Gingiva / dental implant courses by Indian dental academy

Aims Of This PresentationAims Of This Presentation
 To identify one of the constituents of the
periodontium
 To develop a basic understanding of the gingiva
 Clinical features
 Microscopic details
 Correlation of clinical and microscopic features
INDIAN DENTAL ACADEMY
Leader in continuing Dental Educationwww.indiandentalacademy.comwww.indiandentalacademy.com

Oral Mucosa
Consists of three zones:
 The gingiva and the covering of the hard palate
- masticatory mucosa
 The dorsum of the tongue covered by -
specialized
mucosa
 Oral mucous membrane lining the remainder of
the oral cavity www.indiandentalacademy.comwww.indiandentalacademy.com

DefinitionDefinition
 Gingiva is the part of oral mucosa that coversGingiva is the part of oral mucosa that covers
the alveolar processes of the jaws andthe alveolar processes of the jaws and
surrounds the necks of teethsurrounds the necks of teeth
www.indiandentalacademy.comwww.indiandentalacademy.com

DivisionsDivisions
Divided anatomically into
MarginalMarginal
AttachedAttached
InterdentalInterdental

Marginal Or Unattached GingivaMarginal Or Unattached Gingiva
Terminal edge or border of the gingivaTerminal edge or border of the gingiva
Surrounds the neck in a collar like fashionSurrounds the neck in a collar like fashion
In 50% of cases it is demarcated from theIn 50% of cases it is demarcated from the
adjacent attached gingiva by a shallowadjacent attached gingiva by a shallow
linear depression known as the freelinear depression known as the free
gingival groovegingival groove

1mm wide1mm wide
Forms the soft tissueForms the soft tissue
wall of the gingivalwall of the gingival
sulcussulcus
May be separated fromMay be separated from
the tooth surface with athe tooth surface with a
periodontal probeperiodontal probe

Gingival SulcusGingival Sulcus
 Shallow crevice or
space around the
tooth
 Bounded by the
surface of the tooth
on one side and the
epithelium lining free
margin of the gingiva
on the other

V shaped & barely permits the entrance ofV shaped & barely permits the entrance of
a probea probe
Histlogical depth of the gingival sulcus isHistlogical depth of the gingival sulcus is
1.8mm, ranges from 0 to 6 mm1.8mm, ranges from 0 to 6 mm
Probing depth is 2 to 3 mmProbing depth is 2 to 3 mm

Attached GingivaAttached Gingiva
 Continuous with the marginal gingivaContinuous with the marginal gingiva
 Firm, resilient, and tightly bound to theFirm, resilient, and tightly bound to the
underlying periosteum of the alveolar boneunderlying periosteum of the alveolar bone
 Facial aspect extends up to the alveolarFacial aspect extends up to the alveolar
mucosa which is relatively loose & movablemucosa which is relatively loose & movable
…….Mucogingival junction…….Mucogingival junctionwww.indiandentalacademy.comwww.indiandentalacademy.com

On the lingual aspect of mandible itOn the lingual aspect of mandible it
terminates at the junction with lingualterminates at the junction with lingual
alveolar mucosaalveolar mucosa
Palatal surface blends with palatalPalatal surface blends with palatal
mucosamucosa

Width of the attached gingiva is anWidth of the attached gingiva is an
important clinical parameterimportant clinical parameter
Distance between the mucogingivalDistance between the mucogingival
junction and the projection on the externaljunction and the projection on the external
surface of the bottom of gingival sulcus orsurface of the bottom of gingival sulcus or
periodontal pocketperiodontal pocket
Increases with age & supraeruptionIncreases with age & supraeruptionwww.indiandentalacademy.comwww.indiandentalacademy.com

Variations in Size of Attached Gingiva

Greatest in the incisor regionGreatest in the incisor region …………
3.5 to 4.5 mm in maxilla & 3.3 to 3.93.5 to 4.5 mm in maxilla & 3.3 to 3.9
mm in mandiblemm in mandible
Least in first premolar regionLeast in first premolar region …………
1.9 mm in maxilla & 1.8 mm in1.9 mm in maxilla & 1.8 mm in
mandiblemandible

Interdental GingivaInterdental Gingiva
 Occupies the gingivalOccupies the gingival
embrasureembrasure
 Pyramidal or “col” shapePyramidal or “col” shape
 Shape depends uponShape depends upon
the contact pointthe contact point
between the two teeth &between the two teeth &
the presence orthe presence or
absence of recessionabsence of recession

 Facial & lingualFacial & lingual
surfaces are taperedsurfaces are tapered
towards the contacttowards the contact
area & mesial & distalarea & mesial & distal
surfaces are slightlysurfaces are slightly
concaveconcave
 If Diastema is presentIf Diastema is present
it is tightly bound toit is tightly bound to
bonebone

 Gingiva consists of a central core of CTGingiva consists of a central core of CT
covered by stratified squamous epitheliumcovered by stratified squamous epithelium
 Principal cell type is keratinocytePrincipal cell type is keratinocyte
 Other cells areOther cells are
 Langerhans cellsLangerhans cells
 Merkel cellsMerkel cells
 MelanocytesMelanocytes

Three Different Areas Can Be Defined From
The Morphologic And Functional Points Of
View
Oral or outer epithelium
 Sulcular epithelium
Junctional epithelium

Main function of the protect the deepMain function of the protect the deep
structuresstructures
 It also allows selective interchange withIt also allows selective interchange with
the oral environmentthe oral environment
This is brought about byThis is brought about by KeratinocyteKeratinocyte
Gingival EpitheliumGingival Epithelium

Cellular Layers of the OralCellular Layers of the Oral
EpitheliumEpithelium
 Stratum BasaleStratum Basale
 Stratum SpinosumStratum Spinosum
 Stratum GranulosumStratum Granulosum
 Stratum CorneumStratum Corneum

Stratum BasaleStratum Basale
 Cuboidal or columnar cellsCuboidal or columnar cells
 Bundles of tonofibrilsBundles of tonofibrils
 Almost all cell organellesAlmost all cell organelles
 Site of most cell divisionsSite of most cell divisions

Stratum SpinosumStratum Spinosum
 Larger elliptical or spherical cellsLarger elliptical or spherical cells
 Also called prickle cell layerAlso called prickle cell layer
 Alignment of cells on histo. SecAlignment of cells on histo. Sec
 Contain dense granules called Odland BodiesContain dense granules called Odland Bodies
which are modified lysosomeswhich are modified lysosomes

Stratum granulosumStratum granulosum
 Granular layerGranular layer
 Flattened cellsFlattened cells
 Keratohyalin granules seenKeratohyalin granules seen
 Internal membrane thickeningInternal membrane thickening

Stratum CorneumStratum Corneum
 Surface layerSurface layer
 Very flat cells termed squamesVery flat cells termed squames
 Cornified layerCornified layer

 Covers the crest & outer surface of theCovers the crest & outer surface of the
marginal gingiva & the surface of themarginal gingiva & the surface of the
attached gingivaattached gingiva
 Keratinized or parakeratinized or combinationKeratinized or parakeratinized or combination
 Palate most keratinized, then gingiva, ventralPalate most keratinized, then gingiva, ventral
aspect of tongue & cheek least keratinizedaspect of tongue & cheek least keratinized

Keratinized Epithelium

Non Keratinized Epithelium

Parakeratinized Epithelium

Sulcular EpitheliumSulcular Epithelium
Lines the gingival sulcusLines the gingival sulcus
Thin non keratinized stratifiedThin non keratinized stratified
squamous epithelium without rete pegssquamous epithelium without rete pegs
Extends from the coronal limit of theExtends from the coronal limit of the
junctional epithelium to the crest of thejunctional epithelium to the crest of the
gingival margingingival margin

Shows many cells with hydropicShows many cells with hydropic
degenerationdegeneration
Lacks granulosum & corneum strataLacks granulosum & corneum strata
 Contains K4 & K13 cytokeratinsContains K4 & K13 cytokeratins
 Has a potential to keratinize ifHas a potential to keratinize if
Reflected & exposed to oral cavityReflected & exposed to oral cavity
Bacterial flora of the sulcus is totally eliminatedBacterial flora of the sulcus is totally eliminated
 Acts as a semipermeable membraneActs as a semipermeable membrane

Gingival fluid (sulcular fluid)Gingival fluid (sulcular fluid)
Seeps into the gingival sulcus from theSeeps into the gingival sulcus from the
gingival connective tissuegingival connective tissue
FunctionsFunctions
Cleanse material from the sulcusCleanse material from the sulcus
Contains plasma proteins which helps inContains plasma proteins which helps in
adhesion of the epithelium to the toothadhesion of the epithelium to the tooth
Possess antimicrobial propertiesPossess antimicrobial properties
Antibody activityAntibody activity

Junctional epitheliumJunctional epithelium
 Collar like band of stratified non keratinizedCollar like band of stratified non keratinized
epitheliumepithelium
 3-4 layers thick in early life. In adults it is3-4 layers thick in early life. In adults it is 10-2010-20
layerslayers
BasalBasal
SuprabasalSuprabasal

* Length of the JE rangesLength of the JE ranges
from 0.25-1.35 mmfrom 0.25-1.35 mm
* Formed by the confluenceFormed by the confluence
of oral epithelium &of oral epithelium &
reduced enamel epitheliumreduced enamel epithelium
during tooth eruptionduring tooth eruption

 Completely restored after pocket eliminationCompletely restored after pocket elimination
 Forms around implantsForms around implants
 Attach to the tooth surface known as epithelialAttach to the tooth surface known as epithelial
attachment by the internal basal laminaattachment by the internal basal lamina
Lamina densaLamina densa
Lamina lucidaLamina lucida
The connective tissue by the external basal laminaThe connective tissue by the external basal lamina

 Cells of the JE are involved in the production ofCells of the JE are involved in the production of
laminin which plays a key role in the adhesionlaminin which plays a key role in the adhesion
mechanismmechanism
 Attachment of JE is reinforced by the gingivalAttachment of JE is reinforced by the gingival
fibers which brace the marginal gingiva againstfibers which brace the marginal gingiva against
tooth surfacetooth surface
 JE & gingival fibers are considered asJE & gingival fibers are considered as
Dentogingival unitDentogingival unit

Cells Of The EpitheliumCells Of The Epithelium

Langerhans cells are the dendritic cellsLangerhans cells are the dendritic cells
These are macrophages with antigenicThese are macrophages with antigenic
propertiesproperties
Found in oral epithelium of normal gingiva &Found in oral epithelium of normal gingiva &
in smaller amounts in sulcular epitheliumin smaller amounts in sulcular epithelium
Merkel cells present in the deeper layersMerkel cells present in the deeper layers
of epitheliumof epithelium
These harbor nerve endingsThese harbor nerve endings
Tactile perceptorsTactile perceptors

MelanocytesMelanocytes
 Dendritic cellsDendritic cells
 Present in basal & spinous layerPresent in basal & spinous layer
 Synthesize melaninSynthesize melanin
 Contain tyrosinaseContain tyrosinase

M – melanocyte
C- connective tissue

L- langerhans cell

Gingival connective tissueGingival connective tissue
 Three types of connective tissue fibersThree types of connective tissue fibers
1.1. CollagenCollagen
 Type I… forms the bulk & gives tensile strengthType I… forms the bulk & gives tensile strength
to the gingival tissueto the gingival tissue
1.1. Reticular fibersReticular fibers
 Type IV… branches between collagen type IType IV… branches between collagen type I
bundles & is continuous with fibers of thebundles & is continuous with fibers of the
basement membrane & blood vessel wallsbasement membrane & blood vessel walls
1.1. Elastic fibersElastic fibers
 Oxytalin, elaunin & elastin fibersOxytalin, elaunin & elastin fibers

Gingival fibersGingival fibers FunctionsFunctions
1.1. To brace the marginal gingiva firmly againstTo brace the marginal gingiva firmly against
toothtooth
2.2. To provide rigidity necessary to withstandTo provide rigidity necessary to withstand
the forces of mastication without beingthe forces of mastication without being
deflected away from the tooth surfacedeflected away from the tooth surface
3.3. To unite the free marginal gingiva with theTo unite the free marginal gingiva with the
cementum of the root & the adjacentcementum of the root & the adjacent
attached gingivaattached gingiva

Gingival fibersGingival fibers
Arranged in three groupsArranged in three groups
Gingivodental groupGingivodental group
Circular groupCircular group
Transseptal groupTransseptal group

Gingivodental GroupGingivodental Group
 On the facial, lingual & interproximal surfacesOn the facial, lingual & interproximal surfaces
 Embedded in the cementum just beneath theEmbedded in the cementum just beneath the
epithelium at the base of the gingival sulcusepithelium at the base of the gingival sulcus
 On the facial & lingual surfaces, they project fromOn the facial & lingual surfaces, they project from
cementum in a fan like conformation towards thecementum in a fan like conformation towards the
crest & outer surface of the marginal gingiva,crest & outer surface of the marginal gingiva,
terminating short of epitheliumterminating short of epithelium

From
cementum
to the crest
of the gingiva
To the
outer
surface
External to the
periosteum on
the labial plate
Circular
fibers

Gingivodental groupGingivodental group
Extend externally to the periosteum of theExtend externally to the periosteum of the
facial & lingual alveolar bones & terminate infacial & lingual alveolar bones & terminate in
the attached gingiva or blend with thethe attached gingiva or blend with the
periosteum of the boneperiosteum of the bone
Interproximally to the crest of interdentalInterproximally to the crest of interdental
gingivagingiva

Circular groupCircular group
Course through CT ofCourse through CT of
the marginal & thethe marginal & the
interdental gingivaeinterdental gingivae
and encircle the toothand encircle the tooth
in a Ring like fashionin a Ring like fashion

Transseptal GroupTransseptal Group
Located interproximallyLocated interproximally
Form horizontal bundles……embedded inForm horizontal bundles……embedded in
cementumcementum
Lie in the area b/n the epithelium at the baseLie in the area b/n the epithelium at the base
of the gingival sulcus and the crest of theof the gingival sulcus and the crest of the
interdental boneinterdental bone
Sometimes classified with the principal fibersSometimes classified with the principal fibers
of PDLof PDL

 Semicircular fibersSemicircular fibers which attach at the proximalwhich attach at the proximal
surface of a tooth below CEJ, go around the facialsurface of a tooth below CEJ, go around the facial
or lingual marginal gingiva of the tooth & attach onor lingual marginal gingiva of the tooth & attach on
the other proximal surfacethe other proximal surface
 Transgingival fibersTransgingival fibers that attach on the proximalthat attach on the proximal
surface of one tooth traverse the interdental spacesurface of one tooth traverse the interdental space
diagonally, go around facial or lingual surface ofdiagonally, go around facial or lingual surface of
adjacent tooth, again traverse the interdentaladjacent tooth, again traverse the interdental
space diagonally & attach on the proximal surfacespace diagonally & attach on the proximal surface
of next toothof next tooth www.indiandentalacademy.comwww.indiandentalacademy.com

Known as lamina propriaKnown as lamina propria
Papillary layer subjacent to the epithelium whichPapillary layer subjacent to the epithelium which
consists of papillary projections between theconsists of papillary projections between the
epithelial rete pegsepithelial rete pegs
Reticular layerReticular layer
CT hasCT has
CellularCellular
Extracellular compartment which contains fibersExtracellular compartment which contains fibers
& ground substance& ground substancewww.indiandentalacademy.comwww.indiandentalacademy.com

Ground substanceGround substance
 Fills the space between fibers & cellsFills the space between fibers & cells
Is amorphousIs amorphous
Has a high content of waterHas a high content of water
Composed of proteoglycans like hyaluronic acidComposed of proteoglycans like hyaluronic acid
& chondroitin sulphate & glycoproteins like& chondroitin sulphate & glycoproteins like
fibronectinfibronectin
Laminin a glycoprotein present in the basalLaminin a glycoprotein present in the basal
laminae…… attach to epithelial cells.laminae…… attach to epithelial cells.www.indiandentalacademy.comwww.indiandentalacademy.com

Cellular ElementsCellular Elements
Predominant cell is Fibroblast whichPredominant cell is Fibroblast which
SynthesizeSynthesize
 Collagen & elastic fibersCollagen & elastic fibers
 GlycoproteinsGlycoproteins
 GlycosaminoglycansGlycosaminoglycans
Regulates collagen degradationRegulates collagen degradation

Cellular ElementsCellular Elements
Mast cellsMast cells
Distributed throughout the bodyDistributed throughout the body
Numerous in the connective tissue of the gingivaNumerous in the connective tissue of the gingiva
& oral mucosa& oral mucosa
Fixed macrophages & histiocytesFixed macrophages & histiocytes
As components of the mononuclear phagocyteAs components of the mononuclear phagocyte
systemsystem
Derived from blood monocyteDerived from blood monocyte

Cellular elementsCellular elements
Adipose cells & eosinophilsAdipose cells & eosinophils
Small foci of plasma cells & lymphocytes areSmall foci of plasma cells & lymphocytes are
found in the CT near the base of the sulcusfound in the CT near the base of the sulcus
NeutrophilsNeutrophils

Blood SupplyBlood Supply
 Supraperiosteal arteriolesSupraperiosteal arterioles
along the facial & lingualalong the facial & lingual
surfaces of alveolar bonesurfaces of alveolar bone
 Vessels of periodontalVessels of periodontal
ligamentligament
 Arterioles which emerge fromArterioles which emerge from
the crest of interdental septathe crest of interdental septawww.indiandentalacademy.comwww.indiandentalacademy.com

LymphaticsLymphatics
 Lymphatics of the connective tissue papillaLymphatics of the connective tissue papilla
 Progresses into the collecting network external toProgresses into the collecting network external to
the periosteum of the alveolar processthe periosteum of the alveolar process
 Then to the regional lymphnodes… submaxillaryThen to the regional lymphnodes… submaxillary
 Lymphatics just beneath the JE extend into theLymphatics just beneath the JE extend into the
periodontal ligament & acompany the bloodperiodontal ligament & acompany the blood
vesselsvessels

NervesNerves
Derived from fibers arising from nerves in theDerived from fibers arising from nerves in the
PDLPDL
From labial, buccal & palatal nervesFrom labial, buccal & palatal nerves
Argyrophilic fibersArgyrophilic fibers
Meissner type tactile corpusclesMeissner type tactile corpuscles
Krause-type end bulbs… temp receptorsKrause-type end bulbs… temp receptors
Encapsulated spindlesEncapsulated spindles

Its time to have a Break …!!!!www.indiandentalacademy.comwww.indiandentalacademy.com

Gingiva / dental implant courses by Indian dental academy

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