Public Insitution State University of Medicine and Pharmacy

« Nicolae Testemițanu »

Department of Stomatological Propaedeutics « Pavel Godoroja »

Marginal Periodontium
 The periodontium
Consists of the investing and supporting tissues
of the tooth. It has been divided into 2 parts:
1. The gingiva;
2. The attachment apparatus:
1. Periodontal ligament;
2. Cementum;
3. Alveolar bone.
Normal Periodontium
The oral mucosa

Consists of 3 zones:
1. The masticatory mucosa – covering of the hard palate;
2. The specialized mucosa – covering the dorsum of the
tongue;
3. The oral mucous membrane lining the remainder of
the oral cavity.
The gingiva is the part of the oral mucosa that covers the
alveolar processes of the jaws and surrounds the necks of
the teeth.
The masticatory mucosa
The lining mucosa
The specialized mucosa
 Morphological structure of the
gingiva Gingival Epithelium
 consists of a central core of connective tissue covered by stratified squamous
epithelium.
 From the morphological and functional point of view, there are 3 different
areas:
1. The oral or outer epithelium;
2. Sulcular epithelium;
3. Junctional epithelium.
 The principal cell type of the gingival epithelium is the keratinocyte and their
proliferation and differentation allow the main function of the epithelium
which consists in the protection of the deep structures.
Gingival Epithelium
 The oral or outer epithelium;

consists of:
1. Stratum basale;
2. Stratum spinosum;
3. Stratum granulosum;
4. Stratum corneum.
The epithelium is joined to the
underlying connective tissue by a
basal lamina.
 Types of Oral Epithelium
Orthokeratinized stratified Nonkeratinized stratified
Parakeratinized stratified
squamous epithelium squamous epithelium
squamous epithelium
Oral or outer epithelium
 Covers the crest and outer surface of the marginal gingiva and the
surface of the attached gingiva. It is keratinized or
parakeratinized.
 Depending on the region of the mouth, the epithelium may be
nonkeratinized or keratinized. Nonkeratinized squamous
epithelium covers the soft palate, inner lips, inner cheeks, the
floor of the mouth, and ventral surface of the tongue. Keratinized
squamous epithelium is present in the gingiva and hard palate as
well as areas of the dorsal surface of the tongue.
 Sulcular epithelium

 Lines the gingival sulcus. It

is a thin, nonkeratinizied
stratified squamous
epithelium.
 The sulcular epithelium is
extremely important,
because it may act as a
semipermeable membrane
through which injurious
bacterial products pass into
the gingiva and tissue fluid
form the gingiva seeps into
the sulcus.
 Junctional
epithelium
 Consists of a collarlike band of
stratified squamous nonkeratinizing
epithelium. It is 3-4 layers thick in
early life, but the number of layers
increase with age to 10-20 layers.
These cells can be grouped in 2
strata: basal and suprabasal.
 The length of the junctional
epithelium is 0,25 to 0,35mm.
 The junctional epithelium is formed
by the confluence of the oral
epithelium and the reduced enamel
epithelium during tooth eruption.
 Junctional epithelium
1. Is attached to the tooth surface (epithelial attachement) by an internal
basal lamina;
2. And to the gingival connective tissue – by an external basal lamina.
 The internal basal lamina consists of a lamina densa (adjacent to the
enamel) and a lamina lucida to which hemidesmosomes are attached.
 The attachment of the junctional epithelium to the tooth is reinforced by
the gingival fibers.
 The gingiva

Is divided anatomically
into:
 Marginal gingiva;
 Attached gingiva;
 Interdental gingiva.
 Gingival sulcus

 Is the 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. It is V shaped
and barely permits the
entrance of a periodontal
probe.
 Attached Gingiva
 Is continuous with the marginal gingiva. It is firm, resilient and tightly bound to the
underlying periosteum of alveolar bone. The facial aspect of the attached gingiva
extends to the relatively loose and movable alveolar mucosa, from which it is
demarcated by the mucogingival junction.
 The width of the attached gingiva is the distance between the mucogingival junction
and the projection on the external surface of the bottom of the gingival sulcus or the
periodontal pocket.
 Attached Gingiva
 It differs in different areas of the mouth. It is greatest in the
incisor region: 3,5 to 4,5mm in the maxilla and 3,3 to 3,9
in the mandible; and less in the posterior segments with the
least width in the first premolar area (1,9mm in the maxilla
and 1,8 – mandible).
 Interdental gingiva
 Occupies the gingival embrasure which is the interproximal space beneath the area of
tooth contact. It can be pyramidal or have a « col » shape.
 The shape of the gingiva in an interdental space depends on the contact point between
the 2 adjoining teeth and the presence or absence of some degree of recession.
 Gingival fibers

They consist of type I collagen. They

have the following functions:
A. To brace the marginal gingiva firmly
against the tooth;
B. To provide the rigidity necessary to
withstand the forces of mastication;
C. To unite the free marginal gingiva with
the cementum of the root and the
adjacent attached gingiva.
The gingival fibers are arranged in 3 groups:
 Gingivo-dental;
 circular
 transseptal.
Gingival fibers

 1.Dentogingival (coronal, horizontal, apical),

 2.Alveologingival,
 3.Interpapillary
 4.Transgingival,
 5.Circular, semicircular,
 6.Dentoperiosteal
Connective Tissue Attachment/
Gingival Fibers
3.Interpapillary
4.Transgingival,
5.Circular, semicircular,
6.Dentoperiosteal
7.Transseptal
8.Periostogingival
9.Intercirular
10.intergingival
 Gingival fibers

I. The gingivodental fibers are those on the facial, lingual and interproximal
surfaces. They are embedded in the cementum just beneath the epithelium at
the base of the gingival sulcus.
II. Circular group: the fibers course through the connective tissue of marginal and
interdental gingivae and encircle the tooth in a ringlike fashion.
III. Transseptal group: located interproximally.
There are also (Page and co-workers):
a) A group of semicircular fibers (attached at the proximal surface of a tooth and
attach on the other proximal surface of the same tooth)
b) A group of transgingival fibers (atthached in the proximal surface of one tooth
and to the proximal surface on the next tooth)
 Clinical aspects of the gingiva
① Color – pink;
② Contours – varies and depends on the shape of the teeth and their
alignment in the arch, the location and size of the area of the proximal
contact. The marginal gingia envelops the teeth in collarlike fashion.
③ Consistency – firm and resilient and tightly bound to the bone (except of
the movable free margin);
④ Surface texture – similar to an orange peel and is referred to as being
stippled.
 Periodontium

 The periodontal ligament, commonly abbreviated as the PDL, is

a group of specialized connective tissue fibers that essentially
attach a tooth to the alveolar bone within which it sits.[1] It inserts
into root cementum one side and onto alveolar bone on the other.
 The PDL consists of principal fibres, loose connective tissue,
blast and clast cells, oxytalan fibres and Cell Rest of Malassez
 Periodontal ligament
Is the connective tissue that surrounds the root and connects it to the bone. The most important elements are
the principal fibers, which are collagenous, and are arranged in 6 groups:
1. Transseptal group: extend interproximally over the alveolar bone crest and are embedded in the cementum
of the adjacent teeth;
2. Alveolar crest group: extend obliquely from the cementum to the alveolar crest.
 Periodontal ligament
3. Horizontal group: extend at right angles to the long axis of the tooth form the cementum
to the alveolar bone.
4. Oblique group: largest group, from the cementum in a coronal direction obliquely to the
bone;
5. Apical group: from the cementum to the bone at the apical region of the socket.
6. Interradicular fibers: from the cementum to the tooth in the furcation areas of
multirooted teeth.
Composition

 The PDL substance has been estimated to be

70% water, which is thought to have a significant
effect on the tooth's ability to withstand stress
loads. The completeness and vitality of the PDL
are essential for the functioning of the tooth.
 The PDL ranges in width from 0.15 to 0.38mm
with its thinnest part located in the middle third
of the root. The width progressively decreases
with age.
Cells of periodontal
ligament
Cells of periodontal ligament can be
categorized as -
Synthetic cells – ”produces”
• Osteoblasts, Fibroblasts, Cementoblasts.
Resorptive cells – ”disolves”
• Osteoclasts, Cementoclasts, Fibroblasts.
Functions

 Functions of PDL are

 supportive,
 sensory,
 nutritive,
 remodeling
Support

 The PDL is a part of the periodontium that

provides for the attachment of the teeth to the
surrounding alveolar bone by way of the
cementum.
 PDL fibres also provide a role in load transfer
between the teeth and alveolar bone. (PDL fibres
absorb and transmit forces between teeth and
alveolar bone. It acts as an effective support
during the masticatory function.)
 Sensory
 PDL is heavily
innervated; it involves
mechanoreception,
nociception and reflexes.
Periodontal
mechanoreceptors are
present in PDL.
 They will transmit
information about the
stimulated tooth,
direction and amplitude
of forces
 Nutritive
 It maintains the vitality of the surrounding
cells. (PDL is heavily anastomosed). There
are three principal sources of blood vessels
which are apical vessels, perforating
vessels and gingival vessels.
 Outer layers of blood supply in PDL may
help in mechanical suspension and support
of the tooth while inner layers of blood
vessels supply surrounding PDL tissues
 Apical vessels
originate from
vessels that
supply the pulp.
 Perforating
vessels originate
from lamina dura
and the vessels
perforate the
socket wall
(cribriform plate).
 Gingival vessels
are derived from
the gingival tissue.
 Remodeling

 There are progenitor cells in the

periodontal ligament that can
differentiate into osteoblasts for
the physiological maintenance of
alveolar bone and for its repair
as well.
 Cementum
 Is the calcified avascular mesenchymal tissue
that forms the outer covering of the anatomic
root.
 Topographic ratio or cement-
enamel junction (variants)

 The relationship
involving the
cementum and enamel:
 Cementum overlaps
the enamel – 60-65%;
 Edge-to-edge – 30%;
 Cementum and enamel
fail to meet – 5-10%.
Cemento-enamel junction CEJ
 Acellular cementum
 Is the first to be formed and covers approximatively the cervical
third or half of the root.
 It is formed before the tooth reaches the occlusal plane and its
thickness – 30-230μm.
 Cellular cementum
 Is formed after the tooth reaches the occlusal plane and is more
irregular and contains cells (cementocytes) in individual spaces
that communicate with each other through a system of
anastomosing canaliculi. It is less calcified than the acellular
type.
 Both acelluar and cellular cementum are arranged in lamellae
separated by incremental lines parallel to the long axis of the root
 Hypercementosis
 Hypercementosis is a non-
neoplastic condition characterised
by excessive deposition of
cementum on the roots of teeth.
 It may affect a single tooth or
multiple teeth. The condition is
asymptomatic and is detected on
radiographic examination.
 Alveolar process
Is the portion of the maxilla and mandible that forms and
supports the tooth sockets. It forms when the tooth errupts
to provide osseous attachment to the forming periodontal
ligament.
The alveolar process consists of:
1. An external plate of cortical bone(inner and outer) formed by
haversian bone and compacted bone lamellae.
2. The inner socket of thin, compact bone called the proper
alveolar bone;
3. Trabecular bone(spongious), between these 2 compact layers,
which acts as supporting alveolar bone.
 Alveolar Crest
 The alveolar crest is the most coronal portion, or the top,
of the alveolar process. It is an extension of both the
mandible and maxilla and holds the tooth sockets.
 The crest of the alveolar bone is normally located
around 1 mm below the cemento-enamel junction.
 The alveolar crest is often the first portion of the alveolar
process that is damaged by periodontal disease and is
therefore the first bone that is lost.
 Crestal Contour of the Interdental Bone

 a. Horizontal crest
of the path. The crest
bones will have
horizontal path when
CEJs adjacent teeth
are on the same level
 B. Angular crest of
the path. The crest
bones will have
vertical contour in
one of the
neighboring teeth are
tilted or have
different height
 Resorption and bone apoptosis
 The process of remodeling of the bone involves the
removal of hard bone tissue by osteoclasts followed by
the creation of new bone by osteoblasts.
 Bone destruction – in periodontal disease- is mediated by
the host immune and inflammatory response to the
microbial challenge.
Occlusal forces and alveolar bone
Thank you for
your attention!
 Classification of Periodontal
Diseases (1999)
Periodontitis Associated with Endodontic Lesions

Combined periodontic-endodontic lesions

 Initiation & Progression of Periodontal Disease
(Health  Gingivitis  Periodontitis)

Shallow gingival sulcus Shallow periodontal pocket Deepened periodontal pocket

Apical termination of JE at CEJ Apical termination of JE at CEJ Loss of CT attachment & bone
Inflamed connective tissue JE on root surface
Inflamed connective tissue

Illustrations courtesy of Gary C. Armitage, DDS, MS

Development of the gingival
sulcus
 After enamel formation is complete, the enamel is covered with
reduced enamel epithelium. When the tooth penetrates the oral
mucosa, the reduced enamel epithelium unites with the oral
epithelium and transforms into junctional epithelium.
 The gingival sulcus is formed when the tooth erupts into the oral
cavity when the junctional epithelium and reduced enamel
epithelium form a broad band attached to the tooth surface from
near the tip of the crown to the cementoenamel junction.