a basic information on gingiva

1. 1

2. Presented by:- Dr K. Abhilasha
Moderated by:- Dr Lalith V
Department of Periodontics

3. CONTENTS
• INTRODUCTION
• DEFINITION
• EMBRYOLOGY OF GINGIVA
• MACROSCOPIC ANATOMY
- Types of gingiva
- Gingival sulcus
• MICROSCOPIC ANATOMY
- Gingival epithelium
- Cells of gingival
epithelium
- Types of Gingival Epithelium
• MICROSCOPIC ANATOMY
- Epithelium connective tissue interface
- Connective tissue
- Gingival fibers
• BLOOD SUPPLY
• NERVE SUPPLY
• LYMPHATIC DRAINAGE
• CLINICAL FEATURES
• AGE CHANGES
• CLINICAL CONSIDERATIONS
• CONCLUSION
• REFERENCES
3

4. INTRODUCTION
• Oral mucosa ( OR mucous membrane)- is continuous with the skin of
lips and mucosa of the soft palate and pharynx.
• The oral mucosa consists of the following three zones:
1. The gingiva and the covering of the hard palate, termed the
masticatory mucosa.
2. The dorsum of the tongue, covered by specialized mucosa.
3. The oral mucous membrane lining the remainder of the oral
cavity.
4

5. Periodontium 5
GINGIVA
PERIODONTAL
LIGAMENT
CEMENTUM
ALVEOLAR BONE

6. Gingiva is the part of oral mucosa that covers the alveolar
processes of jaws and surrounds the neck of teeth.
DEFINITION 6
CARRANZA 10th Ed
Part of masticatory mucosa covering the alveolar processes
of the cervical portions of teeth.
LINDHE 6th Ed

7. The fibrous investing tissue, covered by keratinized epithelium,
that immediately surrounds a tooth and is contiguous with its
periodontal ligament and with the mucosal tissues of the
mouth.
GLOSSARY OF PERIODONTAL TERMINOLOGY(AAP)
It is a combination of epithelium and connective tissue and it
defined as that portion of oral mucous membrane, which in
complete post eruptive dentition of a healthy young individual,
surrounds and is attached to the teeth and the alveolar processes.
SCHROEDER
7

8. Gingiva is the part of oral mucous membrane attached to the
teeth and the alveolar processes.
GRANT
Gingiva is that part of oral mucous membrane that covers
the alveolar processes of the cervical portions of the teeth.
GENCO
8

9. EMBRYOLOGY OF GINGIVA
• Gingiva composed of superficial epithelium of
ectodermal origin and an underlying connective
tissue of mesodermal origin.
9
LISTGARTEN 1972, MACKENZIE 1988

10. 10
ORBAN’S ORAL HISTOLOGY AND EMBRYOLOGY, 14TH ED

11. MACROSCOPIC ANATOMY 11
CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY, LINDHE 6TH ED

12. 12
• Each type of gingiva exhibits considerable variation in
differentiation, histology, and thickness according to its
functional demands.
• All types are specifically structured to function
appropriately against mechanical and microbial
damage.
• This specificity reflects each one’s effectiveness as a
barrier to the penetration by microbes and noxious
agents into the deeper tissue.

13. 1. MARGINAL GINGIVA
• Also known as Unattached gingiva OR Free
gingiva.
• The terminal edge or border of the gingiva
that surrounds the teeth in collar-like
fashion.
• Demarcated from the adjacent attached
gingiva by a shallow linear depression
called the free gingival groove. (50% cases)
• Position- In completely erupted teeth, it is
1.5 to 2mm coronal to CEJ
(cementoenamel junction)
13
NEWMAN AND CARRANZA’S, CLINICAL PERIODONTOLOGY, 13TH ED

14. 14• The most apical point of the marginal gingival
scallop is called the gingival zenith.
• Its apicocoronal and mesiodistal
dimensions vary between
0.06 and 0.96 mm.
Mattos CM, Santana RB: A quantitative evaluation of the spatial maxillary
anterior dentition, J Periodontol 79:1880, 2008

15. GINGIVAL SULCUS
• Also known as Gingival
Crevice.
• 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 side.
• V-shaped
15

16. 16• Significance-
 Important Diagnostic parameter
 Ideal conditions: 0/ close to 0mm
Strict condition of normalcy can be produced
-Experimentally only in germ
free animals
-After intense and prolonged
plaque control
 Histologic depth: 1.8mm (variation from
0 – 6 mm).
 Probing depth: 2-3 mm.

17. 2. INTERDENTAL PAPILLA
 Interdental gingiva occupies the gingival embrasure.
 Formed by:-
• Lateral borders & tip- Marginal gingiva of adjoining teeth
• Central intervening portion- Attached gingiva
 Shape of the gingiva in a given interdental space depends on:
• presence or absence of a contact point between the adjacent
teeth
• Distance between the contact point and the osseous crest
• Presence or absence of some degree of recession
17

18. 18 If a diastema is present, the gingiva is firmly bound over the
Interdental bone to form a smooth, rounded surface without
interdental papillae.

19. 19
Gingival Col- Normal gingiva
Gingival col- After gingival recession
Anterior- Pyramidal
Posterior- Tent shaped
A valley-like depression that
connects facial and lingual papilla
and that conforms to the shape of
interproximal contact.
Col is covered by non-keratinized
stratified squamous epithelium

20. 3. ATTACHED GINGIVA
• Firm, resilient and tightly bound to the underlying
periosteum of alveolar bone by connective tissue fibers.
• Extent-
Coronally- Marginal gingiva
Apically- Facial aspect- Muco-gingival junction
Palatal aspect- Palatal mucosa
Lingual aspect- Alveolar mucosa
• Presence of stippling.
20

21. Width of attached gingiva
• The width of the attached gingiva is the distance
between the mucogingival junction and the
projection on the external surface of the bottom
of the gingival sulcus or the periodontal pocket.
21

22. Width of attached gingiva
 Facial:
Widest in incisor region
Maxilla: 3.5 – 4.5 mm
Mandible: 3.3 – 3.9 mm
Most narrow adjacent to premolar
Maxilla: 1.9 mm
Mandible: 1.8 mm
Lingual:
Wider in molar region
Narrow in incisor region
Increases: By the age of 4 years.
Supra-erupted teeth.
22

23. Measurement of width of
attached gingiva
The width of attached gingiva is determined by subtractting
the sulcus or pocket depth from total width of gingiva.
HALL WB, 1982
Total width of gingiva: from MGJ to crest of marginal gingiva
Methods to determine mucogingival junction:
• 1. Visual method (VM).
• 2. Functional method (FM).
• 3. Visual methods after histochemistry staining (VM-S).
• 4. Tension test
23
Hall WB. Present status of soft tissue grafting. Journal of periodontology. 1977
Sep;48(9):587-97.

24. 24
 Attached gingiva = Total width of gingiva Depth of sulcus
 This is done by stretching the lip or cheek to demarcate the
mucogingival line while the pocket is being probed.

25. 25
Also named as Functional Method
 Mucogingival junction is assessed as a borderline between the movable
and immovable tissue wherein tissue mobility is determined by running a
periodontal probe positioned horizontally from the vestibule toward the
gingival margin with light pressure.

26. 26
 The mucogingival junction can be assessed visually after the staining
the mucogingival complex with Lugol’s iodine solution.
 Principle:- Based on the difference in the glycogen content.
Alveolar mucosa shows indo positive reaction and
attached gingiva shows indo-negative reaction.
Thus, Lugol’s iodine solution stains only the alveolar mucosa and clearly
demarcates the mucogingival junction.

27. 27
Tension applied in
lips in outward,
downward and
lateral directions
Gingival margin is
observed
Any movement of free
gingiva is recorded as
positive response to
tension test.

28. How much zone of attached gingiva necessary to
maintain the health of periodontium??
 Bowers GM,1963: It is possible to maintain clinically
healthy gingiva despite a very narrow zone of
attachment (less than 1 mm).
 Lang & Loe,1972: suggested that 2 mm of
keratinized gingiva (corresponding to 1 mm attached
gingiva ) is adequate to maintain gingival health.
28

29. 29
 Maynard and Wilson, 1979- 5 mm of keratinized gingiva with 3
mm of attached gingiva when subgingival restorations are placed.
 Stetler and Bissada, 1987- When subgingival margins of restorations
are involved, the areas with narrow keratinized gingiva are usually
inflamed and potentially more liable to break down.
 Miyasato et al,1977 reported that even in areas of minimal
attached gingiva, periodontal health can be preserved,
provided that good plaque control is practised.
 Kennedy et al,1985 there is no evidence that narrow zone of
attached gingiva is more prone to inflammation than a wide zone.

30. 30
 Mehta P et al,2010: Width of attached gingiva is not significant to
Maintain periodontal health in the presence of adequate oral
hygiene.
 Systematic review by Chambrone, 2016 concluded that Limited evidence
suggests that presence of keratinized tissue and/or greater keratinized
tissue width decrease the likelihood of recession depth increase or new
gingival recession development.
 Wennstorm, 1987: the lack of minimum amount of
attached gingiva does not necessarily result in a soft
tissue recession. Proper plaque control prevents soft
tissue recession, even when it is out of adequate width.

31. Inadequate width of attached
gingiva
• Friedman, 1992 -Said that “inadequate” zone of gingiva
would facilitate subgingival plaque formation because
of improper pocket closure resulting from movability of
marginal tissue.
• Amount of attached gingiva considered to be
insufficient when stretching of lips or cheek induce
movement of free gingival margin.
31

32. Factors affecting the width of
attached gingiva 32
2. Abnormal frenal
attachment which
exaggerates the pull
on frenal margin
3.Deep pockets that
reached the level of
mucogingival junction
4. Vigorous
brushing
1. Born without sufficient attached gingiva which results in muscles of
alveolar mucosa to pull the gingiva down Gingival recession & Bone loss

33. 33
• Patient age
• Level of oral hygiene practise
• Teeth involved any- tooth malposition
• Existing recession with aesthetics or
sensitivity problems
• Patient’s dental needs like presence
of dehiscence
Hall mentioned
few critical
factors to be
considered in
determination of
adequate
attached gingiva.

34. Functions of attached gingiva
Prevents apical spread of inflammation
Deflects food away from gingival margin
Braces gingiva firmly against teeth.
Acts as buffer between two movable mucosa
Bears the compressive and shear forces during the
mastication
Prevents the transmission of frenal pull
34

35. Attached gingiva around
IMPLANTS
• Absence of keratinized mucosa increases the
susceptibility of peri-implant lesions and plaque
induced destruction.
• Keratinized gingiva around implants have more
hemi-desmosomes.
• Orientation of collagen fibers in the connective
tissue zone of an implant often appear
perpendicular to implant surface, but in mobile
non keratinized tissue these fibers run parallel to
the surface of implants.
35

36. 36

37. 37
 Adell et al 1986- attached mucosa is necessary to
prevent movement of mucosa around an exposed cover
screw from inflecting trauma upon marginal soft tissue.
 Meffert et al 1992- preferred to obtain adequate width of
Keratinized tissue before implant placement.
Lekholm U, Adell R, Lindhe J, Brånemark PI, Eriksson B, Rockler B, Lindvall AM, Yoneyama
T. Marginal tissue reactions at osseointegrated titanium fixtures:(II) A cross-sectional
retrospective study. International journal of oral and maxillofacial surgery. 1986 Feb
1;15(1):53-61.
Meffert RM, Langer B, Fritz ME. Dental implants: a review. Journal of periodontology.
1992 Nov;63(11):859-70.

38. 38 Schrodder et al 2000 - Mobile mucosa may disrupt the
implant epithelial attachment zone and contribute to an
increased risk of inflammation from plaque.
 Mehdi Adibrad et al 2009- there is significant influence of width
of keratinized mucosa on health of peri-implant tissue.
Schroeder HE, Listgarten MA. The gingival tissues: the architecture of periodontal
protection. Periodontology 2000. 1997 Feb;13(1):91-120.
Adibrad M, Shahabuei M, Sahabi M. Significance of the width of keratinized mucosa on the
health status of the supporting tissue around implants supporting overdentures.
Journal of Oral Implantology. 2009 Oct;35(5):232-7.

39. 39
• Uneno et al 2016- Inadequate keratinized mucosa decrease
cleansibility of implant sites and increase mucosal inflammation.
There is possibility that plaque accumulation in implant sites
caused more pronounce inflammatory response compared to
contralateral tooth.
Ueno D, Nagano T, Watanabe T, Shirakawa S, Yashima A, Gomi K. Effect of the keratinized mucosa
width on the health status of periimplant and contralateral periodontal tissues: a cross-sectional
study. Implant dentistry.2016 Dec 1;25(6):796-801.
 Bouri et al 2008 & Schrott et al 2009,-Increased width of
keratinized mucosa around implants is associated with
lower mean alveolar bone loss and improved soft tissue
health.
Bouri Jr A, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of keratinized gingiva and
the health status of the supporting tissues around dental implants. International Journal of
Oral & Maxillofacial Implants. 2008 Apr 1;23(2).

40. Clinical significance of attached
gingiva around implants
Prevents
spread of
inflammation
Prevents
recession of
marginal
tissue
Provides tight
collar around
implants
Enable
patients to
maintain good
oral hygiene.
40

41. MICROSCOPIC ANATOMY 41

42. 42• Histologically, gingiva is composed of :
• 1. Gingival epithelium (predominantly cellular)
• 2. Epithelium-connective tissue interface
(Basement Membrane)
• 3. Connective tissue( less cellular; mainly
composed of fibers and ground substance)

43. Gingival Epithelium
Continuous lining of stratified squamous epithelium.
Function:
Physical barrier to Infection
Participate actively in responding to infection in
signaling further host reactions in integrating
innate and acquired immune responses.
To protect deep structures
Allow a selective interchange with the oral
environment.
43

44. 44

45. 45
• Layers of stratified squamous epithelium as
seen by electron microscopy:

46. 1. Stratum basale
• Cells: cylindric or cuboid.
• Found immediately adjacent to the connective
tissue separated by a basement membrane.
• Germinative layer: having the ability to divide.
• It takes approximately 1 month for a
keratinocyte to reach the outer epithelial
surface, where it is shed from the stratum
corneum.
46

47. 2. Stratum spinosum
• Prickle cell layer.
• Large polyhedral cells with short cytoplasmic
processes.
• Keratinosomes or odland bodies:
Modified lysosomes.
Present in the uppermost part of the stratum
spinosum.
Contain a large amount of acid phosphatase.
47

48. 3. Stratum granulosum
• Flattened cells, in a plane parallel to the gingival
surface.
• Keratohyaline granules :
• Associated with keratin formation, are 1 μm in
diameter, round in shape and appear in the cytoplasm
of the cell.
48

49. 4. Stratum Corneum
• Closely packed, flattened cells that have lost
nuclei and most other organelles as they become
keratinized.
• The cells are densely packed with tonofilaments.
• Clear, rounded bodies probably representing lipid
droplets appear within the cytoplasm of the cell.
49

50. 50Proliferation through mitosis occurs in the basal
layer, less frequently in the suprabasal layer and
migration occurs.
Differentiation includes keratinisation in which
main morphologic changes seen are:
 Progressive flattening of the cell.
 Increased prevalence of tonofilaments.
 Intercellular junctions coupled to the production
of keratohyaline granules.
 Disappearance of the nucleus

51. 51Three types of surface keratinization can
occur in the gingival epithelium:
1. Orthokeratinization
2. Parakeratinization
3. Nonkeratinization

52. 1.Orthokeratinization
• Complete keratinization
superficial
horny layer
• No nuclei in stratum
corneal layer.
• Well-defined stratum
granulosum.
• Few areas of outer
gingival epithelium.
52

53. 2.Parakeratinization
• Intermediate stage of keratinization.
• Most prevalent surface area of the
gingival epithelium.
• Can progress to maturity or
dedifferentiate under different
physiologic or pathologic conditions.
• Stratum cornea retains PYKNOTIC
NUCLEI.
• Keratohyaline granules are dispersed
rather than giving rise to a stratum
granulosum.
53

54. 3. Non-keratinization
• Viable nuclei in
superficial layer.
• Has neither granulosum
nor corneum strata.
• Layers of nonkeratinized
epithelium:
1. Stratum superficiale
2. Stratum intermedia
3. Stratum basale
54

55. Gingival Epithelium
Keratinized
Ortho-keratinized Para-keratinized
STRATUM BASALE
STRATUM SPINOSUM
STRATUM GRANULOSUM
STRATUM CORNEUM
Non-Keratinized
STRATUM BASALE
STRATUM SPINOSUM

56. Ultrastructure Of Epithelium
• Each epithelial type have characteristic pattern
of cytokeratins.
• Keratin proteins are composed of different
polypeptide subunits characterized by their
isoelectric points and molecular weights.
• Basal cells begin synthesis of low molecular
weight keratins.
• High molecular weight keratins are expressed
when they reach superficial layers.
56

57. 57• Other proteins synthesized during maturation process:
Keratolinin
Involucrin
Filaggrin
• Corneocyte:
Most differentiated epithelial cell
Composed of bundles of keratin tonofilaments in
amorphous matrix of filaggrin, surrounded by a
resistant envelope made of keratolinin and involucrin.
• These histochemical patterns change under normal or
pathologic stimuli, thereby modifying the keratinization
process.

58. CELLS PRESENT IN GINGIVAL EPITHELIUM
KERATINOCYTES
NONKERATINOCYTES/CLEAR CELLS:
Langerhans cells
Merkel cells
Melanocytes
Inflammatory cells
58

59. 1. Keratinocytes
• 90% of the total gingival cell population.
• Originate from ectodermal germ layer.
• Cell organelles: nucleus, cytosol, ribosomes, Golgi
apparatus etc
• Melanosomes: Pigment bearing granules
• Proliferation and differentiation of the keratinocytes
helps in the barrier action of the epithelium.
• The microfilaments present in the keratinocytes
help in cell motility and maintenance of the polarity.
59

60. 2. Non-keratinocytes – LANGERHANS CELL
• Dendritics cells - Modified monocytes
belonging to reticuloendothelial system.
• Paul Langerhans used gold impregnation
technique to visualize LCs.
• Reside chiefly in suprabasal layers.
• Act as antigen -presenting cells for
lymphocytes.
• Specific elongated g-specific granules called as
Birbecks Granules.
• Have marked adenosine triphosphatase activity.
60

61. 61• Only epidermal cells which express receptors for C3
and Fc portion of IgG
• Can move in and out of the epithelium unlike
melanocytes.
• Found in oral epithelium of normal gingiva.
• Smaller amounts in sulcular epithelium.
• Absent in healthy junctional epithelium.

62. MERKEL CELLS
• Located in deeper layers of epithelium.
• Not dendritic cells
• Possess keratin tonofilaments and desmosomes.
• Harbor nerve endings.
• Sensory in nature - respond to touch – Tactile
Perceptors
62

63. MELANOCYTES
• Originate from neural crest cells.
• Found in the stratum basale.
• Identified in gingiva by Laidlaw and Cahn,
1932.
• Have long dendritic processes, interspersed
between the keratinocytes.
• Lack tonofilaments and desmosomal
connections.
• Synthesize melanin, responsible for providing
color to gingiva.
63

64. TYPES OF GINGIVAL EPITHELIUM 64
• Oral or Outer Epithelium
• Sulcular Epithelium
• Junctional Epithelium

65. 1.ORAL EPITHELIUM
• Covers the crest and outer surface of the
marginal gingiva and the surface of the
attached gingiva.
• 0.2 to 0.3 mm in thickness.
• Keratinized or parakeratinized, or it
may present combinations of these
conditions.
• The oral epithelium is composed of four
layers.
65

66. 66 K1, K2, K10-12 cytokeratins present are
immunohistochemically expressed with high intensity in
orthokeratinized areas and with less intensity in
parakeratinized areas.
 K6 and K16 , characteristic of highly proliferative
epithelia.
 K5 and K14, stratification-specific cytokeratins , are
also present.

67. 2.SULCULAR EPITHELIUM
• Lines the gingival sulcus.
• Thin, non-keratinized stratified
squamous epithelium
• No rete pegs.
• Extends from the coronal limit
of the junctional epithelium to
the crest of the gingival margin.
• Hydropic degeneration of cells.
• Contains K4 and K13, K19.
• Absence of merkel cells.
67

68. 68Sulcular epithelium has the potential to keratinize:
• If it is reflected and exposed to the oral cavity.
• If the bacterial flora of the sulcus is totally eliminated.
These findings suggest that the local irritation of the
sulcus prevents sulcular keratinization.
 Sulcular epithelium is extremely important because
it act as a semi permeable membrane through which
injurious bacterial products pass into gingival fluid.

69. JUNCTIONAL EPITHELIUM
• Collarlike band of stratified
squamous non-keratinizing
epithelium.
• 3 to 4 layers thick in early life,
but the number increases with
age to 10 or even 20 layers.
• Tapers from its coronal end to
apical termination, located at
the cementoenamel junction in
healthy tissue.
• Length: 0.25 to 1.35 mm.
69

70. 70
HISTORY
G.V.BLACK,1915
SUB-GINGIVAL SPACE‟ extends up to CEJ, under loosely fitting gingiva.
NO JE
GOTTLIEB, 1921
ORGANIC UNION between tooth and gingiva
EPITHELIAL ATTACHMENTWAERHAUG,1952
Gingiva is separated from tooth by a CAPILLARY SPACE
EPITHELIAL CUFF
ORBAN, 1960 EPITHELIAL ATTACHMENT CUFF
STERN ,1962 DENTOGINGIVAL UNIT
ANDERSON,1966
SCHROEDER & LISTGARTEN,1971
JUNCTIONAL EPITHELIUM
ULTRATRUCTURE OF JE MOST ACCEPTED

71. SCHROEDER AND LISTGARTEN
CONCEPT
• The previous controversy was resolved after evolution of
transmission electron microscopy.
• Gave the concept of primary epithelial attachment and
secondary epithelial attachment.
• Primary epithelial attachment refers to the epithelial
attachment lamina released by the REE(reduced enamel
epithelium). It lies in direct contact with enamel and
epithelial cells attached to it by hemidesmosomes.
• When REE cells transform into JE cells the primary
epithelial attachment becomes secondary epithelial
attachment . It is made of epithelial attachment
between basal lamina and hemidesmosomes.
71

72. DEVELOPMENT OF JUNCTIONAL
EPITHELIUM 72

73. 73
• Microscopically, Junctional epithelium
is non-keratinizing stratified
squamous epithelium which is made
up of two strata: basal layer and the
supra-basal layer.
• Basal layer – consisting of cuboidal
cells, are arranged along the
connective tissue interface.
• Supra-basal layer – multiple layers of
flattened cells lying parallel to tooth
surface.
• Junctional epithelium is attached to
gingival connective tissue by an
external basal lamina, while it is
attached to the tooth surface by
internal basal lamina.

74. 74
• Presence of layer of cell, lying in contact
with tooth surface, is referred to as DAT
(Directly attached to tooth) cells.
• Capable of undergoing cell division,
hence they possess the capacity to form
and renew the components of epithelial
attachment of JE.
• External basal lamina contains the
structures similar to that of typical
basement membrane, with the lamina
densa supporting the underlying
connective tissue and lamina lucida lying
in between the lamina densa and the
basal keratinocytes.

75. 75
• The connective tissue supporting junctional epithelium is
different from that of outer and sulcular epithelium both
structurally and functionally .
• It contains extensive blood vascular plexus, and varying
amount of inflammatory cells, such as PMNs and T-cells,
migrate into the gingival sulcus and oral fluid.

76. FUNCTIONS
• Provides attachment to the tooth.
• Forms an epithelial barrier against the plaque bacteria.
• Rapid cell division and funneling of cells towards the sulcus:
 Hinder bacterial colonization and
 Repair of damaged tissue occurs rapidly.
• Allow GCF:
 From connective tissue into crevice – Gingival fluid exudates,
PMNs,etc.
 From crevice to connective tissue – Foreign material such as
carbon particles,
• Produces active antimicrobial substances like defensins, lysosomal
enzymes, Calprotectin and cathelicidin.
• Epithelial cells activated by microbial substances secrete
chemokines that attract and activate professional defense cells.
76

77. 77

78. EPITHELIAL CONNECTIVE TISSUE
INTERFACE 78
Epithelium is separated from connective tissue (LAMINA
PROPRIA) by basement membrane.
The hemi-desmosomes are involved in the attachment of
the epithelium to the underlying basement membrane.

79. 79

80. 80

81. 81

82. 82

83. 83

84. 84

85. 85

86. 86

87. 87

88. 88

89. 89

90. 90

91. 91

92. 92

93. 93

94. 94

95. 95

96. 96

97. 97

98. 98

99. 99

100. 10
0

101. 10
1

102. 10
2

103. 10
3

104. 10
4

105. 105 Various junctional complexes present in gingiva
are:
• Tight junctions/Zonae occludens
• Adhesive junctions:
 Cell to cell
– Zonula adherens
– Desmosomes: 30 nm.
 Cell to matrix
– Focal adhesions
– Hemidesmosomes
• Gap junctions:
Intercellular pipes/channels bridge both adjacent
membranes and intercellular space.
Intercellular space in gap junction is approx. 3 nm.
Major pathway for direct intercellular communication.

106. 106

107. 107
Samiei M, Ahmadian E, Eftekhari A, Eghbal MA, Rezaie F, Vinken M. Cell junctions
and oral health. EXCLI journal. 2019;18:317.

108. CONNECTIVE TISSUE
• Gingival connective tissue (Lamina Propria) is largely fibrous
connective tissue that has elements originating directly from
oral mucosa connective tissue as well as some fibers that
originate from developing dental follicle.
• Components:
Collagen fibers (60%)
Fibroblasts (5%)
Vessels, Nerves & Matrix (35%)
• Layers of connective tissue:
1. Papillary Layer
2. Reticular Layer
108

109. 109
GROUND SUBSTANCE
• Fills space between fibers and cells
• Amorphous
• High water content
• Composed of:
Proteoglycans:
Hyaluronic acid
Chondroitin sulphate
Glycoproteins: (PAS positive)
Fibronectin
Laminin

110. 110
• The different types of cell present in the connective
tissue are:
Fibroblasts
Mast cells
Fixed Macrophages & Histiocytes
Inflammatory cells (Plasma cells, Lymphocytes ,Neutrophils)
Adipose cells
Eosinophils
CELLS

111. 111
Fibroblasts:
• Preponderant cellular element in the gingival connective
tissue.
• Mesenchymal origin.
• Play a major role in the development, maintenance, and
repair of gingival connective tissue.
• Synthesize :
• collagen
• elastic fibers
• glycoproteins and glycosaminoglycans.
• Regulate collagen degradation through phagocytosis and
the secretion of collagenases.
• Fibroblast heterogeneity is now a well-established
feature of fibroblasts in the periodontium which is
necessary for the normal functioning of tissues in health,
disease, and repair

112. FIBERS
• The connective tissue fibers are produced by the
fibroblasts and can be divided into:
• Collagen fibers
• Reticulin fibers
• Oxytalan fibers
• Elastic fibers
112

113. 113Collagen type I:
• forms the bulk of the lamina propria
• provides the tensile strength to the gingival tissue.
Type IV collagen:
• branches between the collagen type I bundles continuous with
fibers of the basement membrane and the blood vessel walls.

114. Oxytalan fibres.
-Initially described by Fullmer.
-Modified type of elastic fibres.
-Scarce in gingiva but more in PDL.
Elastic fibres:
-Only present in association with blood vessels.
-Gingiva seen coronal to mucogingival junction has no elastic fibres
except in association with blood vessels.
-Alveolar mucosa may have many elastic fibres.
Reticulin fibres:
-Have argyrophilic property and are numerous in tissue adjacent to
basement membrane.
-Found in large number in loose CT surrounding blood vessel
-Hence found in endothelial-CT and epithelium-CT interface.
114

115. GINGIVAL FIBERS
• The connective tissue of the marginal gingiva is densely
collagenous, and it contains a prominent system of
collagen fiber bundles called the gingival fibers.
• These fibers consist of type I collagen.
• Functions:
To brace the marginal gingiva firmly against the tooth
To provide the rigidity necessary to withstand the
forces of mastication without being deflected away from
the tooth surface
To unite the free marginal gingiva with the cementum
of the root and the adjacent attached gingiva
115

116. 116
• The gingival fibers are arranged in three groups:
1. Gingivodental
2. Circular
3. Transseptal
• According Page et.al:
Semicircular fibers:
Transgingival fibers
• Lindhe: Dentoperiosteal fibers

117. PRINCIPAL GINGIVAL FIBERS 117

118. DENTOGINGIVAL
Originates from cementum and spreads laterally into
lamina propria.
ALVEOLOGINGIVAL
Originates from periosteum and spreads into lamina
propria.
DENTOPERIOSTEAL
Originates from cementum near CEJ into periosteum of
alveolar crest.
CIRCULAR
Originates from within the free marginal and attached gingiva
coronal to alveolar crest and encircles each tooth.
TRANSEPTAL
Originates from interproximal cementum coronal to crest and courses
mesially and distally in interdental area into cementum of adjacent teeth.
118

119. 119
NEWMAN AND CARRANZA’S, CLINICAL PERIODONTOLOGY, 13TH ED

120. SECONDARY GINGIVAL FIBERS 120

121. 121PERIOSTEOGINGIVAL
INTERPAPILLARY
TRANSGINGIVAL
INTERCIRCULAR
INTERGINGIVAL
SEMICIRCULAR
Originates from the periosteum of the lateral
aspect of alveolar process and spreads into
attached gingiva.
Originates from within interdental gingiva
and follows on orofacial course
Originates within the attached gingiva interwing
along dental arch between and around teeth
Originates from cementum on distal surface of
tooth and insert on mesial cementum of next
tooth
Originates from attached gingiva immediately
subjacent to basement membrane and courses
mesiodistally
Originates from cementum of the mesial surface
of tooth and inserts on the cementum of distal
surface of same tooth

122. 122

123. BLOOD SUPPLY 123
A. DENTOGINGIVAL PLEXUS B. SUBEPITHELIAL PLEXUS

124. NERVE SUPPLY 124

125. LYMPHATIC DRAINAGE 125
• Mainly through Submaxillary group of lymph
nodes.

126. CLINICAL FEATURES 126

127. 1.COLOR
• Generally coral pink.
• Color is a result of:
• Vascular supply
• Thickness
• Degree of keratinisation of epithelium,
• Presence of pigment containing cells.
• Color is also correlated with cutaneous
pigmentation
127

128. Physiologic Pigmentation
(Melanin)
• Melanin (non hemoglobin derived brown pigment)
• Prominent in blacks, diminished in albinos
• Distribution of Oral Pigmentations in blacks:
• Gingiva -60%
• Hard Palate -61%
• Mucous membrane -22%
• Tongue -15%
• As a diffuse , deep purplish discoloration or as irregularly shaped brown
and light brown patches may appear as early as 3 hours after birth
128

129. COLOR (IN DISEASE)
• Color changes may be seen as:- marginal, diffuse
or patch -like.
• Varying shades of reddish blue, deep blue
• Factors responsible-
-Vascular proliferation
-Reduced keratinization
-Tissue necrosis
-Venous stasis.
129

130. 2.SIZE
• Sum total of the bulk of cellular and intercellular
elements and their vascular supply.
• Alteration in size is a common feature of gingival
disease.
130

131. SIZE (IN DISEASE)
• Increased
• Factors responsible:-
-Increase in fibers and decrease in cells
131

132. 3. CONTOUR
• Marginal gingiva envelops the teeth in collarlike
fashion and follows a
• scalloped outline on the facial and lingual surfaces.
• straight line - along teeth with relatively flat
surfaces.
• accentuated - pronounced mesiodistal convexity
(e.g., maxillary canines) or teeth in labial version
• horizontal and thickened - in lingual version.
132

133. 133• Factors responsible:-
-shape of the teeth
-location and size of proximal contact
-Dimensions of facial and lingual gingival
embrasures.

134. CONTOUR (IN DISEASE)
• Marginal gingiva- rolled or rounded
• Interdental papilla- blunt and flat
• Punched out or crater like
depression in interdental papilla
extending till marginal gingiva
• Exaggerated scalloping
apostrophe shaped indentation
extending from and into gingival
margin for varying distance on
facial surface (Stillman’s Cleft)
134

135. 135• Life saver like enlargement of marginal gingiva.
(McCall’s Festoon)
• Factors responsible:-
-Inflammatory changes
-Trauma from occlusion (Stillman’s ceft)

136. 4.CONSISTENCY
• Firm and resilient
• Factors Responsible:-
Collagenous nature of the lamina
propria and its contiguity with the
mucoperiosteum - determine the firmness of
the attached gingiva.
The gingival fibers - contribute to the
firmness of the gingival margin.
• If the gingiva is suppressed, the proteoglycans become
deformed and recoil when the pressure is eliminated.
• Thus, the macromolecules are important for the resilience
of the gingiva.
136

137. CONSISTENCY (IN DISEASE)
• Soggy puffiness that pits on pressure.
• Marked softness and friability
• Firm leathery
• Diffuse puffiness and softening
• Sloughing
• Vesicle formation
• Factors responsible:-
-Infiltration by fluids and cells
-Degeneration of CT and epithelium
-Fibrosis
-Necrosis
137

138. 5.SURFACE TEXTURE
• Orange peel-like appearance – stippled,
• Stippling is best viewed by drying Gingiva.
• Attached Gingiva is stippled, marginal gingival is not.
• Central portion of interdental papilla is usually stippled,
but marginal borders are smooth.
• Less prominent on lingual surfaces and may be absent in
some.
138

139. 139
• Factors responsible:-
-Due to attachment of gingival fibers to underline bone.
-Microscopically the papilary layer of CT projects into the
elevations
• Low magnification a stippled surface,
• Higher magnification cell micropits
• A form of adaptive specialization or reinforcement for function
feature of healthy gingiva
• In 40% of adults Gingiva show stippling.

140. SURFACE TEXTURE (IN DISEASE)
• Reduction of stippling – common sign of Gingival
disease.
• Stippling returns when gingiva is restored to
health.
• Loss of stippling
Smooth and shiny
-Firm and nodular
-Peeling of surface
-Leathery texture
-Minutely nodular surface
140

141. 141
• Generalized absence of stippling is seen in:
• Infancy
• Diseased conditions like gingival enlargements,
mucocutaneous lesions affecting gingiva, inflammation
etc.,
• Factors responsible:-
- due to destruction of gingival fibers as a result of
inflammation

142. 6.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.
• 1.5 to 2mm coronal to cementoenamel junction
• Factors responsible:-
-Position of tooth in arch
-Root bone angle
-Mesiodistal curvature of tooth
surface
142

143. 143
• Continuous eruption, even after meeting their functional
antagonists occurs through out life
• Active Eruption :Movement of teeth in the direction of occlusal
plane
• Passive Eruption: exposure of the tooth by apical migration of
Gingiva
• Gottlieb : active and passive eruption go hand in hand.
• For example- Active eruption is coordinated with attrition, to
compensate for tooth substance worn away.
• Attrition reduces the clinical crown and prevents it from
becoming disproportionately long in relation to the clinical root,
thus avoiding excessive leverage on periodontal tissue.
• Rate of active eruption is in pace with tooth wear in order to
preserve vertical dimension.

144. POSITION (IN DISEASE)
• Apically placed
• Coronally placed
• Factors responsible:-
-Tooth brush trauma
-Gingival inflammation
-High frenum attachment
-Tooth malpositioned
144

145. AGE CHANGES IN GINGIVA
• Stippling usually disappears with age.
• Width of the attached gingiva increases with age.
 Gingival epithelium:
• Thinning and decreased keratinization
• Rete pegs flatten
• Migration of junctional epithelium apically.
• Reduced oxygen consumption.
145

146. 146
 Gingival connective tissue:
• Increased rate of conversion of soluble to insoluble
collagen
• Increased mechanical strength of collagen
• Increased denaturing temperature of collagen
• Decreased rate of synthesis of collagen
• Greater collagen content.

147. CLINICAL CONSIDERATION
 BIOLOGIC WIDTH
(SUPRACRESTAL ATTACHED TISSUE)
• The biological width is defined as the
dimension of the soft tissue, which is
attached to the portion of the tooth
coronal to the crest of the alveolar
bone.
• Gargiulo et al.,: • Established that
there is a definite proportional
relationship between the alveolar crest,
the connective tissue attachment, the
epithelial attachment, and the sulcus
depth.
147

148. 148
• They reported the following mean dimensions:
A sulcus depth of 0.69 mm, (a)
an epithelial attachment of 0.97 mm,(b)
connective tissue attachment of 1.07 mm.(c)
The biologic width is commonly stated to be 2.04
mm,(b+c) which represents the sum of the epithelial
and connective tissue measurements.

149. 149
Biologic Width Evaluation:
• 1. Clinical (discomfort when the restoration margin levels are
being assessed with a periodontal probe)
• 2. Radiographs (for interproximal violation but mesiofacial and
distofacial line angle not seen properly)
• 3. Bone sounding (probing under anaesthesia to bone level and
subtracting the sulcus depth from the measurement)
• If this distance is less than 2 mm or more at one or more
locations, a diagnosis of biologic width violation can be
confirmed
Biologic width violation:
• • Unpredictable bone loss
• • Gingival recession
• • Persistence of gingivitis
Sushama and Gouri have described a new innovative parallel profile radiographic
(PPR) technique to measure the dimensions of the dento gingival unit (DGU).

150. 150
 GINGIVAL BIOTYPE
• Gingival biotype is described as the thickness of the gingiva in
the faciopalatal/ faciolingual dimension.
• Seibert and Lindhe categorized the gingiva into:
1. thick-flat: A gingival thickness of ≥ 2 mm
2. thin scalloped: a gingival thickness of <1.5 mm
• Significant impact on the outcome of the restorative,
regenerative and implant therapy.
• Direct co-relation exists with the susceptibility of gingival
recession followed by any surgical procedure.

151. 151• THICK BLUNTED
• Resists recession
• Reacts to surgical &
restorative insults with
pocket formation
• THIN SCALLOPED
• Attached soft tissue is minimal
• Bony dehiscence & fenestration defects
• Reacts to surgical or restorative
interventions with ST recession, apical
migration of attachment & loss of
underlying alveolar volume .

152. • Gingival tissues play a key role in the protection of tooth
structures and supporting periodontal tissues against
trauma and/or infection
• Making the gingival health, a very essential component for
the success of all periodontal treatment procedures.
• Therefore, Gingiva, a small tissue is a big issue for the
fraternity of periodontics.
CONCLUSION 152

153. REFERENCES
• Newman And Carranza’s, Clinical Periodontology, 13th Ed
• Clinical Periodontology And Implant Dentistry, Lindhe 6th Ed
• Orban’s Oral Histology And Embryology, 14th Ed
• Color Atlas of Dental Hygiene—Periodontology,Herbert wolff & T. Hassal
• Mattos CM, Santana RB: A quantitative evaluationn of the spatial
maxillary anterior dentition, J Periodontol 79:1880, 2008
• Hall WB. Present status of soft tissue grafting. Journal of
periodontology. 1977 Sep;48(9):587-97.
• Malathi K, Singh A, Prem Blaisie Rajula M, Sabal D. Attached gingiva: a
review. Int J Sci Res Rev. 2013;3:188-98
• Manjunath RS, Rana A, Sarkar A. Gingival biotype assessment in a healthy
periodontium: transgingival probing method. Journal of Clinical and Diagnostic
Research: JCDR. 2015 May;9(5):ZC66.
153

154. 154• Chambrone L, Tatakis DN. Long‐term outcomes of untreated buccal
gingival recessions: a systematic review and meta‐analysis. Journal of
periodontology. 2016 Jul;87(7):796-808.
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around the tooth. Journal Of Applied Dental and Medical Sciences.
2018;4:3.
• Bouri A Jr, Bissada N, Al-Zahrani MS, et al. Width of keratinized
gingiva and the health status of the supporting tissues around dental
implants. Int J Oral Maxillofac Implants. 2008;23(2):323-326.
• Wennström JL, Derks J. Is there a need for keratinized mucosa around
implants to maintain health and tissue stability?. Clinical oral
implants research. 2012 Oct;23:136-46.
• Samiei M, Ahmadian E, Eftekhari A, Eghbal MA, Rezaie F, Vinken M.
Cell junctions and oral health. EXCLI journal. 2019;18:317.
• Nugala B, Kumar BS, Sahitya S, Krishna PM. Biologic width and its
importance in periodontal and restorative dentistry. Journal of
conservative dentistry: JCD. 2012 Jan;15(1):12.

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