Clinical Periodontology and Implant Dentistry 4th edition_1 pdf

Clinical Periodontology
and Implant Dentistry
4th edition
Jan Lindhe
Thorkild Karring . Niklaus P. Lang
Editors
Blackwell
Munksgaard
© 2003 by Blackwell Munksgaard, a Blackwell
Publishing Company (Fourth Edition)
©1983 by Munksgaard (First Edition), ©1989 by
Munksgaard (Second Edition), ©1997 by
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Contents
Foreword xv
Giorgio Vogel
Preface xvii
Jan Lindhe
Classification of Periodontal Diseases xix
Denis F. Kinane and Jan Lindhe
Adult periodontitis — chronic periodontitis
Early-onset forms of periodontitis — aggressive
periodontitis
Systemic disease forms of periodontitis
Necrotizing forms of periodontitis — necrotizing
forms of periodontal diseases
Contributors xxi
Basic Concepts
Chapter 1
Anatomy of the Periodontium 3
Jan Lindhe, Thorkild Karring and Mauricio Araujo
Introduction 3
Gingiva 5
Macroscopic anatomy 5

Microscopic anatomy 8
Periodontal ligament 27
Root cementum 31
Alveolar bone 34
Blood supply of the periodontium 43
Lymphatic system of the periodontium 47
Nerves of the periodontium 48
Chapter 2
Epidemiology of Periodontal Diseases 50
Panos N. Papapanou and Jan Lindhe
Methodological issues 50
Examination methods — index systems 50
Critical evaluation 52
Prevalence of periodontal diseases 54
Introduction 54
Periodontitis in adults 54
Periodontitis in children and adolescents 57
Periodontitis and tooth loss 61
Risk factors for periodontitis 61
Introduction and definitions 61
Studies of putative risk factors for periodontitis 63
Longitudinal studies and conclusions 68
Periodontal infections and risk for systemic disease
70
Atherosclerosis — cardiovascular/cerebrovascular
disease 70
Preterm birth 72
Diabetes mellitus 73
Concluding remarks 73
Chapter 3

Dental Plaque and Calculus 81
Niklaus P. Lang, Andrea Mombelli and Rolf Attstrom
Microbial considerations 81
General introduction to plaque formation 83
Dental plaque as a biofilm 85 Structure of
dental plaque 85
Supragingival plaque 85
Subgingival plaque 90
Peri-implant plaque 98
Dental calculus 98
Clinical appearance, distribution and clinical
diagnosis 98
Attachment to tooth surfaces and implants 100
Mineralization, composition and structure 101
Clinical implications 102
Chapter 4
Microbiology of Periodontal Disease 106
Sigmund S. Socransky and Anne D. Haffajee
Introduction 106
Periodontal diseases and other infectious diseases 106
Unique features of periodontal infections 107
Historical perspective 108
The early search 108
The decline of interest in microorganisms 110
Non-specific plaque hypothesis 110
Mixed anaerobic infections 110
VI • CONTENTS
Return to specificity in microbial etiology of
periodontal diseases 110
Changing concepts of the microbial etiology of

periodontal diseases 111
Current suspected pathogens of destructive
periodontal diseases 112
Criteria for defining periodontal pathogens 112
Periodontal pathogens 114 Mixed infections
122
The nature of dental plaque —
the biofilm way of life 122
The nature of biofilms 122
Properties of biofilms 123
The oral biofilms that lead to periodontal diseases 125
Microbial complexes 126
Factors that affect the composition of subgingival
biofilms 127
Microbial composition of supra and subgingival
biofilms 132
Prerequisites for periodontal disease initiation and
progression 132
The virulent periodontal pathogen 133
The local environment 133 Host
susceptibility 134
Mechanisms of pathogenicity 135
Essential factors for colonization of a subgingival
species 135
Final comments 139
Chapter 5
Host-Parasite Interactions in Periodontal Disease
150
Denis F. Kinane, Tord Berglundh and Jan Lindhe
Initiation and progression of periodontal disease

150
Introduction 150
Initiation of periodontal disease 150
Initial, early, established and advanced lesions 155
Host-parasite interactions 163
Introduction 163
Microbial virulence factors 164
Host defense processes 165
Overall summary 175
Chapter
6
Modifying Factors: Diabetes, Puberty, Pregnancy
and the Menopause and Tobacco Smoking 179
Richard Palmer and Mena Soory
Diabetes mellitus 179
Type 1 and Type 2 diabetes mellitus 180
Clinical symptoms 180
Oral and periodontal effects 180
Association of periodontal infection and diabetic
control 181
Modification of the host/bacteria relationship in
diabetes 182
Periodontal treatment 183
Puberty, pregnancy and the menopause 183
Puberty and menstruation 184
Pregnancy 184
Periodontal treatment during pregnancy 186
Menopause and osteoporosis 186
Hormonal contraceptives 187
Tobacco smoking 188

Periodontal disease in smokers 189
Modification of the host/bacteria relationship in
smoking 190
Smoking cessation 192
Chapter 7
Plaque Induced Gingival Disease 198
Noel
Claffey
Histopathologic features of gingivitis 200
Gingivitis associated with local contributing factors
200
Tooth abnormalities such as enamel pearls and
cemental tears 200
Dental restorations 200
Root fractures 201
Cervical root resorption 201
Treatment of plaque induced gingivitis 201
Gingival diseases modified by endocrine factors
(see also Chapter 6) 201
Pregnancy associated gingivitis 201
Puberty associated gingivitis 202
Menstrual cycle associated gingivitis 202
Pyogenic granuloma of pregnancy 202
Gingival diseases modified by malnutrition 202
Gingival diseases modified by systemic conditions
203
Diabetes mellitus 203
Leukemias and other blood dysplasias 203
Gingival diseases modified by medications 203
Necrotizing ulcerative gingivitis (see also

Chapter 10) 205
Microbiology, host response and predisposing factors
205
Host response in acute necrotizing ulcerative
gingivitis 206
Treatment of NUG 207
Chapter 8
Chronic Periodontitis 209
Denis F. Kinane and Jan Lindhe
Risk factors or susceptibility to chronic periodontitis
211
Bacterial risk factors 211
Age 211
Smoking 211
Host response related 212
Scientific basis for periodontal therapy 213
Tooth loss 213
Subgingival instrumentation and maintenance 213
Effect of surgical treatment 214
Comparisons of surgical and non-surgical therapy
214
CONTENTS • VII
Chapter 9
Aggressive
Periodontitis
216
Maurizio S. Tonetti and Andrea
Mombelli
Classification and clinical syndromes 217
Epidemiology 218

Primary dentition 219
Permanent dentition 220
Screening 221
Etiology and pathogenesis 225
Bacterial etiology 225
Bacterial damage to the periodontium 228 Host
response to bacterial pathogens 228 Genetic
aspects of host susceptibility 231 Environmental
aspects of host susceptibility 232 Current
concepts 232
Diagnosis 233
Clinical diagnosis 233
Microbiologic diagnosis 235
Genetic diagnosis 237
Principles of therapeutic intervention 237
Elimination or suppression of the pathogenic flora 238
Chapter 10
Necrotizing Periodontal Disease
243
Palle Holmstrup and Jytte Westergaard
Nomenclature 243
Prevalence 243
Clinical characteristics 244
Development of lesions 244
Interproximal craters 244
Sequestrum formation 246
Involvement of alveolar mucosa 246
Swelling of lymph nodes 246
Fever and malaise 248
Oral hygiene 248

Acute and recurrent/chronic forms of necrotizing
gingivitis and periodontitis 249
Diagnosis 249
Differential diagnosis 249
Histopathology 250
Microbiology 251
Microorganisms isolated from necrotizing lesions 251
Pathogenic potential of microorganisms 252
Host response and predisposing factors 253
Systemic diseases 253
Poor oral hygiene, preexisting gingivitis and history of
previous NPD 254
Psychologic stress and inadequate sleep 254
Smoking and alcohol use 254
Caucasian background 255
Young age 255
Treatment 255
Acute phase treatment 255
Maintenance phase treatment 257
Chapter 11
The Periodontal Abscess 260
Mariano Sanz, David Herrera and Arie J. van
Winkelhoff
Classification 260
Periodontitis-related abscess 260
Non-periodontitis-related abscess 261
Prevalence 261
Pathogenesis and histopathology 261
Microbiology 262
Diagnosis 262

Differential diagnosis 264
Treatment 264
Complications 266
Tooth loss 266
Dissemination of the infection 266
Chapter 12
Non-Plaque Induced Inflammatory Gingival
Lesions 269
Palle Holmstrup and Daniel van Steenberghe
Gingival diseases of specific bacterial origin 269
Gingival diseases of viral origin 269
Herpes virus infections 269
Gingival diseases of fungal origin 272
Candidosis 272
Linear gingival erythema 274
Histoplasmosis 275
Gingival lesions of genetic origin 275
Hereditary gingival fibromatosis 275
Gingival diseases of systemic origin 277
Mucocutaneous disorders 277
Allergic reactions 286
Other gingival manifestations of systemic conditions
287
Traumatic lesions 289
Chemical injury 289
Physical injury 289 Thermal
injury 291 Foreign body
reactions 291
Chapter 13
Differential Diagnoses: Periodontal Tumors and

Cysts 298
Palle Holmstrup and Jesper Reibel
Reactive processes of periodontal soft tissues 298
Fibroma/focal fibrous hyperplasia 298
Calcifying fibroblastic granuloma 300
Pyogenic granuloma 301
Peripheral giant cell granuloma 301
Reactive processes of periodontal hard tissues 302
Periapical cemental dysplasia 302
Benign neoplasms of periodontal soft tissues 303
Hemangioma 303
Nevus 304
Papilloma 304
Verruca vulgaris 305
Peripheral odontogenic tumors 305
Benign neoplasms of periodontal hard tissues 306
Ameloblastoma 306
Squamous odontogenic tumor 307
Benign cementoblastoma 308
Malignant neoplasms of periodontal soft tissues 308
Squamous cell carcinoma 308
Metastasis to the gingiva 309
Kaposi's sarcoma 310
VIII • CONTENTS
Malignant lymphoma 310
Malignant neoplasms of periodontal hard tissues
311
Osteosarcoma 311
Langerhans cell disease 311
Cysts of the periodontium 312

Gingival cyst 313
Lateral periodontal cyst 313
Inflammatory pm-Mental cyst 314
Odontogenic keratocyst 314
Radicular cyst 315
Chapter 14
Endodontics and Periodontics 318
Gunnar Bergenholtz and Gunnar Hasselgren
Influence of pathologic conditions in the pulp on
the periodontium 319
Impact of disease conditions in the vital pulp 319
Impact of pulpal necrosis 319
Manifestations of endodontic lesions in the marginal
periodontium from lateral canals 323
Manifestations of acute endodontic lesions in the
marginal periodontium 324
Impact of endodontic treatment measures on the
periodontium 326
Root perforations 328
Vertical root fracture 330
Influence of external root resorptions 333
Mechanisms of hard tissue resorption 333
Clinical manifestations of external root resorptions
334
Different forms of external root resorption 335
Influence of periodontal disease on the condition of
the pulp 339
Influence of periodontal treatment measures on the
pulp 340
Scaling and root planing 340 Root

dentin hypersensitivity 341
Endodontic considerations in root resection of
multirooted teeth in periodontal therapy 344
Differential diagnostic considerations 344
Treatment strategies for combined endodontic and
periodontal lesions 346
Chapter 15
Trauma from Occlusion
352
Ian Lindhe, Sture Nyman and Ingvar Ericsson
Definition and terminology 352
Trauma from occlusion and plaque-associated
periodontal disease 352
Analysis of human autopsy material 353
Clinical trials 355
Animal experiments 356
Conclusions 364
Chapter 16
Periodontitis as a Risk for Systemic Disease 366
Ray C. Williams and David Paquette
Early beliefs 366
The concept of risk 367
Understanding the concept of risk 369
Periodontitis as a risk for coronary heart disease 370
Consistency, strength and specificity of associations
372
Specificity of the associations between periodontitis
and coronary heart disease 373
Correct time sequence 373
Degree of exposure 373

Biological plausibility 374
Experimental evidence 375
Periodontitis as a risk for pregnancy complications
376
Periodontitis as a risk for diabetic complications 378
Periodontitis as a risk for respiratory infections 380
Summary 381
Chapter 17
Genetics in Relation to Periodontitis 387
Bruno G. Loos and Ubele Van der Velden
Introduction and definitions 387
Evidence for the role of genetics in periodontitis 388
Heritability of aggressive periodontitis (early onset
periodontitis) 388
Heritability of chronic periodontitis (adult
periodontitis) 388
The twin model 388
Human genes and polymorphisms 390
Genetics in relation to disease in general 391
A major disease gene associated with periodontitis
392
Modifying disease genes in relation to periodontitis
392
Cytokine gene polymorphisms 392
IL-1 gene polymorphisms 393 TNF-
a gene polymorphisms 396 IL-10
gene polymorphisms 396
FcyR gene polymorphisms 396
Conclusions and future developments 397
CONTENTS • IX

Clinical Concepts
Chapter 18
Examination of Patients with Periodontal Disease
403
Sture Nyman and Jan Lindhe
Symptoms of periodontal disease 403
The gingiva 404
The periodontal ligament – the root cementum 406
Assessment of pocket depth 406
Assessment of attachment level 406
Errors inherent in periodontal probing 407
Assessment of furcation involvement 409
Assessment of tooth mobility 409
The alveolar bone 409
Radiographic analysis 409
Sounding 410
Diagnosis of periodontal lesions 410
Gingivitis 410
Periodontitis levis
(overt periodontitis) 411
Periodontitis gravis
(advanced periodontitis) 411
Oral hygiene status 412
Conclusion 412
Chapter 19
Treatment Planning 414
Jan Lindhe, Sture Nyman and Niklaus R
Lang
Screening for periodontal disease
415 Diagnosis 416

Treatment planning 416
Initial treatment plan 416 Single
tooth risk assessment 417 Case
presentation 418
Initial (cause-related) therapy 419
Re-evaluation 419
Planning of additional therapy (definitive treatment
plan) 420
Additional (corrective) therapy 422
Supportive periodontal therapy 422
Case reports 422
Patient K.A. (female, 29 years old) 422
Patient B.H. (female, 40 years old) 425
Patient P.O.S. (male, 30 years old) 427
Chapter 20
Cause-Related Periodontal Therapy 432
Harald Rylander and Jan Lindhe
Objectives of initial, cause-related periodontal
therapy 432
Means of initial, cause-related periodontal therapy
432
Scaling and root planing 432
Removal of plaque-retention factors 441
Healing after initial, cause-related therapy 441
Clinical measurements 441
Structural measurements 445
Evaluation of the effect of the initial, cause-related
therapy 446
Chapter 21
Mechanical Supragingival Plaque Control 449

Jose J. Echeverria and Mariano Sanz
Importance of supragingival plaque removal 449
Self-performed plaque control 450
Brushing 450
Interdental cleaning 454
Adjunctive aids 457
Effects and sequelae of the incorrect use of mechanical
plaque removal devices 459
Importance of instruction and motivation in
mechanical plaque control 459
Chapter 22
The Use of Antiseptics in Periodontal Therapy 464
Martin Addy
The concept of chemical supragingival plaque
control 464
Supragingival plaque control 465
Chemical supragingival plaque control 466
Rationale for chemical supragingival plaque control
467
Approaches to chemical supragingival plaque control
468
Vehicles for the delivery of chemical agents 469
Chemical plaque control agents 471
Chlorhexidine 476
Toxicology, safety and side effects 476
Chlorhexidine staining 477
Mechanism of action 478
Chlorhexidine products 478
Clinical uses of chlorhexidine 479
Evaluation of chemical agents and products 481

Studies in vitro 482
Experimental plaque studies 483
Experimental gingivitis studies 484
Home use studies 484
Clinical trial design considerations 485
Blindness 485
Randomization 485
Controls 486
Study groups 486
Chapter 23
The Use of Antibiotics in Periodontal Therapy 494
Andrea Mombelli
Principles for antibiotic therapy 494
The limitations of mechanical therapy 494
Specific characteristics of the periodontal infection 495
Infection concepts and treatment goals 496
Drug delivery routes 497
Evaluation of antimicrobial agents for periodontal
therapy 499
Systemic antimicrobial therapy in clinical trials 501
X • CONTENTS
Local antimicrobial therapy in clinical trials 503
Comparison of treatment methods 506 Overall
conclusion 507
Chapter 24
Breath Malodor
512
Daniel van
Steenberghe and Marc Quirynen
Socio-economic aspects 512

Etiology and pathophysiology 513
Diagnosis 514
Patient history 514
Clinical and laboratory examination 515
Treatment 516
Conclusions 516
Chapter 25
Periodontal Surgery: Access Therapy 519
Jan L.
Wennstrom, Lars Heijl and Jan Lindhe
Techniques in periodontal pocket surgery 519
Gingivectomy procedures 520
Flap procedures 522
Regenerative procedures 531
Distal wedge procedures 531
Osseous surgery 534
General guidelines for periodontal surgery 535
Objectives of surgical treatment 535
Indications for surgical treatment 535
Contraindications for periodontal surgery 537
Local anesthesia in periodontal surgery 538
Instruments used in periodontal surgery 540
Selection of surgical technique 543
Root surface instrumentation 545
Root surface conditioning/ biomodification 546
Suturing 546
Periodontal dressings 549
Postoperative pain control 550
Postsurgical care 550
Outcome of surgical periodontal therapy 550

Healing following surgical pocket therapy 550
Clinical outcome of surgical access therapy in
comparison to non-surgical therapy 552
Chapter 26
The Effect of Therapy on the Microbiota in the
Dentogingival Region 561
Anne D. Haffajee, Sigmund S. Socransky and Jan Lindhe
Introduction 561
The goals of periodontal infection control 561
Measurement of microbiological endpoints 562
Treatment of periodontal biofilms 562
The physical removal of microorganisms — mechanical
debridement 563
Antibiotics in the treatment of periodontal infections
565
Therapies that affect the microbial environment —
supragingival plaque removal 568
Combined antimicrobial therapies 571
Long-term effects of antimicrobial therapy 571
Concluding remarks 571
Chapter 27
Mucogingival Therapy — Periodontal Plastic
Surgery 576
Jan L. Wennstrom and Giovan P. Pini Prato
Gingival augmentation 577
Gingival dimensions and periodontal health 577
Marginal tissue recession 579
Marginal tissue recession and orthodontic treatment
583
Gingival dimensions and restorative therapy 586

Indications for gingival augmentation 586
Gingival augmentation procedures 587
Healing following gingival augmentation procedures
589
Root coverage 592
Root coverage procedures 594
Clinical outcome of root coverage procedures 610
Soft tissue healing against the covered root surface 613
Interdental papilla reconstruction 616
Crown lengthening procedures 619
Excessive gingival display 619
Exposure of sound tooth structure 622
Ectopic tooth eruption 628
The deformed edentulous ridge 630
Prevention of soft tissue collapse following tooth
extraction 630
Correction of ridge defects by the use of soft tissue
grafts 631
Chapter 28
Regenerative Periodontal Therapy 650
Thorkild Karring,
Jan Lindhe and Pierpaolo Cortellini
Introduction 650
Indications 650
Regenerative surgical procedures 651
Reliability of assessments of periodontal
regeneration 652
Periodontal probing 652
Radiographic analysis and re-entry operations 652
Histologic methods 652

Periodontal wound healing 652
Regenerative capacity of bone cells 657
Regenerative capacity of gingival connective tissue
cells 658
Regenerative capacity of periodontal ligament cells
659
Role of epithelium in periodontal wound healing 659
Root resorption 660
Regenerative procedures 661
Grafting procedures 662
Root surface biomodification 667
Growth regulatory factors for periodontal regeneration
668
Guided tissue regeneration (GTR) 669
Clinical application of GTR 669
Conclusions 694
CONTENTS • XI
Chapter 29
Treatment of Furcation-Involved Teeth 705
Gianfranco Carnevale, Roberto Pontoriero and Jan Lindhe
Terminology 705
Anatomy 706
Maxillary molars 706
Maxillary premolars 707
Mandibular molars 707
Other teeth 708
Diagnosis 708
Probing 709
Radiographs 711
Differential diagnosis 711

Trauma from occlusion 712
Therapy 712
Furcation involvement degree 1712
Furcation involvement degree II 712
Furcation involvement degree III 712
Scaling and root planing 712
Furcation plasty 712
Tunnel preparation 713
Root separation and resection (RSR) 714
Maxillary molars 717
Maxillary premolars 719
Mandibular molars 719
Sequence of treatment at RSR 720
Final prosthetic restoration 723
Regeneration of fureation defects 723
Extraction 726
Prognosis 726
Chapter 30
Occlusal Therapy 731
Jan Lindhe and Sture Nyman
Clinical symptoms of trauma from occlusion 731
Angular bony defect 731
Increased tooth mobility 731
Progressive (increasing) tooth mobility 731
Tooth mobility crown excursion/root displacement
731
Initial and secondary tooth mobility 731
Clinical assessment of tooth mobility (physiologic and
pathologic tooth mobility) 733
Treatment of increased tooth mobility 734

Situation 1734
Situation II 736
Situation III 736
Situation IV 738
Situation V 740
Chapter 31
Orthodontics and Periodontics
744
Bjorn U. Zachrisson
Orthodontic tooth movement in adults with
periodontal tissue breakdown 744
Orthodontic treatment considerations 748
Esthetic finishing of treatment results 751
Retention – problems and solutions; long-term
follow-up 751
Possibilities and limitations; legal aspects 752
Specific factors associated with orthodontic tooth
movement in adults 752
Tooth movement into infrabony pockets 752
Tooth movement into compromised bone areas 754
Tooth movement through cortical bone 756 Extrusion
and intrusion of single teeth – effects on
periodontium, clinical crown length and esthetics 756
Regenerative procedures and orthodontic tooth
movement 762
Traumatic occlusion (jiggling) and orthodontic
treatment 763
Molar uprighting, furcation involvement 766
Tooth movement and implant esthetics 766
Gingival recession 768

Labial recession 768
Interdental recession 771
Minor surgery associated with orthodontic therapy
772
Fiberotomy 772
Frenotomy 772
Removal of gingival invaginations (clefts) 774
Gingivectomy 776
Chapter 32
Supportive Periodontal Therapy (SPT) 781
Niklaus P. Lang, Urs Bragger, Giovanni Salvi and Maurizio
S. Tonetti
Definitions 781
Basic paradigms for the prevention of periodontal
disease 782
Patients at risk for periodontitis without SPT 784
SPT for patients with gingivitis 786
SPT for patients with periodontitis 786
Continuous multilevel risk assessment 787
Subject risk assessment 787
Tooth risk assessment 792
Site risk assessment 794
Radiographic evaluation of periodontal disease
progression 796
Clinical implementation 796
Objectives for SPT 797
SPT in daily practice 797
Examination, Re-evaluation and Diagnosis (ERD)
798
Motivation, Reinstruction and Instrumentation (

MRI) 799
Treatment of Reinfected Sites (TRS) 799
Polishing, Fluorides, Determination of recall interval
(PFD) 801
XII • CONTENTS
Implant Concepts
Chapter 33
Osseointegration: Historic Background and
Current Concepts 809
Tomas Albrektsson, Tord Berglundh and Jan Lindhe
Development of the osseointegrated implant 809
Early tissue response to osseointegrated implants
810
Osseointegration from a mechanical and biologic
viewpoint 813
Osseointegration in the clinical reality 817
Future of osseointegrated oral implants 818
Chapter 34
Surface Topography of Titanium Implants 821
Ann Wennerberg, Tomas Albrektsson and Jan
Lindhe
Implant surface/ osseointegration 821
Measurement of surface topography 821
Instruments 821
Measuring and evaluating procedure 822
Implant surface roughness 823
Experimental studies investigating surface roughness
and osseointegration 823
Surface roughness of some commercially available
implants 825

Chapter 35
The Transmucosal
Attachment 829
Jan Lindhe and Tord Berglundh
Normal peri-implant mucosa 829
Dimensions 829
Composition 834
Vascular supply 835
Probing gingiva and peri-implant mucosa 836
Chapter 36
Radiographic Examination 838
Hans-Goran Grondahl
Basic radiologic principles 838
Special requirements in the periodontally
compromised patient 838
Radiographic techniques for primary preoperative
evaluations 838
Intraoral and panoramic radiography 838
Radiographic techniques for secondary
preoperative evaluations 840
Requirements for cross-sectional tomography 842
Implants in the premolar and molar regions 843
Conventional versus computed tomography 845
The single implant case 845
Postoperative radiography 847
At abutment connection 847
Following crown-bridge installation 847
High demands on image quality 847
Analysis of postoperative radiographs 848
Subsequent follow-up examinations 849

Digital intraoral radiography 850
Chapter 37
The Surgical Site 852
Ulf Lekholm
Preoperative examination 852
Primary judgment 852
Secondary assessment 853
Treatment planning 857
Principle comments on implant placement 857
Flap design 857
Bone drilling 858
Implant position 859
Implant direction 860
Cortical stabilization 861
Implant selection 862
Healing time 862
Abutment selection 863
Chapter 38
Alveolar Bone Formation 866
Niklaus P. Lang, Mauricio Araujo and Thorkild Karring
Basic bone biology 866
Bone cells 866
Modeling and remodeling 867
Bone healing – general aspects 867
Model of bone tissue formation 869
Bone grafting 876
Concept of guided tissue regeneration (GTR) 877
Animal studies 877
Human experimental studies 883
Clinical applications 885

Alveolar bone defect closure 885
Enlargement or augmentation of alveolar ridges 885
Alveolar bone dehiscences and fenestrations in
association with oral implants 889
Immediate implant placement following tooth
extraction 889
Perspectives in bone regeneration with GTR 892
Chapter 39
Procedures Used to Augment the Deficient
Alveolar Ridge 897
Massimo Simion
General considerations 897
Flap design 897
Initial preparation of the recipient site 897
Positioning of the barrier membrane 898
Preparation of the donor site 898
Surgical procedure in the region of the ramus 898
Surgical procedure in the region of the symphysis of
the mandible 899
Positioning of the bone graft in the recipient site 900
Closure of the recipient site 900
Postoperative care 900
Case reports 901
Patient 1 – Alveolar ridge augmentation for single
tooth restoration in the anterior maxilla 901
CONTENTS • XIII
Patient 2 — Alveolar ridge augmentation for implant
restoration in the anterior maxilla 903
Patient 3 — Alveolar ridge augmentation for implant
restoration of multiple adjacent maxillary teeth 907

Patient 4 — Vertical ridge augmentation in the
anterior area of the mandible 909
Patient 5 — Vertical ridge augmentation to allow
implant placement in the posterior segments of the
mandible 911
Chapter 40
Implant Placement
in
the Esthetic Zone 915
Urs Belser, Jean-Pierre Bernard and Daniel Buser
Basic concepts 915
General esthetic principles and related guidelines 916
Esthetic considerations related to maxillary anterior
implant restorations 917
Anterior single-tooth replacement 919
Sites without significant tissue deficiencies 922
Sites with localized horizontal deficiencies 925
Sites with extended horizontal deficiencies 928
Sites with major vertical tissue loss 928
Multiple-unit anterior fixed implant restorations 930
Sites without significant tissue deficiencies 934
Sites with extended horizontal deficiencies 934
Sites with major vertical tissue loss 934
Conclusions and perspectives 934
Scalloped implant design 936
Segmented fixed implant restorations in the
edentulous maxilla 936
Chapter 41
Implants in the Load Carrying Part of the
Dentition 945

Urs Belser, Daniel Buser and Jean-Pierre Bernard
Basic concepts 945
General considerations 945
Indications for implant restorations in the load
carrying part of the dentition 947
Controversial issues 950
Restoration of the distally shortened arch with fixed
implant-supported prostheses 950
Number, size and distribution of implants 951
Implant restorations with cantilever units 952
Combination of implant and natural tooth support
954
Sites with extended horizontal bone volume
deficiencies and/or anterior sinus floor proximity 954
Multiple-unit tooth-bound posterior implant
restorations 958
Number, size and distribution of implants 958
Splinted versus single-unit restorations of multiple
adjacent posterior implants 960
Posterior single-tooth replacement 961
Premolar-size single-tooth restorations 962
Molar-size single-tooth restorations 962
Sites with limited vertical bone volume 964
Clinical applications 965
Screw-retained implant restorations 965
Abutment-level impression versus implant
shoulder-level impression 968
Cemented multiple-unit posterior implant prostheses
968
Angulated abutments 970

High-strength all-ceramic implant restorations 970
Orthodontic and occlusal considerations related to
posterior implant therapy 971
Concluding remarks and perspectives 975
Early and immediate fixed implant restorations 975
Chapter 42
Rehabilitation by Means of Implants: Case
Reports 980
Christoph H. F. Hammerle, Tord Berglundh, Jan Lindhe and
Ingvar Ericsson
Patient 1
Implants used to restore function in the mandible
980
Initial examination 980
Treatment planning 980
Treatment 981
Concluding remarks 983
Patient 2
Fixed restorations on implants and teeth 984
Initial examination 984
Treatment planning 985
Treatment 986
Concluding remarks 987
Patient 3
Implants used to restore function in the maxilla
987
Initial examination 987
Treatment planning 987
Treatment 989
Concluding remarks 990

Patient 4
Implants used in a cross-arch bridge restoration
991
Initial examination 991
Treatment planning 991
Treatment 992
Concluding remarks 994
Patient 5
Implants used to solve restorative problems
occurring during maintenance therapy 997
Treatment planning 997
Treatment (1) 999
Treatment (2) 1000
Treatment (3) 1000
Concluding remarks 1000
Patient 6
Implants used to solve problems associated with
accidental root fractures of important abutment
teeth 1002
Initial examination 1002
Treatment planning and treatment 1002
Concluding remarks 1002
XIV • CONTENTS
Chapter 43
Implants Used for Anchorage in Orthodontic
Therapy 1004
Heiner Wehrbein
Implants for orthodontic anchorage 1004
Orthodontic-prosthetic implant anchorage (OPIA)
1006

Potential peri-implant reactions/orthodontic load 1006
Indications for orthodontic-prosthetic implant anchorage
1007
Orthodontic implant anchorage (OIA) 1007
Insertion sites 1007
Implant designs and dimensions 1007
Aspects relating to the use of orthodontic implant
anchors 1007
Direct and indirect orthodontic implant anchorage
1009
Treatment schedule and anchorage facilities with
palatal orthodontic implant anchors 1009
Conclusions 1012
Chapter 44
Mucositis and Peri-implantitis 1014
Tord Berglundh, Jan Lindhe, Niklaus
P.
Lang and
Lisa
Mayfield
Excessive load 1014
Infection 1014
Peri-implant mucositis 1015
Peri-implantitis 1016
Treatment of peri-implant tissue inflammation 1019
Resolution of the inflammatory lesion 1019
Re-osseointegration 1020
Microbial aspects associated with implants in
humans 1020
Microbial colonization 1020

Conclusion 1021
Chapter 45
Maintenance of the Implant Patient 1024
Niklaus
P.
Lang and Jan Lindhe
Goals 1024
The diagnostic process 1024
Bleeding on probing (BoP) 1025
Suppuration 1025
Probing depth 1025
Radiographic interpretation 1025
Mobility 1026
Cumulative Interceptive Supportive Therapy (CIST)
1026
Preventive and therapeutic strategies 1026
Conclusions 1029
Index 1031
Foreword
It often happens that a textbook is obsolete by the time
it is published. Furthermore, a book written by several
authors is frequently lacking in both style and meth-
odology.
This textbook, Clinical Periodontology and Implant
Dentistry, is therefore an unusual and stimulating sur-
prise to the reader. The many chapters included are all
written by authors who apparently share an epistemo-
logical approach that guides the logic of research and
scientific discovery. Each chapter tells the story of how
different problems related to etiology, pathogenesis,

treatment and prevention of different lesions in the
periodontal tissues led to the formulation of hypothe-
ses or theories that were subsequently subjected to
testing.
We know that the formulation of a novel hypothesis
requires fantasy and creativity and that experiments
(testing) can be planned and meaningful observations
can be made after an intelligent hypothesis is formu-
lated. The authors of this book seem convinced, for
logical reasons, that observations and experiments are
always best performed after the formulation of hy-
potheses, and that "science will never grow by merely
multiplying data and observations". Experiments are
performed to examine if the theories proposed were
correct, close to the truth or false.
The history of periodontology — as of any scientific
domain — is also and above all the history of its errors.
Indeed, the errors form the walls of our base of knowl
edge and allow us to appreciate the closeness to the
truth, once unraveled.
The reading of Clinical Periodontology and Implant
Dentistry invites student and specialist to take a fasci-
nating intellectual journey that in the end allows her
or him to understand how knowledge in various fields
of this discipline of medicine was progressed and how
it should be used in the practice of dentistry. Those
reading this book will not only learn what to do or not
to do in diagnosing, treating and preventing peri-
odontal pathologies, but they will never cease to un-
dertake its activity of rational criticism and critical

control, being continuously reminded of Einstein's
words that "all our knowledge remains fallible".
Giorgio Vogel
Professor
Department of Medicine, Surgery and Dentistry
University of Milan
Italy
Preface
Preparations for the 4th edition of Clinical Periodontol-
ogy and Implant Dentistry started in 2001 when all
senior authors of the various chapters of the current
text were identified and invited to join the team of
contributors. The authors were selected because of
their reputations as leading researchers, clinicians or
teachers in Periodontology, Prosthetic Dentistry, Im-
plant Dentistry and associated domains. Their task
was simple but demanding; within your field of ex-
pertise, find all relevant information, digest the
knowledge and present to the reader a "state of the
art" text that can be appreciated by (i) the student of
dentistry and dental hygiene, (ii) the graduate student
of Periodontology and related domains and (iii) the
practicing dentist; the general practitioner and the
specialist in Periodontology and/or Implant Den-
tistry.
I am proud to present the outcome of this collective
effort as it appears in this 4th edition of Clinical Perio-
dontology and Implant Dentistry.
As was the case in the 3rd edition, this textbook
consists of three separate parts; Basic Concepts, Clinical

Concepts and Implant Concepts; that together illustrate
most, if not all, important aspects of contemporary
Periodontology. Several chapters from the 3rd edition
of this book have been thoroughly revised, some have
required only modest amendment, while several
chapters in each separate part are entirely new. The
amendments and additions illustrate that Periodon-
tology is continuously undergoing change and that
the authors of the textbook are at the forefront of this
conversion.
Classification of
Periodontal Diseases
DENIS F. KINANE AND JAN LINDHE
In 1999 the American Academy of Periodontology
staged an International Workshop, the sole purpose of
which was to reach a consensus on the classification
of periodontal disease and conditions. The most nota-
ble changes are in the terminology of the various
disease categories which reflect a better under-
standing of the disease presentations and their differ-
ences but also in the acceptance that adult and early-
onset forms of periodontitis can occur at any age. Thus
we have: adult periodontitis becoming chronic perio-
dontitis; early-onset forms of periodontitis becoming
aggressive forms of periodontitis; systemic disease
forms of periodontitis; and necrotizing forms of peri-
odontitis.
ADULT PERIODONTITIS -
CHRONIC PERIODONTITIS
The International Workshop recommended that the

term "adult periodontitis" be discarded since this
form of periodontal disease can occur over a wide
range of ages and can be found in both the primary
and secondary dentition (Consensus Report 1999).
The term "chronic periodontitis" was chosen as it was
considered less restrictive than the age-dependent
designation of "adult periodontitis". It was agreed
that chronic periodontitis could be designated as lo-
calized or generalized depending on whether less than
or more than 30% of sites within the mouth were
affected.
EARLY-ONSET FORMS OF
PERIODONTITIS - AGGRESSIVE
PERIODONTITIS
The International Workshop recommended that the
term "early-onset periodontitis" be discarded since
this form of disease can occur at various ages and can
persist in older adults. Thus aggressive periodontitis
can be considered either localized or generalized.
Thus the term "localized aggressive periodontitis"
replaces the older term "localized juvenile periodon-
titis" or "localized early-onset periodontitis". The new
term "generalized aggressive periodontitis" replaces "
generalized juvenile periodontitis" or "generalized
early-onset periodontitis". The classification term "
prepubertal periodontitis" has been discarded and
these forms of periodontitis are described as localized
or generalized aggressive periodontitis occurring pre-
pubertally.
SYSTEMIC DISEASE FORMS OF

PERIODONTITIS
The International Workshop agreed that certain sys-
temic conditions (such as smoking, diabetes, etc.) can
modify periodontitis (chronic or aggressive) and that
certain systemic conditions can cause destruction of
the periodontium (which may or may not be his-
topathologically periodontitis), for example neu-
tropenias or leukaemias.
NECROTIZING FORMS OF
PERIODONTITIS — NECROTIZING
FORMS OF PERIODONTAL
DISEASES
It was accepted by the International Workshop that "
necrotizing ulcerative gingivitis" (NUG) and "ne-
crotizing ulcerative periodontitis" (NUP) be collec-
tively referred to as "necrotizing periodontal dis-
eases". It was agreed that NUG and NUP were likely
to be different stages of the same infection and may
not be separate disease categories. Both of these dis-
eases are associated with diminished systemic resis-
tance to bacterial infection of periodontal tissues. A
crucial difference between NUG and NUP is whether
the disease is limited to the gingiva or also involves
the attachment apparatus.
REFERENCE
Consensus Report on Chronic Periodontitis (1999). Annals of
Periodontology, 4, p. 38.
Contributors
MARTIN ADDY
Division of Restorative Dentistry

Department of Oral and Dental Science
Bristol Dental Hospital and School UK
TOMAS ALBREKTSSON
Department of Biomaterials
Faculty of Medicine
The Sahlgrenska Academy at Goteborg University
Sweden
MAURICIO ARAETJO
Department of Odontology
State University of Maringa
Maringa
Brazil
ROLF ATTSTROM
Department of Periodontology
Centre for Oral Health Sciences
Malmo University
Sweden
URS BELSER
Department of Prosthetic Dentistry
School of Dental Medicine
University of Geneva
Switzerland
GUNNAR BERGENHOLTZ
Department of Endodontology and Oral Diagnosis
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
TORD BERGLUNDH
Department of Periodontology
Faculty of Odontology

The Sahlgrenska Academy at Goteborg University
Sweden
JEAN-PIERRE BERNARD
Department of Stomatology and Oral Surgery
School of Dental Medicine
University of Geneva
Switzerland
URS BRAGGER
Department of Periodontology and Fixed
Prosthodontics
School of Dental Medicine
University of Berne
Switzerland
DANIEL BUSER
Department of Oral Surgery and Stomatology
School of Dental Medicine
University of Berne
Switzerland
GIANFRANCO
CARNEVALE
Via Ridolfino
Venuti 38 Rome
Italy
NOEL CLAFFEY
Dublin Dental School and Hospital
Trinity College
Dublin
Republic of Ireland
PIERPAOLO
CORTELLINI

Via C.
Botta 16
Florence
Italy
JOSE ECHEVERRIA
Department of Periodontics
School of Dentistry
University of Barcelona
Spain
INGVAR ERICSSON
Department of Prosthetic Dentistry
Faculty of Odontology
Malmo University
Sweden
HANS-GORAN GRONDAHL
Department of Oral and Maxillofacial Radiology
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
XXII • CONTRIBUTORS
ANNE HAFFAJEE
Department of Periodontology
The Forsyth Institute
Boston, MA
USA
CHRISTOPH H.F. HAMMERLE
Clinic for Fixed and Removable Prosthodontics
Centre for Dental and Oral Medicine and Cranio-
Maxillofacial Surgery
University of Zurich

Switzerland
GUNNAR HASSELGREN
Division of Endodontics
School of Dental and Oral Surgery
Columbia University
New York, NY
USA
LARS HEIJL
Department of Periodontology
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
DAVID HERRERA
Facultad de Odontologia
Ciudad Universitaria, Madrid
Spain
PALLE HOLMSTRUP
Faculty of Health Sciences
School of Dentistry, Department of Periodontology
University of Copenhagen
Denmark
THORKILD KARRING
Department of Periodontology
Royal Dental College
Faculty of Health Sciences
University of Aarhus
Denmark
DENIS F. KINANE
Department of Periodontics, Endodontics and
Dental Hygiene

School of Dentistry
University of Louisville
Kentucky, KY
USA
NIKLAUS P. LANG
Department of Periodontology and Fixed
Prosthodontics
School of Dental Medicine
University of Berne
Switzerland
ULF LEKHOLM
Department of Oral Maxillofacial Surgery
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
JAN LINDHE
Department of Periodontology
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
BRUNO G. Loos
Department of Periodontology
ACTA, Amsterdam
The Netherlands
LISA MAYFIELD
Department of Periodontics and Fixed
Prosthodontics
School of Dental Medicine
University of Berne
Switzerland

ANDREA MOMBELLI
Department of Periodontology and Oral
Pathophysiology
University of Geneva
Switzerland
STURE NYMAN
Deceased
RICHARD PALMER
Department of Periodontology
Guy's, King's and St Thomas' Dental Institute
King's College London
UK
PANOS N. PAPAPANOU
Division of Periodontics
School of Dental and Oral Surgery
Columbia University
New York, NY
USA
DAVID W. PAQUETTE
Department of Periodontology
School of Dentistry University
of North Carolina
Chapel Hill
North Carolina, NC
USA
ROBERTO
PONTORIERO
Galleria
Passarella 2 Milan
Italy

CONTRIBUTORS • XXIII
GIOVAN PAULO PINI PRATO
Department of Odontology
University of Florence Italy
MARC QUIRYNEN
School of Dentistry, Oral Pathology and
Maxillofacial Surgery
Faculty of Medicine
Catholic University of Leuven
Belgium
JESPER REIBEL
Department of Oral Pathology and Oral Medicine
School of Dentistry
University of Copenhagen
Denmark
HARALD RYLANDER
Department of Periodontology
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
GIOVANNI SALVI
Department of Periodontology and Fixed
Prosthodontics
School of Dental Medicine
University of Berne
Switzerland
MARIANO SANZ
Facultad de Odontontologia
Ciudad Universitaria, Madrid
Spain

MASSIMO SIMION
Department of Periodontology and Implant
Rehabilitation
School of Dental Medicine
University of Milan
Italy
SIGMUND SOCRANSKY
Department of Periodontology
The Forsyth Institute
Boston, MA
USA
MENA SOORY
Department of Periodontology
Guy's, King's and St. Thomas' Dental Institute
King's College London
UK
MAURIZIO S. TONETTI
Department of Periodontology
Eastman Dental Institute
University College, University of London
UK
UBELE VAN DER VELDEN
Department of Periodontology
ACTA, Amsterdam The
Netherlands
DANIEL VAN STEENBERGHE
School of Dentistry, Oral Pathology and
Maxillofacial Surgery
Faculty of Medicine
Catholic University of Leuven

Belgium
ARIE J. VAN WINKELHOFF
Department of Oral Microbiology
ACTA
Amsterdam
The Netherlands
GIORGIO VOGEL
Department of Medicine, Surgery and Dentistry
University of Milan
Italy
HEINER WEHRBEIN
Poliklinik fur Kieferorthopaedie
Augustusplatz 2
Mainz
Germany
ANN WENNERBERG
Department of Biomaterials
Department of Prosthetic Dentistry/Dental Material
Science
Faculty of Medicine
The Sahlgrenska Academy at Goteborg University
Sweden
JAN L. WENNSTROM
Department of Periodontology
Faculty of Odontology
The Sahlgrenska Academy at Goteborg University
Sweden
JYTTE WESTERGAARD
Panum Instituttet
School of Dentistry

University of Copenhagen
Denmark
XXIV • CONTRIBUTORS
RAY C. WILLIAMS BJORN ZACHRISSON
Department of Periodontology Stortingsgatan 10
School of Dentistry Oslo
University of North Carolina Norway
Chapel Hill
North Carolina, NC
USA
BASIC CONCEPTS
CHAPTER 1
Anatomy of the Periodontium
JAN LINDHE, THORKILD KARRING AND MAURICIO ARAITJO
Root cementum
Alveolar bone
Blood supply of the periodontium
Lymphatic system of the periodontium
Nerves of the periodontium
Introduction
Gingiva
Macroscopic anatomy
Microscopic anatomy
Periodontal ligament
INTRODUCTION
This chapter includes a brief description of the char-
acteristics of the normal periodontium. It is assumed
that the reader has prior knowledge of oral embryol-
ogy and histology. The periodontium (pert = around,
odontos = tooth) comprises the following tissues (Fig.

1-1): (1) the gingiva (G), (2) the periodontal ligament (PL),
(3) the root cementum (RC), and (4) the alveolar bone
(AP). The alveolar bone consists of two components,
the alveolar bone proper (ABP) and the alveolar process.
The alveolar bone proper, also called "bundle bone"
is continuous with the alveolar process and forms the
thin bone plate that lines the alveolus of the tooth.
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 masticatory mucosa
of the oral cavity. The periodontium, also called "the
attachment apparatus" or "the supporting tissues of
the teeth", constitutes a developmental, biologic, and
functional unit which undergoes certain changes with
age and is, in addition, subjected to morphologic
changes related to functional alterations and altera-
tions in the oral environment.
The development of the periodontal tissues occurs
during the development and formation of teeth. This
process starts early in the embryonic phase when cells
from the neural crest (from the neural tube of the
embryo) migrate into the first branchial arch. In this
position the neural crest cells form a band of ectome-
senchyme beneath the epithelium of the stomatodeum (
the primitive oral cavity). After the uncommitted
neural crest cells have reached their location in the jaw
space, the epithelium of the stomatodeum releases
Fig. 1-1.
factors which initiate epithelial-ectomesenchymal in-
teractions. Once these interactions have occurred, the

ectomesenchyme takes the dominating role in the fur-
ther development. Following the formation of the
dental lamina, a series of processes are initiated (bud
stage, cap stage, bell stage with root development)
which result in the formation of a tooth and its sur-
rounding periodontal tissues, including the alveolar
bone proper. During the cap stage, condensation of
ectomesenchymal cells appears in relation to the
den-
4 • CHAPTER 1
Fig. 1-2.
tal epithelium (the dental organ (DO)), forming the
dental papilla (DP) that gives rise to the dentin and the
pulp, and the dental follicle (DF) that gives rise to the
periodontal supporting tissues (Fig. 1-2). The decisive
role played by the ectomesenchyme in this process is
further established by the fact that the tissue of the
dental papilla apparently also determines the shape
and form of the tooth.
If a tooth germ in the bell stage of development is
dissected and transplanted to an ectopic site (e.g. the
connective tissue or the anterior chamber of the eye),
the tooth formation process continues. The crown and
the root are formed, and the supporting structures, i.e.
cementum, periodontal ligament and a thin lamina of
alveolar bone proper, also develop. Such experiments
document that all information necessary for the for-
mation of a tooth and its attachment apparatus is
obviously residing within the tissues of the dental
organ and the surrounding ectomesenchyme. The

dental organ is the formative organ of enamel, the
dental papilla is the formative organ of the dentin-
pulp complex, and the dental follicle is the formative
organ of the attachment apparatus (the cementum, the
periodontal ligament and the alveolar bone proper).
The development of the root and the periodontal
supporting tissues follows that of the crown. Epi-
thelial cells of the external and internal dental epithe
lium (the dental organ) proliferate in apical
direction forming a double layer of cells named
Hertwig's epithelial root sheath (RS). The odontoblasts (
OB) forming the dentin of the root differentiate from
ectomesenchy-
Fig. 1-3.
mal cells in the dental papilla under inductive influ-
ence of the inner epithelial cells (Fig. 1-3). The dentin
(D) continues to form in apical direction producing the
framework of the root. During formation of the root,
the periodontal supporting tissues including acellular
cementum develop. Some of the events in the cemen-
togenesis are still unclear, but the following concept is
gradually emerging.
At the start of dentin formation, the inner cells of
Hertwig's epithelial root sheath synthesize and se-
crete enamel-related proteins, probably belonging to
the amelogenin family. At the end of this period, the
epithelial root sheath becomes fenestrated and
through these fenestrations ectomesenchymal cells
from the dental follicle penetrate and contact the root
surface. The ectomesenchymal cells in contact with

the enamel-related proteins differentiate into cemen-
toblasts and start to form cementoid. This cementoid
ANATOMY OF THE PERIODONTIUM • 5
Fig. 1-4.
Fig. 1-5.
represents the organic matrix of the cementum and
consists of a ground substance and collagen fibers,
which intermingle with collagen fibers in the not yet
fully mineralized outer layer of the dentin. It is as-
sumed that the cementum becomes firmly attached to
the dentin through these fiber interactions. The forma-
tion of the cellular cementum, which covers the apical
third of the dental roots, differs from that of acellular
cementum in that some of the cementoblasts become
embedded in the cementum.
The remaining parts of the periodontium are
formed by ectomesenchymal cells from the dental
follicle lateral to the cementum. Some of them differ-
entiate into periodontal fibroblasts and form the fibers
of the periodontal ligament while others become
osteoblasts producing the alveolar bone proper in
which the periodontal fibers are anchored. In other
words, the primary alveolar wall is also an ectome-
senchymal product. It is likely, but still not conclu-
sively documented, that ectomesenchymal cells re-
main in the mature periodontium and take part in the
turnover of this tissue.
GINGIVA
Macroscopic anatomy
The oral mucosa (mucous membrane) is continuous

with the skin of the lips and the mucosa of the soft
palate and pharynx. The oral mucosa consists of (1)
the masticatory mucosa, which includes the gingiva and
the covering of the hard palate, (2) the specialized mu-
cosa, which covers the dorsum of the tongue, and (3)
the remaining part, called the lining mucosa.
Fig. 1-4. The gingiva is that part of the masticatory
mucosa which covers the alveolar process and sur-
rounds the cervical portion of the teeth. It consists of
an epithelial layer and an underlying connective tis-
sue layer called the lamina propria. The gingiva obtains
its final shape and texture in conjunction with erup-
tion of the teeth.
In the coronal direction the coral pink gingiva ter-
minates in the free gingival margin, which has a scal-
loped outline. In the apical direction the gingiva is
continuous with the loose, darker red alveolar mucosa (
lining mucosa) from which the gingiva is separated
by a, usually, easily recognizable borderline called
6 • CHAPTER I
Fig. 1-6.
Fig. 1-7. Fig. 1-8.
CEJ
either the mucogingival junction (arrows) or the mu-
cogingival line.
Fig. 1-5. There is no mucogingival line present in the
palate since the hard palate and the maxillary alveolar
process are covered by the same type of masticatory
mucosa.
Fig. 1-6. Two parts of the gingiva can be differentiated:

1. the free gingiva (FG)
2. the attached gingiva (AG)
The free gingiva is coral pink, has a dull surface and
firm consistency. It comprises the gingival tissue at the
vestibular and lingual/palatal aspects of the teeth, and
the interdental gingiva or the interdental papillae. On the
vestibular and lingual side of the teeth, the free
gingiva extends from the gingival margin in apical
direction to the free gingival groove which is positioned
at a level corresponding to the level of the cemento-
enamel junction (CEJ). The attached gingiva is in apical
direction demarcated by the mucogingival junction (
MGJ).
Fig. 1-7. The free gingival margin is often rounded in
such a way that a small invagination or sulcus is
formed between the tooth and the gingiva (Fig. 1-7a).
When a periodontal probe is inserted into this in-
vagination and, further apically, towards the cemento-
enamel junction, the gingival tissue is separated from
the tooth, and a "gingival pocket" or "gingival crevice" is
artificially opened. Thus, in normal or clinically
healthy gingiva there is in fact no "gingival pocket"
or "gingival crevice" present but the gingiva is in close
contact with the enamel surface. In the illustration to
the right (Fig. 1-7b), a periodontal probe has been
inserted in the tooth/gingiva interface and a "gingival
crevice" artificially opened approximately to the level
of the cemento-enamel junction.
After completed tooth eruption, the free gingival
margin is located on the enamel surface approxi-

mately 1.5 to 2 mm coronal to the cemento-enamel
junction.
Fig. 1-8. The shape of the interdental gingiva (the
interdental papilla) is determined by the contact rela-
tionships between the teeth, the width of the approxi-
mal tooth surfaces, and the course of the cemento-
ANATOMY OF THE PERIODONTIUM • 7
Fig. 1-9. Fig. 1-9c.
Vestibular gingiva
5 3
Fig. 1-10.
enamel junction. In anterior regions of the dentition,
the interdental papilla is of pyramidal form (Fig. 1-8b)
while in the molar regions, the papillae are more
flattened in buccolingual direction (Fig. 1-8a). Due to
the presence of interdental papillae, the free gingival
margin follows a more or less accentuated, scalloped
course through the dentition.
Fig. 1-9. In the premolar/molar regions of the denti-
tion, the teeth have approximal contact surfaces (Fig.
1-9a) rather than contact points. Since the interdental
papilla has a shape in conformity with the outline of
the interdental contact surfaces, a concavity —a col — is
established in the premolar and molar regions, as
demonstrated in Fig. 1-9b, where the distal tooth has
been removed. Thus, the interdental papillae in these
areas often have one vestibular (VP) and one lin-
gual/palatal portion (LP) separated by the col region.
The col region, as demonstrated in the histological
section (Fig. 1-9c), is covered by a thin non-keratinized

epithelium (arrows). This epithelium has many fea-
tures in common with the junctional epithelium (see
Fig. 1-34).
Fig. 1-10. The attached gingiva is, in coronal direction,
demarcated by the free gingival groove (GG) or, when
such a groove is not present, by a horizontal plane
placed at the level of the cemento-enamel junction. In
clinical examinations it was observed that a free gin-
gival groove is only present in about 30-40% of
adults.
a
5 7
The free gingival groove is often most pronounced on
the vestibular aspect of the teeth, occurring most fre-
quently in the incisor and premolar regions of the
mandible, and least frequently in the mandibular mo-
lar and maxillary premolar regions.
The attached gingiva extends in the apical direction
to the mucogingival junction (arrows), where it be-
comes continuous with the alveolar (lining) mucosa (
AM). It is of firm texture, coral pink in color, and
often shows small depressions on the surface. The
depressions, named "stippling", give the appearance
b
Lingual gingiva
Fig. 1-11.
2
4
3