyproline content.
•Collagen molecule is a rigid, rod like
structure that resists stretching – fibers
made up of collagen have high tensile
strength.

•Itis important component in periodontal

ligament and tendon in which mechanical
forces need to be transmitted without
loss.
 STRUCTURAL FEATURES

•The word collagen is derived from GREEK

roots KOLLA and GENE.

•FRENCH collagene designates glue –

producing constituents.
•As a group of proteins collagen contains no.
of characteristic features :

1. The presence of triple helical structure

2. With in triple helical domain, glycine

occupies every third position in the
repeating amino acid sequence Gly – X –
Y.

3. The collagen molecule is stabilized through

the formation of a no. of lysine – derived
intra and inter molecular cross – links.
STRUCTURE OF COLLAGEN
TYPES:

•In collagen Types I and III – fibers

Types I – bundles

•Collagen is synthesized by fibroblasts,

chondroblasts, osteoblasts, odontoblasts and
other cells.

•Principle fibers – Type I

•Reticular fibers – Type III
•Basal lamina – Type IV
•Type XII is timed with the alignment and
organization of periodontal fibers and is
limited in tooth development .

•TypeVI – immunolocalized in periodontal

ligament and gingiva.
INORGANIC COMPONENT
HYDROXY APETITE
•Chemical formula : Ca10(PO4)6(OH)2.

•Thisformula indicates only the atomic content of a

conceptual entity known as the unit cell.

•The unit cell biologic apetite is hexagonal.

•When stacked together these cells form lattice of

crystal.

•A layerof water called hydration shell exists around

each crystal.
 Each apetite has three surfaces:

• Crystal interior
• Crystal surface
• Hydration shell

All of which are available for the exchange of ions.

• Magnesium and sodium – calcium

• Fluoride and chloride – hydroxyl position
• Carbonate in hydroxyl and phosphate position
 NON – COLLAGENOUS PROTEINS

•BONE – SIALOPROTEIN
•OSTEOPONTIN
•OSTEOCALCIN
•FIBRONECTIN
•PROTEOGLYCANS
 BONE - SIALOPROTEIN

 Is a highly Glycosylated and acidic

Phospho protein (Fisher et al 1983)

 Major structural protein of the bone matrix

expressed by fully differentiated
osteoblasts.

 Predominant of matrix proteins – 15% of

non – collagenous proteins.
FUNCTIONS :
 Osteoblast attachment – RGD sequence

 Binds to hydroxy apetite providing anchoring mechanism.

 Expressed during early formation of dentin and alveolar bone

 Expressed by cementoblasts during cementogenesis.

 Is closely associated with differentiating Osteoblasts.

 OSTEOPONTIN
 Glycosylated phosphoprotein

 Present in significant amounts in bone at

mineralization fronts.

 Also found in kidneys( loop of henle, distal

convoluted tubule) luminal surface of
epithelial cells of ductal tissue.

 Synthesized by – osteocytes, osteoblasts,

smooth muscle cells and epithelial cells.
 Highest level of osteopontin expression are
observed in :
• Pre – osteoblastic cells
• Mature osteoblasts

 Osteopontin plays an important role in both

mineralization and of bone.

 Plays a key role in wound healing.

 OSTEOCALCIN

 Member of family of extracellular mineral

binding proteins present in bone.

 Found in bone matrix and specifically localizes

to developing bone.
 FIBRONECTIN
 It is a multi functional adhesive glycoprotein
that is co – distributed with Type I and III
collagens in fibers.

 2 major forms :
• Soluble Dimeric form – found in plasma ( pFN )
• Dimeric or multimeric cross – linked form deposited as
fibrils in the extracellular matrix ( cellular fibronectin
cFN )
 pFN – hepatocytes
 cFN – epithelial cells, fibroblasts and other
mesenchymal tissues.
 It binds to fibroblasts and many other cell types
and mediates their - attachment, spreading,
migration.

 Participates in many biological processes during

growth, development and repair.

 Plays an prominent role in phagocytosis,

hemostasis, thrombosis, oncogenic
transformation.
 PROTEOGLYCANS

 Highly anionic complexes in which on or more

hexosamine – containing polysaccharides called
glycosamino glycans are covalently attached to a
protein core.

 They are ubiquitous to all connective tissues, and are

located within the matrix as integral components, on
cell surfaces and within cell organelles.

 VERSICAN & DECORIN are type of extracellular

proteoglycans found in cementum.
FUNCTIONS :

 Tissue hydration

 Retention & regulation of water flow

 Lubrication of synovial and mesothelial surfaces

 Regulation of collagen – fiber formation

 Growth factor binding

 Cell adhesion and growth.

 PERMEABILITY OF CEMENTUM
 Cellular and acellular cementum are very
permeable and permit the diffusion of dyes
from the pulp and external root surface.

 The permeability of cementum diminishes with

age.
CEMENTO ENAMEL JUNCTION
 THICKNESS OF CEMENTUM
 Cementum deposition is continuous process.

 Cementum formation is most rapid in the APICAL

region.

 Thickness of cementum at coronal half 16 - 60µm.

 Between the ages of 11 – 70 average thickness of

cementum increases threefold
• 95µm – 20 yrs
• 215µm – 60 yrs.
 HYPERCEMENTOSIS
 The term Hypercementosis refers to a
prominent thickening of cementum.

 It may be localized – one tooth, affect entire

dentition.

 Hypercementosis occurs as a generalized

thickening of the cementum, with nodular
enlargement of the apical third of the root.
 Cemental spikes:
Created by either the coalescences of cementicles that
adhere to the root or the calcification of periodontal
fibers at the sites of insertion into cementum.

• These may result from excessive tension from

orthodontic appliances or occlusal forces.
 PATHOLOGICAL CONDITIONS AFFECTING
CEMENTUM
 Paget’s disease – Hypercementosis
 Hypophosphatasia – no cementum formation
with exfoliation of teeth

 Hypopituitarism – decreased cementum formation.

RESORPTION AND REPAIR
 Cementum of unerupted as well as erupted
teeth is subject to resorptive changes –
microscopic proportion.

 Resorption appears microscopically as Baylike

concavities in the root surface.

 Resorption may be due to

• Local
• Systemic conditions
 LOCAL :
• TFO
• orthodontic tooth movement,
• pressure from malaligned erupting teeth,
• embedded teeth
• Reimplanted and transplanted teeth
• Periapical disease
• Periodontal disease
 SYSTEMIC CONDITIONS :

• Calcium deficiency
• Hypothyroidism
• Hereditary fibrous osteodystrophy
• Paget’s disease
 Multi nucleated giant cells and macrophages are
generally found adjacent to cementum undergoing
active resorption.

 The resorptive process may extend into dentin and

pulp but is usually painless.

 Cementum resorption is not continuous and may

alternate with periods of repair.

 The newly formed cementum is demarcated from

root by a deeply staining irregular line, REVERSAL
LINE
 REPAIR

 Cementum repair requires the presence of

viable connective tissue.

 Repair of the damaged can be obtained by:

• Formation of new cementum.
• By using chemical agents to promote regeneration.
 Formation of new cementum

 Regenerative cementogenesis on previously

diseased root surfaces is unpredictable.

 The most common outcome is formation of

new tissue that resembles cementum or bone,
is cellular and contains collagen fibers.

 In periodontal regeneration the process of

cementogenesis should repeat.
 Local factors like growth factors and adhesion
molecules motivate the cells to recruit the
dentinal ( root ) surface.

 They induce cementoblast phenotype permit

their attachment to dentin surface and
encourage their proliferation.
 Chemical agents
 This process is mainly called ROOT
SURFACE CONDITIONING.

 It involves the modification of root surfaces to

make them conductive to the attachment of
connective tissue cells.

 Agents used are

• Citric acid
• Tetracycline
• Fibronectin
REFERENCES :

 CLINICAL PERIODONTOLOGY – NEWMAN

TAKEI CARRANZA 10TH EDITION

 FUNDEMENTALS OF PERIODONTICS –
WILSON AND KORNMAN

 BARTHOLD AND NARAYANAN –

 ORAL HISTOLOGY - ORBAN’S

 ORAL HISTOLOGY – TENCATE 6TH EDITION

 PERIODONTOLOGY 2000, VOL - 13

PERIODONTAL
LIGAMENT
 Soft specialized connective tissue situated between the
cementum covering the root of the tooth and the bone
forming the socket wall.

 Also known as Desmodont, Gomphosis,

Pericementum, Dental Periosteum, Alveolodental
Ligament and periodontal membrane.
Devolopment
 Derived form dental follicle(dental sac)
 Related to root formation
 Disintegration of HERS
 Mesenchymal cells differentiate into cementoblasts
 Principal fibers are formed
 Initially formed as short , unorganized fiber bundles
 Eruptive movement and occlusion modifies this initial

arrangement
 Only after final position is established, the fibers

thicken.
General Structure

 Hour glass shape, narrowest at mid root level

 Width- 0.25mm(0.2-0.4)
 Width decreases with age
 Thinner at mesial aspect of all teeth
contents
 Cellular elements
 Fibers
 Ground substance

70%- occupied by cells and fibers

30%- loose connective tissue
This balance is disturbed in inflammation
 PDL may be divided into 3 zones:
1) Bone related region rich in cells and blood vessels
2) Cementum related region with dense ordered collagen bundles
3) Middle zone with fewer cells and fibers

 Intermediate plexus
 A region of collagen fiber splicing and unsplicing
 Not supported by recent studies
 Evidence supports synthesis and collagen turnover over the
entire width of PDL.
Cells of PDL

 Connective tissue cells

 Epithelial rest cells

 Cells of immune system

 Cells associated with neurovascular elements

Connective tissue cells
1. Fibroblasts
 Most abundant cells in pdl
 Fibroblasts are among the oldest and most
conserved structures of multicellular organisms.
 Pdl fibroblasts are of neural crest origin
 Exceptionally high rate of collagen turnover

 A subpopulation of osteoblast like fibroblasts is

also found
 They are rich in alkaline phosphatase
 Give rise to bone cells and cementoblasts
 Also responsible for extrinsic fiber cementum in
mature pdl.
Structure
 Synthetic activity and interaction with surrounding
extracellular matrix determines the shape of the
fibroblast
 Most of them are highly active
 Extensive, elongated, polarized cytoplasm
 Progenitor cells are smaller and less polarized
 Areas of extensive contact with collagen fibers
 Less active cells are found around blood vessels and

near cementum surface.

Cytoplasm
 Abundance of RER and well developed Golgi
complexes

 A cytoskeleton with prominent actin network

 Smooth muscle actin and myosin which help in

forming stress fibers
 Stress fibers
Oriented parallel to the long axis of the cell
Terminates at the cell surface at special attachment plaques
It endows contractility
It allows to exert forces on extracellular matrix.

 Mitochondria distributed throughout the cell

 Lysosomes are fewer in number when compared to

phagocytic cells(neutrophils)
Intra cellular collagen

 PDL fibroblasts contain small amounts of fragments of

collagen fibrils within membrane bound vesicles
(Tencate 1972,Listgarten 1973)

 They help in intracellular collagen degradation (Tencate

et al 1976)
 Vimentin type intermediate filaments are present (type
III)

 Cell contacts:
 Numerous intercellular contacts are present
 Usually not seen in fibroblasts of other tissues.
 2 types of contacts are seen; gap junctions and simplified desmosomes
(macula adherens)
 Gap junctions- 0.1-0.5µ
 Maculae adherens are smaller 0.1-0.4µ
 This high number of contacts are related with the generation of
eruptive forces
 They may also be related to the high turnover of the matrix
Receptors
 Epidermal growth factor
 IL-1β
 Studies suggest receptors for insulin like growth factor,
 Platelet derived growth factor
 Growth hormone,PTH
Nucleus
Prominent, has single distinct nucleolus

Internal dense lamina characteristic of

connective tissues

Nucleus is flattened, disc shape(10µ)

Occupies up to 30% of the cell

At the narrow end of the triangular cell

Fibroblast Contractility
 Fibroblasts exhibit features of smooth muscle cells
with many intracellular microfilaments and expression
of α- smooth muscle actin
 They are called myofibroblasts
 Make connection with extracellular matrix through

fibronexi
 Present in many tissues- spleen, adrenal glands,

tendons,ligaments, etc.
 Myofibroblasts are responsible for contraction of
wounds

 They are also associated with the stroma of many

carcinomas

 Such fibroblasts are common in PDL

 They are supposed to be responsible for generation of

eruptive forces
 It is also significant in post eruptive movements like
those during mastication, growth of jaws, and
compensation for occlusal wear.
 Fibroblasts respond to changes in the matrix
 Integrins help in transmitting mechanical stimuli into

the cell
 This leads to contraction
 Fibroblasts align parallel to direction of principal strain
Functions of fibroblasts

 Synthesis and degradation of collagen

 Collagen synthesis occurs across the entire width oh

the PDL
Collagen

 Most abundant protein in the animal kingdom

 Secreted primarily by fibroblasts

 Also by chondroblasts, osteoblasts and odontoblasts

 More than 19 types have been described

 Encoded by 25 separate genes among 12 chromosomes

composition
 Most important amino acids include glycine, proline,
hydroxyproline and hydroxylysine

 Amount of collagen can be estimated using

hydorxyproline content

 Triple helix or superhelix

 One collagen molecule is made of 3 α chains

Classification
1. Fibrillar collagens
Most abundant group.These form banded
fibrils, have uninterrupted triple helices.
Types I, II, III, V, XI

2. Fibril associated collagens with interrupted triple

helices(FACIT’s)
these associate with the first group, found between
banded fibrils and other filaments.
types IX, XII, XIV, XVI, XIX
3. Network forming collagens
Type IV, VIII, X. These form protein membranes

4. Beaded filament forming collagens

Type VI- Microfibrils, Type VII-Anchoring Fibrils

5. Transmembrane collagens
Types XII, XVII
Sitewise distribution
Type I- Skin, bone, tendon, ligaments,
widespread in connective tissues
Type II- Cartillage, vitreous, nucleus pulporus
Type III- soft tissues, foetal skin, tendon,aorta,
reticulin fibers
Type IV- Basement Membranes
Type V- widespread in all soft tissues,esp.in
foetal connective tissues
Type VI- widespread in skin,cornea,tendon
ligaments
Type VII- anchoring filaments, skin,oral mucosa,cervix
Type VIII- Descemets membrane, foetal heart
Type IX- cartillage,vitreous
Type X- Hypertrophic and mineralising
cartillage,pericellular matrix
Type XI- cartillage
Type XII- Soft tissues, tendons, ligaments
Type XIII- Foetal epidermis ,intestinal
mucosa,plasma membrane
Type XIV- Foetal skin, tendons
Type XVII- Hemidesmosomes
Types of collagen in PDL

 Mostly type I, large proportion of Type III

 Minor amounts of types IV, V, VI, VII

Structure of fibrous collagens
 It is a trimeric molecule made of 3 α chains

 Primary structure- contains abt 1056 amino acids

 Repititive patterns of gly- X- Y

 X- proline, Y- Hydroxylysine, hydroxyproline

Secondary and tertiary structure
αchains form a left handed helix with average 3.3
amino acids per turn

 Long, thin, semi rigid , rope like structure

 Pitch of approx 10 nm

 Stabilized by hydrogen bonds

 This basic structure is called tropocollagen

 Ordered arrangement of millions of tropocollagens
results in formation of cross banded fibrils

 Gives a characterisic periodicity of 67nm

 In collagens types I and III these fibrils associate to

form fibers and in type I,the fibers group to form
bundles
 Cross linking
 Intermolecular and intramolecular crosslinks are formed
 With out this ,the molecules are dysfunctional
 Strong covalent bonds
 Allysine based and hydroxyallysine based
 Lysyl oxidase plays an important role in crosslinking

 This unique structure imparts tensile strength of steel

 Thus collagen provides unique combination of

flexibilty and strength to the tissues.
Biosynthesis
Metabolism
 Breakdown of collagens is a day to day event

 Rigid control is necessary to maintain balance

 Extracellular pathway mediated by

collagenases(MMP’s)

 Intracellular pathway in fibroblasts

Extracellular pathway
 Matrix metalloproteinases
 Group of endopeptidases
 Characterized by metal binding properties(Zn)
 Require Ca as stabilizer
 MMP’s are secreted by fibroblasts, PMN and

Macrophages
 Inhibited by Tissue inhibitors of

metalloproteinases(TIMP’s)
 Induced by enzymes and cytokines esp. IL-1

 TNF, PDGF, TGF-β, FGF

 Glucocorticoids and retinoids inhibit MMP’s

 These increase TIMP’s.

classification
Intracellular pathway
 PDL fibroblasts contain
intracellular striated collagen
fibrils
 Acid phospatase is present
 These have phagocytic ability
 Not mediated by MMP’s
 Lysosomal

enzymes( cathepsins B,L and

N)
 Cell surface receptors and

integrins help in initiation of

the pathway
 Recent studies indicate that intracellular pathway is
responsible for physiologic turnover of collagen in
PDL

 Extracellular pathway is reserved for large scale

indiscriminate removal of collagen as in inflammation.
 Cementoblasts
 Secrete organic matrix of cementum
 They appear as distinct layer on root surface
 Very similar to fibroblasts
 Numerous glycogen granules are present
 Osteoblasts
 Found on surface of alveolar bone
 Cubiodal, with basophilic cytoplasm
 RER, golgi prominent
 Embedded as osteocytes
 Osteoclasts
 Responsible for bone resorption

 Found within resorption lacunae(Howships lacunae)

 Large,multinucleated

 Ruffled border

 Numerous mitochondria
Epithelial cells
 Remains of HERS
 Isolated clusters or interlacing strands
 Numerous in apical and cervical area
 High n-c ratio
 Possible continuity between these cells and REE

(Bernick , Sponge)
 Basal lamina is present (Listgarten)

 Less numerous in adults ,more in children

Functions
 Mediation in cementogenesis

 Very intense binding with EGF

 Implicated in formation of periapical cysts and lateral

root cysts

 Produce PG and MMP’s

 Undifferentiated mesenchymal cells
Perivascular location
Single or multiple progenitor cells?

 Defense cells
 Macrophages, mast cells , eosinophils and PMN
 Perivascular ,loose connective tissues
 Macrophages- RER, Golgi rare
 Interactions between fibroblasts and mast cells?
 During inflammation, balance between zone of loose connective
tissue expands at the expense of dense fiber bundles.
Periodontal Fibers
 Principal fibers are collagenous

 Arranged in bundles, follow wavy course in LS

 Sharpey’s fibers

 They calcify to a certain extent

 Non collagenous proteins ostoepontin and bone

sialoprotein have been identified
 Most collagen is arranged in bundles

 Spliced rope like structure

 Individual strands can be remodeled continually

whereas overall architecture and function is maintained

 Thus adapt to continuous stress

Fiber groups
Gingival fibers
Non collagenous fibers
 Immature forms of elastin: oxytalan and eluanin
 Oxytalan fibers
 Microfibrils containg type VI collgen+ elastin
 Seen when PDL is examine as sheets
 Run vertically form cementum surface apically
 Numerous and dense in cervical portion
 Thought to regulate vascular flow
 They are elastic, can expand
 Implicated in supportive, developmental and sensory roles
Ground Substance
 Fills space between fibers and cells

 2 main components: glycosaminoglycans(GAG) and

glycoproteins

 Hyaluronic acid and proteoglycans(GAG)

 Fibronectin and laminin

GAG
 Polymers of repeating disaccharides
 GAG link with core proteins to form Proteoglycans

(PG)
 Wide variety exists
 Dermatan sulphate is the major class in PDL
 Hyaluronic acid, chondroitin sulfate and heparin

sulfates are also present

 Chondroitin sulphate maintains osmotic pressure

 GAG appear as 10nm short rodlike str.

 Hyaluronic acid forms very long chains

 Regulates permeability of extracellular enviornment

 Conc. Decreases as devpt progresses.

Non collagenous proteins
 Fibronectin
 Widely distributed in PDL
 Loose connective tissues, basement membranes
 Binds to collagen, heparin and fibrin
 Maintains tissue integrity
 Vitronectin
 Asoociated with elastic fibers
 Localized throughout the PDL
 Regulation of blood coagulation, plasminogen activation and
fibrinolysis
 Laminin
 Major component of basement membranes
 Associated with ECR

 Tenascin, Entacin are also found

 Cementicles
 Develop from calcified epithelial cell rests
 Or around spicules of cementum/alveolar bone
 From calcified from Sharpey’s fibers
 Or from calcified, thrombosed vessels
Blood supply
 From 3 sources:
1. Branches of supraperiosteal vessels from gingiva that supply
coronal part of PDL

2. Dental arterioles from max. and amnd. Alveolar arteries that

supply the apical part of PDL

3. Branches from interdental septal arteriole that penetrates the

alveolus and form a plexus in the middle part of PDL
 These vessels pass through Volkmann’s canals in
alveolar plate.

 They form capillary plexus near root surface and post

capillary venous plexus near the bone surface before e
entering the bone marrow via venules.

 Vascular plexus acts as shock absorber

 Helps in cushioning the forces generated during

mastication.

 Lymphatics drain similar to venous drainage.

Nerve Supply
 Fibers running from apical foramen towards gingival
margin are joined by fibers entering laterally through
foramina in the bone.

 These then divide into 2 : one extending apically and

the other gingivally.

 More nerve endings are found in apical aspect except

in maxillary incisors
4 types of nerve endings are found:
1. Free nerve endings that ramify in a tree lkie configuration.
these are found at regular intervals along the root.
2. Ruffini’s corpuscles found in apex.
3. Coiled form of nerve endings in mid root region
4. Spindle like endings surrounded by fibrous capsules in root
apex, they are rare.

 Autonomic supply
 No evidence of parasympathetic supply
 Fibers associated with blood vessels are thought to be
sympathetic.
Functions
 Physical

 Formative and remodeling

 Nutritional

 sensory
Physical functions
a. Provides a soft tissue casing to protect the nerves and
vessels from injury
b. Transmits occlusal forces to bone
c. Attachment of teeth to bone
d. Maintains relationship of gingiva to teeth
e. Resistance to impact of occlusal forces (shock
absorption)
Mechanisms of shock absorption
 Tensional theory
 Principal fibers have major role
 They firs unfold and straighten
 Load is thus transmitted to bone
 Viscoelastic system theory
 Largely controlled by fluid displacement
 Fibers have only minor role

 Rebound effect.
Transmission of occlusal forces
 Principal fibers- suspension bridge or hammock – thus
counter the axial force
 Horizontal force- 2 phases of tooth movement occur
 One within the confines of the PDL and the other a

displacement of facial/lingual plates

 Apical an coronal portions move in opposite directions
 PDL is compressed in pressure areas and distended in

areas of tension
Formative and remodeling functions
 Constant remodeling is taking place
 High turnover rate of collagen ,max. in the body
 Twice that of gingiva and four times that in skin.
 Rapid turn over in ground substance also
 Signalling mechanism exists which makes PDL

respond directly to forces acting on it.

Nutritional and sensory functions

 Supply of nutrients to cementum, bone and gingiva

 PDL is highly vascularised

 Also transmits tactile pressure, pain sensation via

trigeminal pathways
Ageing and PDL
 Decreased no: of fibroblasts, Irregular structure
 Decreased organic matrix production, ECR
 Elastic fiber content increases
 Width of PDL- contradictory
 Decreases in hypofunction
 Increases with excessive loading
 Decrease is due to cementum deposition
ALVEOLAR BONE
 Composition

 Structure- gross and cellular

 Bone matrix

 Physiology of bone formation and resorption

 Factors regulating bone formation and resorption

 Clinical correlations
INTRODUCTION
 A remarkable construction material

 Metabolically active organ

 Very unique properties- tensile strength

 comparable to cast iron, but only 1/3 rd as heavy

 Due to the hollow tubular construction, lamination

 Very dynamic in nature

COMPOSITION
• 67% inorganic, 33% organic

• Organic- chief constituent is type 1 collagen(28%)

• Non collagenous proteins- bone sialoproteins, osteocalcin,

ocsteonectin, osteopontin and proteoglycans

• Inoragnic- mostly hydroxyapatite

• These form small plates which lodge in the pores of collagen

fibrils.
GROSS BONE HISTOLOGY
• Dense outer sheet of compact bone and a central,
medullary cavity

• Cavity may contain yellow or red bone marrow

interrupted by bony trabeculae( cancellous or spongy
bone)

• Mature bones contain layers or lamellae(circumferential,

concentric and interstitial)

• Basic metabolic unit of bone is called osteon

OSTEON
 Cylindrical, arranged parallel to the long axis

 Haversian canal is present in the center

 Adjacent canals are connected by Volkmann’s canals

THE ALVEOLAR PROCESS
 Portion of maxilla and mandible that supports the teeth
sockets( alveoli)

 They are tooth dependent structures- affected by tooth

size, shape, location and function
Components
 External(buccal/lingual) plates formed of cortical bone,
containing haversian bone and compact bone lamellae

 Inner socket wall (alveolar bone proper) made of thin,

compact bone

 Cancellous trabeculae between these two layers,also

known as spongiosa.
Cortical plates
 Consists of fine fibered lamellar bone

 Compact haversian system of varying thickness

 Generally thinner in maxilla

 Thickest on the mandibular premolar and molar

regions

 Cortical plate and alveolar bone proper meet at the

alveolar crest
Alveolar bone proper
• Specifically called bundle bone or woven bone
• It has a coarse fiber structure

• Seen as lamina dura in radiographs

• Increased radiopacity due to increased amount of

trabeculae and not increased mineralisation

• Perforated by many foramina which transmit blood

vessels and nerves; so called cribriform plate
Spongiosa
• Contains larger trabeculae
• Yellow marrow is usually found
• Trabecular bone is absent in the anterior region
• Cancellous bone is more in the interdental and inter
radiclular spaces
• More in maxilla
• Trabeculae are arranged according to functional
pressure
• Irregular in maxilla and ladder like configuration in the
mandible
FENESTRATION AND DEHISCENCE
• Root surface denuded of bone and covered by only
periosteum and gingiva
• When marginal bone is also involved , it I called
dehiscence
• Occur in 20%of teeth, more on facial aspect in
anteriors
• Prominent root contours, malposition, etc
• May complicate outcome of periodontal surgery
periosteum
 Has 2 layers
 Outer layer is rich in blood vessels, nerves, collagen

fibers and fibroblasts

 Inner layer contains osteoblasts and osteo progenitor

cells.
 Cellular changes in these layers modulate bone size
 Balance between osteoblastic and osteoclastic activity
Cellular structure of bone
 Osteogenic cells- preosteoblasts, osteoblasts,
osteocytes and bone lining cells, lamina limitans

 Osteoclasts – bone resorption

Pre osteoblasts

 Resemble inactive fibroblasts

 Many free ribosomes, small golgi

 Differentiation into osteoblasts is preceded by

activation of osf2/ cbfa1 gene block

 It serves as a master gene for expression of osteocalcin,

osteopontin, bone sialoprotein, and collagen synthesis

 Mutations in this gene blocks bone formation

and causes Cleidocranial dysplasia
osteoblasts
 Mononucleated cells – synthesise collagenous and
non collagenous bone matrix proteins

 Active cell- very prominent golgi apparatus, ER

 Appears as intensely basophilic, and golgi appears
pale

 High levels of alk.phosphatase-systemic indicator

of bone formation

 Also contains a Ca pump in the cell membrane

functions
1. Synthesise collagen rich bone matrix- osteoid, 90%
made of type 1 collagen

2. Produces non collagenous proteins like osteocalcin,

osteonectin, bone sialoprotein,osteopontin,etc

3. It also plays a role in mineralisation ( matrix vesicle)

OSTEOCYTES
 During bone formation, osteoblasts become trapped
entrapped in bone matrix

 Diminished secretory granules, RER & golgi are

smaller

 Develops many cytoplasmic processes towards the

more nutrient rich areas

 These processes are found in spaces called canaliculi-

the canaliculi and lacunae form space for circulation of
bone fluid from deepest areas to superficial areas
functions
 Osteocytes are called “nerve cells” of bone

 Maintains the balance between resorption and remodeling

 Participate in Ca homeostasis

 Mechano sensory function- they convert physical changes

into chemical siganals to regulate remodeling activity

 They could thus initiate local alterations of bone shape to

reduce strains exerted by loading forces
BONE LINING CELLS
 A cell layer of osteoblasts over the forming bone
surface
 Act as barrier to control ion flux into and out of bone
 After bone formation these cells are flattened and
called bone lining cells
 80% of bone is covered by such cells

 Act as gate keepers- protect underlying bone from

osteoclasts, regulate ionic compositon of bone fluid
 Lamina limitans/ cement lines
 All inactive bone surfaces covered by thin, densely
stained lamina linitans

 Contain mainly osteopontin

 It is not found over active bone surfaces

 These demarcate successive layers of new bone

formation
Osteoclasts
 Highly specialized cells for bone resorption

 Most cells are large, multinucleated

 Present within Howship’s lacunae

 Identified by positive staining for tartarate resistant

acid phosphatase (TRAP)

 Ruffled border present adjacent to the tissue

surface- indicator of cell activity
 Clear/ sealing zone- area rich in actins and devoid
of organelles

 It establishes a seal between bone resorption

compartment and interstitial fluid

 Bone resorbing compartment

 Synthesises many proteolytic enzymes

 Basolateral plasma membrane- contains receptors

for hormones, cytokines
 May contain upto 20 nucleii ,many RER, golgi

 Highest number of mitochondria among any cell

types

 MMP’s , acid phospahtase

 A proton pump is present in the ruffled border

Development of bone cells
 Osteogenic cells- mesenchymal
 Osteoclasts- hemato poetic system
 Osteoblasts

◦ CBFA-1 and Osx : essential transcription factors for

differentiation
◦ This gene is induced by BMP-7 and decreased by Vitamin D 3
Development of osteoclasts
 Arise from hematopoetic system that give rise to
monocyte and macrophage cell line
 Receptor activator of nuclear factor κ B(RANK)

and RANKL system

 RANK is present on osteoclast progenitors
 RANKL is present of surface of Stromal cells in

Bone marrow
 Osteoprotegrin- resembles RANKL blocks this

interaction
Components of bone matrix
 90%- type 1 collagen
 Non collagenous proteins:
1. Osteocalcin
 Low molecular weight protein
 Index for osteoclatsic activity
 Inhibits mineralisation and recruits bone cell precursors
 May act as chemoattractant for preosteoclasts
 Promotes adhesion and spread of osteoclasts
2.Bone sialoprotein
 Has a stretch of glutamic acid residues giving a
negative charge
 High calcium binding potential
 Can bind tightly to hydroxyapatite as well as cells
 Thus creates high amounts of local calcium
 It also increases osteoclastic resorption by promoting

adhesion
3.OSTEOPONTIN
 Also plays a role in attachment of osteoblasts and
osteoclasts to bone matrix
 It is seen in the cement lines between old and new bone
 It may act as a bonding agent to bone matrix
 It is expressed in many soft tissues
 Also called as early T lymphocyte activator-1
 May play a role in cell mediated immunity
4. OSTEONECTIN
 Most abundant non collagenous protein in bone
 Expressed by osteogenic cells
 Function unclear
 May have a role in organisation of matrix

5. BIGLYCAN AND DECORIN

They are known to regulate collagen fiber growth

6. GROWTH FACTORS
 BMP,TGF-β, bFGF, IGF, CSF-1 are also present
BONE FORMATION
 2 STEPS: poduction of organic matrix and
mineralisation
 3 mechanisms: endochondral, intramembraneous and

sutural
 Sutural- have potential for growth similar to

periosteum
 This type of growth is seen only in skull
BONE RESORPTION
 Osteoclastic bone resorption is called for alteration in
bone mass and shape only in pathologic conditions

 In physiologic conditions, osteocytes and bone lining

cells act through bone fluid to control remodeling
 PGE2, IL- 1 β( Osteoclast activating factor) stimulate
osteoclastic activity

 Resorptive phase is always followed by formative

phase

 A typical resorptive phase lasts for about 8-10 days

MECHANISM
 Exposure of mineralised bone to interstitial fluid-
contraction of osteoblasts and bone lining cells
 PTH, vit. D3, IL-1 act directly on these cells or act

directly on these cells

 This activates MMP’s to degrade organic matrix
 This produces osteocalcin, chemokines which attract

osteoclasts
Attachment of osteoclasts
 Extensive cytoskeleton composed of actins
 This helps in migration and attachment of osteoclasts

 Plasma membrane integrins bind to peptides of bone

matrix proteins like osteopontin, bone sialoprotein

 Produce focal adhesions called podosomes

 In migrating cells , these are found in leading edge
 In resting cells, they are disrtibuted evenly
 Podosomes reorganise to create clear zone between the
ruffled border and bone resorbing compartment

 Seal is between mineral phase and cadherins within the

plasma membrane

 Peptides that interfere with cadherins leads to loss of

clear zone and deactivation of osteoclasts
SYNTHETIC ACTIVITY
 Lysosomal enzymes are produced within golgi and
transported to ruffled border
 Contents are released into bone resorbing compartment
 Acid phosphatase, aryl sulfatase,
 Cysteine proteinases- cathepsins B,D,E,S,L &K
 They are capable of degrading helical collagen in

acidic environment
 MMP’S 1, 2, 3 &9
ROLE OF PROTON PUMP
 Resorbing compartment has a pH of 4.5

 Proton pumps in ruffled border

 Carbonic anhydrase produces protons within cytoplasm

 Low pH leads to dissolution of mineral

 Creates optimal activity of enzymes
ROLE OF CALCIUM
 During resorption, Ca conc. Inside the cell increases to
a high level
 This finally leads to deactivation of osteoclast
 When levels reach threshold, calcium sensors in
plasma membrane open a novel type of Ca channel
 This leads to influx of Ca and detachment of
osteoclasts
 This provides a logical explanation for cyclic activity
 COUPLING
Bone formation + resorption

 Under normal conditions

 Cellular events controlled by autoregulatory mech.

 10 day resoptive phase is usually followed by repair

phase for 3 months

 Chemotaxis, mitosis and differentiation of osteoblasts

take place
 Cutting cone- leading edge of resorption characterised
by howship’s lacunae

 Behind this osteoblasts deposit reversal line or cement

line rich in osteopontin

 Above this cement line, osteoblasts secrete new bone

matrix

 Area where active formation occurs is called filling

cone
 Coupling is controlled by factors like IGF and TGF-
β

 These factors inhibit further osteoclastic activity

and promote osteoblastic activity

 IL-1 acts as uncoupler by inhibiting bone formation

and promoting resorption

 Disruption of coupling may be the cause of

progression of bone loss in periodontitis
Turnover of alveolar bone
 More rapid than other parts of skeleton
 Highest level of resorption occurs in cribriform plate
 Turnover accommodates for mesial and occlusal

shifting of teeth
Factors regulating bone formation

 GROWTH FACTORS AND CYTOKINES

◦ They are all polypeptides
◦ Exert action through receptors on cell surface
◦ Act locally
◦ Natural products of cells
◦ multifunctional
PGDF

◦ Active form is PDGF-BB

◦ Stimulates DNA replication and mitosis in osteoblasts
◦ Increases bone collagen synthesis and matrix apposition
◦ Also increases resorption and collagen degradation
◦ A PGDF receptor is identified on osteoblasts
◦ It is critical in fracture repair and wound healing
Heparin binding growth factor

 Includes Acidic and basic FGF

 FGF’s are mitogenic for bone cells
 Enhance collagen and non collagen protein

synthesis
 Effect may be mediated by TGF-β
IGF
 IGF-1 is the principal growth factor in bone
 Liver is the major source of IGF
 Paracrine, autocrine effects
 Actions similar
 IGF and TGF-β are important in coupling
TGF-β
 Most abundant growth factor in bone matrix
 Large family including BMP
 Synthesised by osteoblasts in inactive form and

stored within matrix

 During bone resorption, it is released and stimulates

proliferation of preosteoblasts
 Also increases collagen alk.phosphatase and

osteopontin
 Also inhibits osteoclasts by down regulation of

ODF/RANKL
Bone Morphogenetic proteins
 Consists of atleast 15 members
 Released during bone repair and amtrix destruction
 Have unique osteoinductive activity
 Induce production of new bone through endochondral

pathway
 Also stimulates differentiation of osteoblasts
 BMP-2 and 7 have been used to accelerate bone

healing and create new bone in defects.

Factors regulating bone resorption
 Interleukin 1
◦ Powerful and potent bone resorbing cytokine
◦ IL-1 α & β are present
◦ Produced by activated monocytes, macrophages, T cells,
neutrophils, fibroblasts
◦ Stimulates production and release of PGE2
◦ Directly act on osteoclasts

 IL -6 also has osteoclast promoting actions

 Tumor necrosis factor and Lymphotoxin
 Produced by activated lymphocytes
 Stimulate osteoclastic bone resorption
 Acts through PGE2 and IL-6
 Osteoprotegrin is a member of this family
 It blocks osteoclast formation

 γ-interferon, CSF also increase bone resorption

PROSTAGLANDINS
 Produced by immune, marrow and bone cells
 PGE1 , E2 are slow but powerful mediators of bone
resorption
 Affect both active cells and precursors
 PGE2 action I mediated by contraction of osteoblasts
to expose mineral
 High doses are osteoclatic but in low doses they
promote bone formation
 Local administration in animals has been proved to be
effective
Action of systemic hormones
 Parathyroid hormone
◦ Acts on osteoblasts and osteoclasts
◦ Net effect depends upon dose
◦ Continuous administration increases resorption
◦ In Intermittent low doses , major effect is stimulation of bone
formation(anabolic effect of PTH)
◦ Raises blood Ca level by 3 mech.
Effect on osteoblasts
 Effect on osteoclasts is mediated through action on
osteoblasts
 PTH stimulates MMP 1,9 and plasminogen activator

production
 Contracts osteoblasts to expose mineral
 Anabolic effect may be due to synthesis of IGF-1
calcitonin
 Inhibits osteoclatsic bone resorption
 Action mediated through cAMP
 Effects can be seen minutes after adminstration
 Decreases ruffled border size and clear zone
 Effects are short lived
 Osteoclasts lose responsiveness
VIT. D METABOLITES
 1, 25 dihydroxy vit. D3 has catablic effect
 24, 25 dihydroxy vit. D3 has anabolic effect
 Very slow onset of action

ESTROGENS
 Inhibits bone resorption caused by menopause
 Direct and indirect action
 Specific receptors are present

GLUCOCORTICOIDS
 Decrease bone formation and promote resorption
 Prolonged exposure may cause osteoporosis
 Increase collagenase production
CLINICAL CORRELATIONS
1. Bone resorption in periodontal disease
 Plaque produces many bilogically active substances
 Bac.LPS is a potent stimulator of IL-1, 6 and TNF
 They induce resorption and production of MMP’s
 Also promote action of PGE2
 Endodtoxins also activate CD4 t cells
 A potent osteoclast stimulating protein has been
isolated from the fimbriae of P. gingivalis
 It stimulates osteoclasts via tyrosine kinase mechanism
 Antibodies to this antigen when injected in animals

prevented periodontal tissue destruction

 Genistein, a blocker of tyrosine kinase prevented the

action of this antigen in vitro

2.Inhibition of osteoclasts
 Estrogens have been tried in osteoporosis
 Biphosphonates may cause osteoclast apoptosis by

GTP mediated actions

 Calcitonin
 TGF-β decreases osteoclastic activity by stimulating

osteoprotegrin production
 Other approaches- blocking attachment of osteoclasts

to bone surface, blocking carbonic anhydrase

action,blocking TRAP, etc.
3.Regeneration of alveolar
bone
 BMP’s have therapeutic properties
 Induce pleuripotent non osteogenic cells in soft tissues

to enter the osteogenic pathway

 Implantation of BMP’s in site that do not ordinarily

form bone results in bone formation

 Combination of BMP+ TGF-β :synergistic effect
 GTR + BMP has also been effective
CONCLUSION
 BONE has many peculiar properties
 Very useful biologic construction material
 Support, protection, reservoir of minerals
 Very dynamic- under constant regulation
 Effective local therapy to control osteoclasts?