GINGIVA AND
IT’S BLOOD
SUPPLY
Dr. Anjali Verma
CONTENTS
Definition
Macroanatomy of gingiva
Structures
Microscopic structures
Connective tissue and fibers
Blood supply
Lymphatic supply
Correlation of clinical features with
microscopic features.
References
DEFINITION
Glickman :
“Gingiva is the part of the oral mucosa that covers the
alveolar processes of the jaws and surrounds the necks of
the teeth”.
A A P 1992 :
The fibrous investing tissue, covered by keratinized
epithelium, which immediately surrounds a tooth and is
contiguous with its periodontal ligament and with the
mucosal tissues of the mouth.
Oral Mucosa consists of :
Masticatory Mucosa - Gingiva
Covering of Hard palate.
Specialized Mucosa - Dorsum of Tongue.
OMM lining remainder of oral cavity.
Structurally :
Keratinized – - masticatory mucosa
-vermilion border of the lip.
Non keratinized - lining or reflecting mucosa,
- specialized mucosa.
MACROANATOMY OF
GINGIVA
Anatomically
Free or Marginal Gingiva.
Attached Gingiva.
Interdental Gingiva.
Functionally
Part facing oral
cavity.
Part facing the
tooth.
FREE/ UNATTACHED/
MARGINAL GINGIVA
Terminal edge or border of gingiva
surrounding the teeth in a collar
like fashion.
Usually 1 mm wide, marginal
gingiva forms the soft tissue wall of
gingival sulcus.
Demarcated from attached gingiva
by a shallow depression – free
gingival groove- 50 % .
GINGIVAL SULCUS
Shallow crevice or space around the
tooth bounded by surface of tooth on one
side and the epithelium lining the free
margin of the gingiva on the other.
V –shaped.
Depth of Gingival Sulcus :
Ideal conditions depth of sulcus - zero.
Clinically healthy gingival sulcus - 2 – 3
mm.
Histologic -1.8 mm with variations from 0
to 6 mm.
ATTACHED GINGIVA
Continuous with marginal gingiva &
is firm, resilient & tightly bound to
the underlying periosteum of the
alveolar bone.
The facial aspect of the attached
gingiva extends to the relatively
loose & movable alveolar mucosa
from which it is demarcated by the
MGJ.
WIDTH OF ATTACHED
GINGIVA
It is the distance b/w the MGJ & projection on the external
surface of the bottom of gingival sulcus/ periodontal
pocket.
Greatest in incisor region :
3.5 to 4.5 mm in maxilla
3.3 to 3.9 mm in mandible
Narrower in posterior region:
1.9 mm in maxilla
1.8mm in mandible
On lingual aspect, Attached Gingiva terminates at the
junction with the lingual alveolar mucosa, which is
continuous with the mucous membrane lining the floor of
mouth.
On palatal surface, it blends imperceptibly with the
equally firm, resilient palatal mucosa.
SIGNIFICANCE OF ATTACHED GINGIVA
FOR MAINTENANCE OF PERIODONTAL
HEALTH
To protect the periodontium from injury caused by
frictional forces encountered during mastication.
An adequate width of attached gingiva prevents plaque
formation and soft tissue recession.
To dissipate the pull on the gingival margin created by the
muscles of the adjacent alveolar mucosa thus protecting
from recession.
INTERDENTAL GINGIVA
It occupies the gingival embrasure, which
is the interproximal space beneath the
area of tooth contact.
Can have a pyramidal or Col shape.
PYRAMIDAL SHAPE-
In this the papilla is located immediately
beneath the contact point. It is present in
anterior teeth
COL SHAPE
It is valley like depression that connects the facial and lingual
papilla and conforms to the shape of interproximal contact and
present in posterior teeth
Its epithelium is non keratinised and same as junctional
epithelium
MICROSCOPIC FEATURES
Microscopic examination reveals that gingiva is composed
of stratified squamous epithelium and underlying
connective tissue.
Three types of keratinisation occurs in gingival epithelium:
A. Orthokeratinised-Complete keratinisation.
B. Parakeratinised- Intermediate stage of keratinisation.
C. Non-keratinised- No granulosum and corneum strata
FUNCTIONS OF GINGIVAL
EPITHELIUM
LAYERS OF ORAL
EPITHELIUM
MORPHOLOGICAL VARIATIONS
OF GINGIVAL EPITHELIUM
Oral epithelium Protective
Sulcular epithelium
Junctional epithelium
1. Oral epithelium- Parakeratinised
0.2-0.3mm thick
composed of four layers
2. Sulcular epithelium- lines the gingival sulcus.
It is non keratinised stratified squamous epithelium.
3. Junctional epithelium- It is a collar-
like band of stratified squamous
nonkeratinising epithelium.
It is formed by confluence of oral
epithelium and REE during tooth
eruption.
Lack of expression of K6 and K16.
Free ribosomes, golgi bodies
present.
Lysosome like bodies are present.
ZONES OF JUNCTIONAL
EPITHELIUM
APICAL- Germinative
MIDDLE- Adhesiveness
CORONAL- Permeability
GINGIVAL CONNECTIVE
TISSUE
The major components of gingival
connective tissue are
Collagen Fibroblas
fibers (60%) ts(5%)
Vessels Nerves
Connective tissue of gingiva is known as lamina propria. It
consists of two layers :
1. Papillary layer.
2. Reticular layer.
Connective tissue
Extracellular Cellular
compartment compartment
Ground
Fibers substance Fibroblasts
Ground substance- Amorphous in nature. Composed of
proteoglycans( HA, Chondroitin sulphate) and glycoprotein
( Fibronectin, laminin).
Fibers- Collagen, reticular and elastic fibers.
Densely packed collagen bundles that are anchored into
the acellular extrinsic fiber cementum below terminal
point of JE form the connective tissue attachment.
The preponderant cellular element in the gingival connective
tissue is the fibroblast.
Fibroblasts are of mesenchymal origin and play a major role in
development, maintenance and repair of gingival connective
tissue, it synthesises collagen and elastic fibers as well as the
glycoproteins and glycosaminoglycans of the amorphous ground
substance.
Cells present- Mast cells, macrophages, histiocytes
Adipose cells and eosinophils although scarce are also present in
lamina propria.
Neutrophils can be seen in relatively large numbers in both
gingival connective tissue and sulcus.
GINGIVAL FIBERS
Gingivodental fibers- present on the facial, lingual and
interproximal surfaces. Embedded in cementum, project
out in a fan like fashion from the facial and lingual aspect.
Circular fibers- Present in marginal and interdental
gingiva and encircle tooth in ring like fashion.
Transseptal fibers- Located interproximally, form
horizontal bundles that extend between cementum of
approximating teeth into which they are embedded.
Semicircular fibers- Attach proximally.
Transgingivalfibers.
FUNCTIONS OF GINGIVAL
FIBERS
To brace the marginal gingiva firmly against the tooth.
To provide the rigidity necessary to withstand the forces
of mastication.
To unite the free marginal gingiva with the cementum of
the root and the adjacent attached gingiva.
BLOOD SUPPLY OF
GINGIVA
Microcirculatory tracks, blood vessels and lymphatic vessels
play an important role in drainage of tissue fluid and in the
spread of inflammation.
A very important artery that supplies the maxillary and
mandibular teeth and its supporting structures is the
internal maxillary artery.
Maxillary artery is divided into 3 parts:
1. Mandibular- posterior to lateral pterygoid muscle
2. Pterygoid- within the lateral pterygoid muscle
3. Pterygotympanic- anterior to lateral pterygoid muscle.
MAXILLARY ARTERY
The maxillary teeth and their supporting structures is supplied by
the PSA artery, Infraorbital, greater palatine and sphenopalatine
artery.
PSA gives off branches to the Maxillary tuberosity supplying
maxillary teeth in molar region, alveolar bone and mucosa.
ASA which is the branch from the infraorbital artery supplies the
anterior teeth in canine and incisor region.
Greater palatine artery and nasopalatine artery in the anterior
region supplies the palatal gingiva.
Mandibular teeth and their supporting structures supplied by the
inferior alveolar artery. Inferior alveolar artery is the branch of
internal maxillary artery. It’s branches include mental, sublingual
and buccal arteries.
Incisive artery, branch of the
inferior alveolar artery supplies
the lower incisors.
There are majorly three sources
of blood supply to the gingiva:
Supraperiosteal arteries.
Vessels of the periodontal
ligament.
Arterioles.
Beneath the epithelium on the outer gingival surface,
capillaries extend into the papillary connective tissue
between the epithelial rete pegs in the form of hairpin
loops with efferent and afferent branches.
Along the sulcular epithelium, capillaries are arranged in
flat anastomosing plexus that extends parallel to enamel
from base of sulcus to gingival margin.
CLINICAL IMPLICATIONS
The vascular path and morphology of the maxillary vestibule have
an essential impact on the outcome of reconstructive surgical
interventions by influencing intraoperative bleeding and
postoperative [Link] upper oral vestibule is chiefly
furnished by the branches of maxillary and facial arteries.
The maxillary artery (MA) supplies the bony maxilla, maxillary
sinus, upper teeth, gingiva and hard palate by the posterior
superior alveolar artery (PSAA), the infraorbital artery (IOA), the
greater palatine artery (GPA), and the nasopalatine artery (NPA).
The facial artery (FA) gives the superior labial artery (SLA) at the
level of the labial angle. The SLA runs medially and anastomoses
with the contralateral SLA and forms the arterial circle around the
mouth together with the inferior labial arteries (ILA)
Several authors described the split-thickness flap in implant
dentistry, which might represent a less compromised
postoperative flap circulation because of the scarcity of vertical or
horizontal periosteal releasing incisions, thereby protecting
collateral blood vessels.
In 2012, Steigmann et al. concluded that splitting the
mucoperiosteal flap can enhance soft tissue mobility and elasticity
significantly and cover severe ridge paucities when utilizing the
periosteal pocket for GBR.
In 2010, Hur et al. and then Ogata et al. (2013) proposed a split-
thickness flap approach for ridge augmentation with a single
mesial split-thickness vertical incision.
Windisch and co-workers (2017) introduced a split-thickness flap
design for GBR without vertical releasing incisions followed by
periosteal-mucosal two-layer flap closure.
The authors have observed a low number of postoperative
complications with undisturbed wound healing.
LYMPHATIC SUPPLY
The lymphatic drainage of gingiva brings in lymphatics of
connective tissue papillae. It progresses in collecting network
external to periosteum of alveolar process, then to regional
lymph nodes, particularly submaxillary group.
In the maxilla gingival lymphatic vessels drain into the deep
cervical lymph nodes, whereas in the mandible they drain
into the mental, submandibular and cervical lymph
nodes.
Lymphatics just beneath the junctional epithelium extend into
periodontal ligament and accompany the blood vessels.
The role of lymphatic system is removig excess fluids,
cellular and protein debris, microorganisms, and other
elements is important for controlling diffusion and
resolution of inflammatory process.
CLINICAL AND MICROSCOPIC
FEATURES CORRELATED
Colour- Coral pink(attached and marginal gingiva)
Size- Corresponds to sum total of bulk of cellular and
intercellular elements and their vascular supply.
Contour- The contour or shape of gingiva varies
considerably and depends on shape of teeth and their
alignment in the arch
Consistency- firm and resilient
Surface texture – Stippled (attached gingiva)
The central portion of interdental papilla is usually stippled
but marginal borders are smooth.
Position-The position of gingiva is the level at which the
gingival margin is attached to the tooth. During the
eruption the junctional epithelium, oral epithelium and
REE undergoes extensive remodelling, without this
remodelling of the epithelia, an abnormal anatomic
realtionship between the gingiva and the tooth would
result.
REFERENCES
Newman and Carranza’s Clinical Periodontology- Third south asian
edition.
Shahbazi A, Feigl G, Sculean A, Grimm A, Palkovics D, Molnár B,
Windisch P. Vascular survey of the maxillary vestibule and gingiva
—clinical impact on incision and flap design in periodontal and
implant surgeries. Clinical oral investigations. 2021 Feb;25:539-
46.