Gingiva Macroscopic Features

1. Macroscopic Structures of Gingiva Presented By – Abhishek Gakhar 23 rd May 2012 Department of Periodontics ITS Dental College, Hospital & Research Center Greater Noida Moderator- Dr. Sachit Anand Arora

2. Gingival Sulcus Marginal Gingiva Free Gingival Groove Gingival Margin Attached Gingiva Interdental Gingiva Interdental Papilla Col Alveolar Mucosa Mucogingival Junction Clinical Anatomy of Gingiva

3. All types are specifically structured to function against the mechanical & microbial damage (1) . Histologically the attached gingiva better suited than non-keratinised mucosa to withstand microbial irritation (2) .

4. Free Gingival Groove A shallow line or depression on the gingival surface at the junction of the free and attached gingivae . (3) Related Studies :Presence of free Gingival Groove in different regions (4) . Region % of Free Gingival Groove Right lower Premolars(44,45) 55% Right lower Canine (43) 54% Upper left Molars(26,27) 15%

5. V- Shaped shallow space around the tooth Junctional Epithelium f orms the base of t he sulcus The space between the f ree gingiva & tooth Surface.

6. Under absolutely normal or ideal conditions the depth of sulcus is 0mm or close to 0 mm (5 ) . Study related depth of sulcus in different aspects of the tooth in a healthy gingiva. (4) Location Highest Lowest Mesio buccal Aspect Right upper second molar (1.96 mm) lower left canine (1.14 mm) Distobuccal aspect Left upper first molar (1.71 mm) Left lower first premolar (1.13 mm) Buccal aspect Upper right molars (1.37 mm) left lower canine (0.86 mm). Lingual & Palatal aspect Right upper second molar (1.31 mm) right lower incisors (0.79 mm)

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8. Definition: It is firm & resilient gingiva, tightly bound to the underlying periosteum of alveolar bone (6 ) . ( Glossary of Periodontal terms, 4 th Edition) Demarcation: Attached gingiva extends to the relatively loose and movable alveolar mucosa, from which it is demarcated by the  mucogingival junction .

9. Dissipates functional and masticatory stresses (7) . Provides a resistant barrier to plaque induced inflammation (8) . Prevents Recession (9) . Deepens vestibule to provide better access for tooth brushing (10) . Improves esthetics, patient comfort and ease of hygiene (11) .

10. Width of attached Gingiva? Definition: T he distance between the mucogingival junction and the projection on the external surface of the bottom of gingival sulcus or the periodontal pocket. The width of attached gingiva varies in different individuals and on different teeth of the same individual. (12)

11. Visual Method Histochemical Staining Lugol’s Solution Shiller’s Iodine Clinical Method

12. Pertinent Question? How much zone of keratinized gingiva is necessary to maintain the health of Periodontium?

13. Landmark Study : Lang & Loe (13) A study of width of attached gingiva : Bowers GM (7) Lack of width of attached gingiva & deviation of soft tissue recession : Wennstorm (14) The width of the attached gingiva--much ado about nothing : Mehta P, Lim LP (15) Assessment of the Width of Attached Gingiva in Different Regions of the Mouth in an Indian Subpopulation : Rajiv Subbaiah, Balaji Manohar (16) .

14. Lang & Loe : First controlled Clinical Trial When the tooth surfaces kept free of clinically detectable plaque. S urfaces >2mm of keratinized gingiva= Healthy Surfaces < 2mm of keratinized gingiva=Inflammed Which means 1mm or less than 1mm of attached gingiva remain inflamed . ( 13) Lang & Loe strongly suggested that 2mm width of keratinized gingiva is important for maintaining the health.  

15. Bower said that less than 1mm of attached gingiva may be sufficient (7). According to Wennstorm , the lack of minimum amount of attached Gingiva does not necessary result in a soft tissue recession ( 14) . The narrow attached gingiva apical to localized recession is a result of recession rather than cause ( 14) .Proper plaque control prevents soft tissue recession, even when it is out of adequate width. ( 14)

16. A study done by Mehta P, Lin LP. A REVIEW TO OUTLINE THE SIGNIFICANCE OF ATTACHED GINGIVA ON TEETH . Concluded: width of attached gingiva is not significant to maintain periodontal health in the presence of adequate oral hygiene. Gingival tissue around teeth with restorations or undergoing labial orthodontic tooth movement may be more susceptible to recession (15). Functional need for attached gingiva around implant has not been established but its aesthetic value has been widely accepted (15) .

17. A study done by Rajiv Subbaiah, Balaji Manohar on Indian population & the average width of the attached gingiva was found to be (16 ) : Table-2 showing the width of attached gingiva in Indian population.

18. Table -1 showing the normal width of attached gingiva Some Studies have also shown that the width of attached gingiva is not significant to maintain periodontal health in the presence of adequate oral hygiene. [8]         Anterior   Premolars   Maxillary   3.5-4.5mm   1.9mm   Mandibular   3.3-3.9mm   1.8mm

19. Mucogingival junction Definition -Junction between masticatory mucosa & lining mucosa (i.e., attached gingiva & alveolar mucosa) Location -on all gingival surfaces except the palatal surface in humans . Clinical Relevance : Important anatomic landmark for determining the "width" of keratinized gingiva; flap designs & gingival grafts etc.

20. Mucogingival Junction

21. DEFINATION : The interdental gingiva occupies the gingival  embrasures, which is the interproximal space beneath the area of tooth contact. Shape : The interdental can be pyramidal or have a "col" shape .

22. Interdental Gingiva

23. Papilla The tissue that resides in the interproximal embrasure is called the interproximal papilla. Shape : The shape of this papilla varies from triangular and knife-edge in the anterior regions due to point sized contacts of the teeth to broader and more square shaped tissue in the posterior sextants due to the teeth having broad contact areas (17) .

24. Facial & Lingual Papillae

25. COL This is a valley-like structure situated apical to the contact area. COL

26. C O L

27.   Colour: The gingiva is typically coral pink in color, but may vary due to physiologic pigmentation among some races . (18) Factors affecting Color of Gingiva Vascular supply Thickness of epithelium Degree of keratinization Presence of pigment containing cells

28. Physiologic Pigmentation Melanin Pigmentation May appear in gingiva as early as 3 hrs. after the birth & often is the only evidence of pigmentation ( Dummet ).  

29. Shape : The shape varies from triangular and knife-edge in the anterior regions due to point sized contacts of the teeth to broader and more square shaped tissue in the posterior sextants due to the teeth having broad contact areas . (18)   Factors affecting the shape : Contour of proximal tooth surface Location & shape of Embrasures

30. Size : The size of gingiva corresponds with sum total of the bulk of cellular & intercellular elements. (18) Contours : The marginal gingiva envelopes the teeth in a collar like fashion & follow a scalloped outline on facial & lingual surfaces . (18)

31. Contours depends on –   Shape of the tooth. Alignment of teeth in arch. Location & size of the area of proximal contact . Dimension of facial & lingual embrasure.

32. Variation in contour of Marginal Gingiva Scalloped outline on the facial & Lingual surfaces . Teeth with relative flat surfaces : straight line . Teeth with pronounced mesio-distal concavity of lingual version :Normal Contour is accentuated . Teeth in lingual version : Horizontal & thickened Contours . In Inflammed conditions : Still man’s & McCall’s Festoons.

33. Consistency : The gingiva is firm & resilient with exception of the movable free margin, tightly bound to underlying bone . The collagenous nature of lamina propria & its contiguity with mucoperiosteum of alveolar bone determines the firmness of attached gingiva. Resilient is due to gingival fibers.

34. Surface Texture : Stippled texture The presence of minute pits & lobulated surface on gingiva. A texture similar to the orange peel appearance is refered as stippled. Varies with age: Absent in Infancy. Appears at about 5 yrs. of age. Increases until adulthood. Frequently disappear in old age.

35. Position : The position of gingiva refers to the level at which the gingival margin is attached to the tooth. It is 0-3 mm coronal to CEJ . (12) Position continues to change with age as eruption continues throughout life (Gottlieb & Orban)

36. Active Eruption- movement of teeth in the direction of occlusal plane. Passive Eruption- Exposure of teeth by apical migration of gingiva. Gottlieb believed that Active & Passive eruption proceed together.

37. Active eruption is coordinated with attrition , preserving the vertical dimension of dentition. Reduces clinical crown & prevents it from becoming too long in relation to clinical root. Tooth substance lost by attrition is replaced by lengthening of root by cementum deposition.

38. Appears to be healthy gingiva

39. 1)Ainamo J & Tallari A: The increase with age of width of attached gingiva, J Periodontal Res ;11:82, 1976 2)Lozdan J, Squier CA. The histology of Mucogingival Junction. J Periodontal Res 1969; 4(2):83-93 3) Ainamo J, LoeH: Anatomical characteristics of gingiva: a clinical & microscopic study of the free & attached gingiva, J Periodontal Res; 37:5, 1966

40. 4) Adileh Shirmohammadi, Masoumeh Faramarzie ,Ardeshir Lafzi ;A Clinical Evaluation of Anatomic Features of Gingiva in Dental Students in Tabriz, Iran. JODDD;Vol. 2(3) :90-95   5)Gottlieb B, Orban B: Active & passive continuous eruption of teeth. J Dent Res; 13:214, 1933   6) Glossary of Periodontal terms, 4 th Edition 7 ) Bowers GM: A study of width of attached gingiva , J Periodontol;34:210, 1963  

41. 8 )Maynard J, Oschenbein C. Mucogingival problems, prevalence & therapy in children. J Periodontol 1975; 46(9): 543-552 9 )Sullivan HC, Akkains JH. Free autogenous gingival grafts; Periodontics 1962; 6(4): 15-160 10) Nabers JM. Extension of the vestibular fornix utilising a gingival graft- Case history. Periodontics 1966; 4(2): 77-79 11)Chang H, Odman PA, Wannstorn JL, Anderson B. Esthetic outcome of implant- supported single-tooth replacement assessed by the patient & by Prosthodontists . Int J Prosthodont . 1999; 12(4):335-341

42. 15) Mehta P, Lim LP. The width of the attached gingiva--much ado about nothing?. JDent2010;38(7):517-25 13)Lang & Loe. Importance of keratinised Gingiva . J Periodontol Res 1972,7(2):133-139 16)Rajiv Subbaiah, Balaji Manohar. Assessment of the Width of Attached Gingiva in Different Regions of the Mouth in an Indian Subpopulation ; JIDA, Vol. 6, No. 2,;96-98   12)( Ainamo A, Aainamo J, Poikkeus R. Continuous widening of the band of attached gingiva from 23-65years of age. J Periodontal Res1981; 16(6): 595-99

43. 12)(Ainamo A, Aainamo J, Poikkeus R. Continuous widening of the band of attached gingiva from 23-65years of age. J Periodontal Res1981; 16(6): 595-99 13)Lang & Loe. Importance of keratinised Gingiva. J Periodontol Res 1972,7(2): 133-139 14) Wennstorm JL: Lack of width of attached gingiva & deviation of soft tissue recession. A 5year long study. J Clin Periodontol 1987;14(3): 181-84.

44. 15) Mehta P, Lim LP. The width of the attached gingiva--much ado about nothing?. JDent2010;38(7): 517-25 16)Rajiv Subbaiah, Balaji Manohar. Assessment of the Width of Attached Gingiva in Different Regions of the Mouth in an Indian Subpopulation; JIDA, Vol. 6, No. 2,; 96-98   17)Cohen B: Morphological factors in pathogenesis of periodontal disease, Br Dent J 107:31,1959 18) The Anatomy and Physiology of the Healthy Periodontium ,Anthony Palumbo ,Stony Brook University, USA

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