Gingiva is the part of the oral mucosa that covers the alveolar processes of the jaws and surrounds

the necks of the teeth.

The gingiva is divided anatomically into :

2)
3)

Marginal Gingiva Attached Gingiva Interdental Gingiva

The marginal, or unattached, gingiva is the terminal edge or border of the gingiva surrounding the teeth in collarlike fashion. It is demarcated from the adjacent attached gingiva by a shallow linear depression, the free gingival groove.

Usually about 1 mm wide

The gingival sulcus is V shaped 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. Sulcus Depth: absolutely normal condition= 0 mm histological sections=1.8 mm (0 to 6 mm) probing depth =2 to 3 mm ( its an important clinical parameter) in children= 2.1mm(0.2mm)

Contains : Sulcular or Crevicular fluid (transudate or exudate)

GCF contains: components of epithelium, connective tissue, inflammatory cells, serum and microbial flora inhabiting the gingival margin, the sulcus or the pocket. Functions : Cleanse material from the sulcus Contain plasma proteins that may improve adhesion of the epithelium to the tooth Posses antimicrobial properties Exert antibody activity to defend the gingiva

It is firm, resilient, and tightly bound to the underlying periosteum of alveolar bone. Extends to the alveolar mucosa and is demarcated by the mucogingival junction. This junction is constant throughout life.

The width of the attached gingiva is another important clinical parameter. Greatest in the incisor region maxilla =3.5-4.5 mm mandible= 3.3-3.9 mm Narrower in the first premolars region maxillary =1.9 mm mandibular 1.8 mm Changes in the width is due to the modifications in the position of the coronal end of the gingiva. It increases with age and in supraerupted teeth.

The interdental gingiva occupies the gingival embrasure, which is the interproximal space beneath the area of tooth contact. The shape of interdental gingiva is determined by : - the contact relationships between the teeth - the width of approximating tooth surfaces - the course of the cemento-enamel junction In presence of diastema or when proximal contact is missing, the interdental papillae is absent.

Anterior : Pyramidal shape

Molars: Papillae are more flattened in a bucco-lingual direction. COL shape

Gingiva is composed of :
I.

Gingival epithelium Stratified squamous type. Predominantly cellular in nature. Gingival connective tissue Less cellular, composed primarily of collagen fibers and ground substance.

II.

Functions :

Protection of underlying structures while permitting selective interchange with the oral environment. Play an active role in innate host defence by responding to bacteria in an interactive manner & produces cytokines, adhesion molecules, growth factors and enzymes.

Stratum Basale (Basal Cell Layer or Stratum Germinativum) Stratum Spinosum (Spinous Cell Layer) Stratum Granulosum (Granular Cell Layer) Stratum Corneum (Corneal or Horny Cell Layer)

The principal cell type of the gingival epithelium, is the keratinocyte . Proliferation of keratinocytes takes place by mitosis in the basal and suprabasal layer.

Differentiation involves the process of keratinization.

From the basal layer to the granular layer: - Progressive flattening of the cell - Increase in the number of tonofilaments (F) & desmosomes (D) in the cytoplasm - Decrease in the number of organelles such as mitochondria (M), rough endoplasmic reticulum (E) and Golgi complexes (G).

In the stratum granulosum, electron dense keratohyaline granules (K) and clusters of glycogen containing granules start to occur. Such granules are believed to be related to the synthesis of keratin.
Disappearance of the nucleus.

Orthokeratinized epithelium(15%) - Complete keratinization - no nuclei in the stratum corneum and a well-defined stratum granulosum Parakeratinized epithelium(75%), - retains pyknotic nuclei in stratum corneum - keratohyaline granules disperse Nonkeratinized epithelium(10%) - has neither granulosum nor corneum strata - superficial cells have viable nuclei INTERCELLULAR PROTEINS: Cytokeratin (K1- K19) Other proteins: keratolinin, involucrin & filaggrin.

DESMOSOME comprises the following structural components: - the outer leaflets(OL) of the cell membrane of two adjoining cells - the thick inner leaflets(IL) of the cell membranes - the attachment plaques(AP), into which tonofibrils insert - zone containing electron-dense granulated material (GM) extracellularly. Less frequently observed forms of epithelial cell connections are TIGHT JUNCTIONS (zonae occludens), where the membranes of the adjoining cells are believed to be fused.

The epithelium is connected to the underlying connective tissue by a basal lamina 300 to 400 thick, lying approximately 400 beneath the epithelial basal layer.

Basal lamina consists of lamina lucida (composed of the glycoprotein laminin) and lamina densa (composed of Type IV collagen).

Hemidesmosomes of the basal epithelial cells abut the lamina lucida.

Melanocytes: -dendritic cells -located in basal and spinous layers of the gingival epithelium -synthesize melanin in premelanosomes or melanosomes
Langerhans cells: -dendritic cells, belong to mononuclear phagocytic system -located in suprabasal layer - act as antigen presenting cells for lymphocytes -contain g-specific granules (Birbeck granules) and have marked adenosine triphosphatase activity

Merkel cells:-located in the deeper layers of the epithelium and harbor nerve endings -act as tactile perceptors

Morphologically and functionally gingival epithelium can be divided into:

Oral or Outer Epithelium Sulcular Epithelium Junctional Epithelium

It covers the crest and the outer surface of the marginal gingiva and the surface of the attached gingiva.
On average it is 0.2 to 0.3mm in thickness. It is composed of 4 layers:a)Stratum basale (basal layer) b)Stratum spinosum (spinous layer) c)Stratum granulosum (granular layer) d)Stratum corneum (cornified layer) Oral epithelium is mostly parakeratinized, but can be keratinized or various combination of the two.

Keratins K1, K2, K10 to K12 are expressed in high intensity in orthokeratinized areas. Parakeratinized areas express K19. Keratinization of different areas are: Palate(most), Gingiva, Ventral aspect of tongue Cheek(least). Degree of keratinization decreases with age and menopause.

It looses its keratinization when placed in contact with the tooth surface.
Langerhans cells are found here.

It lines the gingival sulcus; and is a thin , nonkeratinized stratified squamous epithelium without rete pegs.

It extends from the coronal limit of junctional epithelium to the crest of the gingival margin.
It acts as a semi permeable membrane through which injurious bacterial products pass into the gingiva and tissue fluid from the gingiva seeps into the sulcus. Sulcular epithelium has the potential to keratinize if a) it is reflected and exposed to the oral cavity, or b) the bacterial flora is totally eliminated. It contains K4, K13 and K19 cytokeratins. Few Langerhans cells and PMNs are found but not Merkel cells.

It is a collar-like band of stratified squamous nonkeratinized epithelium formed by the confluence of the oral epithelium and the reduced enamel epithelium during tooth eruption. Thickness = 3 to 4 layers (early life) to 10 or 20 layers (adults). Length = 0.25 to 1.35mm. It is completely restored after pocket instrumentation or surgery and forms around an implant. It expresses K5 , K14and K19 cytokeratins.

It lacks expression of K6 and K16, which is usually linked to highly proliferative epithelia, although the turnover of the cells is very high. And it also doesn't synthesis K4 & K13.

It is attached to the tooth surface by internal basal lamina & to gingival connective tissue by an external basal lamina the cells of which produces laminin and play a key role in adhesion mechanism. The attachment of junctional epithelium is reinforced by the gingival fibers and considered a functional unit, the dentogingival unit.

It has as a cellular and extracellular compartment composed of: Collagen fibres 60% Fibroblast - 5% vessels, nerves, matrix- 35 %

It is known as lamina propria and consists of Papillary layer Reticular layer

Collagen fiber

3 types:-collagen, reticular, and elastic. Collagen type I forms the bulk of the lamina propria and provides the tensile strength to the gingival tissue.

Type IV collagen branches between type I and is continuous with fibers of the basement membrane and blood vessel walls.
Reticular fibers are composed of collagen type III. Elastic fiber system is composed of oxytalan, elaunin, and elastin fibers distributed among collagen fibers.

The stability of the connective tissue attachment is a key factor in limiting the migration of junctional epithelium 26

Collagen fiber (type I) bundles of the connective tissue of the marginal gingiva is called gingival fibers.

Its functions are:a) To brace the marginal gingiva firmly against the tooth b)To provide the rigidity to withstand the forces of mastication without being deflected away from the tooth surface c)To unite the free marginal gingiva with the cementum of the root and the adjacent attached gingiva They are arranged in 3 groups:A. Gingivodental B. Circular C. Transseptal
27

They are found on the facial, lingual and interproximal surfaces.

Gingivodental fibers extending from the cementum (1) to the crest of the gingiva, (2) to the outer surface, and (3) external to the periosteum of the labial plate.

(4) circular fibers.

28

They course through the connective tissue of the marginal and interdental gingiva and encircle the tooth in ringlike fashion.

C. Transseptal Group
Found interproximally between the cementum of approximating teeth and lie in the area between the epithelium at the base of the gingival sulcus and the crest of the interdental bone. Sometimes classified with the principle fibers of the periodontal ligament.

29

Page et al. have also described semicircular and transgingival fibers.

Semicircular fibers attach at the proximal surface of a tooth, go around the facial or lingual marginal gingiva and attach on the other proximal surface of the same tooth.

Transgingival fibers attach on the proximal surface of 1 tooth, traverse the interdental space diagonally, go around the facial or lingual surface of the adjacent tooth, again traverse diagonally and attach in the proximal surface of next tooth.

1. dentogingival 3. interpapillary 4. transgingival 5. semicircular 7. transseptal 9. intercircular 10. intergingival

Fibroblast is the preponderent cellular element -found between the fiber bundles -mesenchymal origin -regulate collagen synthesize & degradation collagen -also synthesize elastic fibers, glycoproteins and glycosaminoglycans Fibronectin binds fibroblasts to the fibers and many other components of the intercellular matrix, helping mediate cell adhesion and migration.

Other types of cells found:

There are 3 sources of blood supply to the gingiva:Supraperiosteal arterioles (along the facial and lingual surfaces of the alveolar bone), Vessels of the periodontal ligament, and Arterioles (which emerge from the crest of the interdental septa).

32

lymphatics of the connective tissue papillae

network external to the periosteum of the alveolar process

Also lymphatics just beneath the junctional epithelium periodontal ligament accompany the blood vessels.
33

Neural tissues are extensively distributed in the connective tissue.

Gingival innervations is derived from fibers arising from nerves in the periodontal ligament and from the labial, buccal and palatal nerves.
Nerve structure present in the connective tissue are as follows:Meissner-type tactile corpuscles Krause-type end bulbs(temperature receptors) encapsulated spindles

34

 Color:

The attached gingiva and marginal gingiva : coral pink. produced by - vascular supply - the thickness and degree of keratinization of the epithelium - the presence of pigment containing cells. The alveolar mucosa is red, smooth and shiny. due to - thin, nonkeratinized alveolar mucosa - no retepegs - loosely arranged connective tissue - numerous blood vessels

35

Physiologic pigmentation:

Melanin is responsible for the normal pigmentation of skin, gingiva and the remainder oral mucous membrane and often found in highly pigmented ethnic groups. According to Dummett,the distribution of oral pigmentation in black individuals is :Hard palate 61%, Gingiva 60%, Mucous membrane 22%,and Tongue 15%.

Systemic diseases like Addisons disease, Peutz-Jeghers syndrome, Albrights syndrome and von Recklinghausens disease increases melanin pigmentation.
36

 Size:

It corresponds to the sum total of the bulk of cellular and intercellular elements and their vascular supply. Alteration in size is a common feature of gingival disease.

Contour:

It depends on the shape of the teeth and their alignment in the arch, the location and size of the area of proximal contact, and dimensions of the facial and lingual embrasures. The marginal gingiva follows a scalloped outline on facial and lingual surface.

In labially placed teeth it is placed further apically whereas in lingually placed teeth it is horizontal and thickened.

37

 Shape:

Shape of interdental gingiva is governed by the contour of the proximal tooth surfaces and the location and shape of gingival embrasures. The height of the interdental gingiva varies with the location of the proximal contact.

Shape of interdental gingival papillae correlated with shape of teeth and embrasures. A, Broad interdental papillae. B, Narrow interdental papillae.

38

 Consistency:

It is firm and resilient and tightly bound to the underlying bone

Surface

texture:-

It presents a textured surface reffered to as being stippled which is best viewed by drying the gingiva. Attached gingiva is stippled but not the marginal gingiva. In interdental gingiva, central portion is stippled.

39

It is less prominent or absent on the lingual surface. It varies with age; absent in infancy, appears at about 5 years, increases until adulthood and begins to disappear in old age.

Microscopically it is produced by alternate rounded protuberances and depressions in the gingival surface.
Stippling is a form of adaptive specialization or reinforcement for function and is a feature of healthy gingiva. Keratinization is also a protective adaptation to function which increases when the gingiva is stimulated by tooth brushing.

40

Position:It refers to the level at which the gingival margin is attached to the tooth. When the tooth erupts into the oral cavity, the margin and sulcus are at the tip of the crown; and as eruption progresses they are seen closer to the root. According to the Concept of Continuous Tooth Eruption, eruption does not cease when teeth meet their functional antagonists but continues throughout life and consists of: Active eruption (movement of the teeth in the direction of the occlusal plane),and Passive eruption( exposure of the teeth by apical migration of the gingiva). Gottlieb and Orban believed that active and passive eruption proceed together.However, passive eruption is now considered pathological.
41

Diagrammatic representation of the four steps in passive eruption according to Gottlieb and Orban.
1,Base of the gingival sulcus (arrow)and the junctional epithelium (JE)are on the enamel.

2,Base of the gingival sulcus (arrow)is on the enamel, and part of the junctional epithelium is on the root.

3,Base of the gingival sulcus (arrow)is at the cementoenamel line, and the entire junctional epithelium is on the root.

4,Base of the gingival sulcus (arrow)and the junctional epithelium are on the root.

42

Some root exposure with age is considered normal and referred to as physiologic recession. However, excessive exposure is termed pathologic recession.

The distance between the apical end of the junctional epithelium and the crest of the alvelous remains constant throughout continuous tooth eruption(1.07mm).

43

Gingiva is an important part of periodontium and its health is necessary for protecting the underlying tissues so that the tooth can function normally.

44