Gingiva is the part of oral mucosa that covers the alveolar
processes of jaws and surrounds the neck of teeth.
Part of masticatory mucosa covering the alveolar processes of
the cervical portions of teeth.
GLOSSARY OF PERIODONTICS (AAP):
The fibrous investing tissue, covered by keratinized epithelium,
that immediately surrounds a tooth and is contiguous with its
periodontal ligament and with the mucosal tissues of the
It is a combination of epithelium and connective tissue and it
defined as that portion of oral mucous membrane, which in
complete post eruptive dentition of a healthy young individual
surrounds and is attached to the teeth and the alveolar processes.
Gingiva is the part of oral mucous membrane attached to the teeth
and the alveolar processes.
Gingiva is that part of oral mucous membrane that covers the
alveolar processes of the cervical portions of the teeth.
10. 10 10
• Gingival crevice – Orban &
• Shallow crevice around the tooth
• V- shaped
Imp. Diagnostic parameter
Ideal conditions: 0/ close to 0mm
Biologic depth: 1.8mm
Probing depth: 2-3 mm
• Occupies gingival embrasure
• Formed by:
Lateral borders & tip – marginal gingiva
Central intervening portion – attached
• Shape: Pyramidal - Anteriors
Col – Posteriors
• Diastema: gingiva is firmly bound over
bone forming a smooth, rounded
surface without interdental papilla.
12. ATTACHED GINGIVA
• Firm, resilient and tightly bound to
the underlying periosteum of alveolar
bone by connective tissue fibers.
• Coronally: marginal gingiva
• Apically: palatally-palatal mucosa
• Mucogingival junction
• Width of attached gingiva
• Widest in incisor region
Maxilla: 3.5 – 4.5 mm
Mandible: 3.3 – 3.9 mm
• Most narrow adjacent to premolar
Maxilla: 1.9 mm
Mandible: 1.8 mm
• Wider in molar region
• Narrow in incisor region
Increases: by the age of 4yrs
HALL WB, 1982: the width of attached gingiva is determined by subtracting the
sulcus or pocket depth from total width of gingiva
Total width of gingiva: from MGJ to crest of marginal gingiva
Methods to determine mucogingival junction:
1. Visual method.
2. Functional method.
3. Visual methods after histochemistry staining.
15. How much zone of attached gingiva is necessary to
maintain the health of Periodontium?
• Lang & Loe,1972: suggested that 2 mm of keratinized gingiva
(corresponding to 1 mm attached gingiva in this material) is adequate to
maintain gingival health.
• Bowers GM,1963: It is possible to maintain clinically healthy gingiva despite
a very narrow zone of attachment (less than 1 mm.).
• Wennstorm, 1987: the lack of minimum amount of attached Gingiva does
not necessarily result in a soft tissue recession. Proper plaque control
prevents soft tissue recession, even when it is out of adequate width.
• Mehta P et al,2010: width of attached gingiva is not significant to maintain
periodontal health in the presence of adequate oral hygiene.
17. GINGIVAL EPITHELIUM – GENERAL ASPECTS :
• Continuous lining of stratified squamous epithelium.
Physical barrier to Infection
Participate actively in responding to infection in signaling
further host reactions in integrating innate and acquired
To protect deep structures
Allow a selective interchange with the oral environment.
18. • Layers of stratified squamous epithelium as seen by
19. Stratum basale:
• Cells: cylindric or cuboid.
• Found immediately adjacent to the connective tissue separated
by a basement membrane.
• Germinative layer: having the ability to divide.
• It takes approximately 1 month for a keratinocyte to reach the
outer epithelial surface, where it is shed from the stratum
20. Stratum spinosum:
• Prickle cell layer.
• Large polyhedral cells with short cytoplasmic processes.
• Keratinosomes or odland bodies:
Present in the uppermost part of the stratum
Contain a large amount of acid phosphatase.
21. Stratum granulosum:
• Flattened cells, in a plane parallel to the gingival surface.
• Keratohyaline granules :
• Associated with keratin formation are 1 μm in diameter)
round in shape and appear in the cytoplasm of the cell.
22. Stratum corneum:
• Closely packed, flattened cells that have lost nuclei and
most other organelles as they become keratinized.
• The cells are densely packed with tonofilaments.
• Clear, rounded bodies probably representing lipid droplets
appear within the cytoplasm of the cell.
23. Proliferation through mitosis occurs in the basal layer , less
frequently in the suprabasal layer and migration occurs.
Differentiation includes keratinisation in which main
morphologic changes seen are:
• Progressive flattening of the cell.
• Increased prevalence of tonofilaments.
• Intercellular junctions coupled to the production of
• Disappearance of the nucleus
24. • Three types of surface keratinization can occur in the gingival
• Intermediate stage of keratinization.
• Most prevalent surface area of the
• Can progress to maturity or de-
differentiate under different physiologic
or pathologic conditions.
• Stratum cornea retains PYKNOTIC
• Keratohyalin granules are dispersed
rather than giving rise to a stratum
• Viable nuclei in superficial layer.
• Has neither granulosum nor
• Layers of nonkeratinized
1. Stratum superficiale
2. Stratum intermedia
3. Stratum basale
28. ULTRASTRUCTURE OF EPITHELIUM:
• Each epithelial type have characteristic pattern of cytokeratins.
• Keratin proteins are composed of different polypeptide subunits
characterized by their isoelectric points and molecular weights.
• Basal cells begin synthesis of low mol. Wt. keratins.
Ex.: K19 (40kD).
• High mol. Wt. keratins are expressed when they reach superficial
Ex.: K1 (68kD).
29. • Other proteins synthesized during maturation proess:
Most differentiated epithelial cell
Composed of bundles of keratin tonofilaments in amorphous
matrix of filaggrin, surrounded by a resistant envelope made of
keratolinin and involucrin.
• These histochemical patterns change under normal or pathologic
stimuli, thereby modifying the keratinization process.
30. EPITHELIAL CELL CONNECTIONS:
• Together with intercellular protein-carbohydrate complexes,
cohesion between cells is provided by numerous structures
Located between the cytoplasmic processes of adjacent
Two hemidesmosomes facing each other.
Large number of desmosomes gives a solid cohesion
31. A desmosome comprises the following structural components:
1. the outer leaflets (OL) of the cell membrane of two adjoining cells,
2. the thick inner leaflets (IL) of the cell membranes
3. the attachment plaques (AP), which represent granular and fibrillar
material in the cytoplasm.
32. • TONOFILAMENTS:
Cytoskeleton of keratin
proteins which radiate in
brush like fashion from the
attachment plaques into
cytoplasm of the cells.
• TIGHT JUNCTIONS
Rarely observed forms of
epithelial cell connections
where the membranes of the
adjoining cells are believed
to be fused
33. ULTRASTRUCTURE OF EPITHELIAL CELL:
• Cytoplasmic organelle concentration varies among different
• Mitochondria, endoplasmic reticulum, golgi complexes etc
are more numerous in deeper strata and decrease towards
• Cytokeratins increase in number from basale to corneal
36. • 90% of the total gingival cell population.
• Originate from ectodermal germ layer.
• Cell organelles: nucleus, cytosol, ribosomes, Golgi apparatus etc
• Melanosomes: Pigment bearing granules
• Proliferation and differentiation of the keratinocytes
helps in the barrier action of the epithelium.
37. • Move from basal to superficial layers of the epithelium as the
process of differentiation occurs, forming a keratin barrier.
• The microfilaments present in the keratinocytes help in cell motility
and maintenance of the polarity.
39. • Dendritics cells - Modified monocytes belonging to RES.
• Paul Langerhans used gold impregnation technique to visualize LCs.
• Reside chiefly in suprabasal layers.
• Act as antigen -presenting cells for lymphocytes.
• Specific elongated g-specific granules called as Birbecks Granules.
• Have marked adenosine triphosphatase activity.
• Only epidermal cells which express receptors for C3 and Fc portion of IgG.
• Can move in and out of the epithelium unlike melanocytes.
• Found in oral ep. of normal gingiva.
• Smaller amounts in sulcular ep.
• Absent in healthy junctional ep.
40. Merkel Cells:
• Located in deeper layers of epithelium.
• Not dendritic cells
• Possess keratin tonofilaments and desmosomes.
• Harbor nerve endings.
• Sensory in nature - respond to touch – Tactile Perceptors
• Originate from neural crest cells.
• Found in the stratum basale.
• Identified in gingiva by Laidlaw and Cahn, 1932.
• Have long dendritic processes, interspersed between the keratinocytes.
• Lack tonofilaments and desmosomal connections.
• Synthesize melanin, responsible for providing color to gingiva.
• Melanin is synthesized in organelle called premelanosomes/melanosomes,
which are transported along microtubules and actin filaments to the cell
42. TYPES OF GINGIVAL EPITHELIUM
Oral or outer epithelium
43. ORAL OR OUTER EPITHELIUM
• Covers the crest and outer surface of
the marginal gingiva and the surface
of the attached gingiva.
• 0.2 to 0.3 mm in thickness.
• Keratinized or parakeratinized, or it
may present combinations of these
• The oral epithelium is composed of
44. • K1, K2, K10-12 cytokeratins present are immunohistochemically
expressed with high intensity in orthokeratinized areas and with
less intensity in parakeratinized areas.
• K6 and K16 , characteristic of highly proliferative epithelia.
• K5 and K14, stratification-specific cytokeratins , also are present
45. SULCULAR EPITHELIUM
• Lines the gingival sulcus.
• Thin, nonkeratinized stratified
• No rete pegs.
• Extends from the coronal limit
of the junctional epithelium to
the crest of the gingival
• Hydropic degeneration of cells.
• Contains K4 and K13, K19.
• Don’t have merkel cells.
46. Sulcular epithelium has the potential to keratinize:
• If it is reflected and exposed to the oral cavity.
• If the bacterial flora of the sulcus is totally eliminated.
Outer epithelium loses its keratinization:
• When it is placed in contact with the tooth.
These findings suggest that the local irritation of the sulcus
prevents sulcular keratinization.
Sulcular epithelium is extremely important because it act as
a semi permeable membrane through which injurious
bacterial products pass into gingival fluid. Less permeable
47. JUNCTIONAL EPITHELIUM
• Collarlike band of stratified squamous
• 3 to 4 layers thick in early life, but the
number increases with age to 10 or even
• Tapers from its coronal end to apical
termination, located at the
cementoenamel junction in healthy
• Length: 0.25 to 1.35 mm.
48. • These cells can be grouped in two strata:
• the basal layer: that faces the
connective tissue (External Basal
• the suprabasal layer: that extends to
the tooth surface.– DAT CELLS (Internal
• 3 zones of junctional epithelium:
1. Apical – germination
2. Middle – adhesion
3. Coronal- permeable.
49. THE DENTOGINGIVAL UNIT:
• The attachment of the junctional epithelium to the tooth is
reinforced by the gingival fibers, which brace the marginal gingiva
against the tooth surface.
• For this reason, the junctional epithelium and the gingival fibers
are considered together as a functional unit.
50. Hypothesis given to explain mode of attachment of epithelium to
1. Gottlieb: gingiva is organically united to surface of enamel. He
termed it as epithelial attachment. (drawback- did not explain
how exactly it attaches.)
2. Waerhaug : in 1952 presented a concept of epithelial cuff, he
concluded that gingival tissues are closely adapted but not
3. Stern: in 1962 showed the attachment to tooth is through
hemidesmosomes, supported by schroeder and listgarten.
51. Unique structural and functional features of JE that contribute to
preventing pathogenic bacterial flora from colonizing the subgingival
Firmly attached to the tooth surface forming an epithelial barrier against
Allows access of gingival fluid, inflammatory cells, and components of the
immunologic host defense to the gingival margin.
Exhibits rapid turnover contributing to the host–parasite equilibrium and the
rapid repair of damaged tissue.
Have an endocytic capacity equal to that of macrophages and neutrophils and
that this activity may be protective in nature.
52. Development/Origin of Junctional Epithelium
REE surrounds the crown of tooth from the moment
enamel is properly mineralized till the tooth erupts .
Migrating epithelium produces an epithelial
mass between oral epithelium and REE so
that tooth can erupt without bleeding.
When tooth has penetrated in oral cavity
large portions immediately apical to incisal
area of enamel are covered by junctional
epithelium containing few layers of cell.
During later phases of tooth eruption all
cells of REE is replaced by JE.
• Provides attachment to the tooth.
• Forms an epithelial barrier against the plaque bacteria.
• Rapid cell division and funneling of cells towards the sulcus:
Hinder bacterial colonization and
Repair of damaged tissue occurs rapidly.
• Allow GCF:
From connective tissue into crevice – Gingival fluid exudates, PMNs,etc.
From crevice to connective tissue – Foreign material such as carbon particles,
• Produces active antimicrobial substances like defensins, lysosomal enzymes,
calprotectin and cathelicidin.
• Epithelial cells activated by microbial substances secrete chemokines, e.g. IL-1, IL-6, IL-
8 and TNF that attract and activate professional defense cells such as lymphocytes and
55. • Represented as either as transudate or an exudate.
• Diagnostic or prognostic biomarker of the biologic state of the
periodontium in health and disease.
• GCF flow increases during inflammation and resembles that of
• Gingival fluid diffuses through the basement membranes.
GINGIVAL CREVICULAR FLUID
56. • Functions:
Cleanse material from the sulcus.
Contain plasma proteins that may improve adhesion of epithelium
to the tooth
Possess antimicrobial properties
Expert antibody activity to defend the gingiva.
57. Epithelium—Connective Tissue Interface
• Ultrastructurally the interface is
composed of 4 elements:
• Basal cell plasma membrane.
• Lamina lucida: 25 to 45 nm wide.
• Lamina densa: 40 to 60 nm
• Reticular layer.
• From the lamina densa so called
anchoring fibrils project in a fan-
shaped fashion into the connective
58. Various junctional complexes present in gingiva are:
• Tight junctions/Zonae occludens
• Adhesive junctions:
Cell to cell
– Zonula adherens
– Desmosomes: 30 nm.
Cell to matrix
– Focal adhesions
• Gap junctions:
Intercellular pipes/channels bridge both adjacent membranes and
Intercellular space in gap junction is approx. 3 nm.
Major pathway for direct intercellular communication.
61. GROUND SUBSTANCE:
• Fills space between fibers and cells
• High water content
• Composed of:
Glycoproteins: (PAS positive)
The different types of cell present in the connective tissue
Fixed Macrophages & Histiocytes
Inflammatory cells (Plasma cells, Lymphocytes,
• Preponderant cellular element in the gingival connective tissue.
• Mesenchymal origin.
• Play a major role in the development, maintenance, and repair of gingival
• Synthesize :
glycoproteins and glycosaminoglycans.
• Regulate collagen degradation through phagocytosis and the secretion of
• Fibroblast heterogeneity is now a well-established feature of
• fibroblasts in the periodontium which is necessary for the normal
functioning of tissues in health, disease, and repair
64. GINGIVAL FIBERS:
The connective tissue fibers are produced by the
fibroblasts and can be divided into:
• Collagen fibers
• Reticulin fibers
• Oxytalan fibers
• Elastic fibers..
65. Collagen type I:
forms the bulk of the lamina propria
provides the tensile strength to the gingival tissue.
Type IV collagen:
branches between the collagen type I bundles
continuous with fibers of the basement membrane and the blood vessel
Densely packed collagen bundles that are anchored into the acellular
extrinsic fiber cementum just below the terminal point of the junctional
epithelium form the connective tissue attachment.
The stability of this attachment is a key factor in the limitation of the
migration of junctional epithelium.
66. Reticulin fibres:
• Have argyrophilic property and are numerous in tissue adjacent to basement
• Found in large number in loose CT surrounding blood vessel
• Hence found in endothelial-CT and epithelium-CT interface.
• Only present in association with blood vessels.
• Gingiva seen coronal to mucogingival junction has no elastic fibres except in assocation
with blood vessels.
• Alveolar mucosa may have many elastic fibres.
• Initially described by Fullmer.
• Modified type of elastic fibres.
• Scarce in gingiva but more in PDL.
• Have thin fibrils with 150 A0 dia.
67. Gingival Fibers:
• The connective tissue of the marginal gingiva is densely
collagenous, and it contains a prominent system of collagen fiber
bundles called the gingival fibers.
• These fibers consist of type I collagen.
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 the tooth
To unite the free marginal gingiva with the cementum of the
root and the adjacent attached gingiva
68. The gingival fibers are arranged in three groups:
According Page et.al:
Lindhe: Dentoperiosteal fibers
69. • Originates from cementum and spreads laterally
into lamina propria
• Orginates from periosteum and spreads into
• Originates from cementum near CEJ into
periosteum of alveolar crest
• Originates from within the free marginal and
attached gingiva coronal to alveolar crest and
encircles each tooth
• Originates from interproximal cementum coronal
to crest and courses mesially and distally in the
interdental area into cementum of adjacent teeth
70. •Originates from the periosteum of the lateral aspect of alveolar
process and spreads into attached gingiva.
•Originates from within interdental gingiva and follows on orofacial
•Originates within the attached gingiva interwing along dental arch
between and around teeth
•Originates from cementum on distal surface of tooth spreading
buccally and lingually around adjacent tooth and inserting on
mesial cementum of next tooth
•Originates from attached gingiva immediately subjacent to
basement membrane and courses mesiodistally
•Originates from cementum of the mesial surface of tooth and
courses distally and inserts on the cementum of distal surface of
75. • Generally coral pink.
• Color is a result of:
Degree of keratinisation of epithelium,
Presence of pigment containing cells.
• Color to be correlated with cutaneous pigmentation
76. Physiologic Pigmentation(melanin)
• Melanin (non hemoglobin derived brown pigment)
• Prominent in blacks, diminished in albinos
• Distribution of Oral Pigmentations in blacks:
Hard Palate -61%
Mucous membrane -22%
• As a diffuse , deep purplish discoloration or
as irregularly shaped brown and light brown patches
and may appear as early as 3 hours after birth.
77. Synthesis of Melanin pigmentation
• Tyrosine is hydroxylated into DOPA in presence of
• DOPA (Dihydroxy Phenylalanine) is converted into
• Melanin is phagocytosed to become Melanophages or
78. • Sum total of the bulk of cellular
and intercellular elements and
their vascular supply.
• Alteration in size is a common
feature of gingival disease
• Marginal gingiva envelops the teeth in collarlike fashion and follows a
scalloped outline on the facial and lingual surfaces.
• straight line - along teeth with relatively flat surfaces.
• accentuated - pronounced mesiodistal convexity (e.g., maxillary
canines) or teeth in labial version
• horizontal and thickened - in lingual version.
80. Anterior region of the dentition, the interdental papilla is pyramidal in form.
the papilla is more flattened in a buccolingual direction in the molar region.
The shape of the interdental gingiva is governed by the contour of the
proximal tooth surfaces and the location and shape of the gingival
81. • Shape depends on:
Presence/absence of contact
Distance btw contact point and osseous crest
Course of CEJ
Width of the approximate tooth surfaces
Presence/absence of recession.
• Firm and resilient
• Collagenous nature of the lamina propria and
its contiguity with the mucoperiosteum
determine the firmness of the attached
• The gingival fibers contribute to the firmness
of the gingival margin.
• If the gingiva is suppressed, the
proteoglycans become deformed and recoil
when the pressure is eliminated.
• Thus, the macromolecules are important for
the resilience of the gingiva.
83. • Orange peel – stippled,
• Stippling is best viewed by drying Gingiva.
• Attached Gingiva is stippled, marginal gingival is not.
• Central portion of interdental papilla is usually stippled, but marginal
borders are smooth.
• Less prominent on lingual surfaces and may be absent in some.
84. • Stippling –produced by alternate round protuberance and
depressions in the gingival surface.
• Low magnification ; a stippled surface,
• Higher magnification; cell micropits
• A form of adaptive specialization or reinforcement for function
–feature of healthy gingiva
85. • Reduction of stippling – common sign of Gingival disease.
• Stippling returns when gingiva is restored to health.
• Keratinisation – protective adaptation , increased by tooth
• In 40% of adults Gingiva show stippling.
• Generalized absence of stippling is seen in:
Diseased conditions like gingival enlargements, mucocutaneous
lesions affecting gingiva, inflammation etc.,
• The level at which the gingival margin is attached to the tooth.
• Continuous eruption, even after meeting their functional antagonists occurs
through out life
Active Eruption :Movement of teeth in the direction of occlusal plane
Passive Eruption: exposure of the tooth by apical migration of Gingiva
• Gottlieb : active and passive eruption go hand in hand.
• Active eruption is coordinated with attrition, to compensate for tooth
substance worn away.
• Attrition reduces the clinical crown and prevents it from becoming
disproportionately long in relation to the clinical root, thus avoiding excessive
leverage on periodontal tissue.
• Rate of active eruption is in pace with tooth wear in order to preserve vertical
88. • Exposure of the tooth via the apical migration of the gingiva is called
gingival recession or atrophy.
• According to the concept of continuous eruption, the gingival sulcus
may be located on the crown, the cementoenamel junction, or the
root, depending on the age of the patient and the stage of eruption.
• Therefore, some root exposure with age would be considered normal
and referred to as physiologic recession.
• Again, this concept is not accepted at present.
• Excessive exposure is termed pathologic recession
• Turnover rate is 10-12 days.
• It is one of the best healing tissues in the body with
little or no scarring.
• However the reparative capacity is lesser than that of
periodontal ligament and epithelial tissue.
Stippling usually disappears with age.
Width of the attached gingiva increases with age.
a. Gingival epithelium:
• Thinning and decreased keratinization
• Rete pegs flatten
• Migration of junctional epithelium apically.
• Reduced oxygen consumption.
b. Gingival connective tissue:
• Increased rate of conversion of soluble to insoluble collagen
• Increased mechanical strength of collagen
• Increased denaturing temperature of collagen
• Decreased rate of synthesis of collagen
• Greater collagen content.
Gingivitis associated with dental
Gingival diseases modified by
Gingival diseases modified by
Gingival diseases modified by
92. Gingival diseases of specific bacterial origin
Gingival diseases of viral origin
Gingival diseases of fungal origin
Gingival lesions of genetic origin
Gingival manifestations of systemic conditions
Not otherwise specified
• The biological width is defined as
the dimension of the soft tissue,
which is attached to the portion of
the tooth coronal to the crest of
the alveolar bone.
• Gargiulo et al.,:
• Established that there is a definite
proportional relationship between
the alveolar crest, the connective
tissue attachment, the epithelial
attachment, and the sulcus depth.
94. • They reported the following mean dimensions:
A sulcus depth of 0.69 mm, (a)
an epithelial attachment of 0.97 mm,(b)
connective tissue attachment of 1.07 mm.(c)
The biologic width is commonly stated to be 2.04 mm,(b+c)
which represents the sum of the epithelial and connective tissue
95. Biologic Width Evaluation:
1. Clinical (discomfort when the restoration margin levels are being assessed
with a periodontal probe)
2. Radiographs (for interproximjal violation but mesiofacial and distofacial line
angle not seen properly)
3. Bone sounding (probing under anesthesia)
If this distance is less than 2 mm or more at one or more locations, a diagnosis
of biologic width violation can be confirmed
Biologic width violation:
• Unpredictable bone loss
• Gingival recession
• Persistence of ginigivitis
96. GINGIVAL BIOTYPE
• Gingival biotype is described as the thickness of the gingiva in the
faciopalatal/ faciolingual dimension.
• Seibert and Lindhe categorized the gingiva into:
1. thick-flat: A gingival thickness of ≥ 2 mm
2. thin scalloped: a gingival thickness of <1.5 mm
• Significant impact on the outcome of the restorative, regenerative and
• Direct co-relation exists with the susceptibility of gingival recession followed
by any surgical procedure.
97. Thick blunted:
reacts to surgical & restorative
insults with pocket formation
Attached soft tissue is minimal
Bony dehiscence & fenestration defects
Reacts to surgical or restorative
interventions with ST recession, apical
migration of attachment & loss of
underlying alveolar volume .
98. • Gingival tissues play a key role in the protection of tooth
structures and supporting periodontal tissues against trauma
• Making the gingival health, a very essential component for the
success of all periodontal treatment procedures.
• Therefore, Gingiva, a small tissue is a big issue for the fraternity
• Clinical Periodontology By Carranza, 12th Edition
• Clinical Periodontology And Implant Dentistry By Jan
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• Biology Of Periodontal Connective Tissue-bartold And
• Oral Histology, Development, Structure And Function – A.R.
Tencate, 5th Edition
• PERIODONTICS REVISITED Shalu Bathla, 1st Edition
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