‫بسم هللا الرحمن الرحيم‬

PERIODONTOLOGY
Dr. Rawand Samy Mohamed Abu Nahla
Oral Medicine, periodontology&oral Radiology
Department.
Dr. Haydar.A.Shafy Faculty Of Dentistry.
El Azhar University.
Curriculum:
1-Normal Periodontium.
2-Classification Of Periodontal Diseases.
3-Etiology Of Periodontal Diseases.
4-Pathogenesis Of Periodontal Diseases.
5-Role Of Local Predisposing Factors.
6- Effect Of Systemic Conditions Of The Periodontium.
Lecture 1
Anatomy of the Periodontium
Periodontium
The tissues that surround and support the
teeth are known as the periodontium.
It includes:
1. Gingiva
2. Periodontal ligament
3. Cementum
4. Alveolar bone
Periodontium: peri = around . odontous =
tooth
Periodontics: the art and science of studying
the periodontium.
Periodontist: specialist in periodontics
1-Gingiva
 Gingiva:

•The fibrous investing tissue covered by keratinized

epithelium. The gingiva is one of the soft tissues that
line the oral cavity.

• All the soft tissue in the mouth are Known as the the
oral mucosa, it is divided into three different types:
1. Masticatory mucosa:
Is a tissue that is firmly attached to the underlying bone and
covered with parakeratinized or keratinized epithelium.
The gingiva and
the tissue covering the hard palate are examples.

2. Lining mucosa:
Loosely attached to their underlying structures and covered
with non-keratinized epithelium. Lips, cheeks, floor of the
mouth.

3. Specialized mucosa:
Covers the dorsal surface of the tongue.
 TYPES OF GINGIVA:

1. Marginal gingiva
(free or unattached)
2. Attached gingiva
(firmly attached to underlying tooth
and bone)
3. Inter-dental gingiva
( located between adjacent teeth.
4. Gingival sulcus
1- Clinical Features

1)Muco-gingival junction.
2)Interdental gingiva.
3)Free gingival groove
4)Attached gingiva.
5)Alveolar mucosa
6) Marginal gingiva.
1:Enamel.
2:gingival margin.
3:gingival sulcus.
4:free gingival groove.
5:alveolar bone.
6:CEJ
7:Cementum
8:PDL
Between 2 and 4 is free
gingiva
Marginal gingiva:
1) Is the most coronally positioned portion
of the gingiva.
2) It is not attached to the tooth, and it
creates the soft tissue wall of the gingival
sulcus.
3) In health, is
• knife-edged in contour,
• firm in consistency,
• smooth in texture.
4) It extends apically to the free gingival
groove, approximately 1 mm wide.
Attached Gingiva:
1) It is firmly bound to the underlying tooth and
alveolar bone.
2) Gingiva is
•tapered in contour,
•stippled in texture,
•firm in consistency.
3) Varies in width from one area of the mouth to
another and from one patient to another.
4) Bound coronally by the free gingival groove and
apically by the mucogingival junction.
 Attached Gingiva is:
• Greatest in incisor region (3.5-4.5 in maxilla, 3.3-3.9 in mandible).

• Least in premolar area (1.9 mm in maxilla, 1.8 in mandible).

• The width increases with age. Depends on :

1. teeth involved,

2. the buccolingual position in the arch ,

3. location of the frenum or

4. muscle attachment.

• It provides gingival tissue that can withstand the mechanical forces of

brushing and tension applied on mucosa
Gingival sulcus:

• It is a shallow fissure between marginal gingival and the enamel

or cementum.
• Clinical normal gingival sulcus depth = 2-3 mm measured with
periodontal probe.
Interdental Gingiva:

• Its that part of the gingiva that occupy the inter-proximal

space, created by adjacent teeth in contact. Therefore, shape
determined by contact relationship with teeth, and width of
proximal surfaces.

• If the contours are flat, interproximal contacts, the gingiva

will be narrow and short.

• If the proximal contours are more convex with a small

coronally positioned contact area, the interdental gingiva will
be broad and high.
 The interdental gingiva can be pyramidal and have col shape.
 Buccolingual dimension the inter-dental gingival terminates
coronally with separate buccal and lingual peaks of tissue as
the gingival col.
Gingival Groove (4):
It is a shallow, v-shaped or indentation that is closely associated
with apical extent of free gingiva.
 • The understanding of clinical features of periodontium is
enhanced by a knowledge of histological component of
tissue.

Microscopic (Histological) Features

• The gingiva consist of central core of connective tissue
covered by stratified squamous epithelium.
 Gingival Epithelium:
1) Oral (outer) Epithelium.
2) Sulcular Epithelium
3) Junctional Epithelium
 ORAL EPITHELIUM:

• Keratinized or parakeratinized consist of four layers:

1) Stratum basale, Basal cell layer (The deepest cells)
2) Stratum Spinosum cell layer
3) Stratum granulosum cell layer
4) Stratum corneum (Keratinized, para, or nonkeratinized)
cell layer
LAYERS OF SQUAMOUS EPITHELIUM
Sulcular Epithelium:
•It lines the gingival sulcus facing the tooth
•similar to oral epithelium
•except the 2nd layer (it lacks granular cell layer)
•it is non keratinized stratified squamous epithelium
•without rete pegs in normal conditions.

1.It acts as semi-permeable membrane from the bacteria

and tissue fluid from the gingiva seeps into the sulcus.
Junctional Epithelium:

• Forms the core of epithelium.

•It is thickest in coronal part.
•Is single or multiple layer of non-keratinized cells
adhering to tooth surface and face the gingiva by means of
basal lamina.
•Basal Lamina consist of:

1. Lamina lucida
2. Lamina densa
details of the sulcular junctional epithelium areas
 Connective Tissue:
• Is known as the lamina propria.
• Divided into two layers:
(1) papillary layer adjacent to epithelium,
(2) reticular layer, contiguous with the periosteum.
• Lamina propria consist of:
• Collagen, reticulin, oxytalan, and elastic fibers.
• Intercellular ground substance
• Cells
• Blood vessels
• Nerves
•
Gingival Collagen Fiber.

1.circular fibers
2.dento-gingival fibers.
3.alveolo-gingival fibers.
4.peri-osto-gingival fibers.
  The collagen fibers help to
1. hold the marginal gingiva tightly against the
tooth
2. provide a firm junction of the attached gingiva
to the underlying tooth root and alveolar bone.

The fibers are grouped:

1. Gingivodental
2. Circular
3. Transeptal
4. Alveolo gingival
The most prominent cells found in the gingival
connective tissue:

1. Plasma cells
2. Fibroblasts
3. Mast cells
4. Lymphocytes
5. Polymorphonuclear leuckocytes (neotrophil).
Vascular Supply:
It’s derived from the branches of the
superior and inferior alveolar arteries:
1. Greater palatine artery
2. Buccal artery
3. Sublingual artery
4. Mental artery
 The lymphatic drainage :
usually follows the blood supply, the major
portion of the lymph drainage from the gingiva
going to the :

submandibular lymph nodes.

Nerve Supply:
 Derived from :
maxillary and mandibular branches of
the trigeminal nerve.
Gingival Fluid:
• The gingival (crevicular) fluid is continually
secreted from the gingival connective tissues into
the sulcus through the sulcular epithelial wall.

• This fluid helps to :

1. mechanically clean the sulcus,
2. possess anti-microbial properties and antibodies
3. enhance the resistance of the gingiva to gingivitis.
Clinical Relationship
Clinical Descriptive Criteria
 Gingival color:
Its pink depends on:
1. amount of melanin
2. thickness of epithelium
3. degree of keratinization
4. vascularity
 Gingival contour:
• The inter-dental gingiva is generally pointed.
• However, the contours of the gingiva vary depending upon :

• the shape of the teeth,

• the buccolingual position of the teeth in the arch,
• the size of the inter-proximal embrasure space.
 Gingival Consistency:
• Usually resilient and firm because of the dense
collagenous nature of the gingival connective tissue.

 Gingival Surface Texture:

• Being stippled like an orange peel or smooth and shiny.
Degree of stippling varies considerably among patients and
in different parts of the same mouth.
 2- Periodontal Ligament
• Connective tissue around and attach teeth to the alveolar
bone.
• Consist of bundles of fibers, according to their directions:
1)Alveolar crest group
2)Horizontal group
3)Oblique group.
4)Apical fibers.
5)Interradicular fibers.
6)Transeptal fibers.
• The ends of the principle fibers are embedded in :
 cementum on the tooth side and in the
 alveolar bone proper on the opposite side.

• The embedded portions of the principle fibers are

the Sharpey’s fibers
 Functions

1. Physical (mechanical)
2. Formative
3. Nutritional
4. Sensory
 The physical functions of PDL
1) Transmission of occlusal forces to the bone.
2) Attachment of the teeth to the bone.
3) Maintenance of the gingival tissues in their
relationship to the teeth.
4) Resistance to the impact of occlusal forces
(shock absorption).
5) Provision of a soft tissue casing
(to protect vessels and nerves from injury by
mechanical forces).
3-Cementum:
• Calcified tissue covers the root of the teeth and provide
attachment to the periodontal ligament.

• Consist of collagen fibers in a ground substance consist of 45-

50% inorganic materials, 50-55% organic materials
  Width vary from :
• 60-68 microns in coronal third ,
• 150-200 microns in apical third.

 Width increase with age.

• 95 microns at age 20,
• 215 microns at age 60

 Two types of cementum :

• Acellular (coronal portion of the root)
• Cellular (apical portion of root and in furcation areas
of multi-rooted teeth).
Cemento Enamel Junction:
The area where cementum and enamel meet
(cervical area).

Three different relationship:

60-50%  cementum overlaps enamel

30%  edge to edge
5%-10%  cementum fail to meet
enamel resulting in exposed
dentine
2: Acellular cementum. • Cellular cementum.
3:PDL with fibroblast. Cementocytes
4:cementoblast within the lacuna of
cementum
 4- Alveolar Process And Alveolar Bone
• The alveolar process is the portion of the jawbone that contains the
teeth and the alveoli in which they are suspended.  

• The alveolar process rests on basal bone.  Proper development of the

alveolar process is dependent on tooth eruption and its maintenance
on tooth retention.
 
• When teeth fail to develop (e.g. anodontia), the alveolar process
fails to form.

• When all teeth are extracted, most of the alveolar process becomes
involuted, leaving basal bone as the major constituent of the
jawbone.  The remaining jawbone, therefore, is much reduced in
height.
• The alveolar process is composed of an outer and inner
cortical plate of compact bone that enclose the spongiosa,
a compartment composed of spongy bone ( also called
trabecular or cancellous bone).

• It is important to distinguish between the terms "alveolar

process" and "alveolar bone" 
• The alveolar bone proper lines the alveolus (or tooth housing)
which is contained within the alveolar process.

• It is composed of a thin plate of cortical bone with numerous

perforations ( or cribriform plate) that allow the passage of blood
vessels between the bone marrow spaces and the periodontal
ligament.

• The coronal rim of the alveolar bone forms the alveolar crest,
which generally parallels the cemento-enamel junction at a
distance of 1-2 mm apical to it .
Diagrammatic cross-
section through a
tooth in the alveolar
process of the jaw
bone.
AB, alveolar bone proper
AB + C, area of fusion of
the alveolar bone and the
cortical plate of the alveolar
process
C, cortical plate
PDL, periodontal ligament
T, tooth
Fenestration Defect
1.roots are prominent
2.overlying bone very thin,
3.bone may actually resorb locally,
4.creating a window in the bone through
which the root can be seen.

This window-like defect in the bone is

referred to as a fenestration (F).
 
 
Dehiscence
In some cases, as shown in this figure,  
the rim of bone between the fenestration
and the alveolar crest may disappear
altogether and produce a defect known as
a dehiscence (D).  

•Awareness of these defects is important

when surgical flaps are reflected,
as the exposure of such defects during
surgery may aggravate ‫طورة‬T‫زيد خ‬TT‫ ي‬their
severity. 
 
 
 Mesio-distal section of a mandible
through a molar alveolus.  Note the
compact nature of the alveolar bone
proper (C) that lines the alveolus,
as compared to the adjacent
cancellous bone (S) of the alveolar
process. Despite its compact
nature, the alveolar bone contains
numerous perforations, particularly
noticeable in the coronal portion of
the alveolus.
 
 
C, cortical alveolar bone lining the
alveolus.
 MICROSCOPIC FEATURES
• Fig. :Cross-section, in the occlusal
plane, through the maxillary
premolar region.   The alveolar
bone proper (AB) can be seen
surrounding each tooth as a
continuous thin plate of compact
bone supported by the trabeculae of
the adjacent spongy bone (S).   It
becomes fused with and
indistinguishable from the cortical
plate (CP) of the alveolar process.
 The periodontal ligament attaches
the tooth (T) to the alveolar bone. 
•  
• Fig. :    Note the bony trabeculae (BT) that
help support the thin alveolar bone layer
(AB).  The histological structure of the
alveolar bone reflects the remodeling that
takes place to accomodate mesial drifting of
the dentition.   As the dentition  wears, the
teeth tend to move through the bone in a
mesial direction to maintain tight contacts
between the teeth.  This means that the bone
mesial to a tooth must resorb to allow the
tooth to move, while the bone distal to it is
undergoing new bone apposition to maintain
the width of the periodontal ligament.  In this
section, mesial is to the left.
•  
• Fig.:   Periapical radiograph of
maxillary posterior region. Dense
structures like teeth and bone
appear light, while non-mineralized
tissues are dark.  The image that
corresponds to the alveolar bone
proper is the thin, white line that
parallels the outline of the roots of
the teeth.  The radiographic term for
this image is the lamina dura (LD).
 The periodontal ligament space
(PDL) appears as a dark line
between the lamina dura and the
root surface.  The trabecular pattern
of the cancellous bone (S) can also
be readily detected.  
• Fig.: Bone is produced by osteoblasts (OB) that are found in the
periosteum, endosteum and periodontal ligament adjacent to bone-
forming surfaces.  These specialized cells originate from less
differentiated precursor cells close to the bone.   These cells are in turn
derived from undifferentiated ectomesenchymal cells found in the
periosteum, endosteum and the periodontal ligament.  
• During bone formation, osteoblasts become incorporated into bone as
osteocytes (OC) that are completely surrounded by bone.  The
chamber in which they are trapped is called
a lacuna (plur. lacunae). Osteocytes remain connected to
osteoblasts and other osteocytes  by cytoplasmic processes that run
through small canals in the bone, or canaliculi (C). 

• Fig. :  Diagram illustrating canaliculi (C) connecting adjacent osteocytes in their

lacunae (OC) to one another.
• Fig.:   Histologic section through compact bone.  The
osteocytes (OC) in their lacunae are distributed throughout
the entire tissue.  In stained sections, such as this one, the
dense array of canaliculi that connect adjacent lacunae is
readily observed.
• Fig.:  Cortical plate of compact bone in the mandible.  The mandible is
enveloped by a well-developed cortex of compact bone.  The bulk of the
compact bone consists of cylindrical units of bone, the osteons or Haversian
systems (HS).  Each osteon has a central canal, the Haversian canal that
houses a blood vessel.  Haversian canals are linked to one another and the
periphery of the cortex by Volkman canals that course perpendicularly to the
Haversian canals.  The outer and inner layers of the cortex consist of parallel
lamellae of compact bone, called the external (ECL) and internal
circumferential lamellae.  The bone that fills the spaces between adjacent
osteons is the interstitial bone.
• Fig. :  Section of mandibular cortex through the external circumferential
lamellae (ECL) and periosteum (P).  The cortical plate undergoes continuous
remodeling.   Dark blue stained osteons (HS1) with wide Haversian canals
are relatively young, while the pink-staining osteons (HS2) with small
Haversian canals are more mature.   Interstitial bone (IB) fills the spaces
between the osteons.    
 BONE REMODELING

• Despite its solid appearance, bone is in a constant state of

remodeling.  
• This means that at all time some parts of the jaw bone are being
resorbed, while other parts are growing by apposition of new bone.
 
• This process requires some coordination between resorption and
apposition so that the normal function of the bone can be
maintained.  Remodeling of the alveolar process
1. allows the normal migration of teeth in a mesial direction, or
mesial drift, as their interproximal surfaces wear down.  
2. It also allows for orthodontic tooth movement and
3. wound healing.
• Fig.:   Magnified view of
interdental septum shown. Note
the large bone marrow spaces
(BMS) in the cancellous bone of
the interdental septum.  The distal
side (D) of the septum has the
characteristics of as a
predominantly bone-resorbing
surface (BRS), whereas the mesial
(M) side has the  typical features
of a bone-forming surface (BFS). 
 Clinical Considerations
• Through remodeling, the alveolar bone may become displaced
in relation to the remaining alveolar process, thereby allowing
tooth movement to take place.
• Interruptions in the continuity of the lamina dura in the apical
region of an alveolus are of diagnostic significance in the
radiographic identification of periapical lesions.
• Proximity of the alveolar bone to sinus cavities or major nerves
(mandibular nerve) may create problems during tooth
extraction or surgical interventions.
• Following tooth extraction, the alveolar process tends to
resorb, a development that may compromise the placement of
endosseous dental implants and affect the construction of
removable prostheses.
• Placement of dental implants in the alveolar process, prior to
its becoming resorbed, following tooth extractions, will
markedly decrease the rate of ridge resorption.
• Fenestrations may convert to dehiscences which, in turn,
may lead to gingival recession.  Surgical interventions may
promote the conversion of fenestrations into dehiscences, as
well as the creation of new fenestrations and dehiscences in
the presence of thin bony plates.
ANY QUESTION?
Thank you