ANATOMI, HISTOLOGI DAN JARINGAN PERIODONTAL GIGI Disusun untuk Memenuhi Tugas Mata Kuliah HISTOLOGI Semester I/Tahun Akademik 2017/ 2018 Kelas Karyawan Reguler
Disusun Oleh : : Ani Andrayani NIM : KEMENTRIAN KESEHATAN REPUBLIK INDONESIA POLITEKNIK KESEHATAN JAKARTA I
JURUSAN KEPERAWATAN GIGI JAKARTA
i
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KATA PENGANTAR
Segala puja hanya bagi Allah yang Maha Pengasi lagi Maha Penyayang. Berkat limpahan karunia nikmatNya saya dapat menyelesaikan makalah yang berjudul “Anatomi, Histologi dan Jaringan Periodontal Gigi” dengan lancar. Penyusunan
makalah ini dalam rangka memenuhi tugas Mata Kuliah… yang dibimbing oleh … Dalam proses penyusunannya tak lepas dari bantuan, arahan dan masukan dari berbagai pihak. Untuk itu saya ucapkan banyak terima kasih atas segala partisipasinya dalam menyelesaikan makalah ini. Meski demikian, penulis menyadari masih banyak sekali kekurangan dan kekeliruan di dalam penulisan makalah ini, baik dari segi tan da baca, tata bahasa maupun isi. Sehingga penulis secara terbuka menerima segala kritik dan saran positif dari pembaca. Demikian apa yang dapat saya sampaikan. Semoga makalah ini dapat bermanfaat untuk masyarakat umumnya, dan untuk saya sendiri khususnya.
Jakarta, 7 Desember 2017 Penulis
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DAFTAR ISI
Halaman Judul ................................ ................................................. .................................. ........................... .......... i Kata Penghantar ................................. .................................................. .................................. ........................ ....... ii Daftar Isi ................................. ................................................. ................................. ................................. ................ iii BAB I Pendahuluan ................................. .................................................. .................................. ..................... ....
1
BAB II Pembahasan....................... Pembahasan........................................ ................................. ................................ ................
2
A. Gingiva .................................. ................................................... .................................. ........................ .......
2
A.1 Histologi Gingiva ..................................... ..................................................... ..................... .....
6
A.1.a Epitel Gingiva ................................. ................................................. ..................... .....
6
A.1.b Epitel Oral ..................................... ..................................................... ..................... .....
7
A.1.c Epitel Surkural ............................... ................................................ ...................... .....
8
A.1.d Junctional Epithelium................................. ............................................. ............
8
A.2 Jaringan Ikat Gingiva .................. .................................. ................................. ................... ..
8
A.2.1 Serat-serat gingiva ................................ ................................................ ................
9
A.2.2 Elemen Seluler ................................ ................................................. ................... .. 11 A.2.3 Suplai Darah ................................. ................................................. ..................... ..... 11 B. Ligament L igament Periodontal ................................ ................................................. ........................... .......... 12 B.1 Serat-Serat Peiodontal ................................ ................................................. ................... .. 13 B.2 Elemen Seluler ........ ................................ ................................................. ................... .. 16 B.3 Substansi Dasar ........ ................................ ................................................. ................... .. 17 B.4 Fungsi Ligamen Periodontal .......................... ............................................ .................... 17 C. Sementum ..................... ..................... ................................ ................................................. ................... .. 18 C.1 Anatomi dan Histologi Sementum ......................
18
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C.3 Sel-sel Pembentuk Sementum ................................ .......................................... .......... 21 C.4 Komposisi Sementum . ................................ ................................................. ................... .. 21 D. Tulang Alveolar ............... ................................ ................................................. ................... .. 22 D.1 Anatomi dan Histologi Tulang Alveolar ........................... ................................ ..... 22 D.2 Matriks Seluler dan Interseluler ........................................ ........................................ 24 D.3 Dinding Soket .......... ................................ ................................................. ................... .. 24 D.4 Periosteum dan Endosteum ................................. ............................................. ............ 25 D.5 Septum Interdental ... ................................ ................................................. ................... .. 26 D.6 Fenestrasi dan Dehisensi................................. ................................................. ................ 26 Bab III Kesimpulan .................... ................................ ................................................. ................... .. 28 Daftar Pustaka......................... ......................... ................................ ................................................. ................... .. 29
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BAB I PENDAHULUAN
Jaringan periodontal terdiri atas jaringan yang meliputi dan mendukung gigi. geligi dalam rahang. Sesuai dengan artinya, periodontal terbagi menjadi dua bagian yang berasal dari bahasa bahasa Yunani, Yunani, yaitu
“ pert” artinya sekitar dan
“odontos” berarti gigi. Jaringan pendukung tersebut terdiri dari: gingiva,
sementum, ligamen periodontal periodontal dan tulang alveolar. alveolar. Fungsi utama gingiva yaitu untuk melindungi jaringan di bawahnya, sedangkan attachment apparatus yang apparatus yang terdiri dari ligamen periodontal, sementum dan tulang alveolar memiliki fungsi, memberikan dukungan bagi serat-serat ligamen periodontal (Lindhe, dkk., 2003). Jaringan periodontal normal berperan sebagai penyedia dukungan yang sangat penting untuk dapat berlangsungnya fungsi mastikasi. Setiap bagian dari jaringan periodontal ini memiliki fungsi dan perannya masing–masing, akan tetapi pada dasarnya, keseluruhannya merupakan satu kesatuan yang saling berhubungan (Newman, dkk., 2012). Jaringan periodonsium dapat bervariasi secara morfologi dan fungsional seiring dengan perubahan umur dan keadaan patologis. Sehingga pengetahuan tentang anatomi, histologi, serta tampilan klinis dari jaringan periodontal yang normal penting dikuasai untuk memfasilitasi pemahaman mengenai kelainan patologis, keadaan fisiologis yang berlebihan, maupun respon terhadap keadaan inflamatif di jaringan periodontal beserta perawatannya. Pengetahuan tentang jaringan periodontal normal bermanfaat untuk memahami serta membedakan keadaan jaringan periodontal dalam keadaan normal dan kondisi patologis, sehingga dapat ditegakkan terapi yang optimal.
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BAB II PEMBAHASAN
Mukosa rongga mulut (mukosa oral) berbatasan dengan kulit, bibir dan mukosa palatum lunak, serta faring. Mukosa rongga mulut terdiri atas: 1.
Mukosa mastikasi (masticatory (masticatory mucosa), mucosa), termasuk gingiva dan bagian yang menutupi palatum keras
2.
S pecialized mucosa, mucosa, yang menutupi dorsum lidah
3.
Oral mucous membrane lining yang berada di dalam rongga mulut (Newman, dkk., 2012)
Gambar 1. Gingiva normal
Gambar 2. Gingiva normal bagian palatal
A. Gingiva Gingiva adalah bagian mukosa rongga mulut yang mengelilingi serviks gigi dan menutupi tulang alveolar serta menutupi akar gigi sampai batas cementoenamel junction. junction. Gingiva merupakan bagian terluar dari jaringan periodontal. Area gingiva dimulai dari garis mukogingiva, menutupi tulang alveolar bagian koronal, kemudian pada ujungnya mengelilingi serviks di setiap gigi. Pada bagian palatal, tidak terdapat garis mukogingiva karena palatum keras dan tulang alveolar maksila diliputi oleh mukosa mastikasi yang sama (Newman, dkk., 2012).
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Gambar 3 Anatomi 3 Anatomi gingiva (Rateitschak., 2004)
Gingiva tersusun dari dari jaringan ikat dan epitel berkeratin yang meluas dari tepi gingiva ke pertemuan mukogingiva. Menurut Fedi, dkk.(2005) dan Newman, dkk., (2012), secara anatomis, gingiva terdiri atas gingiva bebas (margin gingiva/ free gingiva), gingiva), gingiva cekat (attached (attached gingiva), gingiva), gingiva interdental (interdental gingiva). interdental gingiva). 1. Margin gingiva/ gingiva bebas merupakan bagian yang mengelilingi leher gigi, tidak melekat secara langsung pada gigi dan membentuk dinding jaringan lunak sulkus gingiva. Bagian gingiva ini meluas dari tepi gingiva hingga dasar sulkus. Gingiva bebas adalah batas tepi gingiva yang mengelilingi gigi, berbentuk seperti kerah baju. Gingiva bebas dipisahkan dari gingiva cekat oleh depresi dangkal yang membentuk garis yang disebut groove groove gingiva bebas ( free free gingival groove/marginal groove/ gingival
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Gingiva bebas tidak melekat pada gigi, membentuk dinding jaringan lunak dari sulkus gingiva serta dapat dipisahkan dari gigi dengan menggunakan alat. Sulkus gingiva adalah celah dangkal atau ruang sekeliling gigi yang dibatasi oleh permukaan gigi dan epitel gingiva bebas (Fedi, dkk., 2000). Sulkus gingiva merupakan parameter diagnosis yang sangat penting. Pada kondisi normal, kedalaman sulkus gingiva adalah 0 mm. Kondisi tersebut hanya dapat dijumpai secara eksperimental, pada hewan bebas kuman atau setelah plak kontrol intensif berkepanjangan. berkepanjangan. Metode klinis yang digunakan untuk mengukur kedalaman sulkus berupa instrument logam yang dinamakan probe periodontal. Kedalaman histologis sulkus tidak sama persis dengan kedalaman penetrasi probe. Oleh karena itu dikenal kedalaman probing ( probing probing depth) depth ) dari sulkus gingiva normal yakni 2 - 3 mm (Newman, dkk., 2012).
Gambar 5. Pengukuran 5. Pengukuran kedalaman probing (Lindhe, dkk., 2003)
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Gambar 6. Stippling pada Stippling pada gingiva cekat
Lebar gingiva cekat merupakan parameter klinis yang penting karena merupakan jarak antara mucogingival junction dan proyeksi bagian luar dari dasar sulkus atau poket periodontal. Lebar gingiva cekat pada aspek fasial berbeda - beda pada setiap area. Umumnya gingiva cekat pada regio incisal paling lebar ( 3,4 - 4,5 mm di maksila dan 3,3 - 3,9 mm di mandibula ) kemudian makin berkurang di segmen posterior, dengan lebar terkecil pada premolar pertama (1,9 mm di maksila dan 1,8 mm di mandibula) (Newman, dkk., 2012). Lebar gingiva cekat bertambah sesuai umur dan juga pada gigi supraerupsi. Perubahan lebar gingiva cekat disebabkan oleh modifikasi posisi ujung bagian koronal. (Newman, dkk., 2013) Pada aspek lingual mandibula, gingiva cekat dimulai dari pertemuan mukosa lingual alveolar yang berlanjut pada membran mukosa yang melapisi dasar mulut. Pada permukaan palatal gingiva cekat di maksila tidak dapat diketahui batasnya dengan mukosa palatal yang memiliki konsistensi yang
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Gambar 7. Interdental gingiva
Perbedaan variasi anatomi interdental col pada col pada gingiva normal (sisi kiri) dan gingiva resesi (sisi kanan) tampak pada gambar 7A dan 7B regio anterior madibula, sisi fasial dan bukolingual, serta gambar 7C dan 7D regio posterior mandibula sisi fasial dan bukolingual. Bentuk gingiva interdental bergantung pada titik kontak di antara dua gigi yang bersebelahan dan ada tidaknya resesi. Apabila terdapat diastema diantara dua gigi yang bertetangga, maka tidak dijumpai papila interdental. (Newman, dkk., 2012).
A.1. Histologi Gingiva A.1.a. Epitel gingiva Epitel gingiva terdiri atas epitel gepeng berlapis (stratified berlapis (stratified squamous), squamous), Fungsi utama epitel adalah melindungi struktur yang ada di bawahnya dan memungkinkan terjadinya perubahan selektif pada lingkungan oral. secara
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A.1.b. Epitel oral Epitel oral adalah adalah epitel yang melapisi lapisan luar margin gingiva dan permukaan gingiva cekat. Rata-rata ketebalan epitel oral 0,2 hingga 0,3 mm. berkeratinisasi atau parakeratin, membalut permukaan vestibular dan oral (Newman, dkk., 2006).
Gambar 8. A Berkeratin B. Tidak berkeratin C. Parakeratin (Lindhe, dkk., 2003)
Epitel oral yang berkeratin terdiri atas empat lapisan sel, yaitu : 1.
Stratum basale bentuknya basale bentuknya kuboid
2.
Stratum spinosum bentuknya spinosum bentuknya poligon
3.
Stratum granulosum bentuknya granulosum bentuknya pipih
4. Stratum korneum
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A.1.c. Epitel Sulkular Epitel sulkular membentuk dinding sulkus gingiva dan menghadap ke permukaan gigi. Epitel ini merupakan epitel stratified squamous squamous yang tipis, tidak berkeratin dan tanpa rete peg, peg, meluas dari batas koronal junctional epithelium hingga epithelium hingga krista tepi gingiva. Epitel ini penting sekali karena bertindak sebagai membrane semipermeabel yang dapat dilewati oleh produk bakteri menuju gingiva dan melalui cairan gingiva yang keluar ke sulkus gingiva (Newman, dkk., 2006).
A.1.d. Junctional Epithelium Junctional epithelium epithelium membentuk perlekatan antara gingiva dengan permukaan gigi. Epitel ini merupakan epitel stratified squamous squamous yang tidak berkeratin. Pada usia muda junctional muda junctional epithelium terdiri epithelium terdiri atas 3 - 4 lapis, namun dengan pertambahan usia lapisan junctional epithelium bertambah menjadi 10 hingga 20 lapis. Junctional epithelium epithelium melekat pada permukaan gigi dengan bantuan lamina basal.
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antara retepeg retepeg epitel dan lapisan retikuler yang bersebelahan dengan periosteum tulang alveolar di bawahnya (Newman, dkk., 2006). Jaringan ikat memiliki kompartemen selular dan aselular terdiri dari serat dan substansi dasar. Substansi dasar mengisi ruang antara serat dengan sel, amorf, dan memiliki kandungan air yang tinggi, terdiri dari proteoglycans, terutama asam hyaluronic dan kondroitin sulfat, dan glikoprotein, terutama fibronectin (Newman, dkk., 2006). Serat jaringan gingiva terdiri atas tiga tipe, serat kolagen, serta retikular, dan serat elastik. Kolagen tipe I membentuk inti lamina propria dan memberikan tensile strength terhadap strength terhadap jaringan gingiva. Kolagen tipe IV bercabang di antara bundel kolagen tipe I dan menyatu dengan serat-serat membran basah dan dinding pembuluh darah. Sistem serat elastik dibentuk oleh serat-serat oksitalan, eluanin dan elastin yang tersebar di antara serat-serat kolagen (Newman, dkk., 2006).
A.2.1. Serat-serat gingiva Jaringan ikat gingiva bebas mengandung banyak kolagen Tipe 1 yang tersusun dalam sistem bundel serat, yang dinamakan serat - serat gingiva.
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Serat gingiva tersusun atas 3 kelompok: 1.
Serat Gingivodental Merupakan serat yang terdapat pada permukaan fasial, lingual dan interproksimal, melekat pada sementum di bawah epitel pada dasar sulkus gingiva. Pada pemukaan fasial dan lingual, serat ini memanjang dari sementum dalam bentuk seperti kipas angin ke arah crest dan permukaan luar gingiva bebas. Serat ini juga memanjang keluar menuju periosteum pada permukaan fasial dan lingual tulang alveolar.
2.
Serat Sirkular Serat sirkular melewati jaringan ikat pada gingiva bebas dan interdental dan melingkari gigi seperti cincin.
3.
Serat Transeptal Berlokasi di daerah interproksimal, serat transeptal membentuk ikatan horisontal yang meluas di antara sementum pada aproksimal gigi. (Newman, dkk., 2006)
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A.2.2 Elemen Seluler Elemen seluler utama pada jaringan ikat gingiva adalah fibroblas yang banyak dijumpai diantara bundel serat. Fibroblas berfungsi mensintesa serat - serat kolagen dan serat - serat elastik glikoprotein dan glikosaminoglikan pada substansi interseluler dan juga berperan dalam pengaturan degradasi kolagen. Sel- sel inflamasi yang dijumpai pada jaringan ikat gingiva mencakup leukosit, polimorfonukleus, limfosit dan sel plasma. Dalam kondisi normal sel - sel ini dijumpai di jumpai dalam jumlah yang sedikit. Dalam keadaan terinflamasi, sel - sel inflamasi dijumpai dalam jumlah yang banyak dalam bentuk agregrat seluler padat yang menggantikan elemen fibrosa dalam jaringan ikat (Newman, dkk., 2006; Newman, dkk., 2012).
A.2.3 Suplai Darah Suplai darah pada gingiva terdiri atas: 1.
Arteri supraperiosteal pada fasial dan lingual tulang alveolar
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B. Ligamentum Periodontal Ligamen periodontal terdiri dari pembuluh darah yang kompleks dan jaringan ikat yang sangat selular yang mengelilingi akar gigi dan menghubungkan ke dinding bagian dalam tulang alveolar (Gambar 12). Ligamen ini bertemu dengan jaringan ikat di gingiva dan berhubungan dengan sementum maupun ruang sumsum tulang melalui saluran pembuluh darah dalam tulang sehingga ligamen periodontal juga berfungsi untuk memberikan nutrisi kepada sementum, tulang alveolar serta jaringan gingiva (Gambar 13). Selain menjaga perlekatan gigi ke tulang alveolar dan struktur gingiva, ligamen periodontal juga berfungsi sebagai shock absorber dan dan sarana transmisi daya oklusal ke tulang alveolar serta memiliki lebar rata-rata sekitar 0,2 mm dan bervariasi. Pembuluh darah pada ligament periodontal berasal dari tiga cabang, yaitu pembuluh darah apikal, pembuluh darah pada interproksimal tulang alveolar, dan pembuluh darah dari gingiva.
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Gambar 13. Diagram histologis ligamen periodontal (Rateitschak, dkk., 2004)
B.1. Serat-Serat Periodontal Elemen terpenting dari ligamen periodontal adalah serat utama, yang
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Serat oblique merupakan kelompok serat terbesar, serat ini berjalan ke arah koronal dari gigi ke tulang alveolar. Serat ini bertindak untuk melawan tekanantekanan yang berorientasi vertikal (Gambar 16). Serat apikal berada di daerah apikal dari soket. Serat ini menyebar tidak teratur di apikal gigi dan tidak akan terbentuk jika perkembangan akar gigi tidak sempurna (Gambar 17). Serat interradikuler ini menyebar dari sementum ke tulang alveolar di daerah furkasi f urkasi pada gigi berakar ganda (Gambar 18) (Newman, dkk., 2006; Hoag dan Pawlak, 1990; Rateitschak, dkk., 2004; Wikesjo, dkk., 1992)
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Gambar 16. Gambaran histologi dari serat apikal (A) (Litsgarten, 2013).
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B.2. Elemen Seluler Elemen seluler ligamen periodontal dibagi menjadi empat tipe sel, yaitu sel jaringan ikat, sel epitel, sel sistem imun, dan sel yang berhubungan dengan elemen neurovaskuler (Gambar 18). Sel jaringan ikat meliputi fibroblas, sementoblas, dan osteoblas. Fibroblas merupakan sel yang paling banyak terdapat di ligamen periodontal, sel ini mensintesis kolagen serta memfagositosis dan menghilangkan kolagen yang sudah tua. Osteoblas dan sementoblas sama seperti osteoklas dan sementoklas terdapat di area semental dan tulang pada ligamen periodontal. Sel epitel res malassez terdistribusi dekat dengan sementum melalui ligamen periodontal dan terdapat paling banyak di daerah apikal dan servikal. Sel ini mengalami degenerasi sesuai bertambahnya usia dan kemudian
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B.3. Substansi dasar Substansi dasar ligamen periodontal mengisi ruang antara serat-serat serat -serat dan selsel, yang terdiri dari dua komponen utama, yaitu glikosaminoglikan seperti asam hialuronik and proteoglycans, serta glikoprotein seperti fibronektin
dan
laminin.
Komponen-komponen
ini
juga
memiliki
kandungan air yang tinggi sekitar 70%. Ligamen periodontal ini juga mengandung masa terkalsifikasi yang dinamakan sementikel yang melekat di permukaan akar (Newman, dkk., 2004).
B.4. Fungsi Ligamen Periodontal
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c. Fungsi Nutrisional dan Sensoris Ligamen periodontal mensuplai nutrisi ke sementum, tulang, dan gingiva melalui
pembuluh
darah
serta
menyediakan
drainase
limfatik.
Periodontal ligamen ini juga menerima suplai transmisi taktil, tekan, dan
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Komposisi ini membuat sementum sedikit lebih keras dari tulang. Lebar sementum bervariasi dari 16 hingga 60 µm pada seperdua akar dan lebih tebal pada sepertiga sepertiga akar (Newman, dkk., dkk., ; Rateitschak, dkk., 2004). Fungsi sementum adalah sebagai berikut : 1.
Menahan gigi pada soket tulang dengan perantaraan ligamen periodonsium
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lebih sedikit daripada tipe aselular. Serat sharpey memiliki bagian yang lebih sedikit daripada sementum aselular dan terpisah dari serat lain yang tersusun paralel pada permukaan akar (Newman, dkk., 2006). Berdasarkan hal tersebut sementum diklasifikasikan menjadi : 1. Acellular 1. Acellular Afibrial Cementum Cementum (AAC)
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5. Intermediate Cementum Intermediate
cementum
adalah
zona
ill-defined
di
dekat
cementodentinal junction pada junction pada gigi tertentu yang terlihat mengandung sisa
selubung
hertwig’s
tertanam
terkalsifikasi (Newman, dkk., 2006)
pada
substansi
dasar
yang
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kolagen lainnya, termasuk jenis V, VI, dan jenis XIV. Hampir semua noncollagenous protein matriks diidentifikasi dalam sementum juga ditemukan dalam tulang. Ini termasuk t ermasuk sialoprotein tulang, protein dentin matriks
1
(DMP-1),
dentin
sialoprotein,
fibronektin,
osteocalcin,
osteonectin, osteopontin, tenascin, proteoglikan, proteolipids, dan beberapa faktor pertumbuhan seperti faktor pertumbuhan (IGF) molekul-
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