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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
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
Macroscopic Anatomy of Gingiva
 The gingiva is divided anatomically into:
 Marginal
 Attached
 Interdental
Gingiva
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
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.
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.
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
Width of attached Gingiva
Maxilla Mandible
Incisors
3.5-4.5mm
Premolars
1.9 mm
Incisors
3.3-3.9mm
Premolars
1.8 mm
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.
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.
 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.
 If a diastema is present,
the gingiva is firmly
bound over the
interdental bone and
forms a smooth, rounded
surface without
interdental papillae.
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.
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.
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)
Cells of Gingival Epithelium
 Principal cell
 Keratinocytes
 Clear cells / Nonkeratinocytes:
 Langerhans cells
 Merkels cells
 Melanocytes
 Inflammatory cells
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
 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
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.
 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.
 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.
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
 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.
Stratum Granulosum
 The cytoplasm of these cells characteristically displays
KERATOHYALINE GRANULES (arrows) that
have been associated with KERATIN FORMATION
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.
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.
 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
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.
Activity towards surface:
 Pentose shunt  Glucose-6-phosphatase
Ribonucleic acid (RNA)
Synthesis of keratinization proteins
 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.
Non-keratinocytes
Langerhans
cells
Merkel cells
Inflammatory
cells
Melanocytes
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
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.
• 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
Merkel Cells
 Located in the deeper layer of epithelium.
 Harbors nerve endings.
 Connected to adjacent cells by desmosomes.
 Act as a tactile receptors.
Inflammatory Cells
 Clinical normal areas of mucosa
 Lymphocytes : Most frequent
Associated with langerhans cells
 Polymorphonuclear leukocytes
 Mast cells
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
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
 Keratins
Ortho-
keratinized
areas
• K1
• K2,
• K10 - K12
Highly
proliferative
epithelia
• K6
• K16
Stratification-
specific
cytokeratins
• K5
• K14
Para-
keratinized
areas
• K19
 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.
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.
 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.
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.
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.
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.
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.
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.
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.
 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)
 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.
 Interconnections
 Few desmosomes only
 Occasional gap junctions
Schroeder & Listgarten, 1977 Saito et al, 1981 Hashimoto et
al, 1986
 Wide fluid-filled intercellular spaces
 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
Epithelial Attachment
Internal basal lamina
External basal laminaLamina lucida
Lamina densa
Anchoral fibril
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
Junctional
epithelium
Gingival
fibers
Dentogingival
unit
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.
 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
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.
Cellular Extracellular
• Fibroblasts
•Mast cells
•Macrophages
•Inflammatory cells
• Fibers
•Ground substance
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
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
Macrophages
 Phagocytic function
 Numerous in inflammed tissue
Inflammatory cells
 Polymorphonuclear leukocytes
 Lymphocytes
 Plasma cells
Fibers
Fibers
Collagen
Reticulin Oxytalan
Elastic
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.
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.
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
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
Principalgroup Dentogingival
Alveologingival
Dentoperiosteal
Circular
Transeptal
Secondarygroup
Periostogingival
Interpapillary
Transgingival
Intercircular
Intergingival
Semicircular
Gingival Fibres
1 Dentogingival
– Coronal
– Horizontal
– Apical
2 Alveologingival
3 Interpapillary
4 Transgingival
5 Circular,
semicircular
6 Dentoperiosteal
7 Transseptal
8 Periosteogingival
9 Intercircular
10 Intergingival
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.
 Glycosaminoglycans
 Dermatan sulfate (60%)
 Chondroitin sulfate (30%)
 Hyaluronan and Heparan sulfate (10%)
 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
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.
Blood Supply
 Upper gingiva
 Anterior
 Anterior superior alveolar
artery
 Lingual
 Major palatine artery
 Buccal
 Buccal artery
 Posterior
 Posterior superior alveolar
artery
 Lower gingiva
 Anterior buccal
 Mental artery
 Anterior lingual
 Incisive artery and
sublingual artery
 Posterior lingual
 Inferior alveolar artery
and sublingual artery
 Posterior buccal
 Inferior alveolar artery
and buccal artery
 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.
 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
 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.
 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.
Lymphatics
• Remove excess fluids, cellular and protein debris,
microorganisms & other elements
• Control diffusion
• Resolution of inflammatory processes
Lymphatics of connective
tissue papillae
Collecting network external
to periosteum
Regional lymph nodes
(Submaxillary Group)
Lymphatics beneath JE
PDL
Accompany blood vessels
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
 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
 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.
Correlation of Clinical & Microscopic Features
 Color
 Size
 Contour
 Shape
 Consistency
 Surface texture
 Position
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.
 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
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%
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.
Size
Cellular &
Intercellular
elements
Vascular
supply
size
Alteration in size is a common feature of gingival disease
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 .
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
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
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.
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.
 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
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
 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.
 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.
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.
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
 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
 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
 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.
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

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Gingiva

  • 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)
  • 17. Cells of Gingival Epithelium  Principal cell  Keratinocytes  Clear cells / Nonkeratinocytes:  Langerhans cells  Merkels cells  Melanocytes  Inflammatory cells
  • 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
  • 40.  Keratins Ortho- keratinized areas • K1 • K2, • K10 - K12 Highly proliferative epithelia • K6 • K16 Stratification- specific cytokeratins • K5 • K14 Para- keratinized areas • K19
  • 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
  • 54. Epithelial Attachment Internal basal lamina External basal laminaLamina lucida Lamina densa Anchoral fibril
  • 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.
  • 60. Cellular Extracellular • Fibroblasts •Mast cells •Macrophages •Inflammatory cells • Fibers •Ground substance
  • 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
  • 70. Gingival Fibres 1 Dentogingival – Coronal – Horizontal – Apical 2 Alveologingival 3 Interpapillary 4 Transgingival 5 Circular, semicircular 6 Dentoperiosteal 7 Transseptal 8 Periosteogingival 9 Intercircular 10 Intergingival
  • 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.
  • 72.  Glycosaminoglycans  Dermatan sulfate (60%)  Chondroitin sulfate (30%)  Hyaluronan and Heparan sulfate (10%)
  • 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.
  • 75. Blood Supply  Upper gingiva  Anterior  Anterior superior alveolar artery  Lingual  Major palatine artery  Buccal  Buccal artery  Posterior  Posterior superior alveolar artery  Lower gingiva  Anterior buccal  Mental artery  Anterior lingual  Incisive artery and sublingual artery  Posterior lingual  Inferior alveolar artery and sublingual artery  Posterior buccal  Inferior alveolar artery and buccal artery
  • 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