Dimensions and Relations of the Dentogingival Junction in Humansby Anthony W. Gargiulo, d.d.s., m.s., Frank. M. ¥entz, d.d.s., ph.d., and

balint OrBAN, m.d., d.d.s.*

IN 1921, Gottlieb's discovery of the epi-thelial attachment of the gingiva openednew horizons which served as the basis

for a better understanding of the biologyof the dental supporting tissues in healthand disease. Three years later his pupils,Orban and Kohler (1924), undertook thetask of measuring the epithelial attachmentas well as the surrounding tissue relationsduring the four phases of passive eruptionof the tooth. Gottlieb and Orban's descrip-tions of the epithelial attachment unveiledthe exact morphology of this epithelialstructure, and clarified the relation of thisstructure to the enamel of the tooth.

In recent years the prevailing concept ofthe epithelial attachment was challengedby Waerbaug.3 He returned to the old con-

cept of a potential space extending fromthe gingival margin to the cementoenameljunction. Waerhaug's altered convictionswere based upon several observations. Theseare: (1) he was able to insert a thin steelblade into this space without pressure.From histologic sections, he claimed thatthere was no difference between the epithe-lium of the intact areas and in the areawhere the blade was inserted. (2) In addi-tion he claimed that after a gingival flaphad been pulled away from the enamel sur-face and the flap repositioned, no differencecould be seen between the operated and thenon-operated areas. Repetition of these pro-cedures by Orban4 have shown Waerhaug'sfindings could not be verified under similarexperiments. Gottlieb's discovery was inthe least reconfirmed; however Waerhaug'schallenge was not without benefit. The so-

called strength of adherence of the epithe-lial attachment, and the organic nature ofthe attachment had to be reconsidered. Theauthor's are now inclined to subscribe toWeski's5 idea; mainly that the epithelium

Department of Periodontics, Loyola University,Chicago, 111.

*Dr. Orban died June 1, 1960.

after enamel maturation, produces a ce-

menting substance that attaches the epithe-lium to the enamel surface and later to thesurface of the cementum. It now seemsimpossible that Gottlieb's original idea of aunion between ameloblast and the formingand maturing enamel rods could survivethe final calcification of the enamel matrix.

Discussions with Sicher (1959)° lead tothe reconsideration of the mode of attach-ment and the formulation of a physiologicdivision of labor of the supporting tissuesat the "dento-gingival junction." This es-tablished the concept of the dentogingivaljunction as a functional unit composedof two parts: (1) the connective tissuefibrous attachment of the gingiva and (2)the epithelial attachment. The two sepa-rate components share a division of func-tion.

The biologic protection of the dentogin-gival junction is the function of the epi-thelial attachment. The epithelium attachesto the circumference of the tooth as abroad band the "attached epithelial cuff."The epithelial attachment to the tooth isnot firmly attached in spite of the fact thatit is stronger than the individual cohesive-ness of the epithelial cells. The firmness ofthe gingival attachment to the tooth isderived by the fibrous connective tissuebound to the cementum, alveolar bone andgingiva.

Because of the dynamic alterations in thecomponent parts of the dentogingivaljunction it is important to know their po-sitions in all phases of eruption undernormal conditions. The importance of thisrelation is enhanced when one considers theimbalance of these components in perio-dontal disease. Thus, these dimensions canserve as a base line for future studies in-volving the pathologic status of the dento-gingival junction and serve as "the physi-ologic dentogingival junction."

Page 261

Page 262 The Journal of Periodontology

Henlii Schmelz Epithel tm Alveole CementFigure No. 1

The present study consisted of two

parts; first to re-evaluate the measure-ments in the Orban-Kohler paper, but now

as part of the dentogingival junction andnot as a single isolated structure; and sec-ond to add new measurements. It also es-

tablishes a norm for the dentogingivaljunction in all phases, chronologic ages,surfaces and six measured distances.

material and method

The material for this study were themeasurements obtained from human au-

topsy specimens by Dr. Balint Orban inearlier studies. Additional measurementswere obtained from 30 human jaws in thecollection of Dr. Rudolph Kronfeld. Allspecimens were taken at autopsy as blocksections in order to obtain the componentparts of the dentogingival junction intact.The age range was from 19 to 50 years.The specimens were fixed in 10'/, formalin,embedded in cellodin and 15-20u sectionscut. The sections were stained in hemo-toxylin and eosin.

The measurements were made from themicroscopic specimens of 30 jaws, 287 in-dividual teeth and their respective dento-gingival components. A total of 325 sur-faces were measured; of these 83 were on

the mesial surface, 82 were on the distal

surface, 82 on the vestibulär surface and78 on the oral surface. All specimens were

free of extensive pathology and fulfilledthe requirements of clinically normal speci-mens. The actual measurements were madewith a disc micrometer, and all are re-

corded in millimeters.A total of six different measurements

were made for each individual specimen.These areas changed their relations in thefour different phases of eruption in whichmeasurements were made. In Figure 1, one

can observe the various phases of passiveexposure as established by Orban andKohler in 1934.

The areas measured were: a) depth ofthe gingival sulcus, b) length of the at-

tached epithelium, c) most apical point ofthe epithelial attachment from the cemento-enamel junction, d) distance from the baseof the sulcus to the cemento-enamel junc-tion, e) distance of the cemento-enameljunction from the alveolar bone, f) distancefrom the most apical point of the epithelialattachment to the alveolar bone (connec-tive tissue).

findings

The findings from each of the phaseswere analyzed according to the six indi-vidual measurements. All surfaces (mesial,

Dentogingival Junction Page 263

Table IPhase I Analysis

Measurement Range(mm)

MeanAverage(mm)

A. Sulcus depthB. Attached epitheliumC. Apical point of Epithelial Attachment below Cemento-

Enamel JunctionD. Bottom of Sulcus from Cemento Enamel JunctionE. Cemento Enamel Junction to Alveolar BoneF. Deepest point of Epithelial Attachment to Alveolar Bone

0.00 to 2.620.28 to 3.72

0.00 to 0.00+0.28 to 3.36

0.04 to 3.360.04 to 3.36

.80135

0.00+ 1.35

LOS1.03

distal, vestibulär, oral) were placed in one

average value for the given measurement.The analysis first was done according to

each of the individual phases of eruptionin the dynamic relation existing at the den-togingival junction throughout life. Re-sults of the measurements were as shownin the following tables.

The number of specimen surfaces in thephase I analysis were 25. The total lengthof the dentogingival unit, (from the tip ofthe gingival margin to the crest of thealveolar bone) A+B+F, represents themagnitude of the dentogingival junction.For phase I this magnitude was 3.23 mm.

The total attachment (B+F) was 2.43mm. The average age for phase I was 24.5years and the specimens ranged from 19 to

43 years.Due to the definite anatomy of phase I,

measurement C was zero, those for B, and

D; and E, and F, were equal. However, thisrelation is altered as the epithelial attach-ment progresses in an apical direction inthe later phases.

One hundred and twenty-six (126)specimen surfaces were analyzed in phaseII. The total length of the dentogingivalunit (A+B+F+) was 3.06 mm. The totalattachment (B+F) was 2.45 mm. The av-

erage age for phase II was 31.4 years, andranged from 19 to 50 years.

Phase III is a highly precise arrange-ment of the dentogingival apparatus, andthe least number of specimens were foundat this phase. In phase III eleven specimensurfaces were measured.

There was no recorded reading for "D"since in the phase III relation, the base ofthe sulcus is just at the cemento-enameljunction.

Table IIPhase II Analvsis

Measurement(mm)

MeanAverage(mm)

A. Sulcus depthB. Attached epitheliumC. Apical point of Epithelial Attachment below Cemento-

Enamel JunctionD. Bottom of Sulcus from Cemento Enamel JunctionE. Cemento Enamel Junction to Alveolar BoneF. Deepest point of Epithelial Attachment to Alveolar Bone

0.00 to 5.360.34 to 2.90

0.03 to 2.36+0.02 to 2.60

0.35 to 5.000.02 to 4.38

.611.10

0.43+0.68

1.551.07

Page 264 The Journal of Periodontology

Table IIIPhase III Analysis

MeanMeasurement Range Average

(mm) (mm)A. Sulcus depth 0.00 to 0.94 .61B. Attached epithelium 0.16 to 1.04 .74C. Apical point of Epithelial Attachment below Cemento-

Enamel Junction 0.16 to 1.04 .74D. Bottom of Sulcus from Cemento Enamel Junction 0.00 to 0.00 0.00E. Cemento Enamel Junction to Alveolar Bone 0.88 to 3.20 1.71F. Deepest point of Epithelial Attachment to Alveolar Bone 0.16 to 2.37 1.06

The total length of the dentogingivalunit (A+B+F) was 2.41 mm. The totalattachment (B+F) was 1.80 mm. The av-

erage age for phase III was 32.3 years, andranged from 22 to 5 0 years.

One hundred and sixty-three (163)specimen surfaces were measured in phaseIV. The total length of the dentogingivalunit (A4-B+F) was 2.5 3 mm. The totalattachment (B4-F) was 1.77 mm. The av-

erage age for phase IV was 39.7 years, andranged from 20 to 50 years.

The previous analysis was a total averageof all surfaces. In order to obtain the totalmean average all tooth surfaces were meas-

ured for each of the distances, thus one can

calculate the mean average for each of the4 tooth surfaces. From this one can see thevariance which occurs on the four differentsurfaces of the same tooth and for the same

area measured. See Tables V to X.In an earlier paper by Stanley' he states

that "the type of tooth and type of toothsurface (mesial or distal) has no effect on

the mean lengths of the distances." As can

obviously be seen from the present study,the tooth surface is rather variable in thetotal circumference, and on each of theindividual teeth.

DISCUSSION

This work has indicated that there is a

somewhat definite proportional dimensionalrelation between the dentogingival junc-tion and the other supporting tissues ofthe tooth.

The validity of the concept of the dento-gingival junction has been fortified, andthe duality of its components (epithelialand fibrous connective tissue) has beenidentified as an orderly one.

One can no longer speak of passive ex-

posure only being associated with the apical

Table IVPhase IV Analysis

Measurement Range(mm)

MeanAverage(mm)

A. Sulcus depthB. Attached epitheliumC. Apical point of Epithelium Attached below Cemento-

Enamel JunctionD. Bottom of Sulcus from Cemento Enamel JunctionE. Cemento Enamel Junction to Alveolar BoneF. Deepest point of Epithlial Attachment to Alveolar Bone

0.00 to 2.250.08 to 2.65

0.39 to 6.0S-0.03 to 5.841.10 to 10.880.00 to 6.52

1.760.71

1.41-1.142.811.06

Dentogingival Junction Page 265

Table VMeasurement A.—Sulcus Depth

Visttb- TotalPhase Mesial Distal ular Oral Average

IIIIIIIV

1.09.51.94.81

s464.50.87

.87

.76

.62.82

.40

.53

.41.57

.80

.61

.61.76

migration of the epithelial attachment. Thecorrect interpretation of the gingiva andits relation to the tooth with increasing agecan only be understood, if the connectivetissue attachment is also considered. (SeeTable XI).

The physiologic apical shift of the den-togingival junction from stage to stageduring passive eruption, is responsible forthe passive exposure of the tooth and isnot merely due to the "peeling back" ofthe epithelial attachment.

From chart XI, one can readily see thatthe epithelial attachment is our most vari-able, while the connective tissue attach-ment is the most constant measurement.This observation further supports Stanley's'finding that the "epithelial attachmentappeared to be the most variable anatomicstructure within the periodontium." Thus,during passive eruption the magnitude ofthe epithelial attachment diminishes. Earlyin phase I the amount of epithelial attach-ment is 1.3 5 mm. and decreases in phaseIV to 0.71 mm., this represents a signifi-cant diminution. In correlating the epithe-lial attachment with age it was seen thatthere was less attachment with an increasein dental and physiologic age. On the otherhand the connective tissue component ap-

Table VIMeasurement B.—Length of Attached Epithelium

Vestib-Phase Mesial Distal ular

TotalOral Average

III

III[V

1.561.35

44.83

1.371.20

1.351.08

S7.63

1.14.80.7753

1.351.10

.74

.71

pears to be a constant through the stagesof passive eruption.

Upon closer interpretation the meaningsof these data indicates a need for a revisionof the phases of passive eruption. A furtheralignment of measurements, it is seen thatthe four phases of eruption can rightfullybe classified into two divisions. The basisfor this statement is further emphasizedfrom Table XI. It is seen that the at-

tached epithelium is significantly greaterin phase I and II, than the attached epi-thelium is in phase III and IV. The sig-nificant thing is that the total attachment(B+F) measures similar in phase I and II(Division A) ; and phase III and IV (Di-vision B). Therefore it is thought that we

truly have only two divisions of passiveeruption.

Table VIIMeasurement C.—Distance of Attached Epithelium

Below Cemento Enamel JunctionVesttb- Total

Phase Mesial Distal ular Oral AverageI

II111IV

.00

.51

.441.76

.00

.45

.881.10

.00

.40

.871.68

.00

.36

.771.11

.00

.43

.741.41

In addition it can be seen the greateramount of attached epithelium in phase Iand II, and the greater amount of con-

nective tissue attachment in phase III andIV. From this one can also see that indivision A (phase I and II) the total at-

tachment is of a greater magnitude thanthat of division B (phases III and IV).

In analyzing each of the measurementsfor the four phases we can make some

rather revealing observations. In measure-

ment A, sulcus depth, note that under cir-cumstances of normal physiology this re-

mains rather constant. For measurement B,the length of the attached epithelium, note

that as one progresses from phase I to IVthere is less attachment of epithelium tothe tooth surface. From these findings one

can see that there has been approximately

Page 266 The Journal of Periodontology

Table VIII Table IXMeasurement D.—Distance of Bottom of Sulcus from Measurement E.—Distance of Cemento-Enamel

III

III[V

The Cemento Enamel Junction

Phase Mesial DistalVestib-ulär Oral

TotalAverage

1.56.88.00 93

1.37.74.00

1.14

1.35.68.00

1.06

1.14 +1.35.45 4-.68.00 .00

1.45 -1.14

Junction from Alveolar Bone

Vestib- TotalPhase Mesial Distal ular Oral Average

I .75 1.10 1.01 1.49 1.08II 1.39 1.42 1.86 1.56 1.55

III 1.46 1.58 2.40 1.42 1.71IV 2.66 3.08 2.82 3.10 2.81

a 50'/, loss in magnitude from phase I to

(1.33 mm.) to phase IV (.71 mm.). Inmeasurement C, the most apical point ofthe epithelial attachment below the ce-

mento-enamel junction, there is an increasein the clinical crown which is a normalcourse from phase I to IV as the epithelialattachments shifts in an apical direction.Measurement D, the distance of the bottomof the sulcus from the cemento-enameljunction, is another shift in an apical di-rection with a progression from phase Ito IV.

Measurement E, distance of the cemento-enamel junction from the alveolar bone,is a value which increases from phase I toIV. This is interesting in that as the toothundergoes active eruption the alveolar bonecrest doesn't appear to keep "pace" withthe cemento-enamel junction. However,this no doubt is due to the passive exposureof the tooth at the dentogingival junction

Table XMeasurement F.—Distance from Base of AttachedEpithelium to Aveolar Bone (Connective Tissue

Attachment)Vestib- Total

Phase Mesial Distal ular Oral AverageI .75 1.10 1.01 1.49 1.08

II .81 .96 1.21 1.32 1.07III 1.02 .69 1.53 1.03 1.06IV .89 1.09 1.22 1.07 1.06

which is occurring simultaneously withactive eruption. Measurement F, the dis-tance from the base of the epithelial at-tachment to the alveolar bone, representsthe connective tissue attachment of thegingival fibers and appears to be the mostconstant value that the normal dentogingi-val junction possesses. The values were so

close that 3 of the 4 phases almost dupli-cate each other to the hundredth of a

millimeter.

Table XIDentogingival Junction

Total Attachment(Measurement B-fF)

Phase and Environment Total Attachment (mm)Length of ConnectiveEpithelial Tissue B-\-F

Attachment—B Attachment—F

DIVISION A

DIVISION B

I Attachment on Enamel 1.35

II Attachment on Enameland Cementum 1.10

III Attachment on Cementum 0.74

IV Attachment on Cementum 0.71

1.08

1.07

1.05

1.06

2.43

2.17

1.80

1.77

Dentogingival Junction Page 267

Table XIIDENTOGINGIVAL JUNCTION

Total Average MagnitudeSulcus Depth (A)

Epithelial Attachment (B) andConnective Tissue Attachment (F)

Average Measurementin mm.

Sulcus Depth (A) .69 mm.

Length of EpithelialAttachment (B) .97 mm.

Connective TissueAttachment (F) 1.07 mm.

The total magnitude, or length of thedentogingival junction is seen to decreasefrom phase I to IV. From this observationwe can see an apparent loss of total attach-ment to the tooth enamel and cementum.This is evidenced by the fact that the mag-nitude in phase 1 is 3.23 mm. and regressesto 2.5 3 mm. in phase IV.

While the preceding findings are of greatvalue in themselves, one must fully realizethe impetus this has upon pathology of thedentogingival junction and what the effectof surgical encroachment upon these areas

has on the final dimensional proportions.This study will serve as a basis by which to

understand the results obtained in osseous

surgery and other approaches which denudeand expose the dentogingival junction.

In an analysis of age, these findingswould support the fact that about anychronologic age can be found in any ofthe four phases. Usually phase III and IVwere absent in the chronologic ages below

21 years. In addition the average age herereported can create a false impression sinceonly a given age range of 19 to 50 yearswas used.

SUMMARY

The prevailing concepts of the dentogin-gival junction are reviewed to re-emphasizethe importance of this functional unit withits two component parts, 1) The connec-tive tissue fibrous attachment and, 2) theepithelial attachment.

The dimensions of the dentogingivaljunction in four phases of passive eruptionwere ascertained from earlier studies ofOrban and from thirty additional humanjaws. A total of six different measure-ments were made on all types and surfacesof teeth. Upon comparison of all measure-ments we can observe that the previousfour phases of eruption can be categorizedin two divisions.

Of the measurements made, the distancefrom the base of the epithelial attachmentto the crest of the alveolar bone (connec-tive tissue attachment), is the most con-stant. It had a mean average length in allphases of 1.07 mm. The most variable partof the dentogingival junction was thelength of the epithelial attachment.

This study will permit a better under-standing of the alterations which occur at

the dentogingival junction following osse-

ous surgery, and surgical exposure of thedentogingival junction.

BIBLIOGRAPHY

1. Gottlieb, B.: Der Epithelansatz am Zahne(The Epithelial Attachment), Deutsche Monat-scher f. Zahnh. 39:142, 1921.

2. Orban, B. and Kohler, J.: Die physiologisicheZahnfleischetasche, Epithelansatz und Epitheltie fen-wuch erung. (The physiologic Gingaval Salcus),Ztschr. f. Stomatol. 22:3 53, 1924.

3. Waerhaug, Jens: Gingival Pocket. Odont.Tskr. (Supp. 1) 60: 1952.

4. Orban, B., Bhatia H., Kollar J., and Went-. F.

Epithelial Attachment. J. Periodent. 27:167, 1956.

5. Weski, O.: Die chronisch—margin alem Ent-zündungen des Alveolar Pyorrhoe. 11. Ujschr.Zahnh. 38:1, 1922.

6. Sicher, Harry: Changing Concepts of theSupporting Dental Structure. O.O.O. 12:31-35,1959.

7. Stanley, H. R.: The Cyclic Phenomenon ofPeriodontitis. O.O.O. 8:598-610, 1955.