1. CLINICAL PERIODONTOLOGY
Presented by
Dr. SARANG SH, BDS

2. ONLY AUTHENTIC BOOK OF PERIODONTOLOGY

3. PERIODONTOLOGY
“Periodontology” is the study
of the tooth-supporting
tissues, the “periodontium.”

4. PERIODONTIUM
GINGIVA
PERIODONTAL
LIGAMENT
ROOT
CEMENTUM
ALVEOLAR
BONE

5. THE NORMAL PERIODONTIUM
CHAPTER 1

6. THE NORMAL PERIODONTIUM
PeriodontiumPeriodontium
GingivaGingiva
Attachment
Apparatus
Attachment
Apparatus
PDLPDL
CementumCementum
Alveolar
Bone
Alveolar
Bone

7. FUNCTIONS OF PERIODONTIUM
SupportSupport
ProtectionProtection
NourishmentNourishment

9. ORAL MUCOSA
• The gingiva and the covering of the hard palate, termed the masticatory
mucosa.
• The dorsum of the tongue, covered by specialized mucosa.
• The oral mucous membrane lining the remainder of the oral cavity.
• The gingiva is the part of the oral mucosa that covers the alveolar
processes of the jaws and surrounds the necks of the teeth.

10. ANATOMY OF GINGIVA
• Gingiva begins at the
mucogingival line, and covers
the coronal aspect of the
alveolar process.
• On the palatal aspect, the
mucogingival line is absent;
here, the gingiva is a part of the
keratinized, non-mobile palatal
mucosa.

11. ANATOMY OF GINGIVA

12. ANATOMY OF GINGIVA
Marginal Gingiva
Attached Gingiva
Interdental
Gingiva

13. MARGINAL GINGIVA
• Unattached gingiva; is the
terminal edge or border of the
gingiva surrounding the teeth in
collar like fashion.
• Forms the SOFT TISSUE WALL OF
GINGIVAL SULCUS.
• Usually 1 mm wide.

14. GINGIVAL SULCUS / GINGIVAL POCKET
• The sulcus is a narrow V shaped
groove surrounding the tooth, about 2
– 3 mm deep in clinically normal
gingiva.
• The bottom of the sulcus is made up
of the most coronal cells of the
junctional epithelium.
• One lateral wall of the sulcus is made
up of the tooth structure, the other
wall is the oral sulcular epithelium

15. ATTACHED GINGIVA – WIDTH OF ATTACHED GINGIVA
• width of the attached gingiva important clinical parameter.
• It is the distance between the mucogingival junction and the projection on the
external surface of the bottom of the gingival sulcus or the periodontal pocket.

16. ATTACHED GINGIVA – WIDTH OF ATTACHED GINGIVA
• The attached gingiva becomes wider as a patient ages.  why???
• The width varies between individuals and among various groups of
teeth in the same person.
▫ greatest in the incisor region
 3.5 to 4.5 mm in maxilla,
 3.3 to 3.9 mm in mandible
▫ narrower in the posterior segments
 1.9 mm in maxillary
 1.8 mm in mandibular first premolars

17. SIGNIFICANCE OF ATTACHED GINGIVA
•Protect the Periodontium from injury caused by
frictional forces encountered during mastication.
•To dissipate the pull on the gingival margin
created by the muscles of adjacent alveolar
mucosa.

18. INTERDENTAL GINGIVA
• Pyramidal or col shaped – occupies the gingival embrasure.
▫ Pyramidal Interdental Gingiva; tip of papilla
▫ Col Shaped; valley like depression that connects facial & lingual papilla

20. Absence of interdental
papillae and col where
proximal tooth contact
is missing.

21. Variation in Interdental Gingiva

22. HEALTHY GINGIVA
(CLINICAL FEATURES)
• pink and firm with a knife-edge
appearance, scalloped around the
teeth.
• the gingival margin is a few millimeters
coronal to the cement–enamel
junction.

23. HEALTHY GINGIVA (CLINICAL FEATURES)

24. HEALTHY PIGMENTED GINGIVA
• Healthy gingiva is
described as “salmon”
pink in color; in
▫ Blacks (seldom also in
Caucasians) the gingiva
may exhibit varying
degrees of brownish
pigmentation.
This pigmentation results from the synthesis of
melanin by melanocytes located in the basal
layer of the epithelium.

25. HEALTHY GINGIVA (CLINICAL FEATURES)
VARIATIONS IN CONSISTENCY
• Gingiva exhibits varying
consistency and is not mobile
upon the underlying bone.
• The gingival surface is
keratinized and may be firm,
thick and deeply stippled

27. ANATOMY OF GINGIVA – HISTOLOGICAL AREAS
• Gingival epithelium
▫ Oral epithelium (OE).
▫ Oral sulcular epithelium (SE).
▫ Junctional epithelium (JE).
• The gingival sulcus is lined by
SE and JE.

29. ORAL EPITHELIUM
• The OE is an ortho keratinized, stratified, squamous
epithelium.
▫ Surface cells lose their nuclei and are packed with the
protein keratin.
• It presents an impermeable physical barrier to oral
bacteria.
• The basal layer of epithelial cells is thrown up into
folds overlying the supporting connective tissue.
▫ These folds increase the surface area of contact
between the epithelium and connective tissue and are
known as rete ridges or rete pegs.

30. A, Keratinized. B, Nonkeratinized. C, Parakeratinized

31. • 1. Junctional Epithelium
• 2. Oral Sulcular
Epithelium
• 3. Connective Tissue
• 4. Gingival Sulcus

32. ORAL SULCULAR EPITHELIUM
• There are no rete ridges.
• Cells are keratinised but still have nuclei (parakeratinised).
• act as a semipermeable membrane through which injurious bacterial
products pass into the gingival and tissue fluid from the gingiva seeps
into the sulcus.

33. JUNCTIONAL EPITHELIUM
• Collar like band of stratified
squamous nonkeratinizing
epithelium.
• The JE is non-keratinised and has a
very fast turnover of cells (2–6 days
compared to 1 month for OE).
• The most apical part of the JE lies at
the cement-enamel junction in
health.
A. Gingival Sulcus B. Epithelial Attachment C. Apical Extent of JE

34. JUNCTIONAL EPITHELIUM
• The JE is permeable with wide
intercellular spaces through which
cells and substances can migrate (such
as bacterial toxins or host defense
cells).
• Migration of the JE from its position in
health apically onto the root
cementum indicates a loss of
periodontal attachment and
progression to the disease state of
periodontitis.
A. Gingival Sulcus B. Epithelial Attachment C. Apical Extent of JE

35. EPITHELIAL ATTACHMENT
• The junctional epithelium is
attached to the tooth surface by
means of an internal basal lamina.
• It is attached to the gingival
connective tissue by an external
basal lamina that has the same
structure as other epithelial–
connective tissue attachments
elsewhere in the body.

36. FUNCTION & CLINICAL IMPORTANCE OF
JUNCTIONAL EPITHELIUM
• Forms firm, direct mechanical junctional with tooth structure.
• Seals the underlying connective tissue of periodontium from the oral
environment.
• Forms epithelial barrier against plaque bacteria.
• Allows access of gingival fluid, inflammatory cells.

37. GINGIVAL CONNECTIVE TISSUE
The gingival connective tissue (or lamina
propria) is made up of collagen fiber
bundles called gingival fibers, around
which lie ground substance, fibroblasts,
blood and lymph vessels and neural tissues

38. GINGIVAL FIBERS

39. FUNCTIONS OF GINGIVAL FIBERS
• To brace marginal gingiva against tooth.
• To provide the rigidity necessary to withstand the forces of mastication
without being deflected away from tooth surface.
• To unite the free marginal gingiva with the cementum of root and the
adjacent attached gingiva.

40. BLOOD SUPPLY TO THE GINGIVA
• Supra periosteal arteries.
• Vessels of PDL
• Arterioles emerging from Crest of Interdental Bone.
• Capillaries from adjacent Connective Tissues.

41. GINGIVAL LYMPHATICS
• Labial & lingual gingiva of the mandibular incisors – submental lymph
nodes.
• Palatal gingiva of maxilla – deep cervical lymph node.
• Buccal gingiva of maxilla & buccal and lingual gingiva in the mandibular
premolar – molar – submandibular lymph node.

43. PDL
• The periodontal ligament forms the attachment between
the cementum and alveolar bone.
• It is a richly vascular connective tissue within which lie
bundles of collagen fibers;
▫ these are divided into four groups based on their position.
• Within the ligament are mechanoreceptors that provide
sensory input for jaw reflexes.
• The periodontal ligament acts to dissipate masticatory
forces to the supporting alveolar bone and its width,
height and quality determine a tooth’s mobility

44. Cementum is a mineralized tissue overlying the root dentine. It does
not undergo physiological remodeling but is continuously deposited
throughout life.

45. TYPES OF CEMENTUM
• Acellular, Afibrillar Cementum
(AAC; red)
▫ AAC is formed at the most cervical enamel border
following completion of pre-eruptive enamel maturation,
and sometimes also during tooth eruption. It is probably
secreted by cementoblasts.
• 2 Acellular, Extrinsic-fiber Cementum
(AEC; green)
▫ AEC forms both pre- and post-eruptively.
▫ It is secreted by fibroblasts.
▫ On the apical portions of the root, it comprises a portion
of the mixed-fiber cementum.

46. TYPES OF CEMENTUM
• 3 Cellular, Intrinsic-fiber Cementum
(CIC; blue)
▫ CIC is formed both pre- and posteruptively.
▫ It is synthesized by cementoblasts, but does not contain
extrinsic Sharpey’s fibers.
• 4 Cellular, Mixed-fiber Cementum
(CMC; orange/green)
▫ CMC is formed by both cementoblasts and fibroblasts;
▫ it is a combination of cellular intrinsic- fiber cementum
and acellular extrinsic-fiber cementum.

47. The alveolar processes of the maxilla and the mandible are
tooth-dependent structures. They develop with the formation
of and during the eruption of the teeth, and they atrophy
for the most part after tooth loss.

48. PARTS OF ALVEOLAR BONE
• 1 Alveolar Bone
▫ Synonyms:
 Anatomically
 Alveolar Wall
 Cribriform Plate
▫ Radiographically
 Lamina dura
• 2 Trabecular Bone
• 3 Compact Bone

49. ALVEOLAR BONE
• The walls of the sockets are lined with a layer of dense
bone called compact bone, which also forms the
buccal and lingual/palatal plates of the jaw bones.
• In between the sockets and the compact jaw bone
walls lies cancellous bone that is made up of bony
trabeculae.

50. ALVEOLAR BONE
• The compact bone plates of the jaws are thicker on
the buccal aspect of the mandibular molars and
thinnest on the labial surface of the mandibular
incisors.
• The thickness of the compact bone layer is relevant to
the choice of local analgesia techniques as the
anesthetic solution passes through bone to reach the
nerve supply

51. CORRELATION OF CLINICAL & MICROSCOPIC FEATURES
• Color
• Size
• Contour
• Shape
• Consistency
• Surface Texture
▫ stippling
• Position
▫ Active & passive eruption

52. ACTIVE & PASSIVE ERUPTION
•Active Eruption is movement of teeth in direction
of occlusal plan.
•Passive eruption is the exposure of tooth by apical
migration of gingiva.

53. STAGES OF PASSIVE ERUPTION
1. Base of the gingival sulcus and the junctional epithelium (JE) are on the
enamel.
2. Base of the gingival sulcus is on the enamel, and part of the junctional
epithelium is on the root.
3. Base of the gingival sulcus is at the cementoenamel line, and the entire
junctional epithelium is on the root.
4. Base of the gingival sulcus (arrow) and the junctional epithelium are on the
root.

54. STAGES OF PASSIVE ERUPTION