Introduction
A sound knowledge of the anatomy of the periodontium and the surrounding hard and soft structures is essential to determine the scope and possibilities of surgical periodontal procedures and to minimize their risks.
Blood vessels, and nerves located in the vicinity of the periodontal surgical field, are particularly important during various surgical procedures.
Arterial Supply
Common Carotid Artery
Carotid Sinus & Carotid Body
Applied Anatomy of CCA
CAROTID PULSE :
CCA may be compressed against the carotid tubercle of transverse process of C6 vertebra about 4cm above the sternoclavicular joint.
External Carotid Artery
Generally it lies anterior to the Internal Carotid Artery.
It is the chief artery of supply to structures in the front of neck, oral cavity and in the face.
In carotid triangle
Crossed superficially by:
Cervical branch of facial nerve
Hypoglossal nerve
Facial, lingual &superior thyroid vein
Deep to artery lies:
Wall of pharynx
Superior laryngeal nerve
Ascending pharyngeal artery
Above the carotid triangle
ECA lies deep in the substance of parotid gland
Branches
Lingual Artery
Principal artery of tongue.
Arises anteromedially from ECA opposite the tip of greater cornu of hyoid bone.
Divided into three parts by hyoglossus muscle.
Applied anatomy
Sublingual artery injury occurs in premolar & molar region, when sharp instrument or rotating disks slips off a lower molar & injure the floor of mouth.
Sublingual and submental arteries may course anteriorly in close proximity to the lingual plate, and branches of these blood vessels enter accessory foramina along the lingual cortex.
Hofschneider et al (1999)
Inadvertent penetration through the lingual cortical plate into the floor of the mouth while preparing an osteotomy can cause arterial trauma, thereby resulting in development of a sublingual or submandibular hematoma
Flanagan D. et al.2003
Facial Artery
ORIGIN: Arises from the ECA just above the tip of greater cornua of hyoid bone.
COURSE:
Runs upwards in neck as cervical part ;
On face as facial part.
Tortuous course—
In neck allows free movements of pharynx during deglutition,
On face allows free movements of mandible , lips, & cheek during mastication & facial expressions, escapes traction & pressure during movements.
Cervical part :
Cervical part runs upwards on superior constrictor of pharynx deep to the posterior belly of digastric.
It grooves the posterior border of submandibular gland, makes S-bend [2 loops]
1st winding down over submandibular gland &
then up over the base of mandible.
Facial part:
The vessel enters the face by winding around the base of the mandible, and by piercing the deep cervical fascia,at the anteroinferior angle of the masseter muscle, here it can be palpated & is called as anaesthetist’s artery. Using contracted masseter as a landmark, pulse of facia
1. D R . P A L L A V I P R A S H A R
D E P T T . O F P E R I O D O N T O L O G Y A N D O R A L
I M P L A N T O L O G Y
Gingiva
2. Definition
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 11th edition
3. Macroscopic Anatomy of Gingiva
The gingiva is divided anatomically into:
Marginal
Attached
Interdental
5. Marginal Gingiva
The terminal edge / border of the gingiva surrounding the teeth in
collarlike fashion.
In about 50% of cases, it is demarcated from the adjacent, attached
gingiva by a shallow linear depression, the free gingival groove.
Usually about 1 mm wide, it forms the soft tissue wall of the gingival
sulcus. It may be separated from the tooth surface with a periodontal
probe.
The most apical point of the marginal gingival scallop is called the
gingival zenith.
Its apicoronal and mesiodistal dimensions varied between 0.06 and
0.96 mm
6. Gingival Sulcus
The gingival sulcus is the shallow crevice or space around the
tooth bounded by the surface of the tooth on one side and the
epithelium lining the free margin of the gingiva on the other.
It is V shaped and barely permits the entrance of a periodontal
probe.
Under absolutely normal or ideal conditions, the depth of the
gingival sulcus is or is about 0. These strict conditions of
normalcy can be produced experimentally only in germfree
animals or after intense, prolonged plaque control.
In clinically healthy gingiva in humans, a sulcus of some depth
can be found. The depth of this sulcus, as determined in
histologic sections, has been reported as 1.8 mm, with
variations from 0 to 6 mm.
7. Attached Gingiva
The attached gingiva 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, from
which it is demarcated by the mucogingival
junction.
8. Width of keratinized gingiva
Width of attached gingiva
Distance between the mucogingival
Junction & the projection on the external
surface of the bottom of gingival sulcus
Width of Attached Gingiva
9. Width of attached Gingiva
Maxilla Mandible
Incisors
3.5-4.5mm
Premolars
1.9 mm
Incisors
3.3-3.9mm
Premolars
1.8 mm
10. Measurement of Width of attached Gingiva
Total width of gingiva – Sulcus depth
Roll test Schillers iodide test
Tension test
IJSRR 2013, 3(2)Malthi K et al.
11. Interdental Gingiva
Occupies gingival embrasure,
which is the interproximal space
beneath the area of tooth contact.
The interdental gingiva can be
pyramidal or have a "col" shape.
In the pyramid shape, the tip of
papilla is located immediately
beneath the contact point; the col
shape presents a valleylike
depression that connects a facial
and lingual papilla and conforms to
the shape of the interproximal
contact.
12. The shape of the gingiva in a given interdental space
depends on the
contact point between the two adjoining teeth
the presence or absence of some degree of recession.
13. If a diastema is present,
the gingiva is firmly
bound over the
interdental bone and
forms a smooth, rounded
surface without
interdental papillae.
14. Microscopic Features
Stratified squamous epithelium
Predominantly cellular in nature
Central core of connective tissue
Less cellular and composed primarily of collagen fibers and
ground substance.
15. Gingival Epithelium
The epithelium covering the free
gingiva may be differentiated as
follows:
ORAL EPITHELIUM: which faces
the oral cavity
ORAL SULCULAR EPITHELIUM:
which faces the tooth without being in
contact with the tooth surface.
JUNCTIONAL EPITHELIUM :
which provides the contact between
the gingiva and the tooth.
16. General Aspect
The gingival epithelium is a KERATINIZED,
STRATIFIED, SQUAMOUS EPITHELIUM which
on the basis of the degree to which the keratin
producing cells are differentiated can be divided into
the following cell layers :
BASAL LAYER (STRATUM BASALE OR STRATUM
GERMINATIVUM)
SPINOUS CELL LAYER (STRATUM SPINOSUM)
GRANULAR CELL LAYER (STRATUM GRANULOSUM)
KERATINIZED CELL LAYER (STRATUM CORNEUM)
18. Keratinocytes
The main function is to protect the deep structure,
while allowing a selective interchange with the oral
environment.
This is achieved by
Proliferation
Differentiation
19. The main morphologic
changes are
Progressive flattening of the
cells with an increase
prevalence of tonofilaments.
Intercellular junctions coupled
to production of keratohyaline
granules
Disappearance of nucleus.
Schroeder 1981
M- Mitochondria, G- Golgi Bodies, E-
Endoplasmic Reticulum, D- Desmosomes,
F- Tonofilaments, K- Keratohyalin Granules
20. Basal layer (stratum basale, stratum
germinativum)
The cells in the basal layer are either cylindric
or cuboid, and are in contact with the
basement membrane that separates the
epithelium and the connective tissue.
The basal cells possess the ability to divide, i.e.
undergo mitotic cell division.
It is in the basal layer that the epithelium is
renewed.
Therefore, this layer is also termed stratum
germinativum, and can be considered the
progenitor cell compartment of the epithelium.
21. When two daughter cells (D) have been
formed by cell division, an adjacent
"older" basal cell (OB) is pushed into the
spinous cell layer and starts, as a
keratinocyte, to traverse the epithelium.
It takes approximately 1 month for a
keratinocyte to reach the outer epithelial
surface, where it becomes shed from the
stratum corneum.
Within a given time, the number of cells
which divide in the basal layer equals the
number of cells which become shed from
the surface.
22. Immediately beneath the basal cell an approximately 400 A wide
electron lucent zone can be seen which is called lamina lucida.
Beneath the lamina lucida an electron dense zone of
approximately the same thickness can be observed. This zone is called
lamina densa.
From the lamina densa so called anchoring fibers (about 1 μm)
project in a fan-shaped fashion into the connective tissue.
The cell membrane of the epithelial cells facing the lamina lucida
harbors a number of electron-dense, thicker zones appearing at
various intervals along the cell membrane. These structures are called
hemidesmosomes.
The cytoplasmic tonofilaments in the cell converge, towards
such hemidesmosomes.
The hemidesmosomes are involved in the attachment of the
epithelium to the underlying basement membrane.
23. Stratum Spinosum (Prickle cell layer)
10-20 layers
Large, polyhedral cells
Short cytoplasmic processes resembling spines
Prickly appearance
Cohesion : Desmosomes Located between the
cytoplasmic processes of adjacent cells
24. Desmosome may be considered to consist of
two adjoining hemidesmosomes separated
by a zone containing electron-dense
granulated material (GM).
Thus, a desmosome comprises the following
structural components:
(1) the outer leaflets (OL) of the cell
membrane of two adjoining cells,
(2) the thick inner leaflets (IL) of the cell
membranes and
(3) the attachment plaques (AP), which
represent granular and fibrillar material in
the cytoplasm.
25. Stratum Granulosum
The cytoplasm of these cells characteristically displays
KERATOHYALINE GRANULES (arrows) that
have been associated with KERATIN FORMATION
26. Stratum Corneum
Filled with keratin
The entire apparatus for protein synthesis and
energy production, i.e. the nucleus, the
mitochondria, the endoplasmic reticulum and the
Golgi complex, is lost.
In a parakeratinized epithelium, however, the cells of
the stratum corneum contain remnants of nuclei.
27. Keratinization
The keratin proteins are composed of different
polypeptide subunits characterized by their isoelectric
points and molecular weights.
They are numbered in a sequence contrary to their
molecular weight.
Generally, basal cells begin synthesizing lower-
molecular-weight keratins, such as K19 (40 kD), and
express other higher-molecular-weight keratins as they
migrate to the surface.
K1 keratin polypeptide (68 kD) is the main component of
the stratum corneum.
28. Other proteins:
Keratolinin
Involucrin
Filaggrin
In the sudden transition to the horny layer, the
keratohyalin granules disappear and give rise to
filaggrin, which forms the matrix of the most
differentiated epithelial cell, the corneocyte.
In the fully differentiated state, the corneocytes are
mainly formed by bundles of keratin tonofilaments
embedded in an amorphous matrix of filaggrin and
are surrounded by a resistant envelope under the cell
membrane.
Precursors of chemical resistant structure,
located below the cell membrane- Envelope
Precursors packed in
keratohyaline granules
29. According to histochemical demonstrastion
In deeper strata
Cytoplasmic organelle concentration varies among different
epithelial strata.
Mitochondria are more numerous in deeper strata and
decrease toward the surface of the cell.
Succinic dehydrogenase
Nicotineamide-adenine dinucleotide
Cytochrome oxidase
Reveals more active
Tricarboxylic
Cycle, in basal and parabasal
cells, in which the proximity
of blood supply facilitates
energy production through
aerobic glycosis.
30. Activity towards surface:
Pentose shunt Glucose-6-phosphatase
Ribonucleic acid (RNA)
Synthesis of keratinization proteins
31. The uppermost cells of the stratum spinosum
contain numerous dense granules, keratinosomes
or Odland bodies (modified lysosomes).
Acid phosphatase: Enzyme involved in the
destruction of organelle membranes,
It occurs suddenly between the granulosum and
corneum strata and during the intercellular
cementation of cornified cells.
Therefore, it is closely related to degree of
keratinization.
33. Melanocytes
Dendritic cell
Located in the basal and
spinous layer of gingival
epithelium
Synthesize melanin in organelle
called premelanosomes or
melanosomes.
Tyrosine
Dihydroxyphenylalanine
(DOPA)
Melanin
Melanophore/
Melanophages
Pigmented gingiva showing
melanocytes (M) in the basal
epithelial layer and
melanophores (C) in the
connective tissue
tyrosinase
34. Langerhans Cells
Dendritic cells located among
keratinocytes at all suprabasal levels.
They belong to the mononuclear
phagocytes system (reticulo-
endothelial system) as modified
monocytes derived from bone
marrow.
They contain elongated granules and
are considered macrophages with
possible antigenic properties.
(J PERIODONTOl 56:48,1985)
Human gingival epithelium,
oral aspect. Immunoperoxidase
technique showing Langerhans
cells.
35. • They have an important role in immune reaction as
antigen- presenting cells for lymphocytes.
• They contain g-specific granules (Birbeck’s granules)
and have marked adenosine triphosphatase activity.
• They are found in oral epithelium of normal gingiva
and in smaller amounts in sulcular epithelium; they
are probably absent from junctional epithelium of
normal gingiva
36. Merkel Cells
Located in the deeper layer of epithelium.
Harbors nerve endings.
Connected to adjacent cells by desmosomes.
Act as a tactile receptors.
37. Inflammatory Cells
Clinical normal areas of mucosa
Lymphocytes : Most frequent
Associated with langerhans cells
Polymorphonuclear leukocytes
Mast cells
38. Extracellular Matrix
Since the epithelia of the gingiva are composed primarily of
cells in close apposition, there is very little extracellular space.
Extracellular matrix contains:
Glycoproteins, lipids, water
Proteoglycans: Hyaluronan, decorin, syndecan
CD 44 – being identified on cell surface
Cell adhesion molecules: ICAM-1, β1 integrin family
Extracellular matrix serves the purpose of:
Cell adhesion
Adhesion to tooth surface & basement membrane
Diffusion of water, nutrients & toxic materials
Bartold et al. Periodontol 2000 vol. 24, 2000
39. Oral Epithelium
The 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 presents
various combinations of these conditions.
Degree of keratinization decreases with
age & onset of menopause.
Palate > Gingiva > ventral aspect of tongue
> cheek
41. Histoenzyme reactions for acid phosphatase and
pentose-shunt enzymes are very strong.
Glycogen can accumulate intracellularly when it is
not completely degraded by any of the glycolytic
pathways.
Thus, its concentration in normal gingiva is inversely
related to the degree of keratinization and
inflammation.
42. Sulcular Epithelium
Thin, non-keratinized stratified squamous epithelium
No rete pegs
It may act as a semipermeable membrane through which
injurious bacterial products pass into the gingiva and tissue
fluid from the gingiva seeps into the sulcus.
Lacks:
Stratum granulosum
Stratum corneum
Merkels cells
Keratins: K4, K13(Esophageal-type Cytokeratins), K19.
43. Histochemically, a lower degree of enzyme activity in the
sulcular, particularly in the case of enzymes related to
keratinization.
Acid phosphatase staining is negative.
Despite these morphologic and chemical characteristics,
the sulcular epithelium has the potential to keratinize if
it is reflected and exposed to the oral cavity
the bacterial flora of the sulcus is totally eliminated
Conversely, the outer epithelium loses its keratinization
when it is placed in contact with the tooth.
44. Junctional Epithelium
The junctional epithelium consists of a collarlike band
of stratified squamous nonkeratinizing
epithelium.
It was originally described by Gotlieb as the
epithelial attachment and then by Waer-haug as
the epithelial cuff.
45. Formation of Junctional Epithelium
When the enamel of the tooth is fully developed, the enamel-producing cells
(ameloblasts) become reduced in height, produce a basal lamina and form, together
with cells from the outer enamel epithelium, the so-called reduced dental epithelium
(RE). The basal lamina (epithelial attachment lamina: EAL) lies in direct contact
with the enamel. The contact between this lamina and the epithelial cells is
maintained by hemidesmosomes. The reduced enamel epithelium surrounds the
crown of the tooth from the moment the enamel is properly mineralized until the
tooth starts to erupt.
46. As the erupting tooth approaches the oral epithelium, the cells of the outer layer of
the reduced dental epithelium (RE), as well as the cells of the basal layer of the
oral epithelium (OE), show increased mitotic activity (arrows) and start to migrate
into the underlying connective tissue. The migrating epithelium produces an
epithelial mass between the oral epithelium and the reduced dental epithelium so
that the tooth can erupt without bleeding. The former ameloblasts do not divide.
47. When the tooth has penetrated into the oral cavity, large portions immediately
apical to the incisal area of the enamel are covered by a junctional epithelium (JE)
containing only a few layers of cells. The cervical region of the enamel, however, is
still covered by ameloblasts (AB) and outer cells of the reduced dental epithelium.
48. During the later phases of tooth eruption, all cells of the reduced enamel
epithelium are replaced by a junctional epithelium. This epithelium is continuous
with the oral epithelium and provides the attachment between the tooth and the
gingiva.
If the free gingiva is excised after the tooth has fully erupted, a new junctional
epithelium, indistinguishable from that found following tooth eruption, will
develop during healing. The fact that this new junctional epithelium has developed
from the oral epithelium indicates that the cells of the oral epithelium possess the
ability to differentiate into cells of junctional epithelium.
49. Histology of Junctional Epithelium
It is triangular in cross section , widest at the junction
with the sulcular epithelium ,and narrowing down to the
width of few cells at the apical end.
Three to four layers of cells thick in the young and up to
20 cells thick in later life.
The length ranges from 0.25 to 1.35 mm.
Only two morphotypes of epithelial cell are evident in the
junctional epithelium.
The cells of the stratum basale proliferate rapidly,
while those of the suprabasale layer have no mitotic capacity.
50. Lacks rete pegs.
Numerous migrating polymorphonuclear leukocytes
and lymphocytes (particularly T lymphocyes) are
evident.
Cell layers not juxtaposed to the tooth exhibit
numerous free ribosomes and prominent
membranebound structures, such as Golgi complexes,
and cytoplasmic vacuoles.
Lysosome-like bodies also are present, but the
absence of keratinosomes (Odland bodies)
51. Histochemically, demonstrable acid phosphatase, correlated with the
low degree of differentiation.
Exhibits lower glycolytic enzyme activity than outer epithelium
Keratins:
K19
K5 & K14 (Stratification specific)
Lack of expression:
Morgan et al : Junctional area is the only stratified
nonkeratinized epithelium in the oral cavity that does not
synthesize K4 or K13
Lack of K6 & K16 : Though turnover of the cells is very high.
52. Interconnections
Few desmosomes only
Occasional gap junctions
Schroeder & Listgarten, 1977 Saito et al, 1981 Hashimoto et
al, 1986
Wide fluid-filled intercellular spaces
53. Junctional epithelium can be divided into three
zones:
Apical zone
Germinative characteristics
Middle zone
higher density of hemidesmosome
role in adhesion
Coronal zone
numerous intercellular space
increased permeability
55. A schematic illustration of a DAT cell shows the structural and molecular composition of the epithelial
attachment apparatus (EAA). N=nucleus of a DAT cell, IF =cytoplasmic keratin filaments
(intermediate size filaments). The hemidesmosomes at the plasma membrane are associated with the
a6b4 integrin that communicates with Ln-5 = laminin 5 located mainly in the internal basal lamina,
the extracellular domain (?) for BP180 is a collagenous protein (perhaps type VIII), that has not yet been
definitely characterized. LL = lamina lucida, LD = lamina densa, SLL = sublamina lucida, IBL = internal
basal lamina.
Periodontology 2000 Vol 31, 2003
Characteristically, the internal
basal lamina lacks laminin- 1
and type IV collagen, which are
components of true basement
membranes
57. Renewal of Gingival Epithelium
Thickness of oral epithelium is maintained by a
balance between new cell formation in the basal and
spinous layers and the shedding of old cells at the
surface.
The mitotic activity exhibits a 24-hour periodicity,
with the highest and lowest rates occurring in the
morning and evening, respectively.
The mitotic rate is higher in nonkeratinized areas
and is increased in gingivitis, without significant
gender differences.
58. Mitotic Rate:
buccal mucosa > hard palate > sulcular epithelium >
junctional epithelium > outer surface of the marginal
gingiva > attached gingiva.
Turn over rate:
palate, tongue, and cheek: 5 to 6 days
gingiva: 10 to 12 days, with the same or more time required
with age and
junctional epithelium: 1 to 6 days
59. Gingival Connective Tissue
The major components of the gingival connective
tissue are
collagen fibers (about 60% by volume),
fibroblasts (5%),
vessels, nerves, and matrix (about 35%).
The connective tissue of the gingiva is known as the
lamina propria and consists of two layers:
A papillary layer subjacent to the epithelium, which
consists of papillary projections between the epithelial rete
pegs,
A reticular layer contiguous with the periosteum of the
alveolar bone.
61. Cellular Elements
Fibroblast
Predominant
Mesenchymal origin
Play a major role in the development, maintenance
and repair of gingival connective tissues.
The principal function of fibroblasts is to synthesize
and maintain the components of the extracellular
matrix of the connective tissue.
Degradation of collagen
62. Mast cells
Numerous, located perivascular region
Vasoactive substances which can affect the function
of the microvascular system and control the flow of
blood through the tissue:
Histamine
Heparin
Proteolytic enzymes
63. Macrophages
Phagocytic function
Numerous in inflammed tissue
Inflammatory cells
Polymorphonuclear leukocytes
Lymphocytes
Plasma cells
65. Collagen Fibers
Collagen type I forms the bulk of the lamina
propria and provides the tensile strength to the
gingival tissue.
Type IV collagen (argyrophilic reticulum fiber)
branches between the collagen type I bundles and is
continuous with fibers of the basement membrane
and blood vessel walls.
66. Reticulin Fibers
Exhibit argyrophilic staining properties
Numerous in the tissue adjacent to the basement
membrane.
Also occur in large numbers in the loose connective
tissue surrounding the blood vessels.
Present at the epithelium-connective tissue and the
endothelium-connective tissue interfaces.
67. Oxytalan Fibers
Scarce in gingiva
Long thin fibrils with Diameter =150 Å
Parallel to long axis of tooth
Function= not known
Elastic Fibers
Only found in associaton with blood vessels
68. Function
To brace marginal gingiva firmly against the tooth
To provide the rigidity necessary to withstand the
forces of mastication without being deflected away
from tooth surface
To unite the free marginal gingiva with the
cementum of the root & the adjacent attached
gingiva
71. Ground Substance
The matrix of the connective tissue is produced
mainly by the fibroblasts, although some
constituents are produced by mast cells, and other
components are derived from the blood.
The transportation of water, electrolytes, nutrients,
metabolites, etc., to and from the individual
connective tissue cells occurs within the matrix.
It contains proteoglycan and glycoproteins.
73. Glycoprotein
Fibronectin
Distributed throughout gingival connective tissues
Localized over collagen fibers
Binds fibroblasts to fibers
Mediate cell adhesion & migration
Osteonectin, Vitronectin, Elastin & Tenascin
Present diffusely
Near the subepithelial basement membrane in the upper connective
tissue & capillary blood vessels
Laminin
Basal laminae
Attach it to epithelial cells
74. Repair of gingival connective tissue
High turnover rate,(remarkably good healing and
regenerative capacity).
Shows little evidence of scarring after surgical
procedures.
This is likely caused by rapid reconstruction of the fibrous
architecture of the tissues.
76. Three sources of blood supply to
gingiva are as follow:
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.
Occasional branches of the arterioles pass
through the alveolar bone to the periodontal
ligament or run over the crest of the alveolar
bone.
Vessels of the periodontal ligament
which extend into the gingiva and
anastomose with capillaries in the sulcus area.
77. Arterioles from the crest of
the interdental septa
extend parallel to the crest of
the bone
Anastomosis
Vessels of PDL
Capillaries in gingival
crevicular areas
Vessels that run over
alveolar crest
78. Beneath the epithelium on the outer gingival surface
Capillaries extend into the papillary connective tissue between
the epithelial rete pegs in the form of terminal hairpin loops
with efferent and afferent branches, spirals, and varices.
The loops are sometimes linked by cross-communications,
and flattened capillaries serve as reserve vessels when the
circulation is increased in response to irritation.
79. Along the sulcular epithelium
capillaries are arranged in a flat, anastomosing plexus that
extends parallel to the enamel from the base of the sulcus to
the gingival margin.
In the col area,
a mixed pattern of anastomosing capillaries and loops occurs.
In the absence of inflammation
The vascular network is arranged in a regular, repetitive, and
layered pattern.
In the inflamed gingival
Vasculature exhibits an irregular vascular plexus pattern, with
the microvessels exhibiting a looped, dilated, and convoluted
appearance.
80. Lymphatics
• Remove excess fluids, cellular and protein debris,
microorganisms & other elements
• Control diffusion
• Resolution of inflammatory processes
81. Lymphatics of connective
tissue papillae
Collecting network external
to periosteum
Regional lymph nodes
(Submaxillary Group)
Lymphatics beneath JE
PDL
Accompany blood vessels
82. Nerve Supply
Maxillary & Mandibular branches of Trigeminal nerve
Labial aspect of maxillary incisors, canines & premolars
Superior labial branches from infraorbital nerve
Buccal gingiva in maxillary molar region
Posterior superior alveolar nerve
Palatal gingiva in maxillary molar region
Greater palatine nerve
Palatal area of incisors
Long sphenopalatine nerve
83. Lingual gingiva in mandible
Lingual nerve
Labial gingiva of mandibular incisors & canines
Mental nerve
Gingiva at buccal aspect of molars
Buccal nerve
Inferior alveolar nerve
84. Within the gingival connective tissues, most nerve fibers
are myelinated and are closely associated with the
blood vessels.
Gingival innervation is derived from fibers arising from
nerves in the periodontal ligament.
The following nerve structures are present in the
connective tissue:
a meshwork of terminal argyrophilic fibers, some of which extend
into the epithelium;
Meissner-type tactile corpuscles;
Krause-type end bulbs, which are temperature receptors; and
encapsulated spindles.
85. Correlation of Clinical & Microscopic Features
Color
Size
Contour
Shape
Consistency
Surface texture
Position
86. Color
The color of the attached and
marginal gingiva is generally
described as “coral pink”
Produced by :
the vascular supply,
the thickness,
degree of keratinization of the
epithelium, and
the presence of pigment-containing
cells.
87. Alveolar mucosa as compared to attaced gingiva is
Red, smooth & shiny rather than pink and stippled
Comparison of the microscopic structure of the attached
gingiva with that of the alveolar mucosa
Epithelium : Thinner
Nonkeratinized
No rete pegs
Connective tissue : Loosely arranged
Blood vessels : Numerous
88. Physiologic Pigmentation (Melanin)
Non-hemoglobin derived brown pigment
Melanin pigmentation in the oral cavity is
prominent in black individuals
Skin, gingiva, oral mucous membrane
Gingiva : 60%
Hard palate : 61%
Mucous membrane : 22%
Tongue : 15%
89. Gingival pigmentation
Occurs as a diffuse, deep-purplish discoloration or as
irregularly shaped, brown and light-brown patches.
It may appear in the gingiva as early as 3 hours after
birth and often is the only evidence of pigmentation
Oral repigmentation
Refers to the clinical reappearance of melanin pigment
after a period of clinical depigmentation of the oral
mucosa resulting from chemical, thermal, surgical,
pharmacologic, or idiopathic factors.
91. Contour
Depends on:
the shape of the teeth
their alignment in the arch
the location and size of the area of proximal contact
the dimensions of the facial and lingual gingival embrasures.
The marginal gingiva envelops the teeth in collarlike
fashion
Usually follows a scalloped outline on the facial and lingual
surfaces.
It forms a straight line along teeth with relatively flat surfaces.
On teeth with pronounced mesiodistal convexity (e.g., maxillary
canines) or teeth in labial version, the normal arcuate contour is
accentuated, gingiva is located farther apically.
On teeth in lingual version, the gingiva is horizontal and
thickened .
92. Shape
The shape of the interdental gingiva is governed by:
the contour of the proximal tooth surfaces
the location and shape of gingival embrasures.
When proximal surfaces relatively flat
faciolingually
Roots are close together
Interdental bone thin mesiodistally
Gingival embrasures & interdental
gingiva are narrow mesiodistally
93. When proximal surfaces flare away from area of contact
Mesiodistal diameter of interdental gingiva is broad
• The height of the inter-dental gingiva varies with the location of the
proximal contact
•Anterior region : Pyramidal
• Molar region : Flattened in buccolingual direction
94. Consistency
Firm and resilient, with the exception of the
movable free margin
Tightly bound to the underlying bone.
The collagenous nature of the lamina propria and its
contiguity with the mucoperiosteum of the alveolar
bone determine the firmness of the attached gingiva.
The gingival fibers contribute to the firmness of the
gingival margin.
95. Surface Texture
A textured surface similar to an orange peel
and is referred to as being stippled.
Stippling is best viewed by drying the
gingiva.
The attached gingiva is stippled; the
marginal gingiva is not.
The central portion of the interdental
papillae is usually stippled, but the marginal
borders are smooth.
The pattern and extent of stippling vary
among individuals and different areas of the
same mouth.
96. Less prominent on lingual than facial surfaces and
may be absent in some persons
Absent : Infancy
Appears : About 5 years
until adulthood
Disappear : Old age
97. Microscopically
Produced by alternate rounded
protuberances & depressions in
gingival surface.
The papillary layer of the connective
tissue projects into the elevations,
and the elevated and depressed areas
are covered by stratified squamous
epithelium.
The degree of keratinization and the
prominence of stippling appear to be
related
98. Low magnification : Rippled surface interrupted by
irregular depressions (50 µm)
Higher magnification : Cell micropits
Stippling is form of Adaptive specialization/
Reinforcement for function
Reduction or loss of stippling
Gingival disease
When the gingiva is restored to health after treatment,
the stippled appearance returns.
99. The surface texture of the gingiva is also related to
the presence and degree of epithelial keratinization.
Keratinization is considered a protective adaptation
to function.
It increases when the gingiva is stimulated by
toothbrushing.
100. Position
The position of the gingiva refers to the level at which
the gingival margin is attached to the tooth.
When the tooth erupts into the oral cavity, the margin
and sulcus are at the tip of the crown; as eruption
progresses, they are seen closer to the root.
During this eruption process, JE, OE, and REE undergo
extensive alterations and remodeling while maintaining
the shallow physiologic depth of the sulcus.
Without this remodeling of the epithelia, an abnormal
anatomic relationship between the gingiva and the tooth
would result.
101. Continuous Tooth Eruption
According to the concept of continuous eruption,
eruption does not cease when teeth meet their
functional antagonists but continues throughout life.
• Active eruption : Movement of the teeth in the
direction of the occlusal plane
Passive eruption : Exposure of the teeth by apical
migration of the gingiva
102. Active & passive eruption proceed together
Gottlieb & Orban, 1933
Active eruption
Attrition
Loss of tooth substance
Tooth eruption
Cementum deposited at
apices and furcations of
roots
Bone formed along
fundus of alveolus and at
crest of alveolar bone
103. Although originally thought to be a normal
physiologic process, passive eruption is now
considered a pathologic process.
Passive eruption is divided into the following four
stages
104. Stage 1: The teeth reach the line of occlusion. The junctional
epithelium and base of the gingival sulcus are on the enamel.
Stage 2: The junctional epithelium proliferates so that part is on
the cementum and part is on the enamel. The base of the sulcus
is still on the enamel.
Stage 3: The entire junctional epithelium is on the cementum,
and the base of the sulcus is at the cementoenamel junction. As
the junctional epithelium proliferates from the crown onto the
root, it does not remain at the cementoenamel junction any
longer than at any other area of the tooth.
Stage 4: The junctional epithelium has proliferated farther on
the cementum. The base of the sulcus is on the cementum, a
portion of which is exposed. Proliferation of the junctional
epithelium onto the root is accompanied by degeneration of
gingival and periodontal ligament fibers and their detachment
from the tooth.
105. Conclusion
Knowledge of architecture of the gingiva, how the tissue
structure develops & how it relates to function is of
fundamental importance for understanding the disease
process, and for devising effective therapeutic strategies