IN THE NAME OF GOD

PERIODONTOLOGY LECTURE 1

PERIODONTIUM : PERI : around DONT : tooth

 So the Periodontium
eriodontium is the tissues that surround and
support the teeth ,
 It is composed of four main parts :
- Gingiva
ingiva : which covers everything .
- Periodontal ligaments (PDL):black lines extending
between the teeth and the alveolar bone .
- Alveolar bone .
- Cementum : covers the dentine of the roots .
 In this lecture we will talk about the first two of them ,
and remember that we will study each one of them
separately , although they are interconnected .

Development of the periodontal tissues :

A) In the primitive oral cavity ,some thickenings
thickening
of the epithelium occur , these thickenings
are called the tooth bud .
B)) then we move to cap stage
C) then the bell stage , in which the enamel
organ becomes concave and resembles a bell .
 D and E) then dentinogenesis starts followed by
amelogenesis .
F) the crown starts to mature ,during this stage ,the two
layers of epithelium fuse together to form the epithelial
diaphragm .
G and H ) all the dental tissues mature , and the tooth
erupts ,the periodontal ligaments are complete .
 When do the periodontal tissues develop ?
During tooth development ,when the tooth bud is being
formed ,along time the periodontal tissues develop
gradually , so there is intervegetation between them .

In the pic : this is a tooth bud (dental fact)

- ENAMEL ORGAN
- DENTAL PAPILLA(future dental pulp)
- DENTAL FOLLICLE (gives rise to
most of the periodontal tissues ).

DENTAL LAMINA
DL (It attaches the enamel organ
to
the oral cavity )
in the pic : we can see the
AB dental lamina (DL),
we can see also from the previous picture :
outer enamel epithelium (OEE),inner enamel epithelium
(IEE),dental follicle (DF),dental papilla (DP),stellate
reticulum (SR).
and we can see the alveolar bone (AB) is being formed
alongside the development of tooth bud.
- Once we reach the late bud stage , the inner and
outer enamel epithelium continue together alone
without the stellate reticulum .
- Then they will form a very tiny structure called THE
EPITHELIAL DIAPHRAGM (ED).
- In multi rooted teeth ,The epithelial diaphragm will
give the shape of the furcation area .
- In single rooted teeth ,the ED is very small ,it
continues downward apically at something called the
hertwing epithelial root sheath which is very
important structure in cementum formation .

always During tissue development there will be an

epithelial-mesenchymal interactions ,which means that the
epithelial components and the connective tissue
components interact with each other by means of small
molecules of cytokines and growth factors ,they give
orders to each other for behavior .

 the oral epithelium which is the part that covers

everything (the part we can see in the mouth) is derived
from the epithelium of the oral cavity (oral epithelium).
 the rest of the periodontal tissues (PDL,alveolar bone
,cementum, gingival connective tissue
tissue ) are derived from
the ectomesenchyme of the dental follicle (surrounding the
enamel organ from the outside )
 The oral mucosa is composed of three main parts :
 the masticatory mucosa : which is the keratinized
part, it covers the hard palate and the gingiva .
 the lining mucosa : it is non keratinized , it lines
cheeks ,the buccal mucosa , lip , floor of the mouth.
the specialized mucosa : it covers the tongue ,it is
specialized because it contains taste buds .

THE GINGIVA :
- The gingiva is part of the masticatory mucosa
because it is keratinized ,
- It is the part that covers the necks of the teeth and
the coronal portion of the alveolar process

The ANATOMICAL parts of the gingiva :

 free or marginal gingiva :
exactly at the margins of the teeth
 attached gingiva :
the area between the 2 black lines
 interdental gingiva (papilla):
Triangles between the teeth
 THE FREE GINGIVA :
- It extends from the margins of the gingiva to the free
gingival groove or the marginal groove (the
groove between marginal gingiva and attached
gingiva).
- it is called free because it is not attached to the tooth
,so there is a space between them
called gingival sulcus .
- We can insert a periodontal probe in
the gingival sulcus to measure its depth
for examination of periodontal diseases
- This measurement could be between
0 - 2.8 mm .

 THE ATTACHED GINGIVA :

- It is extends between the free gingival
groove to the junction of the gingiva with
the alveolar mucosa (mucogingival
junction) .
- Under the mucogingival junction we can see the
alveolar mucosa which is a part of the lining mucosa
which is elastic and mobile and non keratinized .
- The attached gingiva is firmly attached to the
underlying teeth and bone ,so even if u try to remove
it ,it is very hard to do .
- There is no alveolar mucosa on the palate ,so there
is just free gingiva and then a fully keratinized
masticatory mucosa covering the whole palate ,so on
the palate there is free gingiva + mucosa of the
palate . there is no neither alveolar mucosa nor a
mucogingival junction .
  why the attached gingiva is firmly attached to the
underlying bone ???
1) To withstand the forces of mastication .
2) To withstand the forces of tooth brushing and any
abnormal habits .
3) To prevent movements of marginal gingiva

- The width of the attached gingiva is variable , so it

differs between :
1) Upper and lower teeth
2) Right and left teeth
3) Individuals
4) Buccal and lingual
5) Increases with age .
For example , width of the attached gingiva labial to
upper incisors differs from that around molars .
☺ Examples :
Maxilla : buccally :it is widest around incisors
:it is narrowest around premolars
Mandible :lingually : narrowest around incisors
: widest around premolars
- The width of the attached gingiva is subject to
change ,so it is not a stable anatomical landmark ,
It can be changed if the tooth moved ,or with teeth
brushing or by the presence of inflammation .
 - There has been a long standing
stand debate in
periodontology about is the width of the attached
gingiva is important or the thickness (the distance
between the tooth and the outside of the gingiva ) ?
- Some says that the width is very important ,it
shouldn'tt be more than 3 mm
- But the general
neral consensuses is that we don't have
any measurements of the width of the gingival to
maintain health ,so u don'tt have to have exactly 3
mm to have healthy gingiva ,for for example if u have 2
mm u can have healthy gingival also .
- But if u have reduced gingival width or thickness ,
then u will be more susceptible to gingival recession
(sliding toward apical ).
In the pic :
- We can see here different width of the gingiva

- And the width of the gingiva is also determined

by the position of teeth , so if the tooth is
outside the dental arch (labially proclined ),
then we will end up with thinner gingiva and
gingival recession .

keratinized vs attached gingival :

- The attached gingiva is the distance between free
gingivall groove and the mucogingival junction
- Whereas the keratinized gingival = marginal G +
attached G .
 THE INTERDENTAL PAPILLA (GINGIVA):
- The shape of the interdental papilla is determined by:
1) The relation between teeth
2) The shape of CEJ
3) The amount of spaces between teeth
4) The position and the width of the contact points or
areas .

- It is triangular in shape 2-dimenshionally

- But 3-dimenshionally it is :
ANTERIORLY : it is pyramidal
BOSTERIORLY :it is it is flattened in a bucculingual
direction , as if we cut the apex of the pyramid and
make it flat .
- We have buccal and lingual interdental papilla ,and
they meet in the middle in a non keratinized area
called '' the col " ,which is a good area for bacterial
accumulation .

what are the clinical features of healthy gingival ??

1) The color must be pink ,however in dark people there
will be melanin pigmentation on their gingiva which is
called the physiologic\racial pigmentation .
2) The contour of the gingiva has a scalloped outline
3) The margins should be thin and knife-edge, shouldn't
be inflamed or bold .
4) The surface texture must be stippled (like a peel of
orange )
During time of gingival inflammation ,the gingiva
becomes edematous ,this stippling disappears ,so
loss of stippling is a sign of gingival inflammation .
 5) The consistency is resilient : it is not very hard or soft
, so that it accommodate the functions of the gingiva
6) Pointed and thin interdental papilla .
7) The probing depth should be between 0-3mm
8) No bleeding when gently probing ,if it bleeds ,it is a
sign of gingivitis .

HISTOLOGY OF THE GINGIVA :

- The gingiva consists of two main parts ;

The epithelium and the connective tissue ,and they're
attached to each other by a basement membrane .

 THE EPITHELIUM :
It is stratified squamous keratinized epithelium

 FUNCTIONS OF THE EPITHELIUM :

1) Protection of the underlying connective tissue ,
2) The selective interchange with the oral environment
3) Active production of cytokines ,adhesion molecules
,growth factors ,enzymes,proteoglycans
For example ,B defensins ,interlukin 8\1B,EGF.

- The main cell type of the epithelium is the

keratinocytes ,they are arranged in 4 layers :
  stratum basale (basal cell layer) : where the
production of cells occur ,these cells divide ,the older
cells leave upward ,the daughter cells remain down

- so stratum basale cells are very

active ,they are dividing continuously
,they produce molecules .
These cells contains a lot of energy producing
organelles such as mitochondria ,ribosomes ,Golgi
apparatus , rough endoplasmic reticulum .
 startum spinosum layer (spinous cell layer) :
As the cell matures ,it becomes rich with tonofilaments
and more characteristic protein (keratin) .
 stratum granulosum layer (granular cell layer) :
The cell continues to mature , as it matures and going
upward ,it loses some of the organelles necessary for the
production of proteins ,
It starts to be more cropped with tonofilaments and with
granules containing keratohyalin .
stratum corneum (corneal or horny cell layer) :
As the cell mature even more ,and pushed more upward
,it loses it's nuclei ,and being filled with keratin .

 WHAT IS THE TYPE OF KERATINIZATION OF THE

GINGIVA AND ORAL MUCOSA ???
THEY ARE PARAKERATINIZED .

 what is the difference between parakeratinization and

orthokeratinization ????
Ortho : means straight ,original
Para : means around ,adjacent
- So in orthokeratinization ,the cells of stratum
corneum layer must not have nuclei
- But in the oral cavity and particularly in the gingiva
the cells don't lose their nuclei ,which is called
parakeratinization .
 why the epithelial cells are parakeratinized ??
- Because The epithelial cells have a very high turn
over rate , so they are renewed very quickly ,in some
areas there will be a complete renewal of the
epithelium in only two weeks , so the epithelial cells
don't have the chance to lose their nuclei ,so they are
parakeratinized .

Cytokeratins :
They are proteins that fill the keratinocytes ,
 - We have keratin subtypes (k1-k19).
- Different epithelial cells contain different cytokeratins
,and not all the epithelial cells produce all the types of
cytokeratins .
- The epithelial cells also produce other types of
proteins such as keratolinin ,involucrin ,filaggrin

OTHER CELL TYPES are also present within the

gingival epithelium such as :
1) langerhans cells :they are derived from monocytes
- they are responsible immunity ,
- they are present in the suprabasal layer
2) merkel cells :contain nerve endings
3) melanocytes :contain melanin
- they are found in basal and spinous cell layer .

HISTOLOGICAL TYPES OF GINGIVAL EPITHELIUM:

 oral epithelium (outer epithelium):

- It is the epithelium facing the oral
cavity .
- It is parakeratinized .
- It shows RETE PEGS (RP) (dark orange).
- On the opposite of the RETE PEGS ,
we can see the connective tissue papilla
- It is believed that this arrangement is
responsible for the stippled texture of
the gingiva
- The turnover rate is very high (10-12 days).
  why the gingival epithelium has a very high turnover
rate ???
Because it is subjective to continuous load all the time
(heat,cold,eating,cheek biting) .

 the sulcular epithelium :

- Faces the tooth without contacting it ,
- The space between them is called the gingival
sulcus .
- It extends from the coronal end of the junctional
epithelium to the crest of the gingival margins.
- It is thin and non keratinized stratified squamous
epithelium .
- It doesn't contain any granulosum or corneum layers
- It is semi permeable ,it allows the passage of
defense cells into the gingival crevice
- It also allows the passage of materials and
substances from the gingival crevice into the rest of
the gingiva

 the junctional epithelium :

- It is a very small and thin structure ,
but in this picture ,there is a mistake ,
because the truth is that the junctional
epithelium is smaller than the
sulcular epithelium.
- the junctional epithelium provides contact
between the gingiva and the tooth
 - it is composed of stratified squamous non keratinized
epithelium
- it is composed of 3-4 cells in early stages of life , but
this thickness increases with age to reach up to 20
cells
- it has only 2 layers ( basal and suprabasal layers) .
- the length = 0.25-1.35 mm ,so it is very short
- it has no rete pegs

 so remember there is rete pegs for the oral

epithelium and sulcular epithelium ,but not for the
junctional .

in the picture :
- This is the last junctional epithelial cell
(the final cell which lies on the PDL )
So it is attached on one side to the tooth
by what is called inner basal lamina ,
- and on the other side it is attached to
the connective tissue by an outer basal
lamina .
- the basal lamina is also composed of two
parts :
1) a translucent part called lamina lucida .
2) a denser part called lamina densa

 how the junctional epithelial cells are attached to to the

tooth ???
By means of hemidesmosomes ,which are very tiny
structures composed of attachment proteins attaching the
cells to the tooth and to the connective tissue.

 What are the characteristics of the junctional epithelial

cells ??
- they are very large
- the intercellular spaces are wide ,and this is so good
when we think of the passage of materials from
inside to the outside ,but it is not good when we think
of invasion of bacteria to these spaces.

THE EXTRACELLULAR MATRIX OF THE

EPITHELIUM (ECM):
- it means the substances between cells
- there is just a small space between cells of the
gingival epithelium , so there is no abundant ECM.
 What are the components of the ECM ??
- Proteoglycans : CD44,HAYLORONIC ACID
,SYNDECAN DECORIN .
- Glycoproteins : integrin family .

 what are the differences between the junctional

epithelial (JE) cells and sulcular (SE) and oral
epithelium (OE) ??
1) Cell size \ tissue volume in JE is higher than that in
OE or SE.
 2) The intercellular spaces in JE are greater than those
in OE .
3) The number of desmosomes in JE is less than in OE
4) There is difference in cytokeratin expression and cell
surface markers according to function, so not all the
keratinocytes show exactly the same molecules .
5) JE originates from the reduced enamel epithelium
,whereas the OE and SE originate from the oral
mucosa .

- There is always a balance between cell division and

cell shedding ,and by that the thickness of the
epithelium is maintained .
 what is the dentogingival junction ,and what are its
components ??
It is the junction between the gingiva and the tooth ,and
it is composed of enamel , cementum ,junctional
epithelium , gingival fibers ,and adhesion molecules .

in the picture :
- This is during tooth development
- What is left of the enamel organ is
Called the reduced enamel epithelium
- It covers the crown of the tooth before it
Erupts
- Once eruption starts ,the tooth will move
More coronally ,and the epithelium of the oral
Cavity will thicken and move downward .
- then they will meet ,and the epithelium between them
will disintegrate ,
- this is why eruption of teeth happens without
bleeding .
- the tooth continue to erupt ,and the junctional
epithelium is formed from this reduced enamel
epithelium .
- this epithelium loses its ability to form ameloblasts
forever .
- and remember that the sulcular epithelium and the
oral epithelium originates from outer epithelium of the
oral cavity .

- the space between the gingiva and the tooth (gingival

sulcus) is filled with a fluid called the gingival
crevicular fluids (GCF).
- It has a lot of functions ;cleaning and antimicrobial
effect ,it aids in the adhesion of the gingiva to the
tooth .

THE CONNECTIVE TISSUE OF THE GINGIVA :

- The main components :

1) Cells : the main component.
Fibroblasts ,blood cells (mast cells ,macrophages
,neutrophils ,lymphocytes ,plasma cells )
2) Collagen fibers :
The main collagen types are ;collagen type 1,
collagen type 3 ,and less of types 5 and 6 , and
this is true for all periodontal tissues .
3) Extarcellular matrix : it is the medium in which all
other components are embedded ,
 - it consists of :
Water ,proteins ,glycoproteins ,proteoglycans
(decorin ,biglycan ,versican),growth factors
,attachement molecules ,adhesion molecules .

THE FIBERS OF THE C.T :

- Collagen fibers are the main fibers ,but there are
another types of fibers such as ,reticulin ,oxytalan
fibers.

- What are the functions of the fibers :

1) They provide structure and strength and
framework for the gingiva .
2) Elastic fibers give elasticity and resiliency to the
gingiva .

 the fibers of the gingival are arranged in groups :

1) dentogingival fibers :
they extend from the cementum to just underneath
the epithelium ,so they end within the C.T
of the gingiva ,and they don’t reach the
epithelium .

2) Transseptal fibers :
They cross the septum (interdental
alveolar bone) ,these fibers join the
adjacent teeth together ,and they are
part of the PDL fibers .
 3) Dentoperiosteal fibers :
They originate from the cementum of the tooth ,and
they go down ,but they don’t touch the periosteum
,they still within the C.T of the gingiva .

4) circular fibers :
they are circular in a longitudinal section .

THE END OF THE FIRST PART OF THE

LECTURE

DONE BY : OMAR MARZOUQ

 THE SECOND PART OF THE LECTURE

THE PERIODONTAL LIGAMENTS

in the picture :
PDL : are the black fibers that are drawn
around the tooth.

 What is the periodontal ligament ???

- It is a connective tissue surrounds
the root of the tooth and attaches it to the alveolar
bone .
- It is continuous with the tissues of the gingiva and
communicates with the marrow spaces in bone .
- So it is continuous with the cementum on one side
,and with gingiva ,and with marrow spaces of the
alveolar bone from other sides .

 What are the characteristics and functions of the PDL ?

- It is very small physically ,it is like a hair in diameter
,but it contains a lot of structures ,and still poorely
understood .
- It is the component that hold our teeth in place ,and
allows them to mobile when we eat or clench our
teeth
 - So it is subjected to continuous mechanical loading
,even more than the gingiva .
- It has a very high turnover rate ,which make it
embryonic like tissue ,but unfortunately ,this high
turnover rate is reduced during disease .

components of the PDL :

- Cells
- Fibers : the main component (as opposite to gingiva )
- ECM
- Nerves
- Blood vessels
- Lymphatics

 general functions of the PDL :

1) Teeth support
2) Propriception :which means perception of the
position in the space ,because the PDL contains
nerve endings that transmit the information to the
brain .
3) Regulation of alveolar bone volume .

- The fibers are the most important component ,and

the most important fibers are the principal fibers
,although there are another types of immature elastic
fibers such as oxytalan and eluanin .

THE PRINCIPAL FIBERS :
- They are composed mainly by type 1 and 3 collagen
,and a little of type 5 and 6 ,but
but they are not fibrous
types of collagen .
- Type 1 collagen is arranged in bundles ,and they are
not straight , they follow a wavy course ,why??

To increase the surface area ,so it will be longer

,because we need it to be stretched during function .

- The terminal portions which are inserted into

cementum and alveolar bone are called sharpey's
fibers .

In the picture :
- This is a very high
Magnification of PDL
Inserted into a cellular
Cementum .
- We can see the wavy
course of the PDL.
PDL

In the picture :
- This is again PDL fibers
Drawn in yellow ,and then
they are inserted inside
cementum and bone ,and
become named
sharpey's fibers .
 PDL fibers are arranged into specific groups :
1) Transseptal fibers : they are the same
As the transseptal fibers of the gingiva .
So we can consider them gingival or
PDL fibers .
Function : they connect the cementums
of the adjacent teeth together .

2) Alveolar crest fibers : they extend

From the cementum to the crest of
the alveolar bone .
function : resist lateral movements.

3) Horizontal fibers : they are horizontal

Function : resist lateral movements.

4) Oblique fibers : the largest group ,

They carry the bulk of the occlusal forces .

5) Apical group of fibers : surround the apex of the

tooth ,they resist intrusion and extrusion.

6) Interradicular group : between the roots of the

same tooth (in the furcation area).

formation of the principal fibers :
- It starts before the cementum and alveolar bone are
mineralized ,because these collagen fibers have to
be inserted very strongly ,then mineralization occur
,so that they are tightly held .

- Fibroblasts are the cells

which produce sharpey's
fibers .
- They are produced on
one side from the
alveolar bone ,and
on the other side not by
cementoblasts ,but
fibroblasts on the surface within the PDL .
- So the fibroblasts from each side produce collagen
fibers ,which starts to be elongated
- Each time a new segment of collagen fibrils are
added .
- Then they meet and intervegetate in an area which is
closer to cementum than the alveolar bone .

- Microfibrils  fibrils  fibers  bundles .

- Sharpey's fibers :at insertion ,PDL
fibers are fully or partially mineralized.
- There are a lot of non collagenous
proteins surrounding these fibers such
as osteopentin to control mineralization at certain
time .

cells of the PDL :
- The main cells of the PDL are fibroblasts ,which are
responsible for the production of collagen fibers ,and
they are responsible for degradation of collagen
fibers when needed .
- Why we need remodeling of the PDL ?because PDL
are always subjected to load .
- The fibroblasts are very specialized cells ,and their
structure is totally adapted to their function .
- There are different subpopulations of fibroblasts in
different areas of PDL with a different functions .

- Other cell types :

1) Osteoblasts :they are closer to the alveolar bone .

2) Cementoblasts :they are closer to cementum

3) Osteoclasts : bone resorbing cells , they are

present in Howship's lacunae .

4) Defence cells : lymphocytes ,neutrophils

,eosinophils,plasma cells ,mast cells
,macrophages .

5) Sensory cells

6) Epithelial rest of malassez :

Look like beautiful flowers around

The root at light microscopic level
 - But the scanning electron
microscope reveals an
interconnected network around
the root ,but till now ,their function
during function is still unknown ,
although they can give rise to
some odontogenic tumors .

the ECM of the PDL :

- It contains collagen
- proteoglycans
- glycoprotiens,
- integrin ,
- growth factors
- cytokines

specific functions of the PDL :

1) mechanical : the main function .
2) formative : we have undifferentiated mesenchymal
(stem cells) which have the tendency to form
colonies more than bone marrow cells ,so we have
cells that can form a whole PDL ; fibroblasts
,osteoblasts ,cementoblasts ,necessary to regenerate
a new PDL ,and also we have undifferentiated
mesenchymal cells
3) Nutritive function : blood vessels pass through the
PDL and give nutrition to all the tissues in that area .
 4) Sensory function : it doesn’t mean that the PDL
itself transmits sensation to bone or cementum ,it
means that there are nerves pass through PDL
space .

- Physical functions :
1) Protection of vessels and nerves
2) Transmission of occlusal forces to bone by tension
and compression of the fibers ,which will affect the
alveolar bone .
3) Attachment of teeth to the bone
4) Maintenance of gingival position
5) Shock absorption .

 theories explaining the functions of the PDL :

 tensional theory : PDL performs its function by being
stretched and compressed .
 viscoelastic theory :when the tooth is subjected to an
occlusal load , and because of the presence of water in
the ECM and blood in the blood vessels ,then this water
will move to the marrow spaces ,and when load is relieved
,the water and blood will come back to their position .

- Maybe both of these theories are correct ,so it is a

combination of both of them .
thixotropic theory :historical theory ,
It said that once subjected to load ,the PDL will behave
like a gel , but it is not acceptable nowadays .

FORCE TRANSMISSION :
1) The vertical force :The best force is the vertical
force ,because it is transmitted along the long axis
of the tooth ,but not all the forces are like this .
2) The horizontal (tipping force)

- The axis of rotation of the tooth is about 40% of the

root length from the apex ,this is where the tooth
rotates .
- There is an hour glass shape of the PDL
Which allows it to accommodate these
Forces .

- The shape and structure of the PDL

Are adapted to it's function during
Normal function and during
orthodontic treatment .

in the pic :
- Suppose this tooth is moved by a wire into that
direction (in red ),there will be a compression in the
(right part) of the PDL ,this will lead to bone
resorption on that side
- At the same time ,the PDL fibers on the (left side) will
be stretched ,and this will lead to bone deposition on
that side ,
- So each time the PDL is compressed ,this leads to
bone resorption
- PDL stretching  bone deposition .
- This is a simplified picture for the orthodontic
treatment .
 Jiggling forces ;means vibration

In this picture :
Just to show you how the PDL fibers can
adapt the forces .

in this picture :
- Widened PDL due to
Adaptation because of
occlusal problems .

- and after occlusal

adjustment , the PDL fibers are back to normal

THE END OF THE LECTURE

FORGIVE ME FOR ANY MISTAKES

DONE BY

OMAR MARZOUQ