this presentation holds up maximum information on gingiva in health and disease

1. Dr. Lakkireddy Vasavi reddy
Gingiva in health and disease

2. Contents:
Introduction
Definition
Macroscopic features
Microscopic features
Blood supply, lymphatics and nerve supply
Changes in disease
Correlation of clinical and microscopic features

3. Introduction:
• Masticatory mucosa- gingiva and
covering of the hard palate.
• Specialized mucosa- dorsum of
the tongue.
• Lining mucosa- lining the
remainder of the oral cavity.
The oral cavity is lined
by a mucous
membrane that is
continuous anteriorly
with the skin of the lip
& posteriorly with the
mucosa of the soft
palate
The oral mucosa
consists of three zones:

4. Definition:
The gingiva is that part of the masticatory
mucosa which covers the alveolar process
and surrounds the cervical portion of the
teeth. (Lindhe)
The fibrous tissue, covered by keratinized
epithelium that immediately surrounds a
tooth and is contiguous with its
periodontal ligament and with the
mucosal tissues of the mouth. (GPT 2001)

5. Macroscopic features:
The gingiva is divided
anatomically into
• Marginal
• Attached
• Interdental areas.

6. Marginal gingiva
• It is unattached gingiva, which is the
terminal edge or border of the gingiva
surrounding the teeth in collar like
fashion.
• It is about 1mm wide, it forms the soft
tissue wall of the gingival sulcus
Free gingival groove -In about 50% cases,
marginal gingiva is demarcated from the
adjacent, attached gingiva by a shallow
linear depression, runs parallel to & at a
distance of 0.5 to 2mm from the margin of
gingiva.
• It may be separated from the tooth
surface with a periodontal probe.

7. Gingival sulcus:
• “It is 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.
• Histological depth- 1.8mm with variations
from 0 to 6mm, other studies have reported
1.5mm and 0.69mm, respectively.
• Probing depth - normal gingival sulcus is 2 to
3 mm.
• Ideal condition- 0mm

8. Development
of gingival
sulcus:

9. Attached gingiva
• It is firm resilient and tightly bound to the
underlying periosteum of alveolar bone.
• Width of attached gingiva
“It 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.”
• Greatest in the incisor region -3.5to4.5mm
in maxilla, 3.3to3.9mm in mandible
• Least in first premolar area -1.9mm in
maxilla , 1.8mm in mandible

10. Methods for assessing
attached gingiva

11. FUNCTIONS:
• Dissipates functional and
masticatory stresses.
• Provides a resistant barrier to
plaque induced inflammation.
• Prevents deflection of marginal
gingiva due to effects of frena &
lip musculature.
• Aids in plaque maintenance &
ease of oral hygiene maintenance.
• Improves aesthetics.

12. Studies:
Bowers (1963) measured the
widths of the facial attached
gingiva in the primary and
permanent dentitions of 240
subjects.
Width of the attached gingiva was
determined by subtracting the
sulcus probing depth (free gingiva)
from the total width of the
keratinized tissue (gingival margin
to MGJ).
Extremes of the width of attached
gingiva ranged from 1 to 9 mm.
Values were greatest in the incisor
regions (especially the lateral
incisor) and the least in the canine
and first premolar sites

13. Andlin-
Sobocki and
Bodin (1993)
confirmed the pattern of facial keratinized tissue widths in longitudinal
observations of children.
Increases in widths of facial attached and keratinized tissue were
noted in primary and permanent teeth over 2 years
Facially-positioned teeth had narrower zones of attached and
keratinized tissue than well-aligned or lingually-positioned teeth.
As teeth moved lingually, an increase in the width of attached and
keratinized tissue and a slight decrease in clinical crown height were
observed

14. Voigt et al.
Measurements of the width of lingual attached
gingiva were performed by Voigt et al. (1978) on
clinically normal subjects ranging in age from 3
to 36 years
Greatest widths were recorded on the first and
second molars (4.7 mm), decreasing at premolar
and third molar sites. The smallest widths were
observed on the incisors and canines (1.9 mm).

15. Width of
attached
gingiva:
Friedman* - Said that ‘‘inadequate’’ zone of gingiva would
facilitate Subgingival plaque Formation because of
improper pocket closure resulting from the movability of
the Marginal tissue. The amount of attached gingiva is
generally considered to be insufficient when stretching of
the lips or cheeks induce movement of free gingival margin
Lang* and loe - Reported a study on the relationship
between the gingival width and inflammation, in an effort
to determine the adequate amount. They concluded that
2mm of keratinized gingiva, with less than 1mm of attached
gingiva is adequate to maintain gingival health.

16. Eager divided attached gingiva based on periodontal type:
 Shallow thin gingiva with slender crown formation.
 Wide thick gingiva with quadrant crown formation.
 Unknown combination
TISSUE BARRIER CONCEPT: Goldman and Cohen outlined a “tissue
barrier” concept for mucogingival surgery. They postulated that a dense
Collagenous band of connective tissue retard or obstruct the spread of
inflammation better than does the loose fiber arrangement of the
alveolar mucosa. They recommended increasing the zone of keratinized
tissue to achieve an adequate tissue barrier

17. Thickness of
Free and
Attached
Gingiva
Goaslind et al. (1977) measured the thickness of the free and attached
facial gingiva in a population consisting of 10 males (age 25 to 36) with
clinically healthy gingiva
Free gingival thickness averaged 1.56 mm ± 0.39 mm, increased from
anterior to posterior and was directly proportional to sulcus depth.
Thickness of the attached gingiva averaged 1.25 mm ± 0.42 mm, increased
from anterior to posterior in the mandibular arch, remained relatively
constant in the maxillary anterior, and was inversely proportional to
attached gingival width.
The overall mean thickness for all areas was 1.41 mm.

18. Interdental
papilla:
• The interdental gingiva occupies the gingival embrasure, which is the
interproximal space beneath the area of the tooth contact.
Col shape is because it represents the valley like depression that connects a
facial & lingual papilla and conforms to the shape of the interproximal
contact.

19. • In a study using Rhesus monkeys, McHugh (1974) confirmed that the interdental
area is col-shaped.
• This area consists of soft tissue residing between papillary peaks on the buccal and
lingual.
• Histological analysis of sections through the actual col showed that it is always
lined by squamous epithelium, 5 or more cell-layers thick. Ameloblasts were not
found.

20. Microscopic features:
• Gingival epithelium:
 stratified squamous
epithelium
 0.2-0.3mm in thickness
 Subdivided into
different layers on the
basis of degree of
keratin production.
1.Basal layer (stratum basale)
2. Prickle cell layer (stratum
spinosum)
3. Granular layer (stratum
granulosum)
4. keratinized cell layer (stratum
corneum)

21. Gingival
epithelium:

22. Keratinocyte:
• Major cell type of the gingival
epithelium.
• Proliferation: by mitosis in basal
layer; less frequently in supra
basal layers.
• Differentiation: involve process
of keratinization.
• Progressions of biochemical and
morphological events that occur
as cell migrate from basal layer to
S. corneum.

24. Keratinization:

25. Keratin expression:

26. Non keratinocytes:
MELANOCYTES:
• Present in basal and spinous layers.
• Stellate cells with numerous dendritic processes.
• Synthesise melanin in premelanosomes or melanosomes.
• Attached neither to the subjacent basal lamina nor to
adjacent cells of the stratum basale.
• Contain tyrosinase which hydroxylates tyrosine to
dihydroxy-phenylalanine (DOPA ) which in turn is
converted to melanin. Melanin granules are phagocytosed
and contained within melanophages or melanophores.

27. Langerhans cells
• Dendritic cells located among
keratinocytes at all suprabasal
levels belong to mononuclear
phagocyte system (R.E system).
• Considered macrophages with
possible antigenic properties,
important role in immune
reaction as antigen-presenting
cells for lymphocytes.
• Contain g-specific
granules(Birbeck’s granules) and
have marked adenosine
triphosphatase activity.
• Found in oral epithelium of
normal gingiva and in smaller
amounts in the sulcular
epithelium probably absent from
the junctional epithelium of
normal epithelium.

28. Merkel cells
• Located in the deeper layers
of the epithelium, harbour
nerve endings and are
connected to the adjacent
cells by desmosomes.
• They have been identified as
tactile preceptors.

29. Structure and
metabolic
characteristics:
• The epithelium covering the gingiva may be
differentiated as follows:
• oral epithelium (OE), which faces the
oral cavity.
• oral sulcular epithelium (OSE), which faces
the tooth without being in contact with
the tooth surface.
• junctional epithelium (JE), which
provides the contact between
the gingiva and the tooth.

30. Oral(outer) epithelium
• Covers crest & outer surfaces of marginal gingiva & surface of
attached gingiva .
• Keratinized or parakeratinized or various combinations with
prevalence toward parakeratinization.
• Keratinization varies in following order:
Palate(Most keratinized)> Gingiva>Ventral aspect of Cheek(Least
keratinized)

31. Stratum basale:
•the cells – cylindrical / cuboidal
•Attached to underlying
basement membrane
and to each other by
hemidesmosomes
and gap junctions.
•Cells have ability to undergo
mitosis.
•Also called as stratum
germinativum.
( progenitor cell compartment of
epithelium)
•Consists of keratinocytes,
melanocytes.

32. Stratum spinosum:
• Uppermost layers contains Odland
bodies or keratinosomes.
• Contain fewer cell organelles and
more tonofibrils.
• Expression of K1 & K10
increases.
• Expression of K5 & K14
decreases.
• Keratin bundles increase in
number.
• Cell to cell attachment -
desmosomes.
• Gap junctions - high numbers.
• Langerhans cells are present

33. Stratum granulosam:
• Cells become flattened.
• Named because of
keratohyaline granules.
• They are 1 to 0.1 µm in
diameter round or irregular
and electron dense, present in
cytoplasm and stain with acid
dyes (haemotoxylin)
• Nuclei shows signs of
degeneration.
• Tonofibrils more prominent.
• Sythesizes protein.
• Desmosomes becomes
oriented.

34. Stratum corneum
• Cells undergo transition.
• Increased tonofilaments
• Cell organelles, keratohyaline
granules disappear.
• Consists of flat cells termed
squame (stain pink with
eosin).
• Densely packed filaments –
keratins(K1,K2,K10,K12) ;
covered by filaggrin layer
(envelope).
• Crosslinking of tonofilaments
– disulphide bonds –
mechanical strength &
chemical resistance.

35. Basal lamina
• 300 – 400 Å thick.
• Approx. 400 Å beneath basal layer of
epithelium.
• Permeable to fluids.
• Barrier to particulate.

36. Sulcular epithelium:
• It is a thin, nonkeratinized stratified squamous epithelium without retepegs
and extends from coronal limit of the junctional epithelium to the crest of
the gingival margin.
• It lacks granulosum & corneum strata and normally does not contain
Merkel cells.
• It has potential to keratinize if -exposed to oral cavity
-bacterial flora is eliminated.
• It suggests that local irritation of sulcus prevents sulcular keratinization.
Importance
• It may act as a semipermeable membrane though which injurious bacterial
products pass into the gingiva and tissue fluid from gingiva seeps into the
sulcus

37. Junctional epithelium:
A single or multiple layer of non-keratinizing cells adhering to
the tooth surface at the base of the gingival crevice. Formerly
called epithelial attachment.
• Length : 0.25 to 1.35mm
• Thickness: 3 – 4 cell layer in early life.
10 – 29 cell layers – coronal
1 - 2 cell layers – apical

38. Concepts:
Gottlieb (1921) first coined the term epithelial
attachment and proposed that the oral epithelium
(OE) fused with the outer enamel epithelium (OEE) of
the erupting tooth at the base of the sulcus.
Waerhaug (1952) suggested that the tooth/epithelial
interface which extends to the CEJ was a potential
space maintained tightly against the tooth by vascular
pressure. This concept became known as the
epithelial cuff.
Orban (1960) inserted steel blades into the sulci of
dogs and monkeys and demonstrated a firm
attachment of epithelial cells to the teeth. The author
agreed with Gottlieb's concept of a firm epithelial
attachment

39. Schroeder & Listgarten
• Prior to eruption, the surface of the enamel is
covered by the REE which comprises the
reduced ameloblasts and the former stratum
intermedium.
• These cells produce a basal lamina called the
epithelial attachment lamina, which is in
contact with the hard tissue structure. It is to this
lamina that the epithelial cells attach, via
hemidesmosomes, to form the primary
epithelial attachment in unerupted teeth.
• As tooth erupts, the reduced ameloblasts and
some cells of the stratum intermedium get
converted into junctional epithelial cells. As the
tooth erupts through the oral mucosa, the
attachment of soft to hard tissue is termed the
secondary epithelial attachment, which may
consist simply of a basal lamina (the epithelial
attachment lamina) anhemidesmosomes

40. Dynamic
aspects of
junctional
epithelium:
• Turnover is very high protective &
regeneration
• Earlier thought epithelial cells facing external
basal lamina divide rapidly.
• proteoglycans , hyaluronan , decorin , syndecan
and CD-44…on epithelial cell surfaces and
within intercellular spaces.
• β1 integrin family and intercellular adhesion
molecule-1….. Cell adhesion
• Evidence  DAT cells high mitotic activity
• DAT cells  Role in tissue dynamics &
reparative capacity of JE.

41. DAT cells:
• Daughter cells replace degenerating cells on tooth surface
• Daughter cells enter exfoliation pathway & gradually
migrate coronally between basal cells & DAT cells
• Epithelial cells move in coronal direction along tooth
surface

42. Renewal of gingival epithelium:
• Skougaard and Beagrie (1962) investigated renewal time in the
gingival epithelium of marmosets using injections of tritiated
thymidine and autoradiography.
• Epithelial cells in the attached gingiva exhibited a renewal rate of 10.4
days, whereas the corresponding rate for the epithelial cuff was 5.8
days

43. Cuticular structures of tooth:
• Cuticle describes a thin acellular structures with homogenous matric that is
sumtimes enclosed within clearly demarcated linear borders.
• Listgarten divided the as:
• Acquired – saliva, bacteria, calculus and surface stains
• Developemtal origin- REE, coronal epithelium, dental cuticle

44. Gingival connective tissue:
• 60% - collagen fibres, 5%- fibroblasts, 35%- vessels, nerves & matrix.
• Also known as LAMINA PROPRIA.
Papillary layer Reticular layer
Sub adjacent to epithelium;
consists of papillary projections
between epithelial rete pegs.
Density - 120+30/mm2
gingival surface.
Contiguous with the
periosteum of the alveolar
bone.

45. Cellular elements:

46. Fibroblast:
• 65% of cells of gingival C.T.
• Ovoid/spindle shaped with branching processes;
• Pale staining elongated/disc like nucleus with basophilic
cytoplasm
• Well developed RER, Mitochondria and Golgi complex.
• Fibrocytes- Produce ECM components of developing CT.
Classified as:
• Lamellar / pyriform shaped – immature cells
• Spindle/ fusiform – intermediate cells
• Stellate/ star shaped – mature cells
Fibroblast:

47. Functions:
• To secrete collagen and elastin, glycoproteins and GAG’s.
• Secrete active collagenase & MMP’s .
• Secrete number of growth factors, cytokines and inflammatory mediators like IL-
1, IL-6, IL-8, TNF-α, PDGF, keratinocyte growth factor etc.
• Role in developmental processes, wound healing and tissue re-modelling.
• In health: produce & maintain ECM, role in homeostasis and modification of
parts of matrix they created.
• In disease: enlarged, cytopathically altered due to dispersion of chromatin,
formation of surface blebs, enlargement and dilation of mitochondria, breaks in
plasma membrane.

48. MACROPHAGES:
• Derived from monocytes.
• Also known as tissue
histiocytes.
• Spindle/irregularly shaped
with oval nuclei.
• Short projections -
phagocytosis.
• There are tissue
macrophages and wandering
macrophages.

49. Functions:
• In health: less well defined. Role in homeostasis.
• In disease: produce powerful hydrolytic enzymes: act as scavengers dispensing
with the bacteria, toxins & debris.
• Release neutrophil chemotactic factors, PG’s , IL-1 that regulate immune
response.
• Activated macrophages can regulate C.T turnover (potent substances – stimulate
fibroblast proliferation – enhanced collagen production).

50. Neutrophils:
• Represent the first line of host defence
mechanism.
• Omnipresent in gingival tissues and
likely to play major role in periodontal
homeostasis in health.
• Migrate rapidly from blood to enter the
C.T as a result of immune response and
tissue injury.
Function:
• Play a role in phagocytosis by release of
certain intracellular enzymes like
myeloperoxidase, lysozyme, lactoferrin,
collagenase-2 or PMN type collagenase
or MMP-8 and alkaline phosphatase.

51. Ground substance:
Proteoglycans:
• In gingiva: Decorin, biglycan,
versican and syndecan.
• Bind growth factors, cytokines and
other biologically active molecules.
• GAG’s in supra-alveolar fiber
apparatus, loose connective tissue and
basement membranes.
glycoproteins
• Major - fibronectin, laminin, tenascin ,
elastin.
• Fibronectin: binds fibroblasts to fibres;
mediate cell adhesion and migration
• Laminins: attach basal lamina to
epithelium.

52. Gingival fibres:
• Collagen fibres
• Elastic fibres – Oxytalin, elastin, elaunin
• Reticular fibres
Functions:
• 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 surface.
• To unite the free marginal gingiva with the cementum of the root and the adjacent attached gingiva.

53. • Three groups of fibers:
Gingivodental group
• On the facial, lingual and interproximal surface embedded in
the cementum just beneath the epithelium at the base of the
gingival sulcus.
• They extend externally to the periosteum of the facial and
lingual alveolar bones and terminate in the attached gingiva or
blend with the periosteum of the bone.
Circular group
• Course through the connective tissue of the marginal and
interdental gingiva and encircle the tooth in ring like fashion.
Transseptal group
• Form horizontal bundles that extend between the cementum
of approximating teeth into which they are embedded.

54. According to Bartold:
Primary fibers:
• Circular
• Dentogingival
• Dentoperiosteal
• Alveologingival
• Transseptal
Secondary fibres:
• Periosteo-gingival
• Interpapillary group
• Inter gingival
• Transgingival
• Inter circular
• Semi circular
Page and co workers:
• Semicircular and
• Transgingival

55. Clinical importance of gingival fibres:
• Circumferential supracrestal fiberotomy( pericision)
• Gingivoplasty of thick interdental papilla
• frenectomies

56. Epithelial connective
tissue interface:
• The boundary between the oral epithelium OE and
the underlying (CT) has a wavy course. The
connective tissue portions which project into the
epithelium are called connective tissue papillae
(CTP) and are separated from each other by
epithelial ridges — so-called rete pegs (ER).
• In normal gingiva, a characteristic morphologic
feature of the oral epithelium and the oral sulcular
epithelium is the presence of rete pegs, while these
structures are lacking in the junctional epithelium.

57. Blood supply of gingiva:
• Three sources of blood supply to the gingiva are as follows
1. Supraperiosteal arterioles
2. Vessels of periodontal ligament, which extend into the gingiva
and anastomose with capillaries in the sulcus area.
3. Arterioles which emerge from the crest of the interdental
septa

58. Vasculature:
• Nuki and Hock (1974) studied the organization
of the gingival vasculature noting that the
subepithelial vasculature consisted of a series
of interconnecting capillary units made up of
at least 2 terminal arterial capillaries, 4
primary venular capillaries, and numerous
connecting vessels.
• The capillary units were among the first
vessels affected by inflammation as evidenced
by an increase in vessel width (5 to 10 m)
and length (400 to 1,000 ^im as well as
alteration of vessel morphology

59. Lymphatics and
nerve supply:
• Lymphatic drainage
• Lymphatics beneath the junctional epithelium extend
into the periodontal ligament and accompany the blood
vessels.
•
• Gingival innervation
• It is derived from fibers arising from nerves in the
periodontal ligament and from the labial buccal and
palatal nerves
• The following nerve structures are present in the
connective tissue, a meshwork of terminal argyrophilic
fibers some of which extend into the epithelium.
• Meissner type- tactile corpuscles
• Krause-type end bulbs- temperature receptors
• Encapsulated spindles

60. Epithelial
changes in
disease:
• Epithelial permeability increases.
• The intercellular spaces of the J/E widen and
serve as a primary pathway for the progress of
the inflammatory exudate from the gingiva to
the gingival sulcus.
• There is a significant influx of neutrophils that
the intercellular spaces of the junctional
epithelium become pathologically altered, with
disruption to the intercellular junctions and
increasing widening of the intercellular spaces.

61. • Once this level of infiltration has occurred, and if the driving stimulus (dental plaque) remains, then the
normal rapid turnover of the junctional epithelium is insufficient to restore health and the pathway to
ongoing tissue damage is established.
• With continuing plaque accrual, neutrophil migration and early activation of macrophages and
lymphocytes within the gingival connective tissue, the junctional epithelium can be seen to commence
migration in an apical direction and result in the earliest formation of a periodontal pocket.
• Communicative pathways may be established through a variety of cells known to reside in the
epithelium. For example, Langerhans cells, which act as antigen-presenting cells, have been noted to
increase in number with increasing inflammation.

62. Connective tissue changes:
• Subsequent to the initial inflammatory response, CT destruction occurs within 3-4 days after
plaque accumulation and begins at perivascular collagen bundles.
• As the inflammatory process continues, destruction expand deeper towards pdl and alveolar bone –
tooth mobility.
• Simultaneously with destruction, fibrosis and scarring may coexist.
• Qualitative and quantitative changes occur to the gingival collagens, gingival proteoglycans .
• The glomerular nature of gingival plexus increases with increase in the number and size of the
capillary loops.
• During this process, the post capillary venules adopt the appearance of high endothelial venules
which facilitates emigration of lymphocytes.

63. Gingival
biotypes:
• Pioneers: Ochsenbein and Ross

64. THICK
• Most prevalent.
• Consists of flat soft tissue.
• Thick bony architecture.
• Dense & fibrotic with large zone of
attachment.
• More resistant to recession
THIN
• Delicate
• Highly scalloped soft tissue.
• Thin bony architecture.
• Characterized by fenestration and
dehiscence.
• More prone to recession, bleeding
and inflammation

65. Methods to determine
gingival biotype:
• Conventional histology on cadaver jaws
• Endodontic reamers
• Trans-gingival probing
• Histologic sections
• Cephalometric radiographs
• CBCT

67. Correlation of clinical and
microscopic features:
Colour
Health
Normally coral pink in color.
Depends on the thickness and degree of the keratinisation of
the epithelium and the presence of pigment producing cells.
Alveolar mucosa is red, smooth and shiny.
Epithelium is thinner, non keratinised
and contains no rete pegs.

68. Physiological pigmentation:
• Melanin pigmentation – can occur as
early as 3hrs after birth and often is
the only evidence of pigmentation.
According to Dummett: In Blacks
• Gingiva : 60%
• Hard palate : 61%
• Mucous membrane : 22%
• Tongue : 15%

69. Gingivitis:

70. Smokers melanosis melanoma
Puetz juegher syndromeHypermelanosis

71. LEAD TOXICITY COPPER PIGMENTATION MINOCYCLINE
PIGMENTATION
AMALGAM TATOO HEAVY METAL POISONING

72. SIZE:
Health
The size of the gingiva corresponds with the sum total of
the bulk of cellular & intercellular elements & their
vascular supply.
Disease
• Size of the gingiva is enlarged and is called as gingival
enlargement.
Inflammatory- increase in cells and decrease in fibres.
Non-inflammatory - decrease in cells and increase in
fibres.

73. consistency
Health
• The gingiva is firm and resilient with exception of the movable free
margin.
• The collagenous nature of the lamina propria and its contiguity with
the mucoperiosteum of the alveolar bone determines the firmness of
the attached gingival margin.
• The normal consistency of the gingiva can be checked by palpation
either with a blunt instrument or digital pressure.
Disease:
• Pitting on pressure indicates soft and oedematous gingiva.

74. Shape:
• Anteriors :Triangular to knife-edged
• Posteriors : broader and more square shaped
Factors affecting shape:
• Contour of proximal teeth.
• Location and shape of embrasure.
• In disease:

75. Contour:
• Facial & lingual surfaces:
Scalloped
• Teeth with relatively flat surfaces:
straight line
• Pronounced MD convexity,
labially placed teeth: accentuated
• Linguo-version teeth: horizontal
and thickened.
Depends on
• Shape of teeth and their alignment
in arch
• Location and size of area of
proximal contact
• Dimensions of facial and lingual
gingival embrasures

76. In disease:
Thickened shelf like
contour of gingiva on tooth
in lingual version
aggravated by local
irritation caused by plaque
accumulation.
ACCENTUATED CONTOUR
STILLMAN’S CLEFTS

77. In disease:
• Chronic gingivitis- marginal gingiva
becomes rolled or rounded and interdental
papilla becomes blunt and flat.
• ANUG- Punched-out crater like
depressions at the crest of interdental
papilla.
• Chronic desquamative gingivitis-
irregularly-shaped denuded appearance of
the gingiva.
• Gingival recession- exaggerated
scalloping of the gingiva.
• Stillmans clefts: apostrophe shaped
indentation extending from the gingival
margin.
• Mc calls festoons: life-saver like
enlargement on the marginal gingiva,
most commonly seen on the canine and
premolar facial surface.

78. Surface texture
Health:
• The gingiva presents a textured surface similar to an orange peel and is
referred to as being stippled.
• Best viewed by drying the gingiva. Attached gingiva is stippled but not
marginal gingiva.
• Stippling is absent in infancy, appears in some children at about 5years
age, increases until adulthood and frequently begins to disappear in
old age.
• Form of adaptive specialisation or reinforcement for function

79. • In Chronic inflammation
Smooth and shiny gingival surface
firm and nodular
• Smooth surface texture is also produced by epithelial atrophy in
atrophic gingivitis and peeling of the surface occurs in Chronic
desquamative gingivitis.
• Hyperkeratosis-leathery texture
• Drug induced gingival overgrowth- nodular surface.

80. Position:
The normal position of the gingiva is 1mm above the cemento enamel junction.
Physiologic factors
Position of the teeth in the arch.
Root-bone angle
Mesio-distal curvature of tooth surface.
Pathologic factors
Toothbrush trauma.
Gingival inflammation.
High frenal attacment.
Tooth malposition.
Friction from soft tissue.

81. Traumatic lesions
• Physical injuries
• Chemical injuries
• Thermal injuries.
• In acute cases, the appearance of the slough (necrotising epithelium),
erosion or ulceration and the accompanying erythema are the common
features.
• In chronic cases, permanent gingival defects are usually present in the
form of gingival recession

82. Continuous tooth eruption
Eruption does not cease when teeth meet their functional antagonists but
continues throughout life.
• Active tooth eruption is the movement of the teeth in the direction of the
Occlusal plane, whereas passive tooth eruption is the exposure of the tooth
by apical migration of the gingiva. This concept distinguishes between the
anatomic crown and between the clinical crown and clinical root .
Gottlieb and Orban believed that active and passive eruption proceed
together.
• Originally, passive eruption was thought to be a physiological process.
Now, it is considered as a pathologic process.

84. Effect of aging:
On Gingival Epithelium
Thinning & decreased keratinization.
Flattening of rete pegs & altered cell density.
Width of the AG increases.
Gingival connective tissue
coarser & more dense gingival CT.
changes in collagen :
-increased rate of conversion of soluble to insoluble collagen.
-increased mechanical strength.
-increased denaturing temperature.

86. Oxygen consumption of gingiva:

88. Conclusion:
• Knowing the normal gingival architecture in health is important to
differentiate between health and disease state of an individual.
• Hence it is significant to understand the morphological and clinical
alterations in the gingiva during disease state which helps us to
identify the intensity and prognosis of a particular disease.

89. References:
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2006;40:11–28.
• I Glickman, Manhold, John H. The Oxygen Consumption of Healing Gingiva J DENT RES August
1950 29: 429-435.
• Mundeja N, Baiju CS, Khashu H, Jain D, Gupta A. Gingival biotype: A key determinant in
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