Macroscopic features of gingiva

1. Presented by:- Dr.Himanshu singh
Macroscopic Structures of
Gingiva

2. Contents
Gingiva & its Anatomy
Marginal Gingiva
Gingival Sulcus
Attached Gingiva
Interdental Gingiva
Clinical features of Healthy Gingiva
Age changes with Gingiva

3. Oral mucosa – 3 zones :-
Masticatory mucosa Specialized mucosa Lining or reflecting mucosa

4. Anatomy
of
Gingiva

5. Gingival Sulcus
Marginal Gingiva
Free Gingival Groove
Gingival Margin
Attached Gingiva
Interdental Gingiva
Interdental Papilla
Col
Alveolar Mucosa
Mucogingival Junction
Clinical Anatomy of Gingiva

6. Functions:-
 The main function of gingiva is to protect the underlying tissues.
 It obtains its final shape and texture in conjunction with
eruption of the teeth.
 It is tooth-dependent. When there are teeth, there are gingivae,
and when teeth are extracted, the gingivae disappear.
(Manson,Eley 4th edition)

7.  The gingiva is located around the necks of each tooth and is
structured to resist the forces of mastication.
 The gingiva coupled with tongue and palate in mastication
as a support for bolus of food, food is deflected from the
gingiva to the tongue and is in turn, forced between the
teeth.
 The gingiva has sensory function, as it is well innervated
with pain, touch and temperature receptors. This capability
for sensitivity offers protection.
 The gingiva acts as a compartment and functions to protect
the periodontium from the oral cavity.
 Defense mechanism.

8. CHARACTERISTICS
EXTENT
Terminates in the free gingival margin
(Scalloped Outline)
Continuous with the loose, dark, red alveolar
mucosa from which the gingiva is separated by
an easily recognizable borderline –
Mucogingival junction

9. Parts of Gingiva
Marginal
Gingiva
Attached
Gingiva
Interdental
Gingiva
All types are specifically structured to function against
the mechanical & microbial damage.
Histologically the attached gingiva better suited than
non-keratinised mucosa to withstand microbial
irritation .

10. Marginal
Gingiva

11. Marginal Gingiva
Unattached Gingiva
Terminal edge or border
of gingiva .
in 50% cases it is
Demarcated by free
gingival groove.
It forms the soft tissue
wall of the Gingival
Sulcus.

12. Free Gingival Groove
 A shallow line or depression on the gingival surface at
the junction of the free and attached gingiva.
 Related Studies :Presence of free Gingival Groove in
different regions.
Region % of Free Gingival Groove
Right lower Premolars(44,45) 55%
Right lower Canine (43) 54%
Upper left Molars(26,27) 15%

13. Gingival Sulcus
• V- Shaped shallow space
around the tooth
• Junctional Epithelium
forms the base of
the sulcus

14. The depth is 0-3mm for a
clinically normal gingival
sulcus.
The depth is measured
using a periodontal
probe.

15.  Under absolutely normal or ideal conditions the depth of
sulcus is 0 mm or close to 0 mm.
 Study related depth of sulcus in different aspects of the
tooth in a healthy gingiva.
Location Highest Lowest
Mesio buccal
Aspect
Right upper second molar
(1.96 mm)
lower left canine
(1.14 mm)
Distobuccal
aspect
Left upper first molar
(1.71 mm)
Left lower first premolar
(1.13 mm)
Buccal
aspect
Upper right molars
(1.37 mm)
left lower canine
(0.86 mm).
Lingual &
Palatal aspect
Right upper second molar
(1.31 mm)
right lower incisors
(0.79 mm)

16. Attached
Gingiva

17. Definition: It is firm & resilient gingiva, tightly bound
to the underlying periosteum of alveolar bone.
( Glossary of Periodontal terms, 4th Edition)
Demarcation: Attached gingiva extends to the relatively
loose and movable alveolar mucosa, from which it is
demarcated by the mucogingival junction.

18. Functions and clinical importance
 Dissipates functional and masticatory stresses.
 Provides a resistant barrier to plaque induced inflammation.
 Prevents Recession.
 Deepens vestibule to provide better access for tooth
brushing.
 Improves esthetics, patient comfort and ease of hygiene.

19. Width of attached Gingiva?
Definition:
The distance between the mucogingival junction and
the projection on the external surface of the bottom of
gingival sulcus or the periodontal pocket.
 The width of attached gingiva varies in different
individuals and on different teeth of the same
individual.

20. Methods of measuring the width of Attached Gingiva
Visual Method
Histochemical Staining
 Lugol’s Solution
 Shiller’s Iodine
Clinical Method

21. Visual Method

22. Histochemical Method of Evaluation

24. THICKNESS OF ATTACHED GINGIVA
MEASURED BY KRUPP SDM DEVICE

25. Question?
How much zone of
keratinized gingiva is
necessary to maintain
the health of
Periodontium?

26. Landmark Study : Lang & Loe
A study of width of attached gingiva : Bowers GM
Lack of width of attached gingiva & deviation of soft
tissue recession : Wennstorm
The width of the attached gingiva--much ado about
nothing : Mehta P, Lim LP
Assessment of the Width of Attached Gingiva in
Different Regions of the Mouth in an Indian
Subpopulation : Rajiv Subbaiah, Balaji Manohar.
STUDIES

27. Lang & Loe : First controlled Clinical Trial
When the tooth surfaces kept free of clinically detectable
plaque.
 Surfaces >2mm of keratinized gingiva= Healthy
 Surfaces < 2mm of keratinized gingiva=Inflammed
 Which means 1mm or less than 1mm of attached gingiva
remain inflamed .
 Lang & Loe strongly suggested that 2mm width of
keratinized gingiva is important for maintaining the
health.

28.  Bower said that less than 1mm of attached gingiva may
be sufficient .
 According to Wennstorm, the lack of minimum amount
of attached Gingiva does not necessary result in a soft
tissue recession. The narrow attached gingiva apical to
localized recession is a result of recession rather than
cause. Proper plaque control prevents soft tissue recession,
even when it is out of adequate width.

29.  width of attached gingiva is not significant to maintain
periodontal health in the presence of adequate oral hygiene.
 Gingival tissue around teeth with restorations or undergoing
labial orthodontic tooth movement may be more susceptible
to recession.
 Functional need for attached gingiva around implant has not
been established but its aesthetic value has been widely
accepted.
A STUDY DONE BY Mehta P, Lin LP. - A REVIEW TO OUTLINE
THE SIGNIFICANCE OF ATTACHED GINGIVA ON TEETH

30.  A study done by Rajiv Subbaiah, Balaji Manohar on
Indian population & the average width of the attached
gingiva was found to be :
Table-2 showing the width of attached gingiva in Indian population.

31.  Table -1 showing the normal width of attached gingiva
 Some Studies have also shown that the width of
attached gingiva is not significant to maintain
periodontal health in the presence of adequate oral
hygiene.
Anterior Premolars
Maxillary 3.5-4.5mm 1.9mm
Mandibular 3.3-3.9mm 1.8mm

32.  Definition -Junction between masticatory mucosa & lining
mucosa (i.e., attached gingiva & alveolar mucosa)
 Location -on all gingival surfaces except the palatal surface
in humans.
 Clinical Relevance: Important anatomic landmark for
determining the "width" of keratinized gingiva; flap designs
& gingival grafts etc.

33. 3) Rolling test – The gingiva is
rolled occlusally using the flat
end of a probe or a finger.
The loose alveolar mucosa
moves whereas the attached
gingiva being attached to the
underlying periosteum doesnot
move.
METHODS TO DETERMINE MGJ
1) By stretching the lip or cheek while the pocket is being probed.
The amount of attached gingiva is considered to be insufficient when stretching of lip
or cheek induces movement of free gingival margin.
(Carranza 1996)
2) Painting the mucosa with Schiller’s iodide solution.
The glycogen-containing alveolar mucosa takes on a brown coloration,while the
attached, glycogen-free gingiva remains unstained(FASSEK in 1953)

34. Interdental Gingiva
 DEFINITION : The interdental gingiva occupies the
gingival embrasures, which is the interproximal space
beneath the area of tooth contact.
 Shape : The interdental can be pyramidal or have a
"col" shape.

35. Interdental Gingiva

36. Papilla
 The tissue that resides in the interproximal embrasure
is called the interproximal papilla.
 Shape : The shape of this papilla varies from triangular
and knife-edge in the anterior regions due to point
sized contacts of the teeth to broader and more square
shaped tissue in the posterior sextants due to the teeth
having broad contact areas.

38. COL
This is a valley-like structure situated apical to the
contact area.
COL

40. Interdentally, the gingiva adapts its shape to the form, size and position
of adjacent teeth. Therefore in the vestibular or oral dimension, the
interdental portion of the gingiva is narrow between front teeth and
broader between premolars and molars.

41. Co-relation of clinical and microscopic features
 Colour: The gingiva is typically coral pink in color, but may
vary due to physiologic pigmentation among some races.
 Factors affecting Color of Gingiva
 Vascular supply.
 Thickness of epithelium.
 Degree of keratinization.
 Presence of pigment containing cells.
Color varies among different persons and appears to be correlated
with the cutaneous pigmentation.

42.  It is lighter in blonde individuals with fair complexion than
dark-haired individuals.
 Pigmentation is most abundant at the base of the
interdental papilla.
 The alveolar mucosa is red, smooth and
shiny rather than pink and stippled.
 The epithelium is thinner, non-keratinized
and contains no rete pegs.
 The connective tissue is loosely arranged
and the blood vessels are more numerous.

43. Physiologic pigmentation (melanin) :-
- Melanin, a non-hemoglobin derived brown pigment is
responsible for the normal pigmentation of skin, gingiva and
remainder of the oral mucous membrane.
- It is present in all normal individuals, often not in sufficient
quantities to be detected clinically but is absent or severely
diminished in albinos.
- According to Dummett , pigmentation in :-
Hard palate – 61%
Gingiva – 60%
Mucous membrane – 22%
Tongue – 15%

44. Melanin Pigmentation
May appear in gingiva as early as 3 hrs. after the birth &
often is the only evidence of pigmentation (Dummet).

45. DUMMETT ORAL PIGMENTATION INDEX (DOPI) 1966
 Broad Zone of Pigmentation
completely surrounds the
dentition, displaying a clear apical
contour
 Above the mucogingival line, the
mucosa is pink
 The colour may vary from dark to
light brown
 The zone is symmetric and colour
is uniform
CATEGORY 1 CATEGORY 2
 Narrow zone of non pigmented
gingiva
 Completely surrounds the teeth
i.e the free gingival margin is
pink
 The pigmented zone is
symmetric and colour is uniform

46. CATEGORY 3 CATEGORY 4
• Mucosa is completely pink except
for thick and thin line of
pigmentation at the level of
mucogingival border.
• The pigmented zone is symmetric
and the colour is uniform
• Pigmentation is assymetric,
patchy and irregular
• The colour can be dark at one
tooth and pink at the adjacent
tooth

47. CATEGORY 5 CATEGORY 6
Mucosa is completely pink with the
exception of number of symmetric
islands of pigmentation between
the anterior teeth
The patches are localized and dark
in contrast to the surrounding
tissue
Mucosa is completely pink
with no signs of melanin
pigmentation

48.  Variation in pigmentation is not produced by variation in
the number of melanocytes but by genetically determined
variation in their pigment producing capacity.
- The ratio of melanocytes to the keratin-producing
epithelial cells is relatively constant at 1:36 cells.
 Occurs as :-
A) Diffuse, deep-purplish discoloration.
or
B) irregularly shaped brown and light brown patches.

49. * The difference in degree of pigmentation between races is
the result of a combination of :-
- size and degree of branching of the cells (rather than the
absolute number).
- size of the melanosomes.
- degree of dispersion of melanosomes.
- degree of melanisation of the melanosomes.
- rate of degradation of the pigment.
(Oral Histology-Berkovitz)

50. * In persons with heavy melanin pigmentation, cells
containing melanin may be seen in the connective
tissue.
These cells are probably macrophages that have taken up
melanosomes produced by melanocytes in the
epithelium and are termed melanophages.
* It may appear in the gingiva as early as 3hrs after birth
and often is the only evidence of pigmentation
(Oral Histology-Ten Cate)

51. * With age,the amount of blood vessels decreases
relative to the amount of connective tissue and the
gingiva changes from red to pink.
(Enrique Bimstein)
* 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.

52. Shape: The shape varies from triangular and knife-
edge in the anterior regions due to point sized contacts
of the teeth to broader and more square shaped tissue
in the posterior sextants due to the teeth having broad
contact areas.
 Factors affecting the shape :
Contour of proximal tooth surface
Location & shape of Embrasures

53. Size: The size of gingiva corresponds with sum total
of the bulk of cellular & intercellular elements.
Contours: The marginal gingiva envelopes the
teeth in a collar like fashion & follow a scalloped
outline on facial & lingual surfaces.

54.  Contours depends on –
Shape of the tooth.
Alignment of teeth in arch.
Location & size of the area of proximal contact.
Dimension of facial & lingual embrasure.

55.  Variation in contour of Marginal Gingiva
Scalloped outline on the facial & Lingual surfaces.
Teeth with relative flat surfaces : straight line.
Teeth with pronounced mesio-distal concavity of lingual
version :Normal Contour is accentuated .
Teeth in lingual version : Horizontal & thickened Contours.
In Inflammed conditions : Still man’s & McCall’s Festoons.

56. Consistency: The gingiva is firm & resilient with
exception of the movable free margin, tightly bound to
underlying bone.
 The collagenous nature of lamina propria & its
contiguity with mucoperiosteum of alveolar bone
determines the firmness of attached gingiva.
 Resilient is due to gingival fibers.

57. Surface Texture: Stippled texture
The presence of minute pits & lobulated surface on
gingiva.
A texture similar to the orange peel appearance is refered
as stippled.
Varies with age:
Absent in Infancy.
Appears at about 5 yrs. of age.
Increases until adulthood.
Frequently disappear in old age.

58.  Position: The position of gingiva refers to the level at
which the gingival margin is attached to the tooth.
 It is 0-3 mm coronal to CEJ.
 Position continues to change with age as eruption
continues throughout life (Gottlieb & Orban)

60. Two basic theories were given that explain the cause of stippling:
The first was by King in 1945 who felt that stipples were the result
of attachment of the gum to the alveolar bone by connective tissue
fibers, which exerted a localized tension to depress areas of the
tissue.
In 1948, Orban observed, "that the 'stippling' is caused primarily by
reticular elevations rather than depressions."
According to them the position of the stipple within the epithelium
did not always appear to be related to projections from the lamina
propria . Their analysis “suggested that the deep depressions were
usually related to projections of underlying connective tissue
bundles , but that shallow depression were not related to
underlying connective tissue bundle arrangements

61.  Pattern and extent of stippling vary among individuals and
different areas of the same mouth. It is absent in some
locations (eg.- molar area).
* Males tend to have more heavily stippled gingivae.
* Electron microscopic features :-
- Low magnification – Rippled surface seen, interrupted by
irregular depressions 50µm in diameter.

62.  - High magnification – cell micropits seen.
(Periodontics-Grant, Listgarten 6th edition)
* Stippling is a form of adaptive specialization or reinforcement for
function.
* It is a feature of healthy gingiva and reduction or loss of stippling
is a common sign of gingival disease.( Orban in 1948)
* When the gingiva is restored to health after treatment, the stippled
surface returns.
* The surface texture of 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.
(Mackanzie etal in 1972)

63. Effects of Aging on Gingival Epithelium
• As the age increases the width of the band of
anatomical attached gingiva continues to increase due
to continuous compensatory eruption of tooth/teeth.
As a result the width of attached gingiva will continue
to increase unless there is a concurrent reduction in
height of gingival tissue due to Periodontal breakdown.

64.  Active Eruption- movement of teeth in the
direction of occlusal plane.
 Passive Eruption- Exposure of teeth by apical
migration of gingiva.
Gottlieb believed that Active & Passive eruption
proceed together.

65. Active eruption is coordinated with attrition ,
preserving the vertical dimension of dentition.
Reduces clinical crown & prevents it from becoming
too long in relation to clinical root.
Tooth substance lost by attrition is replaced by
lengthening of root by cementum deposition.

66.  Anatomic crown – Portion of the tooth covered by enamel.
Anatomic root – Portion of the tooth covered with cementum.
Clinical crown – Part of the tooth that has been denuded of its
gingiva and projects into the oral cavity.
Clinical root – Portion of the tooth covered by periodontal
tissues.
*When the teeth reach their functional antagonists, the gingival
sulcus and JE are still on the enamel, and the clinical crown is
approximately 2/3 of the anatomic crown. (Gottlieb and Orban in
1933).

67. Passive eruption (considered to be a
pathologic process) has 4 stages:-

68.  Proliferation of the JE onto the root is accompanied by
degeneration of gingival and PDL fibers and their
detachment from the tooth.
It is believed to be a result of chronic inflammation and is
therefore a pathologic process.
* The distance between the apical end of the JE and the
crest of alveolus remains constant throughout continuous
tooth eruption (1.07mm).
* Exposure of the tooth by the apical migration of gingiva is
called gingival recession/atrophy
It can be physiologic or pathologic.

69.  * Physiologic recession – According to the concept of
continuous eruption, gingival sulcus may be located on
crown, CEJ or root depending on age of the patient and
stage of eruption.
- Therefore, some root exposure with age is normal. This
is known as physiologic recession.
- However, no convincing evidence is available for a
physiologic shift of the gingival attachment.

70.  Pathologic recession – is a result of
cumulative effect of minor pathologic
involvement and repeated minor direct
trauma to the gingiva.
Etiologic factors :-
1) Faulty toothbrushing technique
 (gingival abrasion).
2) Tooth malposition.
3) Friction from soft tissues (gingival
ablation).
4) Gingival inflammation.
5) Abnormal frenum attachment.
6) Iatrogenic dentistry.

71.  CLINICAL CONSIDERATIONS
1) Healing in oral mucosa is faster than in skin owing to
its profuse blood supply due to higher turnover rate of
epithelium.
2) Keratinization of gingiva may afford relative
protection.
Methods to increase keratinization is by massage or
brushing which acts directly by stimulation and by
minimizing plaque accumulation.
3) Mechanical irritation of gingiva may occur from sharp
edges of carious cavities, overhanging fillings or crowns
and accumulation of plaque.

72. These may cause chronic inflammation of gingival tissue.
4) The level of the gingival attachment to the tooth plays an
important role in restorative dentistry. In young persons the
clinical crown is smaller than the anatomic crown. It is therefore
very difficult to prepare a tooth for an abutment/crown in young
individuals.
5) Metal poisoning (Pb,Bi) causes characteristic discoloration of
the gingival margin. (Oral Histology – Orban’s)

73. Appears to be Healthy Gingiva

74. References
 1)Ainamo J & Tallari A: The increase with age of width of attached
gingiva, J Periodontal Res ;11:82, 1976
 2)Lozdan J, Squier CA. The histology of Mucogingival Junction. J
Periodontal Res 1969; 4(2):83-93
 3) Ainamo J, LoeH: Anatomical characteristics of gingiva: a clinical
& microscopic study of the free & attached gingiva, J Periodontal Res;
37:5, 1966
 4) Adileh Shirmohammadi, Masoumeh Faramarzie ,Ardeshir Lafzi
;A Clinical Evaluation of Anatomic Features of Gingiva in Dental
Students in Tabriz, Iran. JODDD;Vol. 2(3) :90-95
 5)Gottlieb B, Orban B: Active & passive continuous eruption of teeth.
J Dent Res; 13:214, 1933

75.  6) Glossary of Periodontal terms, 4th Edition
 7) Bowers GM: A study of width of attached gingiva , J
Periodontol;34:210, 1963
 8)Maynard J, Oschenbein C. Mucogingival problems, prevalence &
therapy in children. J Periodontol 1975; 46(9):543-552
 9)Sullivan HC, Akkains JH. Free autogenous gingival grafts;
Periodontics 1962; 6(4):15-160
 10) Nabers JM. Extension of the vestibular fornix utilising a gingival
graft- Case history. Periodontics 1966; 4(2):77-79
 11)Chang H, Odman PA, Wannstorn JL, Anderson B. Esthetic outcome
of implant- supported single-tooth replacement assessed by the patient
& by Prosthodontists. Int J Prosthodont. 1999; 12(4):335-341