MICRO AND MACRO ANATOMY OF

PERIODONTAL TISSUES
GUM
Gross anatomy
The oral mucosa (mucous membrane) is continuous with the skin of the lips and
the mucous membranes of the soft palate and pharynx.
The oral mucosa consists of:
1) the masticatory mucosa that includes the gum and the covering of the hard
palate,
2) the specialized mucosa that covers the dorsal surface of the tongue and
3) the remaining part called the lining mucosa.
The gum is the part of the chewing mucosa that covers the alveolar process
and surrounds the cervical portion of the teeth. It is composed of an epithelial
layer and an underlying connective tissue called the lamina propria.
The gum acquires its final shape and texture with the eruption of the teeth.
Coronally, the coral pink gingiva ends at the free gingival margin, which has
scalloped contours.
Apically, the gingiva is continuous with the loose, dark red alveolar mucosa
(lining mucosa), from which it is separated by a generally easily recognizable
demarcation line called the mucogingival junction (arrows) or mucogingival line.
 Two parts of the gum can be distinguished:
1. Free gingiva (EL)
2. Attached gingiva (EA)

The free gum is coral pink in color, with an opaque surface and firm
consistency. It includes the gingival tissue on the buccal and lingual/palatal
surfaces of the teeth and the interdental gingiva or interdental papillae.
On the buccal and lingual surfaces of the teeth, the free gingiva extends from
the gingival edge apically to the free gum line, located at a level that
corresponds to the cemented adamantine junction (UCA or cemented
adamantine junction).
The attached gingiva is delimited apically by the mucogingival junction (MGU).
The free gingival margin is often rounded, so that a small invagination or groove
is formed between the tooth and the gum.

The shape of the interdental gingiva (the interdental papilla) is determined by

the contact relationship between the teeth, the width of the proximal tooth
surfaces, and the course of the cemented adamantine junction.
 In the anterior regions of the teeth, the interdental papilla has a pyramidal
shape, while in the molar region, the papillae are more flattened in the
buccolingual direction.
Due to the presence of interdental papillae, the free gingival margin follows a
scalloped course, more or less accentuated, along the teeth.

The free gum line is often most pronounced on the buccal aspect of the teeth
and is most commonly seen in the regions of the lower molars and upper
premolars.
The attached gingiva extends apically to the mucogingival junction (arrows),
from where it continues with the alveolar (lining) mucosa (AM). The attached
gum is firm in texture, coral pink in color and sometimes has small depressions
on its surface.
The depressions, called “stippling”, give it an orange peel appearance. It is
firmly attached to the underlying alveolar bone and cementum by connective
tissue fibers and for that reason is comparatively immobile in relation to the
underlying tissue.
 Microscopic anatomy

oral epithelium

Drawing that schematically represents a histological section in which you can see how the gum is composed and the contact area
between the gum and the enamel (E).

The oral epithelium is a flat stratified keratinized type and based on the degree
of differentiation of the keratin-producing cells, it can be divided into the
following cellular strata:
1. Basal layer (basal stratum or germinative stratum)
2. Layer of spiny cells (stratum spinosum)
3. Granular cell layer (stratum granulosum)
4. Keratinized cell layer (stratum corneum)
In addition to keratin-producing cells (keratinocytes) that make up about 90% of
the total cell population, the oral epithelium contains the following cell types:
• Melanocytes
• Langerhans cells
• Merkel cells
• Inflammatory cells
These types of cells are often stellate in shape and have cytoplasmic processes
of different appearance and dimensions. They are also known as “clear cells”
because in histological sections the area surrounding their nuclei appears
lighter than that surrounding the keratin-producing cells.

periodontal ligament
The periodontal ligament is the highly vascularized and cellular soft tissue that
surrounds the roots of the teeth and connects the root cementum to the wall of
the socket. Coronally, the periodontal ligament is continuous with the lamina
propria of the gum and is delimited from it by the bundles of collagen fibers that
connect the alveolar bone crest with the root (the alveolar crest fibers).

1. The part of the alveolar bone that covers the alveolus, called the “lamina
dura” (arrows).
2. The portion of the alveolar process that has a lattice-like appearance on the
radiograph is the “cancellous bone.”
The periodontal ligament is located in the space between the dental roots (R)
and the lamina dura or the alveolar bone itself (arrows).
 The alveolar bone (AB) surrounds the tooth to a level located apically
approximately 1 mm from the CEJ. The coronal edge of the bone is called the
alveolar crest (arrows).
The thickness of the periodontal ligament is approximately 0.25 mm (between
0.2 and 0.4 mm).
The presence of a periodontal ligament allows for the forces generated during
chewing function. The periodontal ligament is also essential for tooth mobility.
Tooth mobility is largely determined by the thickness, height and quality of the
periodontal ligament.
The tooth is connected to the bone by bundles of collagen fibers that can be
classified into the following groups, according to their arrangement:
1. Crestoalveolar fibers (CAF)
2. Horizontal fibers (FH)
3. Oblique fibers (FO)
4. Apical fibers (AF)

root cement
Cementum is a specialized mineralized tissue that covers the root surfaces and
sometimes small portions of the crown of teeth. The cement does not contain
blood or lymphatic vessels, lacks innervation, does not undergo physiological
remodeling or resorption and is characterized by the fact that it is deposited
throughout life.
Like other mineralized tissues, it contains collagen fibers included in an organic
matrix. The mineral content of cement, mainly hydroxyapatite, represents
around 65% of the weight, that is, it is a little higher than that of bone (60%).
Cement fulfills different functions. The fibers of the periodontal ligament are
inserted into it and contributes to the repair process when the root surface has
been damaged. Different forms of cement were described:
1. Acellular extrinsic fiber cement (AEFC). It is located in the coronal and middle
portions of the root and contains mainly bundles of Sharpey's fibers. This type
of cement is an important part of the insertion apparatus that connects the tooth
to the alveolar bone itself.
2. Stratified mixed cellular cement (CMSC). It is located in the apical third of the
roots and in the furcations. It contains extrinsic and intrinsic fibers and
cementocytes.
3. Cellular cement with intrinsic fibers (CIFC). It is found, above all, in resorption
lacunae and contains intrinsic fibers and cementocytes.

alveolar bone
The alveolar process is defined as the part of the upper and lower jaws that
forms and supports the alveoli of the teeth.
 The alveolar process is composed of bone that is formed both by cells of the
dental follicle or sac (alveolar bone itself) and by cells that are independent of
tooth development.
Together with the root cementum and the periodontal ligament, the alveolar
bone constitutes the insertion apparatus of the tooth, whose main function is to
distribute and absorb the forces generated by chewing and other dental
contacts.

Three structures are distinguished in the alveolar process:

1. The alveolar bone itself
2. spongy bone
3. External compact bone

PERIODONTAL CLINICAL HISTORY

Periodontal disease is a pathology of multifactorial origin that manifests itself
both clinically and radiographically with various signs that can be measured and
recorded in PERIODONTOGRAMA in order to classify or diagnose the severity
of the case.

GOALS:
 Learn the correct registration, use, application and graphing of the
Periodontogram.
 Recognize the characteristics of periodontal disease to transfer them to
the Periodontogram.
 Record and graph the values of clinical attachment level (NIC), probing
depth (PS), gingival margin (MG), bacterial plaque (PL), bleeding on
probing (SS).
 Record and graph the degree of mobility (Miller index) and degree of
furcation (Hamp index).

WAYS TO EVALUATE THE DAMAGE OF CLINICALLY USED

PERIODONTAL TISSUES
 Visual detection of clinical signs of tissue destruction.

 Measurement of the level of clinical insertion.

 GM: Gingival margin
SS: Bleeding on probing
PS: Probing Depth
PL: Bacterial plaque and/or calculus
NIC: Clinical insertion level
GENERALITIES
1. MG: Distance from the cement-adamantine junction (UCA) to the
gingival margin.
  If the MG is apical to the ACU, an integer number is recorded.
 If the GM is coronal to the ACU, an integer with a negative sign (-) is
recorded.

2. PS: Probing depth in mm that marks the periodontal probe from the MG
to the base of the cleft.

3. PL: Bacterial plaque and/or Calculus present on the tooth (distal, middle
and mesial).

4. NIC: It is the level of clinical insertion measured from the gingival margin
to the probing depth. It is the arithmetic sum of MG + PS.

5. SS: Bleeding on probing in the tooth (mesial, middle and distal).

 COLORING OF THE PERIODONTOGRAM
6. MG: Trace the MG in BLUE in relation to the UCA. The horizontal lines
of the periodontogram, which are equivalent to 2mm, can be taken as a
reference.

7. PS: Draw in RED a vertical line from the GM and along the root surface
the probing depth ≥ 4mm.
8. NIC: It can be directly calculated by the arithmetic sum of the MG and
the PS. The measurement is placed with BLACK color.
 9. SS: The presence of bleeding on probing is marked with a RED point,
above the number of NIC in the site corresponding to mesial, middle or
distal.

10. PL: The presence of bacterial plaque and/or calculation on the PS number
in the site that corresponds to mesial, middle or distal is marked with a BLUE
dot.

SPECIFICATIONS
1. Lost or absent dental structures:
Color completely with BLACK color.

2. Mobility degree (Miller)

Numbers on occlusal faces with BLACK color.

3. Degree of Furcation (Hamp)

 ● Class I: < 3 mm.
● Class II: ≥ 3mm. It does not cross from side to side.
● Class III: Passage of the probe from side to side.

4. Keratinized or Inserted gum ≤ 2mm:

Represented by asterisks that are drawn in GREEN between the MG box and
the corresponding piece.

SPECIFICATIONS
 5. SUPPURATION:
A circle with a RED dot in the center of the pieces that have pus.
6. OVERFLOW OR CARIES RESTORATION:
RED vertical zig-zag line on the coronary surfaces of the affected teeth.
7. DIASTEMS AND ALTERED CONTACT POINTS: BLUE line in a
vertical zigzag that is placed over the area of altered contact between
pieces.

INTRODUCTION
In this work, a brief description of the characteristics of the normal periodontium
is made.
 The periodontium (peri = around, odontos = tooth) includes the following
tissues: the gingiva, the periodontal ligament, the root cementum and the
alveolar bone. The alveolar bone consists of two components, the alveolar bone
itself and the alveolar process (alveolar process). The alveolar bone itself, also
called “fasciculated alveolar bone,” is continuous with the alveolar process and
forms the thin bony plate that lines the dental socket.
The main function of the periodontium is to attach the tooth to the bone tissue of
the jaws and to maintain the integrity of the surface of the chewing mucosa of
the oral cavity. The periodontium, also called “insertion apparatus” or “teeth
support tissues”, constitutes a developmental, biological and functional unit,
which undergoes certain changes with age and is also subject to morphological
modifications related to functional and of the oral environment.