GINGIVA
Presented by:
Dr. Namita Adhikari
2nd year PG Resident
Department of Periodontology and Oral
Implantology
CONTENTS
Introduction
Macroscopic & microscopic features of gingiva
Structural & metabolic characteristics of different areas of
gingival epithelium
Gingival connective tissue
Blood supply, nerve supply and lymphatic drainage
Co-relation of clinical and microscopic features
Continuous tooth eruption
Conclusion
References
PERIODONTIUM
The periodontium (peri = around, odontos = tooth)
comprises following tissues :
Soft tissues
Gingiva
Periodontal ligament
Hard tissues
Alveolar bone
Cementum
ORAL MUCOSA
4
GINGIVA
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 13th edition
5
DEVELOPMENT
6
As the tooth erupts, the reduced
enamel epithelium grows gradually
shorter
A shallow groove, the gingival
sulcus, may develop between the
gingiva and the surface of the tooth
and extend around its circumference
7
Macroscopic features
(Schluger et al 1990)
8
Marginal gingiva
• Terminal edge or border of the gingiva surrounding the teeth
in collar like fashion
• Demarcated by free gingival groove
• Forms soft tissue wall of the pocket
9
Gingival Sulcus
Ideal conditions – 0 mm{Pristine
Gingiva} (Gottlieb, Orban 1933)
Clinically normal depth - 2 to 3 mm
Histologic depth -1.8 mm with
variations from 0 to 6 mm
10
INTERDENTAL
GINGIVA
• Occupies the gingival
embrasure, which is the
interproximal space beneath
the area of tooth contact
• Pyramidal or have a "col"
shape
• PYRAMIDAL SHAPE- Tip
of the papilla is located
immediately beneath the
contact point
11
COL SHAPE
• It is valley like depression that
connects the facial and lingual
papilla and conforms to the
shape of interproximal contact
• Thin, non keratinized, stratified
squamous epithelium
• Has many features in common
with junctional epithelium
12
Formed by
• Lateral border and tip : Marginal gingiva
• Central interevening portion : Attached gingiva
Shape
• Pyramidal : anteriors
• Col shape : posteriors
Diastema : Firmly bound over the interdental bone to form
a smooth, rounded surface without interdental papillae
ATTACHED GINGIVA
• Firm, resilient and tightly bound to the
underlying periosteum of alveolar bone
• Facial aspect of the attached gingiva
extends to the relatively loose and
movable alveolar mucosa
• Demarcated by the mucogingival
junction
14
Methods of measuring width of attached gingiva
Visual Method after using Schiller’s potassium
iodine solution
Tension test- Done by stretching the lip or cheek to
demarcate the muco-gingival line and to see for any
movement of the gingival margin
Roll test or tiggling test : Done by pushing the adjacent
mucosa coronally with a dull instrument. The loose
alveolar mucosa moves whereas attached gingiva being
attached to underlying periosteum does not move
15
Measurement Method
Greatest in the incisor region :
3.5-4.5 mm in maxilla
3.3-3.9 mm in mandible (Ainamo and Loe 1966)
Narrower in the posterior segments:
1.9 mm in maxillary first premolar
1.8 mm in mandibular first premolars
16
• The increase with age of the width of attached gingiva J.
Ainamo A. Talari 1976
• Width of attached gingiva increases with age due to
the supra eruption of teeth to compensate for the
occlusal wear
• As the width of the attached gingiva is measured from
the mucogingival junction which is a constant landmark
throughout life, so there is slight increase in the width of
attached gingiva with age Ainamo J,1976
17
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
Improves esthetics, patient comfort and ease
of hygiene
18
How much zone of keratinized gingiva is necessary to
maintain the health of periodontium?
Lang & Loe (1972) : First controlled Clinical Trial
When the>2mm
Surfaces tooth of
surfaces keptSurfaces
free of clinically
< 2mm of
detectable
keratinized gingiva= plaque. keratinized
Healthy gingiva=Inflammed
Which means 2 mm or less than 2mm of attached
gingiva remain inflamed
Lang & Loe strongly suggested that 2mm width
of keratinized gingiva is important for maintaining
the health
19
How much zone of keratinized gingiva is necessary to
maintain the health of periodontium?
How much zone of keratinized gingiva is necessary to
maintain the health of periodontium?
• Facilitate subgingival plaque
formation because of improper
Inadequate pocket closure resulting from the
zone of movability of the marginal tissue
Friedman 1962
attached
gingiva • Favors attachment loss and soft
tissue recession because of less
tissue
• Accumulation of food particles
during mastication
• Impede proper oral hygiene
measures
Gottsegen 1954, Rosenberg 1960, Corn 1962,
Carranza & Carraro 1970
24
Microscopic anatomy
Histologically gingiva is composedStratified
of : Squamous
Epithelium
- Cellular
1. Gingival epithelium
Central core of connective
tissue
- Collagen fibres and ground
2. Epithelial connective tissue interface
substance
(Listgarten 1972;Mackenzie 1988)
3. Connective tissue
25
Gingival epithelium
Oral epithelium
Oral sulcular epithelium
Junctional epithelium
Cell type of gingival epithelium
Principle cell: Keratinocyte
Other cell: Clear cells or non keratinocyte
Langerhans cells
Merkel cells
Melanocytes
Lymphocyte
26
FUNCTIONS OF GINGIVAL EPITHELIUM
To protect the deeper structure
Allow selective interchange with oral environment
(Achieved by proliferation & differentiation of
keratinocytes)
Physical barrier to infection
Play an active role in innate defense by responding to
bacteria in an interactive manner
(Dale BA, Periodontal 2000 30:70, 2002 )
As important initiator,regulator and host immune
response against periodontal pathogens
27
EPITHELIAL PROLIFERATION
• Takes place by mitosis in the basal layer and less frequently in
the suprabasal layers
a)Progenitor cells- Divide & provide new cells
b)Maturing cells- Differentiate & mature to
form a protective surface layer
Differentiation
(1) Progressive flattening of the cell with an increasing
prevalence
• Process of tonofilament
of keratinization
• Progressions of biochemical and morphologic events that
(2)occur
Intercellular
in the celljunctions coupledfrom
as they migrate to thethe
production of
basal layer
keratiohyline granules
(3) Disappearance of the nucleus 28
Cells of various layers by electron microscope
29
STRATUM BASALE (ST. GERMINATIVUM)
• Cells are cylindrical or
Cuboidal
• Synthesize DNA and can
undergo mitosis thus providing
new cells
• Most of the new cells are
generated in the basal layer
30
STRATUM SPINOSUM
• They frequently shrink away from
each other, remaining in contact
only at points known as intercellular
bridges Spiny or prickly like
profile
• Spinous cells are the most active in
protein synthesis
31
STRATUM GRANULOSUM
• Cells are larger and flatter
• Cells show increase in maturation
• Nuclei shows signs of degeneration and
pyknosis
• Cytoplasm is predominantly occupied
by the tonofilaments & tonofibrils
• Cells contain large no of small granules
– keratohyaline granules
32
STRATUM CORNEUM
CORNEOCYTES
Made of keratinized,larger and flatter
Most cells than granular
differentiated cells cell
epithelial
Formed bylack
Cells bundles
nucleiof keratin
and other organelles
tonofilaments embedded in
amorphous matrix of filagrin
Lack keratohylin granules &
surrounded by resistant envelop
made up of keratolinin &
Ultrastructurally comprises of
involucrin
densely packed tonofilaments in
matrix proteins
Inter Connected through
desmosomes
Layer is acidophic
33
Keratinocyte
Low molecular wt-40kDa e.g. Glandular,
simple epithelium
Intermediate [Link]. e.g. Stratified
epithelium
High [Link].-67kDa e.g. Keratinizing
stratified epithelium
Basal cell: LMW keratin, K19 & express other HMW
keratin as they migrate to the surface.
St. corneum : K1 keratin (68kD)
Stratified oral epithelium : Possess keratin 5,14,15
Keratinized oral epithelium : Possess keratin 1, 6, 10, 16
Nonkeratinized : keratin 4 and 13 and 19 34
• Complete keratinization process leads to the
production of an orthokeratinized epithelium
Orthkeratinized Parakeratinized
similar to that of the Intermediate stage of
skin keratinization
No nuclei in the stratum stratum corneum retains
corneum and a well- pyknotic nuclei
defined stratum keratohyalin granules
granulosum are dispersed, not giving
rise to stratum
granulosum
Non keratinized epithelium has neither granulosum nor
corneum strata where as superficial cells have viable nuclei36
Epithelial connective tissue interface
DESMOSOMES (Macula adherens)
keratinocytes are interconnected by structure
on the cell periphery called Desmosomes
Consist of 2 dense attachment plaque into
which tonofibrils insert
Intermediate electron dense line in
extracellular compartment
Tonofibrils radiate in brush like fashion from
attachment plaque into cytoplasm of the cells
37
MELANOCYTES
• Embryologically derived from the neural
crest ectoderm
• Enter the epithelium at about 11 weeks of
gestation
• Present in basal & suprabasal layer The ratio of melanocytes to
the keratin-producing
epithelial cells is relatively
• Possess long dendritic processes constant at 1:36 cells
• Synthesizes melanin in the organelles
called premelanosomes or melanosomes 38
Langerhans cells
Dendritic cell
Suprabasal layer
Belongs to Mononuclear
phagocytic system
Marked ATPase activity
39
Antigen presenting for lymphocytes
Contain g-specific granules (Birbeck’s granules)
Immunologic function, recognizing and processing
antigenic material that enters the epithelium from the
external environment and presenting it to T
lymphocytes.
Found in oral epi. of normal gingiva & in sulcular
epithelium
Absent from the junctional epithelium
40
Merkel cells:
• Located in deeper layers
• Harbors nerve endings and connected
to adj cells via desmosomes
• Tactile perceptors / specialized neural
pressure-sensitive cells
Lymphocytes:
• Seen in nucleated cell layer
• No desmosomes or tonofilament
• Associated with inflammatory response
41
Basal lamina
30-60 nm
Glycoproteins &
laminin
30-50 nm
Type IV collagen 300-400 A°
thick.
42
Oral or outer epithelium
0.2-0.3 mm
Covers crest and outer surface of marginal
gingiva and surface of attached gingiva
Keratinized or parakeratinized , prevalent
surface is parakeratinized
K1,K2,K10,K12 specific to epidermal type
differentiation
K6,K16 highly proliferative epithelium
43
SULCULAR EPITHELIUM
Lines gingival sulcus
Thin, nonkeratinized, stratified squamous
epithelium without rete pegs (Contain K4,
K13, K19)
Extends from coronal limit of JE to crest of
gingival margin
Acts as semipermeable membrane through
which injurious bacterial products pass into
gingiva and tissue fluid from gingiva seeps
into sulcus
44
Oral sulcular epithelium lacks merkel
cells
Though nonkeratinized have potential to
keratinize
1. If reflected and exposed to oral
enviroment and
2. Bacterial flora of sulcus is totally
eliminated
45
JUNCTIONAL EPITHELIUM
• Junctional epithelium is the non keratinised stratified
squamous epithelium which attaches and form a collar
around the cervical portion of the tooth that follows
CEJ Carranza’s clinical periodontology
• Attached to the tooth surface (epithelial attachment)
by an internal basal lamina (lamina densa and lamina
Lucida)
• Attached to the gingival connective tissue by an
external basal lamina
46
Gottlieb (1921) was the first to describe the junctional
epithelium. He termed it as epithelial attachment.
WAERHAUG -1952 Based on his animal experiments(in dogs) he
postulated that the cells of the epithelial attachment adhere weakly
to the tooth surface and it forms the lining of the physiologic
pocket
Orban’s concept (1953) stated that the separation of the epithelial
attachment cells from the tooth surface involved preparatory
degenerative changes in the epithelium.
47
Waerhaug’s concept (1960) Epithelial cuff
Based on insertion of thin blades between the surface of tooth and the
gingiva. Blades could be easily passed apically to the connective
tissue attachment at CEJ without resistance.
It was concluded that gingival tissue and tooth are closely adapted but
not organically united
Max Listgarten- 1966-67 Based on transmission electron microscopic
studies he proved the existence of a hemidesmosome basement
lamina attachment between the tooth and the cells of the so called
cells of epithelial attachment
48
Schroeder and Listgarten concept (1971)
• Primary epithelial attachment refers to the epithelial
attachment lamina released by the REE
• It lies in direct contact with enamel and epithelial cells
attached to it by hemi-desmosomes
• 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
hemi-desmosomes.
49
ANATOMICAL FEATURES
Thickness: Early life: 3-4 layers
With age: 10-20 layers
Width: Coronal aspect: 10-29 cells wide
Apical aspect: 1-2 cells wide
Length: 0.25mm-1.35 mm
• Interproximally JE of adjacent teeth fuse to form
the lining of the col area
• Epithelial connective tissue interface is smooth (no
rete pegs)
50
Zones of JE
Apical zone: Germinative characteristics
Middle zone: Higher density of hemidesmosomes
Role in adhesion
Coronal zone: Numerous intercellular space
Increased permeability
51
MICROSCOPIC FEATURES
• 15-30 cell layers coronally and 1-3 layers
at apical termination
• It has two strata- stratum basale and
stratum suprabasale
• The innermost suprabasal cells(facing the
tooth surface) also called DAT cells
(Salonen et al 1994) form and maintain the
epithelial attachment apparatus
52
FUNCTIONS OF JE
JE is firmly attached to the tooth and thus forms an
epithelial barrier against the plaque bacteria.
It allows the access of GCF, inflammatory cells and
components of the immunological host defense to the
gingival margin.
JE cells exhibit rapid turnover, which contributes to the
host parasite equilibrium and rapid repair of damaged
tissue
Genco RJ et al AAP 1996
53
RENEWAL OF GINGIVAL EPITHELIUM
Turnover times for different areas
of the oral epithelium :
Palateactivity
Mitotic and cheek : 5 to
exhibits 6 days periodicity, with the
a 24-hour
highest in the morning and lowest rates occurring in
Gingiva : 10 to 12 days,
evening
Junctional
Mitotic epithelium
rate is higher : 1 to 6
in nonkeratinized areas and is
days in gingivitis
increased
54
GINGIVAL CONECTIVE TISSUE
Collagen fibres (60%)
Fibroblasts (5%)
Vessels
Nerves
Matrix (about 35%)
55
Connective tissue
(Lamina propria)
Papillary layer
Adjacent to epithelium and Reticular layer
consists of papillary Contiguous with
projections between the periosteum, collagen
epithelial rete pegs fibers arranged in thick
Collagen fibers are loosely bundles
arranged, thin & many
capillary loops are present
Extra-cellular
Cellular compartment compartment
56
Ground substance
Fills space between fibres and cells, is amorphous
and has high content of water
Proteoglycans: glycosaminoglycan (mainly
hyaluronic acid and chondroitin sulfate)
Glycoprotein: fibronectin and osteonectin
(predominant is protein )
Glycoprotein as carbohydrate unit of proteoglycan
contains polysaccharide as macromolecules that is
important for resilency of gingiva
57
FIBRES OF CONNECTIVE TISSUE
• Fibers are produced by fibroblast
Collagen:
1. Collagen fibres Primarily type I & III
2. Reticulin fibres in lamina propria
3. Oxytalan fibres Provide tensile strength
4. Elastic fibres to the gingival tissue
Type IV & VII in basal
lamina
Type V may be in
inflamed tissue
58
GINGIVAL FIBERS
Connective tissue of the marginal gingiva is
densely collagenous and contains a prominent
system of collagen fiber bundles called
gingival fibers
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 tooth surface
To unite the marginal gingiva with the
cementum of the root and adjucent attached
gingiva
59
Supragingival fiber
Principal groups
Name of fiber Origin and orientation Supposed
group function
Dentogingival From cementum, Provide
splay laterally into gingival
lamina propria support
Alveologingival From periosteum of Attach gingiva
the alveolar crest, to bone
splay coronally into
lamina propria
Dentoperiosteal From cementum near Anchor tooth
the cementoenamel to bone;
junction, into protect
periosteum of the periodontal
alveolar crest ligament
60
Name of fiber group Origin and orientation Supposed function
Circular Within free marginal and Maintain contour
attached gingiva coronal and position of
to alveolar crest, free marginal
encircle each tooth gingiva
(“purse string”)
Transeptal From interproximal Maintain
cementum coronal to relationships of
alveolar crest, course adjacent teeth;
mesially and distally in protect
interdental area into interproximal bone
cementum
61
Secondary group fibers
Periosteogingival From periosteum of Attach gingiva
the lateral aspect of to bone
alveolar process,
splay into attached
gingiva
Interpapillary Within interdental Provide
gingiva (gingival support for
papilla), orofacial interdental
course gingiva
Transgingival Within attached Secure
gingiva, alignment of
intertwining along teeth in arch
the dental arch
between and around
the teeth
62
Secondary group fibers
Intercircular From cementum on distal Stabilize teeth in
surface of a tooth, splaying arch
buccally and lingually around
adjacent tooth and inserting on
mesial cementum of next tooth
Intergingival Within attached gingiva, Provide support
immediately subjacent to and contour of
epithelial basement membrane, attached gingiva
course mesiodistally
Semicircular From cementum on mesial None intuitively
surface of tooth, course distally, obvious
insert on cementum of distal
surface
63
FIBROBLAST
Principle cell, Mesenchymal in origin
Functions:
Primarily responsible for synthesis of
extracellular matrix
Maintenance of tissue homeostasis, via
phagocytosis & collagenase production
Contract & participates in wound
contraction
MAST CELLS:
Contain granules that composed
of histamine & heparin
Derived from blood monocytes
64
Macrophages:
• Ingest damaged tissue & foreign
material
• Stimulation of the fibroblast
proliferation
Inflammatory cells: Plasma cells,
lymphocytes
65
REPAIR OF GINGIVAL CONNECTIVE TISSUE
Because of high turn over rate, the connective tissue
of gingiva has high regenerative capacity and good
healing
Shows little evidence of scarring after surgical
procedures because of rapid reconstruction of the
fibrous architecture of the tissues
Melcher AH
66
BLOOD SUPPLY
67
NERVE SUPPLY
68
LYMPHATIC DRAINAGE
69
Clinical correlation
COLOUR OF GINGIVA
Coral pink(attached and marginal
gingiva)
ALVEOLAR MUCOSA-
1. vascular supply
2. Thickness
Red ,smooth ,shiny
of the and
epithelium
Stippled,
3. Degree of keratinization
Thinner, non keratinized,
4. Presence of pigment-containing
No rete pegs, more vascular, cells
loosely arranged connective
tissue
70
CONTOUR
Scalloped outline on facial & lingual
surfaces
Varies and depends on;
1. Shape of teeth and their alignment
in arch
2. Location and size of area of
proximal contact
3. Dimensions of the facial and lingual
gingival embrasures
71
• Teeth with relative flat surfaces : straight
line
• Teeth with pronounced M-D concavity of
labio version :Normal Contour is
accentuated
• Teeth in lingual version : Horizontal &
thickened contours
• In Inflamed conditions : Stillman’s
cleft& McCall’s Festoons.
• ANUG : Reverse contour
72
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
Resiliency is due to gingival fibers
Gingival fibers contribute to the firmness of gingival
margin
73
SHAPE
Triangular and knife- edge in the anterior regions due to
point sized contacts of the teeth
Broader and more square shaped tissue in the posterior
sextants due to the teeth having broad contact areas
74
SIZE OF THE GINGIVA
Sum total of the bulk of cellular and
intercellular elements and their
vascular supply
Alteration in size is a common feature
of gingival disease
75
POSITION OF THE GINGIVA
• 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)
76
SURFACE TEXTURE OF GINGIVA
• Similar to an orange peel
• Viewed by drying the gingiva
• Attached gingiva and central portion of
the interdental papillae is usually
stippled
Absent in Infancy
Appears at about 5 yrs of age
Increases until adulthood
Frequently disappear in old age
77
King in 1945, 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.
78
Active Eruption- Movement of teeth in the direction of occlusal
plane
Passive Eruption- Exposure of teeth by apical migration of gingiva
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
79
PASSIVE ERUPTION
• Gottlieb and Orban believed that active and
passive eruption proceed together
• Passive eruption is divided into the four stages
Stage 1: The teeth reach the line of occlusion. The junctional epithelium
and the 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.
Stage 4: The junctional epithelium has proliferated farther on the
80
cementum.
• 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).
• 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
81
• 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
• Pathologic recession – is a result of cumulative effect of
minor pathologic involvement and repeated minor direct
trauma to the gingiva
82
• Term “Periodontal biotype” introduced by Seibert and
Lindhe categorized the gingiva into ‘‘thick-flat’’ and ‘‘thin
scalloped’’ biotypes
Thick Biotype Thin Biotye
1. Broad zone of the 1. Thin band of the keratinized
keratinized tissue tissue,
2. Flat gingival contour 2. Scalloped gingival contour
3. Thick bony architecture 3. Thin bony architecture
4. More resistant to 4. More sensitive to
inflammation and trauma inflammation and trauma
83
• Predict the outcome of root coverage procedures and
restorative treatments
• Gingival or periodontal diseases are more likely to
occur in patients with a thin biotype
• Thick biotypes show greater dimensional stability
during remodeling compared to thin biotypes
84
Age changes of gingiva
Stippling usually disappears with age.
Width of the attached gingiva increases with
age. Gingival connective tissue:
• Increased rate of conversion of soluble to
insoluble collagen
Gingival
• Increased epithelium:
mechanical strength of collagen
Thinningdenaturing
• Increased and decreased keratinization
temperature of collagen
• Decreased
Rete rate of synthesis of collagen
pegs flatten
Migration • Greater collagen
of junctional content. apically
epithelium
Reduced oxygen consumption.
85
CONCLUSION
Gingiva is an important part of periodontium that
plays a significant role in maintaining tooth
integrity.
So, a clinician needs to have sound knowledge
regarding its normal anatomical and
ultrastructural characteristics and function for
making clinical decision that will maintain the
gingival health.
86
REFERENCES
Carranza’s Clinical periodontology 13th edition
Clinical Periodontology and Implant Dentistry , Jan
Lindhe, 5th edition
Ten Cate’s Oral Histology, 8th ed.
Schroeder, listgarten, The gingival tissues: the
architecture of periodontal protection, Periodontology
2000, Vol. 13, 1997, 91-120
Ainamo J & Tallari A: The increase with age of width
of attached gingiva, J Periodontal Res;11:82, 1976
Tissues and cells of the periodontium Periodontology
2000, Thomas M. Hassell,vol 3,9-38
87