Periodontology 2000, Vol.

24, 2000, 9–27 Copyright C Munksgaard 2000

Printed in Denmark ¡ All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

Development and general

structure of the periodontium
M OON- I L C HO & P HILIAS R . G ARANT

The periodontium is a collective term describing senchyme (25, 61). The failure of the normal mi-
tooth supporting and investing tissues including the gration of neural crest ectomesenchymal cells to ap-
root cementum, periodontal ligament, alveolar bone propriate sites during craniofacial development
and gingiva. These periodontal tissues develop and leads to serious developmental defects, including
function as a unit (60, 114). The majority of peri- the absence of teeth (anodontia) and underdevel-
odontal tissues develop along with the formation of oped jawbones (micrognathia). Neural crest ectome-
the roots of teeth and tooth eruption and have an senchymal cells interact in a series of reciprocal in-
origin from the dental follicle that is derived from ductive interactions with early oral epithelium to
neural crest. This chapter discusses the development form tooth primordia (81). Subsets of cranial neural
of these tissues by emphasizing the origin and lin- crest cells give rise to chondrocytes, osteoblasts,
eage of the cells responsible for formation of their periodontal ligament fibroblasts, cementoblasts and
structural components. odontoblasts. Final phenotype differentiation is
regulated by interaction of the ectomesenchymal
cells with extrinsic factors, such as growth factors, in
Development of the dental follicle the local microenvironment (69).
The dental papilla and dental follicle, the non-ec-
During the past decade, developmental biologists todermal components of the tooth buds, are formed
have made numerous studies of gene expression in by concentration of neural crest ectomesenchymal
tooth formation. Most of these studies were focused cells (Fig. 1). Schroeder (114) and Moxham & Grant
on the earliest stages of tooth bud development, (99) have reviewed the classical descriptive and ex-
with emphasis on the interaction between the en- perimental studies that described the development,
amel organ and the dental papilla. Less attention has histology and the fate of the dental follicle in form-
been given to the role of gene activation and growth
factor regulation in the development of the peri-
odontium. Information on gene expression in the
dental follicle and the developing periodontium may
be obtained in the Web site http://honeybee
.helsinki.fi/toothexp.
Following the development of the neural tube by
invagination of the overlying ectoderm, migratory
pluripotent neuroepithelial cells, the neural crest
cells, migrate from the dorsal midline region of the
neural tube to invade the developing branchial arch-
es (22). In exiting from the neural tube, neural crest
cells lose their epithelioid nature and assume a mes-
enchymal phenotype capable of directed cell mi-
gration. By tracing the movement of dye-injected
neural crest cells in organ cultures of developing
dental arches, it was shown that neural crest cells
from the posterior midbrain, and to a lesser extent Fig. 1. Diagrammatic view of a developing tooth at the cap
from the anterior hindbrain, formed dental ectome- stage

9
Cho & Garant
ing the tissues of the periodontium. It has been sug-
gested that the interaction between cell surface syn-
decan and tenascin, an extracellular matrix adhesion
molecule, reduces migration and promotes aggre-
gation of the ectomesenchymal cells to form the
dental papilla and dental follicle (136, 140, 141).
During tooth development, the dental papilla
gives rise to odontoblasts and the dental pulp, while
the dental follicle gives rise to cementum, peri-
odontal ligament and alveolar bone. Anatomically,
the dental follicle consists of the dental follicle
proper, a rather well-defined band of cells juxta-
posed to the dental papilla and the convex outer sur-
face of the enamel organ; and the perifollicular mes-
enchyme, a more loosely defined population of cells
bordering the developing bony trabeculae which
partly surround the tooth bud. A poorly populated
zone of loose connective tissue separates these
layers. The loose connective tissue interface creates
a natural cleavage plane during tooth bud extir-
pation; the dental follicle proper remains attached to
the tooth bud, while the perifollicular mesenchyme
remains associated to the bony trabeculae.
The developmental potential of the dental follicle
was studied in numerous tooth transplantation ex-
periments. Hoffman demonstrated the formation of
all elements of the periodontium following tooth
bud transplantation to subcutaneous sites (60). Al-
though he was quite certain that cementum and
periodontal ligament originated from the trans-
planted tissue, he was less certain about the origin
of the surrounding bone. He speculated that bone
cells might have been induced in host cells by the
epithelial components of the tooth bud. Ten Cate et
al. studied the fate of transplanted tooth buds pre-
viously labeled with tritiated thymidine (132). Ce-
mentoblasts and periodontal ligament fibroblasts in
the developing tooth were clearly labeled, indicating
their origin from the transplanted tooth bud. Since
osteoblasts were only weakly labeled, their origin
was less certain. Ten Cate et al. noted that since only
the dental follicle proper was transplanted along
with the tooth bud, it must be the source of progeni-
tor cells for cementum, alveolar bone and peri-
odontal ligament fibroblasts (132, 133). Palmer &
Lumsden confirmed these results but cautioned that
it was difficult to exclude cellular contamination
from the perifollicular mesenchyme (104).
The role of the dental follicle was clarified by
studies of the development of tooth buds trans-
planted to sites known to have an inability to form
mineralized tissue. When tooth buds were trans-
planted into the anterior chamber of the eye, root
10
formation with cementum and alveolar bone forma-
tion were noted (104, 155). These and other trans-
plantation experiments led to the conclusion that
the tooth bud developed as a biological unit, capable
of giving rise to all components of the mature tooth.
Yoshikawa & Kollar (155) also demonstrated that the
dental papilla and the dental follicle had similar de-
velopmental potentials, and could be substituted for
one another in reconstituting a fully developed
tooth.
Despite the fact that the dental follicle proper
contains all the precursors needed for cementum,
bone and periodontal ligament formation, migrating
fibroblasts from the perifollicular mesenchyme pro-
liferate during root development to contribute to the
pool of periodontal ligament fibroblasts. The perifol-
licular mesenchyme and perivascular cells may also
give rise to osteoblasts of the alveolar bone.
Cementum
Types of cementum
Cementum is an avascular mineralized tissue cover-
ing the entire root surface. It forms the interface be-
tween root dentin and the periodontal ligament. Tra-
ditionally, cementum has been classified as cellular
and acellular cementum depending on the presence
and absence of cementocytes in cementum, further
grouped into intrinsic and extrinsic fiber cementum
depending on the presence of collagen fibers formed
by cementoblasts or by fibroblasts, respectively (63,
115). Acellular afibrillar cementum is located over
cervical enamel at the cementoenamel junction (77,
79, 115, 119). Its major structural components are
glycosaminoglycans (115) and its functional signifi-
cance is unknown. Cellular intrinsic fiber cementum
contains cementocytes embedded in a collagenous
matrix of intrinsic collagen fibers. These collagen
fibers are oriented mostly parallel to the root surface
and course in a circular fashion around the root
(115). Cellular intrinsic fiber cementum is found in
old resorption lacunae and in root fracture sites. Cel-
lular mixed stratified cementum is located primarily
on the apical one third of the root and in the fur-
cation area of multirooted teeth. It is composed of
alternating layers of acellular extrinsic fiber ce-
mentum and cellular intrinsic fiber cementum/acel-
lular intrinsic fiber cementum, and is covered by a
thin layer of acellular extrinsic fiber cementum for
attachment to the periodontal ligament (115). Cellu-
lar mixed stratified cementum serves to reshape the
root surface in order to compensate for physiological

Fig. 2. A. Light micrograph of the developing root of the
first maxillary rat molar which shows the dental follicle
proper (DFP) (I) and precementoblast (II) stages. The dot-
ted line separates the areas showing these two stages. At
the cervical end of the developing root, the cells of both
the inner (i) and outer (o) epithelial layers of Hertwig’s
root sheath are intact and arranged parallel to one an-
other. Adjacent to the outer layer of the root sheath, there
are several layers of elongated DFP cells, whose long axis
is parallel to the root sheath epithelial cells. Note the per-
ifollicular mesenchymal cells (PFM) with a stellate shape
in the PF area bordered by the DFP and the alveolar bone
(AB). Also, note precementoblasts (arrowheads) that in-
vade and push their way toward the newly formed preden-
tin surface. The outer and inner epithelial cells of the root
Development and general structure of the periodontium
drift and nonphysiological shifting of teeth in their
alveolar sockets (21, 115, 118). Acellular extrinsic
fiber cementum covers 40% to 70% of the root sur-
face and is comprised of collagen fibers and glycosa-
minoglycans. It serves the exclusive function of an-
choring the root to the periodontal ligament. The
monograph of H.E. Schroeder should be consulted
for the further information on the classical histologi-
cal and ultrastructural aspects of cementum (115).
Since information on the development of acellular
afbrillar cementum, cellular intrinsic fiber ce-
mentum and cellular mixed stratified cementum is
limited, our discussion of cementogenesis will focus
on acellular extrinsic fiber cementum formation, a
topic of resurgent study.
Acellular extrinsic fiber cementum formation in
animals and humans
Animals. Formation of acellular extrinsic fiber ce-
mentum has been studied during root formation in
rodents (27, 31, 45, 72, 82–85, 102, 120, 130, 151,
152), dogs and humans (12, 19, 101, 103, 116, 121).
Such studies have informed us about the develop-
ment, biological potential, microanatomy and
physiological responsiveness of cementum in ani-
mals. Not all of the knowledge gained from such
studies is applicable to humans (20, 21, 118). But,
based upon what we have learned from other organ
systems, it is reasonable to expect that there is a sig-
nificant carry-over. Apparent differences may be-
come resolved as we come to a better understanding
of the molecular events in cementogenesis.
Cementoblast differentiation and cementogenesis
are closely related with root formation. Previous
studies have noted two different mesenchymal cell
populations adjacent to the apical end of developing
roots (Fig. 2, 3). There are the cells of the dental fol-
licle proper, located nearest to the odontogenic cells
and developing dentin surface, and the cells of per-
sheath become discontinuous as the cells of the DFP in-
vade. B. Light micrograph showing cementoblasts (III)
and postcementoblast (IV) stages. Note fully differentiated
cementoblasts (C) on the dentin surface (D) and postce-
mentoblastic cells (arrowheads) migrating away from the
dentin surface. Cementoblasts are characterized by an
oval shape and a high degree of cellular polarization to-
ward the dentin surface. They are more intensely stained
with toluidine blue than PDL fibroblasts. Post cemento-
blastic fibroblasts are elongated in shape and maintained
an intensely stained. The dotted line separates the areas
occupied by these cell types. Od: odontoblast. PD: Pre-
dentin.
11
Cho & Garant
Fig. 3. Electron micrograph showing Hertwig’s root sheath
at the cervical end of the developing root. Note both the
inner basal lamina (thick arrows) under the inner epi-
thelial cells (IE) and external basal lamina (arrowheads)
adjacent to the outer epithelial cells (OE). Cells (*) in the
ifollicular area, located more peripherally (47, 72,
102, 103, 120).
The most apical portion of the developing root
contains an intact epithelial root sheath, located be-
tween the preodontoblasts of the dental papilla and
the dental follicle proper (Fig. 2, 3). The inner and
outer epithelial cells of the Hertwig’s root sheath are
closely parallel to one another with a minimum of
intervening intercellular space. The internal basal
lamina separates the root sheath cells from the pre-
odontoblasts, while the external basal lamina separ-
ates them from the cells of the dental follicle proper.
Elongated fibroblast-like dental follicle proper cells
are oriented parallel to the external basal lamina,
which forms a continuous intact surface all along the
outer root sheath cells. These follicle cells have long
cytoplasmic processes, inactive Golgi complexes,
numerous free ribosomes, and a small number of
rough endoplasmic reticulum cisternae. The cells of
the perifollicular area are stellate-shaped and ran-
domly oriented. In contrast to the dental follicle
12
DFP have a close and parallel arrangement to the outer
epithelial cells. In contrast, the mesenchymal cells (thin
arrows) in the PF area located next to the cells of DFP are
randomly oriented. Pod: Preodontoblast.
proper, the cells of the perifollicular area were rather
widely separated.
The cells of dental follicle proper project cytoplas-
mic processes from their leading edge towards and
eventually into the intercellular space between the
root sheath cells. The dental follicle proper cells ap-
pear to invade the intercellular spaces of the root
sheath. These cells are identified as precemento-
blasts on the basis of their enlarged cell bodies that
contain numerous profiles of rough endoplasmic
reticulum, lysosomes and a moderately developed
Golgi complex (26, 27) and by their ability to syn-
thesize matrix components (27). The unidirectional
migration of precementoblasts towards the preden-
tin surface appears to contribute to the break up of
the root sheath and the formation of Sharpey’s
fibers. Precementoblasts synthesize and deposit col-
lagen fibrils while moving towards the predentin sur-
face, thereby establishing Sharpey’s fibers (27, 31).
Upon contact with the predentin surface, the
elongated precementoblasts become cuboidal in

shape and differentiate into cementoblasts. They are
characterized by a well-developed Golgi complex po-
larized toward the root surface, and by numerous
cisternae of rough endoplasmic reticulum (27, 31).
The cells responsible for depositing the first layer of
acellular extrinsic fiber cementum exhibit a high
level of basophilia consistent with a well-developed
rough endoplasmic reticulum (27). A high level of al-
kaline phosphatase (10, 56) also characterizes these
cells. Specific collagen secretory granules are formed
in a large and conspicuous Golgi complex. Acellular
extrinsic fiber cementum matrix secretory activity
has been documented by electron microscopic auto-
radiography of tritiated mannose utilization as an in-
dicator of glycoprotein synthesis during acellular ex-
trinsic fiber cementum formation in rat molars (27).
Following a brief period of cementogenesis, the
cementoblasts appear to detach from the newly
formed cementum surface and join the fibroblast
population in the periodontal ligament. During this
process, cementoblasts lose their cuboidal shape
and assume a more elongated shape. Thus, during
root formation, cementoblasts originate primarily
from the cells of dental follicle proper, and ce-
mentogenic cells become a part of the periodontal
ligament fibroblast population (27, 31).
Human. In human acellular extrinsic fiber ce-
mentum formation, Hertwig’s epithelial root sheath
does not remain in contact with the root surface fol-
lowing odontoblast differentiation (18, 20, 27, 31,
117). Hertwig’s epithelial root sheath detaches from
the dentin surface very close to the apical edge of
the developing root. After the detachment and disin-
tegration of Hertwig’s epithelial root sheath, acellular
extrinsic fiber cementum forms at the growing root
tip when fibroblasts of the dental follicle make con-
tact with the predentin matrix. According to Bossh-
ardt & Schroeder, fibroblasts secreting in a unipolar
direction deposit and bundle collagen fibrils at the
dentin surface to form a thin layer of perpendicu-
larly oriented ‘‘fringe fibers’’ (18). The collagen fibrils
of the fringe fibers appear to interdigitate and there-
by become linked with the unmineralized dentin
collagen fibers at the dentinocemental junction.
Acellular extrinsic fiber cementum-forming cells
have sheath-like cytoplasmic processes that delin-
eate extracellular compartments within which the
fringe fibers are assembled (17, 18, 152). Acellular ex-
trinsic fiber cementum formation proceeds along
the developing root at a rate of about 5 to 7 mm per
day, requiring 43 to 65 months for completion in hu-
man premolars (117). As the mineralization front ad-
Development and general structure of the periodontium
vances to reach of the most peripheral mantle den-
tin, it contacts the fringe fibers and they undergo
slow mineralization to complete the process of acel-
lular extrinsic fiber cementum formation. The first
evidence of mineralization in the fringe fibers ap-
pears in the central core of each fiber bundle, pre-
sumably by epitaxy from the mineralized dentin (18).
With time, the mineralization spreads across the en-
tire width of the fringe fibers, and the resulting uni-
form mineralization front subsequently advances in
proportion to the growth of the acellular extrinsic
fiber cementum. Whether or not the acellular extrin-
sic fiber cementum–forming fibroblasts deposit
special glycoproteins and/or glycosaminoglycans
needed for the supramolecular organization of colla-
gen fibers, or for supporting mineralization, remains
to be established. After the fringe fibers reach a
length of about 20 mm they become associated and
continuous with the principal fibers developing in
the periodontal ligament (117). During the life of the
tooth, the acellular extrinsic fiber cementum con-
tinues to grow in thickness at a slow rate of 1.5 to
3.0 mm per year. Closely spaced incremental (ce-
ment) lines suggest that the growth of acellular ex-
trinsic fiber cementum is episodic. Presumably the
periodontal ligament cells adjacent to the root sur-
face respond to appropriate environmental signals
calling for an increase in acellular extrinsic fiber ce-
mentum matrix and its mineralization.
When root development is about two thirds com-
pleted and the tooth is about to enter its functional
stage, cementum formation converts from acellular
extrinsic fiber cementum to a cellular mixed strati-
fied cementum (cellular intrinsic fiber cementum
and acellular intrinsic fiber cementum) type (18, 21).
The conditions and factors responsible for this tran-
sition are unknown. The formation of cellular intrin-
sic fiber cementum closely resembles bone forma-
tion. Cementoblasts and cementocytes are involved
in the secretion of intrinsic fibers (in contrast to the
extrinsic fibers that are a product of periodontal liga-
ment fibroblasts). The rate of apposition of cellular
mixed stratified cementum (about 0.1 to 0.5 mm per
day) is less than that of bone (13). The intrinsic colla-
gen fibers are assembled in bundles that follow a
spiral course along and around the root. These fibers
are best observed in scanning electron micrographs
of the root surface (114).
Mature cementoblasts are relatively large cells
with a highly basophilic cytoplasm. During cellular
intrinsic fiber cementum formation, they secrete in
a relatively rapid multipolar mode and become en-
trapped in the matrix as cementocytes (16, 114, 117,
13
Cho & Garant
153, 154). Slow matrix deposition is thought to occur
in a unipolar fashion during acellular intrinsic fiber
cementum formation, permitting the cementoblasts
to escape entombment in the matrix. Cementoblasts
share similar morphological features with osteo-
blasts, suggesting that these two cell types might
originate from a common progenitor pool located in
the periodontal ligament and the marrow spaces of
the adjacent alveolar bone.
Cementoblasts express parathyroid hormone re-
ceptors, but unlike osteoblasts and bone-lining cells,
they do not retract in response to parathyroid hor-
mone to expose the root surface to preosteoclasts
(73). Also, rat cementoblasts (like osteoblasts) and
their precursors express growth hormone receptors
(157). Growth hormone receptors are expressed in
precementoblasts adjacent to the Hertwig’s epi-
thelial root sheath. Receptor expression increases
during cementum formation and thereafter declines
in cementocytes. Periodontal ligament cells next to
acellular extrinsic fiber cementum do not express
growth hormone receptors. Excessive amounts of
growth hormone cause hypercementosis (5). In con-
trast, hypophysectomy leads to reduced amounts of
cellular cementum. In humans, growth hormone de-
ficiency causes some teeth to fail to form and others
to undergo delayed eruption.
The role of the epithelial root sheath of Hertwig in
root formation and cementogenesis
Hertwig’s epithelial root sheath has an origin from
the inner and outer enamel epithelial cells. Hertwig’s
epithelial root sheath consists of a double layer of
epithelial cells continuous with and extending apic-
ally from the apical rim of the enamel organ. At this
stage, the sheath forms a circumferential structure
encompassing pulpal ectomesenchyme, separating
it externally from dental follicular and perifollicular
ectomesenchyme (Fig. 2, 3). Apical growth of Hert-
wig’s epithelial root sheath occurs by proliferation of
the epithelial cells of the sheath. Continuity between
the enamel organ and Hertwig’s epithelial root
sheath is lost soon after root formation begins. The
apical region of the developing root contains ecto-
mesenchymal progenitor cells that give rise to
fibroblasts, preodontoblasts and precementoblasts.
The coordinated proliferation of the epithelial and
ectomesenchymal cells at the apical site gives rise
to cells needed for root elongation and mineralized
tissue formation. Preodontoblasts differentiate ad-
jacent to the inner layer of the root sheath and its
basal lamina (Fig. 3). The inner layer of the root
14
sheath appears to perform the same inductive func-
tions attributed to the inner enamel epithelium dur-
ing coronal odontoblast development. Slavkin and
colleagues have reported that Hertwig’s epithelial
root sheath secrets polypeptides that are related to,
but different from, enamelin and amelogenin pro-
teins (126, 127, 129). The inductive effects that these
matrix polypeptides may have on adjacent fibro-
blasts and precementoblasts have not been estab-
lished. However, an epithelio/mesenchymal interac-
tion between cultured cells of Hertwig’s epithelial
root sheath and fibroblasts has been demonstrated
in vitro (138). When fibroblasts were grown with cells
of Hertwig’s epithelial root sheath they showed in-
creases in rough endoplasmic reticulum, Golgi
membranes and associated secretory granules and
increased secretion of collagen.
The role of Hertwig’s epithelial root sheath in root
development and especially as it relates to the initia-
tion of cementogenesis has become a focus of con-
siderable attention (138). Since the epithelial cells of
the inner layer of Hertwig’s epithelial root sheath are
analogous to the preameloblasts, it was suggested
early on that they might secrete enamel matrix pro-
teins over the newly deposited root dentin (101, 102,
125, 129, 142). Based on various studies, it is now
generally accepted that there is a transient period
of secretion of proteins, including bone sialoprotein,
osteopontin and amelin by the cells of Hertwig’s epi-
thelial root sheath (14, 15, 44, 74). In addition to
these matrix proteins there are also the components
of the epithelial basement membrane, such as lami-
nin and collagen type IV, which are included in the
narrow band of matrix juxtaposed to the dentin ma-
trix. This layer is sometimes identified as intermedi-
ate cementum, a misleading term since the matrix
in question is a product of epithelial and dentinog-
enic cells (102). According to Schroeder (114) and
Bosshardt & Selvig (21), there is no such layer inter-
posed between cementum and dentin in human
teeth. This layer becomes highly mineralized as de-
velopment continues (59). The potential role for
these epithelial matrix molecules in triggering the
differentiation of cells capable of forming acellular
extrinsic fiber cementum and cellular intrinsic fiber
cementum is a primary question that remains most-
ly unanswered. Yet, the concept that epithelial (en-
amel organ) proteins stimulate cementogenesis has
found clinical application in experimental tissue re-
generation protocols. It has been reported that the
application of hydrophobic amelogenin peptides to
denuded root surfaces promotes new cementum for-
mation (58).

It is generally accepted that the breakup of the in-
ner and outer cell layers of Hertwig’s root sheath
along the predentin surface is due to epithelial cell
degeneration (4, 47, 72, 101, 103, 125). In rat molar
root development acellular extrinsic fiber cementum
formation occurs only after cells of the adjacent fol-
licular ectomesenchyme invade the Hertwig’s epi-
thelial root sheath (102). The follicular cells appear
to migrate to the dentin surface concomitant with
the breakup of the root sheath. In migrating to the
predentin the cells of the dental follicle proper may
be responding to a chemoattractant present in the
dentin matrix or to one produced by the inner epi-
thelial layer of the root sheath.
The fate of Hertwig’s epithelial root sheath follow-
ing the onset of cementogenesis is also a subject of
debate that remains unresolved. Traditional thinking
proposed that Hertwig’s epithelial root sheath disin-
tegrated into small clusters and/or strands of epi-
thelial cells that survived indefinitely in the peri-
odontal ligament. More recent studies have sug-
gested that epithelial cells might undergo epithelial/
mesenchymal transition into fibroblasts and ce-
mentoblasts that deposit acellular and cellular ce-
mentum respectively (137). The possibility that some
epithelial cells of the root sheath undergo epithelial-
mesenchymal transformation and subsequently se-
crete cementum matrix must be investigated further.
There is evidence that cells of the inner layer of the
root sheath become incorporated in cellular ce-
mentum or trapped between cementum and dentin
during formation of the apical part of the root (1, 46,
72). However, the evidence that many of the cells of
the root sheath retain an epithelial phenotype, and
survive in the periodontal ligament as the epithelial
rests of Malassez, is incontrovertible (114, 143).
Periodontal ligament collagen fiber attachment to
the root surface: implications of cell migration and
cytoplasmic polarization
The attachment of the principal fibers of the peri-
odontal ligament to the root surface provides an in-
formative example of the role that cells play in or-
ganizing and orienting extracellular fibers into func-
tional networks.
Prior to the onset of cementogenesis, the dental
follicle proper cells nearest to the root sheath are
aligned parallel to the epithelial cells (26, 152). Colla-
gen bundles that lie parallel to the root sheath are
partly enveloped in cytoplasmic grooves formed by
the dental follicle proper cells. Cytoplasmic microtu-
bules and collagen secretory granules are oriented in
Development and general structure of the periodontium
the same direction as the extracellular collagen
fibers. With the onset of the disruption of the root
sheath, the dental follicle proper cells assume an
elongated profile with polarity toward the dentin
matrix. The cells appear to move toward the dentin
in the spaces created by the disruption of the root
sheath. During shifting of the dental follicle proper
cells the collagen bundles that were initially parallel
to the root sheath are reorganized, so that they come
to lie in the lateral intercellular between the dental
follicle proper cells, oriented perpendicular to the
root surface (26, 152). Many small cytoplasmic pro-
cesses extend from the leading edge of the dental
follicle proper cells. Collagen fibrils secreted from
these leading edge processes intermingle with the
dentin matrix collagen. Although many of the small
collagen fibers appear to have no preferred orien-
tation, most are aligned perpendicular to the root by
the microtubule-secretory-granule apparatus in the
cytoplasmic processes (152).
In a later stage of acellular extrinsic fiber ce-
mentum formation, fibroblasts (or dental follicle
proper cells) extend thin cytoplasmic sheets that
partially surround the developing fringe fibers, or
Sharpey’s fibers. These sheets or veils of cytoplasm
are best developed on the part of the cell nearest the
periodontal ligament. Examination of the cytoskel-
eton in the cytoplasmic sheets reveals that the
microtubules and collagen secretory granules are
aligned mostly parallel to the fringe fibers, indicating
that fringe fibers grow in circumference by secretion
from the surface of cytoplasmic sheets (152). In con-
trast, small cytoplasmic processes that give rise to
intrinsic fibers characterize the end of the cell near
the dentin (or the previously deposited cementum).
In the early development of cellular intrinsic fiber
cementum, cementoblasts appear to deposit fiber
bundles parallel to the surface of the root. Subse-
quently, the cementoblasts engage in binding these
fibers with smaller intrinsic fibers deposited from
cytoplasmic processes extending from the end of the
cell facing the dentin. Transmission electron micro-
scopic analysis of the small cell processes show that
microtubules align collagen secretory granules par-
allel to the developing intrinsic fibers. In the forma-
tion of cellular intrinsic fiber cementum, these ce-
mentoblasts are eventually surrounded by matrix as
new waves of cementoblasts differentiate at the ce-
mental surface.
Although the full story has yet to be developed,
preliminary evidence suggests that cells orient newly
deposited collagen by aligning secretory granules
parallel to microtubules within the cytoplasmic pro-
15
Cho & Garant
cesses and sheets that demarcate extracellular
microcompartments (11, 29). Cell migration and/or
movements of cell processes, controlled by the cyto-
plasmic actin contractile network, could also play a
role in organizing the fibers of the extracellular ma-
trix. This has been observed in developing tendons
as well as in the periodontal ligament. The cell sur-
face receptors and cytoplasmic signaling steps that
control the flow of cell membrane components and
secretory granules to the cell surface and the sub-
sequent cell/matrix interactions needed to construct
the fibrous architecture of a specific tissue are un-
doubtedly complex.
Periodontal ligament
Development of the periodontal ligament
The development of the periodontal ligament begins
with root formation prior to tooth eruption. The
continuous proliferation of the inner and external
enamel epithelium forms the cervical loop of the
tooth bud. This sheath of epithelial cells grows apic-
ally, in the form of Hertwig’s epithelial root sheath,
between the dental papilla and the dental follicle.
At this stage, the sheath forms a circumferential
structure encompassing dental papilla separating it
externally from dental follicle cells. The dental fol-
licle cells, located between the alveolar bone and the
epithelial root sheath, are composed of two sub-
populations with distinct morphological character-
istics and locations; mesenchymal cells of the dental
follicle proper and the perifollicular mesenchyme
perifollicular mesenchyme (Fig. 2). The morpholog-
ical features and their differentiation into cemento-
blasts during acellular extrinsic fiber cementum for-
mation were discussed earlier. The mesenchymal
cells of the perifollicular mesenchyme bounded by
the dental follicle proper and the developing alveolar
bone are stellate-shaped, small, and randomly
oriented. In contrast to the dental follicle proper, the
cells of the perifollicular mesenchyme are rather
widely separated. Ultrastructural study of these cells
indicates that they contain an euchromatic nucleus
and small cytoplasm that contains a small number
of short cisternae of rough endoplasmic reticulum,
mitochondria, free ribosomes, and an inactive Golgi
area. These cells also have several long and thin
cytoplasmic processes that connect with those from
neighboring cells. A small number of short collagen
fibrils are located close to the cell surface (27, 31,
47). As the root formation continues, cells in the per-
ifollicular area gain their polarity, increased cellular
16
volume and synthetic activity. These cells become
elongated and contain increased numbers of rough
endoplasmic reticulum and mitochondria and an ac-
tive Golgi complex. As a result, they actively synthes-
ize and deposit collagen fibrils and glycoproteins in
the developing periodontal ligament (27, 31, 47).
The developing periodontal ligament, as well as
the mature periodontal ligament, contains undiffer-
entiated stem cells that retain the potential to differ-
entiate into osteoblasts, cementoblasts and fibro-
blasts (90, 91, 93). Experimental studies suggest that
stem cells occupy perivascular sites in the peri-
odontal ligament and in adjacent endosteal spaces
(54, 71, 93). Stem cell progeny undergo further matu-
ration during migration to the bone and cemental
surfaces (92, 110). Whether or not osteoblasts, ce-
mentoblasts and fibroblasts originate from a com-
mon ancestor or from a specific line of progenitor
cells remains to be clarified.
Development of the principal fibers
Development of the major collagen bundles, the
principal fibers of the periodontal ligament, is
closely correlated to root formation. Fiber bundles
originate at the surface of the newly formed root
dentin in close relation to elongated and highly po-
larized fibroblasts. These nascent fiber bundles
(fringe fibers) are tightly packed (bundled) by the ac-
tion of cementoblasts during the initial development
of acellular extrinsic fiber cementum. During tooth
eruption, as the periodontal ligament matures, the
fringe fibers merge across the width of the ligament
to form the principal fiber bundles. In the middle of
the periodontal ligament the collagen fiber bundles
are less tightly packed. In general, the majority of the
principal fibers course in a coronal direction from
cementum to bone, forming the oblique fiber group.
During the development of the fringe fibers, fibro-
blasts exhibit cytoplasmic polarity toward the root
and alveolar bone surfaces respectively. The ultra-
structural appearance of these cells is consistent
with directed cell migration toward each of these
surfaces, concurrent with the deposition of a colla-
gen and proteoglycan-rich extracellular matrix (26).
A specific cementum attachment protein may favor
periodontal ligament fibroblast attachment to the
cementum surface (107).
With continued development of the root, major
collagen bundles, the principal fibers, are estab-
lished as continuous structures embedded as Shar-
pey’s fibers in bone and cementum. Sloan & Carter
have reviewed the subject of the structural organiza-
 Development and general structure of the periodontium

tion of the fibers of the ligament (128). In histological

sections the following distinct groups of principal
fibers are noted: dentogingival, alveolar crest, trans-
septal, interradicular, horizontal, oblique and apical
fiber bundles. The oblique fibers, occupying nearly
two thirds of the ligament, are inserted into bone
coronal to their insertion into cementum. This geo-
metric arrangement of the oblique fibers is ideally
suited to absorb intrusive forces generated during
mastication. In order to attach the tooth in its al-
veolus, the fibers must be embedded in mineralized
bone and cementum. A nonfibrillar matrix that
stains with ruthenium red appears to ‘‘cement’’ the
terminus of the fringe fibers (Sharpey’s fibers) at
their insertion in newly formed acellular extrinsic
fiber cementum and bone, and in the case of fully
developed specimens on a reversal line deep within
cementum or bone. Immunocytochemical studies
have shown that osteopontin is a significant compo-
nent of the matrix of the reversal line. The mature
periodontal ligament can be subdivided into three
regions (Fig. 4): a) a bone-related region, rich in cells
and blood vessels, b) a cementum-related region
characterized by dense well-ordered collagen Fig. 4. Histological section showing the periodontal liga-
bundles, and c) a middle zone containing fewer cells ment (PDL), dentin (D), cementum (C) and alveolar bone
and thinner collagen fibrils (128). (AB)

Cellular components
Fibroblasts are the most abundant cells in the peri-
odontal ligament, and are responsible for met-
abolism of extracellular matrix components. The
periodontal ligament is known to have heterogen-
eous population of fibroblasts. A subpopulation of
osteoblast-like fibroblasts, rich in alkaline phospha-
tase, has been identified in the periodontal ligament
(34, 52, 65, 80). These cells have the capacity to give
rise to bone cells and cementoblasts. They are also
responsible for the production of acellular extrinsic
fiber cementum in the mature periodontal ligament
(56, 57). Periodontal ligament fibroblasts are also
needed to maintain the normal width of the peri-
odontal ligament by preventing the encroachment of
bone and cementum into the periodontal ligament
space (94, 95). The factors responsible for this activ-
ity have yet to be identified.
Morphology of periodontal ligament fibroblasts
Mechanical strain applied to periodontal ligament
fibroblasts appears to determine their shape, syn-
thetic activity and adhesive interaction with the sur-
rounding extracellular matrix. Most periodontal liga-
ment fibroblasts are highly active cells, exhibiting an
elongated well-polarized cytoplasm with extensive
areas of contact to collagen fibers (8, 49). These
fibroblasts contain large amounts of rough endo-
plasmic reticulum and well-developed Golgi com-
plexes, indicative of a high rate of protein synthesis
(7, 29). The Golgi complex of the periodontal liga-
ment fibroblast contains several Golgi stacks com-
prised of cisternae and terminal saccules. Each Golgi
stack is made up of five cisternae, about 2 mm in
length, terminating at each end in an expanded sac-
cule (30). Immature cisternae at the cis surface of
the Golgi complex are slightly dilated and in routine
preparations devoid of any stainable content. The
saccules associated to these cisternae contain fine,
loosely arranged filaments. The cisternae of the trans
surface contain dense material and their associated
saccules contain rod-like structures with globular
terminal elements, resembling segment-long-spa-
cing collagen aggregates. These saccules are released
to form presecretory granules that quickly associate
to microtubules (29). Autoradiographic and bio-
chemical studies have confirmed a high rate of pro-
tein secretion in the periodontal ligament (29, 66).
Proline is incorporated into collagen polypeptides in

17
Cho & Garant
the rough endoplasmic reticulum of periodontal
ligament fibroblasts within minutes of its exit from
the bloodstream. At 10 minutes, newly synthesized
procollagen molecules are present inside Golgi ves-
icles, and by 20 minutes are ready for secretion
within secretory granules associated with microtu-
bules. In less than 30 minutes, newly synthesized
collagen fibrils are present in the immediate extra-
cellular vicinity of fibroblasts (29). At 60 minutes,
newly secreted collagen fibrils are heavily labeled
with tritiated proline. An intact microtubular net-
work is required for movement of collagen secretion
granules from the trans-Golgi network to the se-
cretory pole of the cell (29, 30). During trans-
migration, the secretory pole of the periodontal liga-
ment fibroblast is also its leading edge.
Polarization of cellular organelles
The anatomical and functional polarization of
fibroblasts in the periodontal ligament was clearly
established in animals fed a diet containing beta-
aminopropionitrile, a substance that blocks the for-
mation of intermolecular cross-links in the collagen
molecules. Autoradiographic analysis of collagen se-
cretion in the periodontal ligament of these animals
showed that secretion of new (-labeled) collagen oc-
curred from the end of the cell that was also the
leading edge. The secretion of extracellular matrix at
the leading edge of a transmigrating cell may have
significance in modeling the construction of three-
dimensional fiber networks. Chemotactic migration
of matrix forming cells toward bone and cementum
could establish the orientation of fringe-fibers dur-
ing periodontal ligament development and sub-
sequent repair. The presence of actin networks and
stress fibers endow the periodontal ligament fibro-
blast with a high degree of contractility, with which
it can exert tractional forces on the extracellular ma-
trix (2, 43, 51). Highly developed stress fibers have
been described in fibroblasts of the transseptal fibers
(50).
Intracellular collagen fibrils
The fibroblast is not only responsible for the forma-
tion of collagen fiber networks but also in the re-
moval of collagen fibrils (6, 42, 48, 96). With the ad-
vent of electron microscopy, striated collagen fibrils
were observed inside vesicles of fibroblasts, particu-
larly abundant in the periodontal ligament fibro-
blasts (48, 78, 96). Localization of acid phosphatase
inside the same vesicles that contained intracellular
18
collagen fibrils gave added support to the idea that
fibroblasts were involved in lysosomal digestion of
collagen fibrils (39, 48). In vitro studies have demon-
strated that fibroblasts are eminently capable of
phagocytozing collagen fibrils from the extracellular
environment and degrading them inside phagolyso-
mal bodies (9, 131). Additional study of this activity
indicates that collagenase (matrix metalloprotein-
ase-1) is not involved in the intracellular phase of
the degradation of collagen fibrils (41). Lysosomal
cysteine proteinases (cathepsins B, L and N) of the
lysosomal granules are capable of rapid degradation
of internalized collagen fibrils. It has been suggested
that cell surface matrix metalloproteinases and inte-
grin collagen receptors localized in phagocytic clefts
may regulate the initial steps in fibril internalization
(70). However, in our previous studies, we observed
that secretory granules formed in the Golgi complex
are translocated to the periphery of periodontal liga-
ment fibroblasts on microtubules prior to their fu-
sion with the cell membrane. In some cases, several
secretory granules translocated on the same micro-
tubule fuse together and undergo polymerization in-
tracellularly. These observations strongly suggest a
possibility that some intracellular collagen fibrils
may represent those in the process of secretion
rather than phagocytosed ones (29, 117).
Fibroblast-to-matrix adhesion and traction
Fibroblasts attach to the substratum of the extracel-
lular matrix via surface receptors for collagen and
fibronectin. Attachment to the substratum is essen-
tial for cell migration and for organization of the
extracellular fibrillar matrix. The focal adhesion and
its mature form, the fibronexus, has received a great
deal of attention over the past decade (37, 124). In
the formation of these adherent contacts, the cell
membrane integrin a5b1 attaches to the RGD se-
quence (arginine-glycine-aspartic acid) of fibronec-
tin (97). Fibronectin molecules can polymerize to
form pericellular matrices. Assembly is initiated by
binding soluble fibronectin molecules to cell surface
integrin receptors (a5b1 and avb3) (98, 149). The
cytoplasmic domain of the integrin receptor attaches
to the peripheral cytoplasmic protein, talin, which in
turn interacts with a protein called vinculin. Confor-
mational changes in vinculin cause it to bind to actin
microfilaments in the cortical cytoplasm, thereby
completing a molecular ‘‘bridge’’ between the cell’s
contractile apparatus and fibronectin in the extracel-
lular matrix (3). With the binding of fibronectin to
collagen fibrils, the molecular linkage extends from

the cytoplasmic contractile apparatus to an extracel-
lular collagen fiber network, establishing a mechan-
ism for exerting traction on the collagen fibers.
Through such cell-to-matrix contacts, the extracellu-
lar matrix can exert an effect on cell shape and be-
havior. Tension in the extracellular matrix is trans-
mitted to fibroblast integrin receptors, leading to sig-
naling events that alter the activity of the cell.
Human periodontal ligament fibroblasts respond to
increased tension by upregulating the expression of
interleukin-1a and interleukin-1b (38) and by secret-
ing prostaglandin E2 (150). In this ‘‘outside-in’’ type
of signaling, tension transmitted to the fibroblast
causes a rise in the activity of several small gua-
nosine triphosphatases, which regulate the enzyme
cascades that lead to changes in cell shape and func-
tion. Cells can also alter the binding strength of their
integrin receptors through cytoplasmic signaling
pathways. This represents a form of inside-out signal
transduction (100). The linkage between the cell sur-
face and the immediate extracellular matrix serves
as a node whereby the cell can receive regulatory in-
formation from the outside, as well as providing a
mechanism for exerting an organizing influence on
the adjacent matrix (64, 89, 112, 156).
On highly mobile fibroblasts these receptors are
diffusely distributed, while in stationary cells they
are arranged in linear arrays, codistributed with
cytoplasmic actin and extracellular fibronectin ag-
gregates. Immunocytochemical localization of
fibronectin in the periodontal ligament has shown
that it forms aggregates about 90 nm thick on the
surface of fibroblasts (32). These aggregates are
usually codistributed with intracellular components
of the fibronexus contact (106).
Morphology and roles of undifferentiated cells
Progenitor fibroblasts are smaller, less polarized, and
contain less rough endoplasmic reticulum and Golgi
saccules (53). Exceptions are noted around blood
vessels and near the surface of the cementum where
fibroblast-like cells appear smaller and less active.
Cells of the osteoblastic subtype can be identified
by their high level of alkaline phosphatase and by
their ability to bind a newly discovered cementum
attachment protein (80). Cells of this subtype pro-
duce mineralized nodules in vitro, while maintaining
a fibroblast phenotype. Analysis of the mineralized
matrix revealed the presence of osteopontin and
bone sialoprotein, characteristics shared with osteo-
blasts and cementoblasts (108). Transmission elec-
tron microscopy of these mineralized nodules re-
Development and general structure of the periodontium
veals a tissue with similarities to acellular extrinsic
fiber cementum. These results demonstrate the im-
portant role of periodontal ligament fibroblasts in
anchoring collagen fibrils to the mineralized matrix
of the root surface.
In repair, new fibroblasts are derived from perivas-
cular progenitor cells in the adjacent normal peri-
odontal ligament. Migration of fibroblasts into the
area to be repaired is facilitated by the presence of
fibrin and fibronectin networks. New collagen fibers
are laid down rapidly and often without functional
orientation or attachment to the adjacent hard
tissues. Reorganization of the initial collagen matrix
into oriented principal fiber bundles requires con-
tinued cell activity over several weeks.
Studies of potential progenitor-cell pools have
shown that the marrow spaces of the alveolar bone,
particularly along lateral communications between
the periodontal ligament and the marrow, are sites
of cell proliferation. Of interest is the finding that
newly divided cells from these sites appear to con-
tribute to new cementum formation as well as to the
deposition of new periodontal ligament collagen. Al-
though there is still uncertainty surrounding the ori-
gin of cementoblasts and osteoblasts in the peri-
odontal ligament, evidence suggests that cells of the
osteoblastic subtype develop from perivascular cells
in the periodontal ligament proper, as well as from
the progenitor cells arising from adjacent marrow
compartments. After extensive damage to the peri-
odontal ligament connective tissue, the periodontal
ligament compartment is populated by an increased
number of bone-forming cells, and ankylosis of the
tooth to the alveolar bone usually results.
Role of epidermal growth factor receptor in
stabilization of periodontal ligament fibroblast
phenotype
The regulatory mechanism by which periodontal
ligament fibroblasts maintain their phenotype and
differentiate into cementoblasts or osteoblasts re-
mains largely unknown. We demonstrated for the
first time that numerous epidermal growth factor re-
ceptor are expressed on the cell membrane of fibro-
blastic cells in the functional periodontal ligament
(periodontal ligament fibroblasts, paravascular cells
and preosteoblasts), whereas no epidermal growth
factor receptor is expressed on fully differentiated
cementoblasts and osteoblasts (28, 31). Also, peri-
odontal ligament fibroblasts express many epider-
mal growth factor receptors during differentiation.
For example, epidermal growth factor receptors are
19
Cho & Garant
found on the precursor cells of periodontal ligament
fibroblasts (parafollicular cells), throughout their dif-
ferentiation, as well as on mature periodontal liga-
ment fibroblasts with full synthetic activity (28, 31,
33). During differentiation of osteoblasts and chon-
drocytes, however, a large number of epidermal
growth factor receptors is expressed only on undif-
ferentiated preosteoblasts and prechondrocytes. The
number of epidermal growth factor receptors on
these cells falls dramatically as their differentiation
progresses, with fully differentiated osteoblasts and
chondrocytes not expressing epidermal growth fac-
tor receptors (31, 33). Epidermal growth factor re-
ceptors are also known to be associated with pro-
liferation of various cell types, including dental fol-
licle cells (105, 134, 135, 139). The need for the
continued expression of a high density of epidermal
growth factor receptors on periodontal ligament
fibroblasts cannot be suitably explained by the
known physiological functions of epidermal growth
factor. Epidermal growth factor does not show sig-
nificant mitogenic and chemotactic effects on peri-
odontal ligament fibroblasts, as observed with plate-
let-derived growth factor-BB and insulin-like growth
factor-1 (88). However, periodontal ligament fibro-
blasts of the functional periodontal ligament dem-
onstrate an extremely low 3H-thymidine-labeling
index ranging from 0.5% to 3% under normal physio-
logical conditions (62, 92, 109). On the basis of these
observations, we proposed that the expression of
epidermal growth factor receptor on periodontal
ligament fibroblasts is associated with maintaining
the cells in an undifferentiated state, while the loss
of epidermal growth factor receptor is related to dif-
ferentiation of the cells. Our recent in vitro study
with periodontal ligament fibroblastic cells sup-
ported this notion (87). Untreated periodontal liga-
ment cells showed a gradual increase in spon-
taneous alkaline phosphatase activity, a osteogenic
cell differentiation marker, from 2 days to 7 days of
culture. Alkaline phosphatase activity was further in-
creased at 7 days after treatment with dexametha-
sone, an osteogenic cell differentiation inducer,
whereas epidermal growth factor treatment reduced
it to a lower level than the baseline. Interestingly, un-
treated periodontal ligament cells have both high-
and low-affinity forms of epidermal growth factor re-
ceptor, while fully differentiated rat osteosarcoma
cells (ROS 17/2.8) did not have any detectable epi-
dermal growth factor receptor. Treatment with dexa-
methasone for 2 days decreased the number of epi-
dermal growth factor receptors, the synthesis of epi-
dermal growth factor receptor protein and the
20
expression of epidermal growth factor receptor
messenger RNA by 50% compared with control. On
the other hand, epidermal growth factor treatment
increases the expression of epidermal growth factor
receptor messenger RNA. These observations
strongly indicate that epidermal growth factor recep-
tor on periodontal ligament fibroblastic cells is re-
sponsible for maintenance of their relative undiffer-
entiated state functioning as a negative regulator.
Gingiva
The gingiva, comprised of gingival epithelium and
connective tissue, is a portion of the oral mucosa
that covers the tooth-bearing part of the alveolar
bone and the cervical neck of the tooth. The epi-
thelial component of gingiva shows regional
morphological variations that are a reflection of
tissue adaptation to the tooth and alveolar bone
(113). These include the oral gingival epithelium,
oral sulcular epithelium and junctional epithelium.
The gingiva evolves as the crown enters the oral cav-
ity by breaking through the oral epithelium. As the
development of gingiva prior to tooth eruption into
the oral cavity has not been studied (113), our de-
scription on the formation of gingival structural
components in association with the tooth is limited
to the stage of mucosal penetration of the crown and
subsequent differentiation.
Development of gingival epithelium
As an erupting tooth approaches the oral epithelium,
the enamel epithelium rapidly proliferates, forming
the thick reduced enamel epithelium. As the crown
erupts further, the reduced enamel epithelium over-
lying the enamel fuses with the oral epithelium, un-
dergoes transformation, and establishes the dento-
gingival junction forming the junctional epithelial
cells.
The junctional epithelium maintains a direct
attachment to the tooth surface. During eruption,
contact is established between the reduced enamel
epithelium and the oral gingival epithelium. Since
epithelial cells of the junctional epithelium contact
with the tooth surface, they produce an internal
basal lamina and are anchored to this basal lamina
by numerous hemidesmosomes (75, 76, 114, 119).
The basal cells of the junctional epithelium, how-
ever, are separated from the connective tissue by the
external basal lamina. The interface between the
junctional epithelium and the underlying connective

tissue is relatively smooth, unlike the condition
found in the oral gingival epithelium. Although junc-
tional epithelium does not exhibit true phenotypic
stratification, the outermost cells tend to be elon-
gated and to lie with their long axis parallel to the
tooth surface. Suprabasal cells of the junctional epi-
thelium express markers typically found in basal
cells and simple epithelia. The junctional epithelium
tapers from its coronal end, which may be 10 to 20
cells wide, to 1 or 2 cells at its apical termination,
located at the cementoenamel junction in healthy
tissue. Of interest is the observation that keratin
tonofilaments are not inserted into the hemidesmo-
somes along the internal basal lamina. The internal
basal lamina is approximately three times thicker
than the external basal lamina. It contains laminin
and proteoglycans. Cells in contact with the internal
basal lamina express the a6b4 integrin, a laminin re-
ceptor. The cells in contact with the internal basal
lamina contain a relatively well-developed rough en-
doplasmic reticulum, and numerous Golgi compo-
nents. Several investigators indicate that the cells of
the junctional epithelium have an endocytotic ca-
pacity equal to that of macrophages and neutrophils
and that this activity might be protective in nature.
Cells leave the external basal lamina and migrate
to the free surface of the junctional epithelium
located at the base of the gingival sulcus, where they
are exfoliated. As measured in nonhuman primates,
the rate of cell turnover in the junctional epithelium
(4–6 days) is significantly faster than in the oral sul-
cular epithelim. The oral gingival epithelium has the
slowest rate of proliferation of all three regions, with
a turnover time of 9 to 12 days. It appears that differ-
ences in cell proliferation among the three regions
of gingival epithelium may be due to their respon-
siveness to the growth inhibitory effect of trans-
forming growth factor-b and stimulatory effect of
epidermal growth factor.
In healthy teeth, the junctional epithelium (epi-
thelial attachment) ends at the cementoenamel
junction. Densely packed collagen bundles are an-
chored to the acellular extrinsic fiber cementum just
below the terminal point of the junctional epithel-
ium. These collagen bundles form the connective
tissue attachment. The stability of this connective
tissue attachment is a key factor in limiting the mi-
gration of the junctional epithelium.
Development of gingival connective tissue
Prior to emergence of the crown, the connective
tissue in the future eruption pathway shows alter-
Development and general structure of the periodontium
ations including the degeneration of collagen fibers,
cells and blood vessels. Formation of this eruption
pathway accelerates the rate of tooth eruption.
Gingival connective tissue fibroblasts originate
from perifollicular mesenchyme, a derivative of the
stomodeal mesoderm. During normal development
of the periodontium, gingival fibroblasts do not
come into contact with the tooth surface. In con-
trast, the fibroblasts of the periodontal ligament be-
come juxtaposed to the tooth surface soon after the
disruption of the root sheath. New fibroblasts are de-
rived from the proliferation of undifferentiated peri-
vascular cells. Gingival collagen turns over more
rapidly than that of skin and bone, but slower than
that of the periodontal ligament.
Gingival fibroblasts show considerable variation in
morphology. In general they contain an abundance
of rough endoplasmic reticulum, well developed
Golgi complexes and mitochondria. Other fibro-
blasts may show signs of swelling and degeneration
depending on site-to-site microenvironmental vari-
ations in cytokines and other biological mediators of
inflammation.
The collagen matrix of gingival connective tissue
is well organized into fiber bundles, which constitute
the gingival supra-alveolar fiber apparatus. It is
made up of the transseptal, circular, semicircular,
transgingival, and intergingival fibers, which connect
and link the adjacent teeth of one arch. These fibers
secure the teeth against rotation and maintain tooth
linkage during mesial drift. Tractional forces in the
extracellular matrix produced by fibroblasts are be-
lieved to be the motive forces responsible for gener-
ating tension in the collagen, keeping the teeth
tightly bound to each other and to the alveolar bone.
Alveolar bone
The maxilla and mandible of the adult human can
be subdivided into two portions: (a) the alveolar pro-
cess that involves in housing the roots of erupted
teeth and (b) the basal body that does not involve in
housing the roots (114). The alveolar processes con-
sist of the thin alveolar bone proper that forms the
alveolar wall of the tooth socket, the inner and outer
cortical plates, and spongy bone between the al-
veolar bone proper the cortical plates. Since the al-
veolar processes develop and undergo remodeling
with the tooth formation and eruption, they are
tooth-dependent bony structures (116). Therefore,
the size, shape and location and function of the teeth
determine their morphology.
21
Cho & Garant
The alveolar bone proper is 0.1 to 0.4 mm thick
and is consisted of a Harversian system and lamel-
lated and bundle bone (114). The coronal and apical
regions of the alveolar bone proper have a sieve-like
structure. These openings connect the periodontal
ligament to the bone marrow spaces and correspond
to Volkmann’s canals through which blood vessels,
lymphatic vessels and nerve fibers pass.
Development of the alveolar bone proper
Since the development of the alveolar bone proper
has not been systemically studied in animals and
humans, the information on this subject is very
much fragmented. Tooth germs develop within bony
structures. At the late bell stage, bony septa and
bony bridge start to form, and separate the individ-
ual tooth germs from another, keeping individual
tooth germs in clearly outlined bony compartment
(114). At this stage, the dental follicle surrounds each
tooth germ, which is located between a tooth germ
and its bony compartment. Even prior to root forma-
tion, the tooth germs within bony compartments
show continued bodily movement in various direc-
tions to adjust to the growing jaws. This movement
causes minor remodeling of bony compartment
through bone resorption and deposition of new
bone.
The major changes in the alveolar processes begin
to occur with the development of the roots of teeth
and tooth eruption. As the roots of teeth develop, the
alveolar processes increase in height. Also, cells in
the dental follicle start to differentiate into peri-
odontal ligament fibroblasts and cementoblasts re-
sponsible for the formation of the periodontal liga-
ment and cementum, respectively. At the same time,
some cells in the dental follicle also differentiate into
osteoblasts and form the alveolar bone proper (60,
114, 132, 133). The formation of the alveolar bone
proper is closely related to the formation of the peri-
odontal ligament and cementum during root forma-
tion and tooth eruption (114). Thus, the size and
shape of the individual developing tooth roots deter-
mine the overall structure of the alveolar bone
proper. On the other hand, the rest of bony struc-
tures in the alveolar process are achieved by perios-
teal bone formation (114).
Remodeling of the alveolar processes during tooth
eruption
The tooth germs develop within the alveolar pro-
cesses, and when the root formation begins, the al-
22
veolar processes have already grown over the occlusal
plane of the developing tooth. Thus, for successful
tooth eruption, there must be bone remodeling. In
order for the developing tooth to escape from the
alveolar bone, a gubernacular canal must be widened
by osteoclastic bone resorption (23, 86). At the same
time, new bone formation at the base of the bony
crypt is believed to be important in producing an
outward eruption force directed against the erupting
tooth. Morphological studies and experimental surgi-
cal interventions have provided evidence that the
post-secretory enamel organ and the highly vascular-
ized dental follicle connective tissue coordinate the
eruption of teeth of limited eruption (24, 145, 146).
The presence of the dental follicle was found to be
essential for bone resorption during the formation of
the eruptive pathway as well as for new bone forma-
tion apical to the erupting tooth (40, 68). Supporters
of the concept that the dental follicle is the key struc-
tural component responsible for regulating eruption
of teeth point to the fact that proteinase activity in
the follicular connective tissue peaks at initiation of
tooth eruption (123). The observation that rootless
teeth undergo eruption (24, 55) is further convincing
proof for the integrated activity of bone resorption
and bone formation under the control of the dental
follicle during eruption. Monocytes containing tar-
trate-resistant acid phosphatase, an indicator of lys-
osomal activity, invade the connective tissue of the
dental follicle early in tooth development and during
tooth eruption (111, 144). These cells are believed to
be osteoclast precursors that play an important role
in alveolar bone resorption during tooth eruption.
Recent evidence shows that colony-stimulating fac-
tor-1 and epidermal growth factor are involved in
tooth eruption (35, 36, 67, 122, 145, 148). Isolated
cells of the dental follicle secrete colony-stimulating
factor-1, a substance involved in the recruitment and
differentiation of preosteoclasts. Epidermal growth
factor upregulates the production of colony-stimulat-
ing factor-1 via its ability to stimulate the cells of the
reduced enamel organ to make interleukin-1a (145–
148).
Functions of the alveolar processes
The general functions of the alveolar bone processes
are to house the roots of teeth and to absorb and
distribute occlusal pressures generated during tooth
contacts. Their most important and unique function
is to anchor the roots of teeth to the alveoli, which
is achieved by the insertion of Sharpey’s fibers into
the alveolar bone proper.

Conclusion
Not long ago knowledge of the development and
general structure of the periodontium was limited to
morphological information. Over the years, exten-
sive use has been made of transmission electron
microscopy, histochemistry, cytochemistry and
radioautography to document the cell and tissue
structure of the periodontium. We have attempted a
brief review of this topic. During the last decade,
rapid progress has been made in understanding of
the molecular and cellular biology of periodontal
tissue development. However, there remain many in-
triguing aspects of this story that remain to be fully
explored at the tissue, cell and molecular level. This
subject is of special importance, for we now know
that periodontal tissue healing and regeneration
share many, if not all, of the events that take place
during normal development. Further studies of how
cells interact with their neighbors and with the extra-
cellular matrix, in vivo as well as in vitro, during de-
velopment, will help to create a firmer foundation
upon which periodontal regeneration techniques
can be developed and implemented clinically.
Acknowledgment
This work was supported by USPHS grant DE 04898.
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