-PERIODONTICS (DPE_4101)
Dr. Guerrero
PRELIMS
___________________________________
TISSUES OF THE PERIODONTIUM
PERIODONTOLOGY
● Study of the tooth-supporting tissues
→ “the periodontium
● Latin: Para = adjacent to
● Greek: Odus = tooth
ORAL MUCOSA
● Masticatory Mucosa - Gingiva,
covering of hard palate, dorsal
surface of the tongue
● Specialized Mucosa - covers
dorsum of tongue
○ Special due to papillae
● Lining Mucosa
○ Not keratinized
○ Keratin is responsible for
protection
Tissues of the periodontium
1. Root Cementum
2. Alveolar bone
3. Gingiva
4. Periodontal Ligament
GINGIVA
● Covers the alveolar bone and tooth
root to a level just coronal to the CEJ
● Divided anatomically into
○ Marginal or free - terminal
edge or border of the gingiva
that surrounds the teeth in
collar like fashion; where you
can enter your probe
○ Attached - attached to the
alveolar bone
○ Interdental - gingiva that is
in between the teeth
● Structured to function appropriately
against mechanical (gingiva is
keratinized) and microbial damage
● Functions as a barrier to the
penetration by microbes and noxious
agents into the deeper tissue
● Epithelial layer and an underlying
connective tissue layer called the
lamina propria
● Mucogingival Junction - junction
between the gingiva and alveolar
mucosa
○ No mucogingival junction and
gingiva only: Hard palate
● Free Gingival groove - shallow
linear depression that demarcates
the marginal gingiva from the
attached gingiva (50% of cases)
○ Usually about 1mm wide,
and it forms the soft tissue
wall of the gingival sulcus
● Gingival zenith - most coronal
aspect of the free gingival margin
○ Not an important landmark
○ More in esthetic
● Healthy Gingiva
○ Free gingival margin is
parallel to the CEJ
● GINGIVAL SULCUS
○ 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, and it barely
permits the entrance of a
periodontal probe in a
healthy sulcus

● CLINICAL RELEVANCE (Gingival
Sulcus)
○ Clinical determination of the
depth of the gingival sulcus -
an important diagnostic
parameter
○ Ideal 0 mm or close to 0mm
○ Can be produced
experimentally only in germ
free animals or after intense
and prolonged plaque control
○ After completed tooth
eruption, the free gingival
margin is located on the
enamel surface
approximately 1.3 - 2mm
Coronal to cemento - enamel
junction
○ In clinically healthy human
gingiva, a sulcus of some
depth can be found.
○ Histologic depth - 1.8 mm,
with variations from 0 to 6
mm; other studies have
reported 1.5 mm and 0.69
mm
○ Clinical evaluation used to
determine the depth of the
sulcus involves the
introduction of a metallic
instrument (periodontal
probe) and the estimation of
the distance it penetrates
probing depth)
○ The histologic depth of a
sulcus does not need to be
exactly equal to the depth of
penetration of the probe.
○ The penetration of the probe
depends on several factors
■ Probe diameter
■ Probing force
■ Level of inflammation
○ Probing depth is not
necessarily exactly equal to
the histologic depth of the
sulcus
○ The so-called probing depth
of a clinically normal gingival
sulcus in humans is 2 to
3mm
■ 1-3 is still normal
● ATTACHED GINGIVA
○ Continuous with the marginal
gingiva
○ Firm, resilient, and tightly
bound to the underlying
periosteum of alveolar bone
■ Periosteum: Outer
covering of the
alveolar bone
■ Important since this is
where you suture the
stitches
○ Facial aspect extends to the
relatively loose and movable
alveolar mucosa
 ○ Comparatively immobile in
relation to the underlying
tissue
○ Most pronounced on the
vestibular aspect of the teeth
○ Free gingival groove -
30-40% of adults
ATTACHED GINGIVA - CLINICAL
RELEVANCE
● Width of the attached gingiva
● Important clinical parameter
○ Helps us determine whether
the patient has gums that
recedes faster than usual
● Distance between the mucogingival
junction and the projection on the
external surface of the bottom of the
gingival sulcus or the periodontal
pocket
● Generally greatest in the incisor
region (3.5 to 4.5 mm in the maxilla,
3.3 to 3.9 mm in the mandible)
● Narrower in the posterior segments
(1.9 mm in the maxillary first
premolars and 1.8 mm in the
mandibular first premolars)
INTERDENTAL GINGIVA / CONSISTENCY
INTERPROXIMAL PAPILLA
● Occupies the gingival embrasure,
which is the interproximal space
beneath the area of tooth contact
● Black triangle: receded interdental
papilla
● Can be pyramidal - the tip of one
papilla is located immediately
beneath the contact point
● It can have a "col" shape valley like
depression that connects a facial
and lingual papilla and that conforms
to the shape of the interproximal
contact
● Facial and lingual surfaces are
tapered toward the interproximal
contact area
● Mesial and distal surfaces are
slightly concave
● Lateral borders and tips of the
interdental papillae are formed by
the marginal gingiva of the adjoining
teeth. The intervening portion
consists of attached gingiva.
● If a diastema is present, the gingiva
is firmly bound over the interdental
bone to form a smooth, rounded
surface without interdental papillae
COLOR
● "Salmon" pink
● Africans may exhibit varying degrees
of brownish pigmentation
● Firm, fibrous gingiva = "thick"
phenotype
● Thicker gingiva provides better
conditions for treatment and wound
healing
● Delicate, scarcely stippled gingiva =
"thin" phenotype
● Thinner gingiva is more prone to
periodontal disease
● Subjacent bone covering the roots is
clearly visible
DISEASED STATES AND CONDITIONS
● Gingivitis
 ● Gingival recession
● Periodontitis
GINGIVITIS
● Limited to the marginal, supracrestal
soft tissues
● Manifested clinically by bleeding
upon probing of the gingival sulcus
○ When the gingiva bleeds, it is
a sign of inflammation
● In more severe cases exhibits
erythema and swelling, especially of
the interdental papillae
GINGIVAL RECESSION
● Apical migration of the gingival
margin
● Facial bony lamella is either
extremely thin or entirely lacking
● Can be initiated and propagated by
improper traumatic tooth brushing
(horizontal scrubbing)
PERIODONTITIS
● At the gingival margin, the
characteristics of periodontitis are
similar to those of gingivitis.
● Inflammatory processes extend
further, into the deeper-lying
periodontal structures (alveolar bone
and periodontal ligament)
● True periodontal pockets are formed
and connective tissue attachment is
lost.
○ True periodontal pockets:
4mm or more pockets
GINGIVAL CREVICULAR FLUID (GCF)
● Clinically healthy gingiva
consistently features a small infiltrate
of inflammatory cells (PMNs)
● Inflammatory reaction - response to
the continuous presence of bacterial
products in the crevice region
(sulcus area)
● Small inflammatory lesion - harbors
lymphocytes and macrophages
● Fluid that contains varying
amounts of plasma proteins leave
the vessels of the dentogingival
plexus and arrive in the gingival
crevice region as the gingival
crevicular fluid (GCF)
● Introduced filter paper into the
gingival sulci of dogs that had
previously been injected
intramuscularly with fluorescein
● Within 3 minutes, the fluorescent
material was recovered on the paper
strips. Fluid passes from the
bloodstream through the tissues and
exits via the gingival sulcus.
● GCF in humans was considered as
a "transudate."
● Others studies - GF is an
inflammatory exudate rather than a
continuous transudate
● In strictly normal gingiva, little or no
fluid can be collected.
● Its composition and its possible role
in oral defense mechanisms were
elucidated by the pioneering work of
Waerhaug et al during the 1950s
SUMMARY
● Anatomy of the gingiva: marginal,
attached, interdental papilla
● Gingival sulcus - space or crevice
around the tooth
● Condition of the gingiva - an
important diagnostic parameter
● GF - fluid from the dentogingival
plexus containing plasma proteins
PRINCIPLES OF POSITIONING

Quiz 1:
● 1-4 Tissues of the periodontium
● Gingiva: Covers the alveolar bone
and tooth root to a level just coronal
to the CEJ
● Gingival sulcus: Shallow crevice or
space around the tooth
● Gingival recession: Apical migration
of the gingival margin
● Gingivitis: Limited to the marginal,
supracrestal soft tissues; Manifested
clinically by bleeding upon probing of
the gingival sulcus
● The penetration of the probe
depends on several factors
○ Probe diameter
○ Probing force
○ Level of inflammation
● Normal probing depth of gingival
sulcus
○ 1-3 mm OR 2-3 mm
● Both periodontium and dental tissue
○ Root cementum
● True periodontal pockets are formed
and connective tissue attachment is
lost.
○ Periodontitis
 LABORATORY DISCUSSION
August 18, 2022
PRINCIPLES OF POSITIONING
● Correct positioning techniques help
to
○ Prevent clinician discomfort
and injury
○ Permit a clear view of the
tooth being worked on
○ Allow easy access to the
teeth during instrumentation
○ Facilitate efficient treatment
Foundational Building Blocks for
Periodontal Instrumentation
● Position
○ Proper use of equipment and
positioning of the patient and
clinician
● Instrument grasp
○ How the clinician hold
periodontal instrument
● Mirror use
○ Allow to view tooth surfaces
or other structures that are
obscured from direct viewing
● Finger rests
○ Manner in which the clinician
stabilizes the hand in the oral
cavity during periodontal
instrumentation.
○ Ring finger is used for finger
rest
● Stroke production
○ Manner in which the
working-end of a periodontal
instrument is moved against
the tooth surface
○ Stroke production involves
smaller component skills
■ Activation
■ Adaptation
■ Angulation
■ Act
Ergonomics Periodontal Instrumentation
● Precise performance is essential to
be
○ Effective
○ Efficient
○ Safe for the patient
○ Comfortable for the clinician
● Faulty performance will lead to
○ Ineffective calculus removal
○ Unnecessary discomfort for
the patient
○ Musculoskeletal stress to the
clinician
Ergonomic Risk Factors Associated with
Periodontal Instrumentation
ERGONOMICS
● Science-based discipline that brings
together knowledge from subjects
such as anatomy and physiology,
psychology, engineering and
statistics
● It ensures that designs complement
the strengths and abilities of people
and minimize the effects of their
limitations
● Designing for people
● Aims to increase efficiency and
productivity and reduce discomfort
● Aims to increase efficiency and
productivity and reduce discomfort
ERGONOMICS IN DENTAL PRACTICE
● Work environment includes the
dental office layout, dental
equipment, and instruments
● Dentists are exposed to ergonomic
tisk factor that often lead to
discomfort, pain and even disabaility
 (Mucoskeletal Disability)Dentists are
exposed to ergonomic risk fact

MUCOSKELETAL DISORDER (MSD)

● Partts of the muscoloskeltal system
are injured over time
● Muscles
● Tendons
● Nerves
● When a body part is overused
repeatedly, the constant stress
causes damage on a body part,
resulting in painors that often lead to
discomfort, pain, and even disability
(Musculoskeletal DIsorders)
Mucoskeletal Disorders
● Parts of the musculoskeletal system
are injured over tim
○ Muscles
○ Tendons
○ Nerves
● When a body part is overuse
repeatedly , the constant stress
causes damage on a body part,
resulting in pain
○ Examples
■ Carpal Tunnel
■ Rotator Cuff Injury
■ Tendinitis

Positioning Challenges
● Nasa babaIdeal posture means that
the joint is being used near the
middle of its full range of motion
● Missed
●

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Fixed working Positions (Static
Postures)
● Maintaining the body in one position
for an extended period of time
● Static position - tensed muscles
compress the blood vessels - rduc
• Maintaining the body in one position for an
extended period of time
Static position - tensed muscles compress
the
blood vessels > reduce blood flow >
decreased
oxygen and energy supply > waste products
accumulate -> muscle fatigue > pain
Periodontal instrumentation - static gripping
of
instrument handles for durations exceeding
20
minutes is common
TIGHT GRIPS
● Amount of effort created by the
musckes and amount of pressure
placed na body part
● Example: holding a small instrument
for prolonged period of time
● Pinch grip - The fingers are on one
side of the object thumb is t
Repetitive movements
● A task that involves the same
fundamental for more than 50% of
the work cycle
● Is periodontal instrumentation a
repetitive task: yes
● compression of the brachial nerve
Ideal posture means that the joint is being
used near the middle on its full range of
motion
* Amount of effort created by the muscles
and the
amount of pressure placed on a body part
Example: holding a small instrument for a
prolonged period of time
• Pinch grip - the fingers are on one side of
the
object and the thumb is on the other and
greatest
contributing risk factor in the development of
MSDs
Causes of Musculoskeletal Pain in Dental
Professionals
Stool adjusted for the clinician
Torso aligned with long axis of the bod
Shoulders level
-Treatment room desten pérmits dinician to
move freel
around the patient chair (in al
"dock positions
Elbows res
in at the clinician's sides durine
periodontal instrumentation
Back of patient chair parallel to the foor lor
maxillary arch
Unit light positioned close to the clinician s
line of sight for maxillary treatment
" Limiting use of a 7:00 to 8:30 or 3.30 to
5:00
clock position as much as possi
Muculoskeletal
1. Thoracic Outlet Syndrome
● Painful disorder of the fingers,
hands, and / or wrist due to the
plexus and vessels between the
neck and shoulders
● Cause: Tilting the head forward,
hunching of shoulders forward,
continuously reaching overhead
● Symptoms - numbness, tingling,
and/or pain in the fingers, hand or
wrist
2. Rotator Cuff Tendinitis
● Painful inflammation of the muscle
tendons in the shoulder region
● Cause: Holding the elbow above the
waist level and holding the upper
arm away from the body
● Symptoms: Severe pain & impaired
function of the shoulder joint
1. Pronator Syndrome
● Painful disorder of the wrist & hand
caused by compression of the
median nerve between the 2 heads
of the pronator teres muscle
○ Reaching far objects
● Cause: holding the lower arm away
from the body
● Symptoms: Similar to those of
Carpal Tunnel Syndrome
•
1. Extensor Wad Strain
● Painful disorder of fingers due to
injury of the extensor muscles of the
thumb and fingers
○ Fingers are always open
● Cause: Extending the fingers
independently of each other
● Symptoms: numbness, pain, and
loss of strength in the fingers
2. Carpal Tunnel Syndrome
● Painful disorder of the wrist and
hand caused by compression of the
median nerve within the carpal
tunnel of the wrist
● Cause: Poor posture, repeatedly
bending of the hand up, down, or
form side-to-side at the wrist and
continuously pinch-gripping an
instrument without resting the
muscles
● Symptoms: Numbness, pain, tingling
in the thumb, index & middle fingers

1. Ulnar Nerve Entrapment
● Painful disorder of the lower arm and
wrist caused by compression of the
ulnar nerve of the arm as it passes
through the wrist
○ The ring and pinky ar always
open
● Cause: Bending the hand up, down,
or form side-to-side at the wrist and
holding the little finger a full span
away from the hand
● Symptoms: numbness, tingling,
and/or loss of strength in the lower
arm or wrist
2. Tenosynovitis
● Painful inflammation of the tendons
on the side of the wrist and at the
base of the thumb
● Cause: Hand twisting, forceful
gripping, bending the hand back or
to the side
● Symptoms: pain on the side of the
wrist & base of the thumb,
sometimes movement of the wrist
yields a cracking noise
9. Tendinitis
● Painful inflammation of tendonitis of
the wrist resulting from strain
● Cause: Repeatedly extending the
hand up or down at the wrist
● Symptoms: pain in the wrist,
especially on the outer edges of the
hand, rather than through the center
of the wrist
Neutral Body Positions
Ergonomic Don’ts
● Altering his or her body position or
equipment in a manner that is
uncomfortable just to "get the job
done”
 ● A mindset that it is acceptable to
assume an uncomfortable position
"just for 15 minutes while performing
periodontal instrumentation on these
two teeth"
● Pain and injury results when the
body's natural spinal curves are not
maintained in a seated position
Ergonomic Do’sSpine Basics: The curves
of a healthy Back
● Dentists assume a neutral, balanced
body position and then alter the
patient's chair and dental equipment
to complete periodontal
instrumentation.
● Good posture requires the seated
dentist to use a neutral spine
position that maintains the natural
curves of the spine
Spine Basics: The Curves of A healthy Back
● The spine is made up of three
segments: the cervical, thoracic, and
lumbar sections.
● The spine has three natural curves
that form an S-shape
● When the three natural curves are
properly aligned, the ears,
shoulders, and hips are in a straight
line.
● When viewed from the side, the
cervical and lumbar segments have
a slight inward curve
● When viewed from the side, the
thoracic segment of the spine has a
gentle outward curve
Neutral Body Position for The Clinician
Figure 1-13. Neutral Neck Position.
Goal:
● Head tilt of 0° to 20°
● The line from eyes to the treatment
area should be as near to vertical as
possible
Avoid:
● Head tipped too far forward
● Head tilted to one side
Neutral Body Position for the Clinician
Figure 1-14. Neutral Back Position.
Goal:
● Lean forward slightly from the hips
(hinge at hips)
● Trunk flexion of O° to 20°
Avoid:
● Overflexion of the spine (curved
back)
Figure 1-15. Neutral Torso Position.
Goal:
● Torso in line with long axis of the
body
Avoid:
● Leaning torso to one side
Twisting the torso
Figure 1-16. Neutral Shoulder Position
GOa
Shoulders in horizontal line
Weight evenly balanced when se
Avoid
Shoulders lifted up tow
holders hunched forward
Sitine with weight on one hip
Figure 1-17, Neutral Upper Arm Position.
Goal;
Upper arms hang parallel to the long axis of
tors
Elbows at waist level held slightly away
from body
Avoid:
• Greater than 20° of elbow abduction away
from
the body
Elbows held above waist level
Important elements
Figure 1-17. Neutral Upper Arm Position.
Goal; Figire 1-22 Step I.
• Upper arms hang parallel to the long axis Clinician Positioning
of torso Position the buttocks all the way back in the
Elbows at waist level held slightly away chair, Distribute the body’s weight evenly on
from body both hips
-
Avoid:
• Greater than 20° of elbow abduction away
from
the body
Elbows held above waist level

Figure 1-18, Neutral Forearm Position

Goal:
•Forearm held parallel to the floor
Forearm raised or lowered, if necessary, by
pivoting
at the elbow joint
Avoid:
• Angle between forearm and upper arm of
less than 60°

Figure 1-19. Neutral Hand Position.

Gasl
Little finger-side of palm is slightly lower
thumb-side of palm
Wrist aligned with forearm
Avoid:
• Thumb-side of palm rotated down so that p
parallel to foor
Hand and wrist bent up or down

Missed: Shoulder position

Gingiva: Microscopic Anatomy and its
Clinical Significance
August 19, 2022

Epithelium
● The epithelium covering the free
gingiva may be differentiated as
follows
○ Oral Epithelium → faces
the oral cavity (external)
○ Oral Sulcular Epithelium →
faces the tooth w/o being in
contact with the tooth surface
○ Junctional Epithelium →
provides the contact between
the gingiva and the tooth

Stipplings
● Exhibits the minute depressions
which, when present, give the
gingiva its characteristics stipples
appearance
● In adults 40% of the AG shows a
stippling on the surface

Oral Epithelium
● Keratinised, stratified squamous
epithelium
● The connective tissue portions which
● Predominant cell → Keratinocyte
project into the epithelium →
(90%)
connective tissue papillae
● Morphologic feature of the oral
epithelium and the oral sulcular
Cell Layers or Oral Epithelium
epithelium is the presence of rete
● Basal layer (stratum basale or
pegs
stratum germinativum)
● Rete pegs are lacking in the
● Prickle cell layer (stratum spinosum)
junctional epithelium
● Granular cell layer (stratum
granulosum)
● Keratinized cell layer (stratum
corneum)

Orthokeratinized → nuclei is lacking on

the outer layer
Parakeratinized → nuclei is present on the
outer layer
Keratinocyte: main cell found on the ○ A structureless zone
epithelium approximately 1-2um wide
○ Contains carbohydrate
Other cells: (glycoproteins)
- Also known as “clear cells” 2 Zones of Basement Membrane
- Stellate and have 1. Lamina lucida
cytoplasmic extensions ■ Electron lucent zone
● Melanocytes 2. Lamina densa
● Langerhans cells ■ Electron dense zone
● Merkel’s cells
● Inflammatory cells ○ Hemidesmosomes
■ Stud like structures
Melanocyte that attach the basal
● Pigment synthesizing cells cell to the basement
● Responsible for the melanin membrane
pigmentation occasionally seen on ○ Anchoring fibers
gingiva ■ Fan shaped in the
● Present in the lower portion of the connective tissue
stratum spinosum ■ From the connective
Merkel’s cells tissue to the
● Suggested to have a sensory basement membrane
function

Langerhans cells
● Play a role in the defense
mechanism of the oral mucosa
● React with antigens which are in the
process of penetrating the
epithelium
● Early immunologic response is
initiated
● Inhibiting or preventing further
antigen penetration of the tissue

Different Epithelial Layers

Stratum Spinosum
Basal layer ● 10-20 layers of relatively large,
● In contact with the basement polyhedral cells
membrane ● Short cytoplasmic processes
● Stratum germinativum resembling spines (arrows)
● Epithelium is renewed in this layer ● Prickly appearance
● Basement membrane ● Presence of desmosomes
○ Separates the epithelium and
connective tissue
 Dentino-Gingival Epithelium
● Achieve their final structural
characteristics in conjunction with
tooth eruption
● Reduced enamel epithelium
surrounds the crown of the tooth
from the moment the enamel is
properly mineralized until the tooth
starts to erupt
● As the tooth approaches the OE, the
cells of the REEM and the OE, show
increased mitotic activity (arrows)
start to
● When the tooth has penetrated,
large portions of enamel are covered
Stratum Granulosum by a junctional epithelium
● Presence of keratohyalin-granules ● All cells of the reduced enamel
● Cells start to get deprived of its epithelium are replaced by
energy and protein producing Junctional epithelium
apparatus ● Junctional epithelium is continuous
with the oral epithelium
● The oral sulcular epithelium
covers the gingival sulcus
● Junctional epithelium
○ Widest coronally and tiniest
apically
○ Does not have epithelial rete
pegs except when inflamed
● Cell membrane of the junctional
epithelium cells harbors
Stratum Corneum hemidesmosomes toward the
● Abruptly converted into a enamel and towards the connective
keratin-filled cells tissue
● Cytoplasmic is filled with keratin ● Junctional epithelium is physically
● Entire apparatus for protein attached to the tooth via
synthesis and energy production is hemidesmosomes
lost
● Keratinization
○ Keratinocyte undergoing
continuous differentiation
○ Process of protein synthesis
Lamina Propria
● The predominant tissue component
● Also known as connective tissue
underneath the epithelial layer
● Major components are:
○ Collagen fibers (around 60%
of CT volume)
■ Produced by
fibroblasts
○ Fibroblast (around 5%)
○ Vessels and nerves (around
5%) 3. Macrophages
● Embedded in an amorphous ground ● Different phagocytic and synthetic
substance (matrix) functions in the tissue
● They are numerous in inflamed
Cell types present in the lamina propria: tissue
1. Fibroblast ● Derived from circulating blood
● Residing in a network of connective monocytes which migrate into the
tissue fibers (Collagen Fibers) tissue
● The intervening space is filled with
matrix (M)
● Engaged in the production
○ Various types of fibers
○ Synthesis of the CT matrix
● Spindle-shaped or stellate cell with
an oval shaped nucleus

4. Inflammatory cells
- Numerous during
inflammation
● Neutrophilic granulocytes / PMN
leukocyte
● Lymphocytes
● Plasma cells
● Plasma cells

2. Mast cells
● Responsible for the production of
certain components of the matrix
● Helps control the flow of blood
through the tissue
CONNECTIVE TISSUE FIBERS
Collagen fibers
● Predominate in the connective tissue
 ● Constitute the most essential ● Present at the epithelium-connective
components of the periodontium tissue and endothelium- connective
● Shows cross sections and tissue interfaces
longitudinal sections of collagen
fibers
● Characteristic cross-banding
between the individual dark bans
● Reinforce the gingiva
● Provide the resilience and tone
● Necessary for maintaining its
architectural form and integrity of the
dento-gingival attachment

Collagen Synthesis
● Collagen is produced by fibroblast Oxytalan
● Smallest unit → tropocollagen ● Scare in the gingiva but numerous in
● Tropocollagen molecule (TC) chain the periodontal ligament
contains about 1000 amino acids ● Composed of long thin fibrils
● Tropocollagen synthesis takes ● Course parallel to the long axis of
places in the fibroblast → secreted the tooth
to the extracellular space and will ● Function is unknown
polymerize
● Tropocollagen molecules → Gingival Fiber Groups
aggregated longitudinally to ● Collagen fibers in the gingiva tend to
protofibrils and subsequently be arranged in groups of bundles
laterally aggregate parallel to dorm
collagen fibrils → an overlapping of According to insertion and course in the
the tropocollagen molecules tissue
1. Circular Fibers
Collagen fiber ● Run in the free gingiva and encircle
● Bundles of collagen fibrils the tooth in a cuff- or ring-like
● Resilience of gingiva, tone w1 fashion
● Cementoblasts and osteoblasts are 2. Dentogingival fibers
cells which also possess the ability ● Embedded in the same portion of
to produce collagen the supra-alveolar portion of the roof
- Blast meaning forming cells ● Project from the cementum in a
fan-like configuration out into the
Reticulin fibers free gingival tissue
● Numerous adjacent to the basement 3. Dento-periosteal fibers
membrane ● Embedded in the same portion of
● Occur in large numbers in the loose the cementum as the DGF
connective tissue surrounding the ● Run apically and terminate in the
blood vessels tissue of the AG
 ● The border area between the FG ○ Junctional epithelium
and AG, lacks support (epithelial attachment)
● In this area the FGG is often present ○ Connective tissue
attachment
4. Trans-septal fibers ● Length of connective tissue
● Extend between the supra-alveolar attachment = 1.07mm
cementum of approximating teeth ● Length of junctional epithelium =
0.97mm
● Biologic width - 2.4 mm (Gargiulo et.
Extracellular Matrix al.
● Produced mainly by the fibroblast
● Some are produced by mast cells Active Eruption
and some are derived from the blood ● Eruption of teeth into the mouth
● A medium in which CT cells are towards the occlusal plane
embedded
● Essential for the maintenance of PASSIVE ERUPTION AND ALTERED
normal function of the CT PASSIVE ERUPTION
● Transportation of water, electrolytes,
nutrients, metabolites, etc to and ● Passive eruption
from CT cells occurs within the ○ Movement of the gingiva
matrix apically to the level of the
● Main constituents of the CT matrix CEJ after the tooth has
are protein-carbohydrate, eruption completely
macromolecules, proteoglycans and ● Altered Passive eruption
glycoproteins ○ Gingival tissues fail to
migrate apically and thus
Importance of the Extracellular Matrix lead to shorter clinical
Proteoglycans crowns with more square
● Regulate diffusion and fluid flow shaped teeth and
through the matrix appearance of what is known
● Important determinants for the fluid as gummy smile.
content
● Maintenance of the osmotic
pressure
● Acr as a molecule filter Passive Eruption Stages (Gottlieb and
● Important role in the regulation of Orban)
cell migration in the tissue ● Stage I
○ Dentinogingival junction is
located on enamel
● Stage II
Biologic Width/ Dento-Gingival ○ Dentinogingival junction is
Unit/Supracrestal Attachment apparatus located on enamel, as well
● The soft tissue attached to the teeth as cementum
was comprised of: ● Stage III
 ○ Dentinogingival junction is
located entirely on cementum
● Stage IV
○ Dentinogingival junction is
located entirely on cementum
and the root surface is
exposed, resulting in gingival
recession

Four Types of altered passive eruption

(Coslet) (All types present with the free
gingival margin located occlusal to the CEJ)
● Type 1A
○ Wider band of dekeratinized
tissue, alveolar crest - CEJ
normal (~1.5 mm)
● Type 1B
○ Wider band of dekeratinized
tissue, alveolar crest - CEJ (~
0 mm)
● Type 2A
○ Normal band of dekeratinized
tissue, alveolar crest - CEJ
normal (~1.5 mm)
● Type 2B
○ Normal band of dekeratinized
tissue, alveolar crest - CEJ
(~0 mm)
August 25, 2022
Periodontal Ligament
● Soft tissue that attaches the tooth to
the bone
Periodontal Ligament
● Absorbs the load of the teeth
● Soft, richly vascular and cellular
connective tissue
○ Composed of mainly
fibroblasts
● Surrounds the roots of the teeth and
joins the root cementum with the
socket wall
● In the coronal direction, the PDL is
continuous with the lamina propria of
the gingiva.
● Hourglass shape and is narrowest at
the mid root
○ Thinner in the middle portion
of the root and thicker at the
coronal and apical portions
● The PDL is situated in the space
between the roots of the teeth and
the lamina dura
○ Periodontal ligament space
○ Radiolucent in radiograph
○ Outlines the roots of the
teeth
● Adjacent to it is the Lamina dura or
socket wall
● The alveolar bone surrounds the
tooth from the apex to a level
approximately 1-2mm apical to the
CEJ
● The coronal border of the bone is
call the bone crest
Periodontal Ligament Space
● Response to increased functional
load is widening of the periodontal
space and thickening of the PDL
● Lost function leads to thin or atrophic
PDL bundles
Key terms:
↑ Functional load
- Widening a of periodontal Space
- Thickening of periodontal ligament
↓Functional load
- Thin or atrophic Periodontal ligament
bundles
Periodontal Ligament Space widends as it
receives excessive occlusive forces
because it is trying to adapt to the
environment that it is in (trying to bear more
load)
Loss of function (extracted opposing tooth):
periodontal ligament will thin out
PERIODONTAL LIGAMENT
● The width of the PDL is
approximately 0.25mm (range
0.200.4mm)
● The PDL permits forces, elicited
during masticatory function, to be
distributed to the alveolar process
● The PDL is also essential for the
mobility of the teeth
○ Physiologic mobility: 0.1 mm
buccolingual movement
○ Pathologic mobility: more
than 0.1)
 ○ Continues collagen and bone
turnover
● Continuous renewal of cell
population

Remember:
Areas of tension: Bone formation
Areas of pressure: Bone resorption

Bone resorption → widening of PDL space

4. Nutritive
● Blood supply maintains the vitality of
Functions: its various cells provides essential
● Supportive nutrients
● Sensory ● Blood supply comes from
● Homeostatic ○ .
● Nutritive ○ .
○
1. Supportive 16:50
● Attaches the tooth to the alveolar Collagen Fibers in the PDL
bone proper ● Predominant in PDL are Type I, III,
● Serves as a shock-absorber and XII
○ Provide resistance to light ● Arranged in distinct and definite fiber
and heavy forces bundles
● Viscoelastic property ● Fiber within a bundle are interwoven
○ Physiologic mobility ● Sharpey's Fibers
○ Able to adapt to increased ○ End of PDL fibers embedded
forces by remodeling in cementum and bone
processes ○ AEFC: Acellular intrinsic fiber
cementum

2. Sensory
● For proper positioning of the jaw
during normal function
● To estimate the amount of pressure
in mastrication
● Identify which tooth is percussed
○ Percussion - tapping of the
tooth/ vitality test of the teeth

3. Homeostatic
● Adjusting to conditions to maintain
stability
● Undergoes continuous remodeling
Dentoalveolar Collagen
fiber Bundle groups
Collagen fibers which
can be divided into the
following main groups
according to their
arrangement:
1. Alveolar Crest
fibers
2. Horizontal fibers
3. Oblique fibers
4. Apical fibers
Sharpey’s fibers
● Collagen fiber bundles (Sharper’s
fibers) insert into the ABP on one
end and into cementum at the other
● Sharper’s fibers embedded in the
cementum have a smaller diameter,
but are more numerous than those
embedded in the bone.
● Sharpey’s fibers embedded in the
ABP are larger in diameter.
Development of the Principal Fibers:
● Collagen Fibrils are seen arising
from the RC and ABP projecting into
the PDL space
Cells of the Periodontal Ligament:
● Fibroblasts
● Undifferentiated Mesenchymal Cells
● Cementoprogenitor
○ Cementoblasts
○ Cementoclasts
● Osteoprogenitor
○ Osteoblast
○ Osteoclast
● Epithelial cells
Fibroblast
● Principal cells of the PDL
● Ability to achieve an exceptionally
high rate of turnover of proteins
(collagen)
● Involved in the synthesis and
degradation of collagen
● Form focal contacts with the
extracellular matrix
● Show frequent cell to cell contacts
○ Adherens and gap junctions
● Aligned along the general direction
of the fiber bundles and have
extensive processes that wrap
around the bundles
 August 26, 2022
Root Cementum
- Hard avascular connective tissue
that covers the roots of teeth
Cementoprogenitor and Osteoprogenitor
- Covers the entire dentin of the root
● Cementoblasts
from the CEJ to the apex
● Cementoclasts
- Continuous deposition throughout
● Osteoblasts
life
● Osteoclasts
- Both tooth and periodontium
- Contains the least mineral compared
to enamel, dentin and bone
- Light yellow in color
- Has no luster
- Permeable to varying degrees
Howship’s lacunae: depression or cavity
due to bone resorption Organic matrix - 50-55%
● Collagen
EPITHELIAL CELLS ● Chondroitin Sulfate
● Epithelial Cell Rests of Malassez ● Water
○ Remnants of the Hertwig's
epithelial root sheath. Inorganic/ mineral components - 45-50%
○ Found as clusters or strands ● hydroxyapatite crystals
of cells
○ Found at a distance of 15-75
um from the cementum Functions of root cementum:
○ With a basement membrane ● Anchors the teeth to the alveolus
○ With presence of ● Seals the surface of the root dentin
desmosomes and ● Compensates for the lost tooth
hemidesmosomes substance due to attrition
○ Function is unknown ● Regulates the periodontal space as
a bone resorbs
● Repair
 ○ Resorbed part of cementum ○ Resorption lacunae are
surface completely filled
○ Fractured roots ○ Continuity of the root surface
■ Provide new surface is re-establish
for the reattachment ○ Fiber apparatus of the
of torn periodontal periodontal ligament is
ligament fibers reattached

Resorption of cementum: Cells of the cementum

● About 90% of permanent teeth show ● Cementoblasts
evidence of small regions of ○ Form of the cementum
cementum resorption ○ Found lining the root surface
● Resorbed surface = scalloped ○ Interposed between bundles
● Causes: of periodontal ligament
○ Exfoliation of deciduous teeth ● Cementocytes
○ Drifting of teeth ○ Cementoblasts that are
○ Traumatic occlusion trapped in the lacunae during
○ Excessive orthodontic forces its development
○ Presence of canaliculi that
normally extend toward the
periodontal ligament side of
the root.

Forms of cementum:
● Acellular afibrillar cementum (AAC)
● Acellular extrinsic fiber cementum
(AEFC)
● Cellular mixed stratified cementum
(CMSC)
● Cellular intrinsic fiber cementum
(CIFC)
Repair of cementum:
● Functional repair Acellular afibrillar cementum (AAC)
○ Resorption lacunae are only ● Formed at the most cervical enamel
partially refilled border
○ Periodontal fibers are ● No cementocytes present
anchored in the surfaces of ● No collagen fibrils present
shallow depressions ● Observed only at the cervical region
○ Alveolar bone becomes of the tooth at the CEJ
thickened through apposition ● Appears as small “islands” upon the
to re-establish the enamel
physiologic width of the
periodontal space
● Anatomic Repair

Acellular extrinsic fiber cementum
(AEFC)
● Primary cementum or fibrous
cementum
● Consists of sharpey’s fibers
○ Extrinsic collagen fibrils
● Found in the coronal and middle
portions of the root and contains
mainly bundles of sharpey’s fibers
● This type of cementum is an
important part of the attachment
apparatus and connects the tooth
with the bundle bone
Cellular mixed stratified cementum
(CMSC)
● Formed by both cementoblast and
fibroblasts
● Occurs in the apical third of the roots
and in the furcations
● Has both extrinsic: sharpey’s fibers
& intrinsic bundles of collagen fibers
in the cementum
● Cementocytes are also present
● Secondary cementum formation is a
continuous process
● The thickness of cementum on the
root surface increases with age
● Combination of CIFC and AEFC
Cellular Intrinsic fiber cementum (CIFC)
● Found mainly in resorption lacunae
and it contains intrinsic fibers and
cementoytes
● Exclusive products of the
cementoblasts
● Formed only during reparative
process
● Repair of root fractures
● Confined to the apical and
interradicular regions of the tooth
**
Acellular Afibrillar Cementum
● Formed at the most cervical enamel
border
● No cementocytes present
● No collagen fibrils present
● Observed only at the cervical region
of the tooth, at the CEJ
● Appears as small "islands" upon the
enamel
Root Cementum
● Hard, vascular connective tissue that
covers the roots of teeth
 ● Covers the entire dentin of the root ○ Traumatic occlusion
from the CEJ to the apex ○ Excessive orthodontic forces
● Continuous deposition throughout
life
● Both tooth and periodontium
● Contains the least mineral compared
to enamel, dentin and bone
● Light yellow in color
● Has no luster
● Permeable to varying degrees
***Covers the entire ____ portion at the root
area
Repair of Cementum
● Functional Repair
○ Resorption lacunae are only
partially refilled
○ Periodontal fibers are
anchored in the surfaces of
shallow depressions
○ Alveolar bone becomes
Functions thickened through apposition
● Anchors the teeth to the alveolus to re-establish the
● Seals the surface of the root dentin physiologic width of the
● Compensates for the lost tooth periodontal space
substance due to attrition ● Anatomical Repair
● Regulates the periodontal space as ○ Resorption lacunae are
bone resorbs completely filled
● Repair ○ Continuity of the root surface
○ Resorbed part of cementum is re-established
surface ○ Fiber apparatus of the
○ Fractured roots periodontal ligament is
■ Provide new surface reattached
for the reattachment
of torn periodontal
ligament fibers

Resorption of Cementum
● About 90% of permanent teeth show
evidence of small regions of
cementum resorption
● Resorbed surface = scalloped
● Causes:
○ Exfoliation of deciduous teeth
○ Drifting of teeth
Cells of the Cementum
● Cementoblasts
○ Form the cementum
○ Found lining the root surface
○ Interposed between bundles
of periodontal ligament
● Cementocytes
○ Cementoblasts that are
trapped in the lacunae during
its development
○ Presence of canaliculi that
normally extend toward the
PDL side of the root
Acellular Afibrillar Cementum
● Formed at the most cervical enamel
border
● No cementocytes present
● No collagen fibrils present
● Observed only at the cervical region
of the tooth, at the CEJ
● Appears as small "islands" upon the
enamel
Acellular Extrinsic Fiber Cementum
● Primary Cementum or Fibrous
Cementum
● Consists of Sharpey's Fibers -
Extrinsic collagen fibrils
● Found in the coronal and middle
portions of the root and contains
mainly bundles of Sharpey's fibers
● This type of cementum is an
important part of the attachment
apparatus and connects the tooth
with the bundle bone
Cellular Mixed Fiber Cementum
● Formed by both cementoblasts and
fibroblasts
● Occurs in the apical third of the roots
and in the furcations.
● Has both extrinsic Sharpey's fibers &
intrinsic bundles of collagen fibers in
the cementum
● Cementocytes are also present
● Secondary cementum formation is a
continuous process
● The thickness of cementum on the
root surface increases with age
 ● Combination of CIFC and AEFC

Cellular Intrinsic Fiber Cementum

● Found mainly in resorption lacunae
and it contains intrinsic fibers and
cementocytes-7 Find duty repentr
● Exclusive products of the
cementoblasts
● Formed only during reparative
process
● Repair of root fractures
● Confined to the apical and
interradicular regions of the tooth.