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The Internolionol Joumal o( Periodontics & Restorolive Dentishy


283

Ultrostructurol Observations The apparent superiority and the


on the Wound Healing of Free predictability of one type of tech-
Gingival Connective Tissue nique over the other is lorgely de-
Autografts With and Without
Epithelium in Humans pendent on fhe ability of the groft to
survive and an its potential for re-
pjjjp 10-13 Isjunnerous histologie studies
in different animal systems have
reparted on the heoling and revas-
culorizotion of the free gingival
graft.'^-^'
Sullivan and Atkins^'" demonstrat-
ed that the epithelial cells of the graft
tend to desquamate and re-epithe-
liaiization occurs from cells deeper
v/ithin the epithelial ridges. Oliver et
Giorgio Colwa, MD, DOS'
CiusHniano Manani. MD' al'^ confirmed in rhesus monkeys that
Slefono Pomio-Benlertoti. MD. DOS. MSCD'
Sergro De Pooli. MD, DDS' the epithelium degenerates and des-
Cariólo Lucchesi, MD' quomates by the fifth day and com-
Paul A. Fugazzotio, DDS^
plete necrosis occurs in some areos.
This study pointed out the contribution
Both the free gingival epithelium- to healing of proliferating epithelial
connective tissue autogrcft and the cells from the adjacent tissues, which
connective tissue outagraft have cavered the entire surface by the
been successfully employed in the eleventh day. Jansan and cawork-
treatment of mucogingival problems. ers," in on animal study, also re-
The goals of both procedures include ported total sloughing of the epithe-
the treatment of recession through the lium in fresh gingival graft tissues
establishment of on adequate zone within 48 hours. The remoining con-
of attached gingiva'"' and the in- nective tissue graft surface undergoes
creose af vestibular depth. re-epitheliolization from the periph-
eral mucosa ond gingiva. In 1969,
Staffileno and Levy" demonstroted
that the success af the graft depends
on the ability of the connective tissue
to withstand its tronsfer to a new lo-
cation. Lange and Bernimoulin^^ em-
" Clinical Director, Deportment of Dentistry, phasized that the role of bosol epi-
University of Ferrora, Ferraro, Italy. theliol cells of free gingival grafts in
' Assistont Professor of Human Anatomy,
University of Ferrara, Ferroro, Italy. the re-epithelialization process pre-
' Instructor of Period onto logy. University af vents Q complete degeneration of the
Ferrora, Ferrora, Itoly. epithelium of the graft.
' Instructor of Period onto logy. University of
Ancono, Ancona, Italy. Parallels hove been drawn in other
* University of Ancona, Ancona, Italy.
" Reseorch Fellow, Boston University, studies of connective tissue gingival
School of Groduote Dentistry, Boston, autografts.'"•^•' There are indications
Mossochu setts. in the literature of o complete epithe-
Correspondence oddress; Dr Poul A. Fu- liolization of a connective tissue graft
gazzotto, 25 FHigh Street, Milton, Mossa-
chusetts 02187. from the palote to alveolar mu-

l l . Number 4, 1991
284

cosa.^^'" Donn^' demonstrated thot Following administratian of local The gingival graft material wos
the kerotinizotian of the epithelium is anesthesia, a horizontal sharp dis- then shaped to correspond to the
directed by the underlying connective section was performed at the mu- donor site and placed in position.
tissue layer. The claim that the free cogingival [unction to separóte the Two coronal marginal sutures were
gingival graft is more predictable alveolar mucosa, elastic, and muscle placed to stabilize the graft. A cir-
thon the connective tissue autograft fibers from the underlying periosteum. cumferential suture was inserted into
in increasing the zone of attached Any remaining muscle fibers and the periosteal bed slightly opical to
gingiva, from a cytologie point of movable connective tissues were re- the inferior margin of the graft,
view, was not studied. moved, and every effort was made looped around the cervical area of
The object of the present investi- to afford on immobile periosteal bed. the tooth, and tied to compress the
gation was to evoluate, by means of Laterally, the initiol incision was made graff against the recipient bed. The
scanning electron microscopy, the ul- slightly coronal to the mucogingival graft wos firmly compressed with a
trastructuraf modifications that occur junction, to "overlap" the gingival moist gauze for two minutes and then
with the placement of epithelium- groft onto the attached gingiva co- dressed with Coe-Pock periodontai
connective tissue grafts, and connec- ronal to the mucagingivai junction. dressing (Coe Laborotories, Inc),
tive tissue grafts. After preparation of the recipient The ultra structura I ona lysis wos
site, measurements were taken with a conducted on 40 autogenous free
Michigan 0 periodontai probe to de- human graft biopsy specimens of tis-
Method and materials
termine the exact dimensions of the sues ¡all less than 1 mm^), taken 30
The present study utilized two differ- free graft materai to be secured from days posto peratively with a punch
ent types of grafts; one composed the hard palate. Masticatory mucoso forceps [Aesculap OK 507). These
of epithelium and connective tissue of the gingival zone of the hord pal- specimens were fixed immediately in
and the ather mode only of connec- ate was used as donor tissue. The 2% glutaraldehyde in 0.1 M caca-
tive tissue. Forty areas in 28 patients, outline of the gingivoi graft was dylate buffer (pH 7.3) followed by
aged 20 to 48, were treated at the scribed with o sharp scalpel. The do- postfixotion in 2% osmium tetroxide
Clinica Odontoiotrica of the Univer- nor graft, composed of epithelium buffered v/ith 0.1 M cocodylate (pfH
sity of Ferrara, Italy, through the and connective tissue, was then dis- 7,3), Tissues were then dehydrated in
plocement of free gingival grafts. sected from the palate ¡Figs 1 to 3). increasing concentrations of ethonol,
Twenty free gingivoi grafts, consisting To procure the "connective tissue- and embedded in epoxy resin. Semi-
of both epithelium and connective tis- only" graft, the mucosal flap was thin sections, 1 mm thick, were
sue and 20 grafts mode up only of partiolly elevated from the hard pal- stained with toluidine blue and ex-
connective tissue, were ploced. ate and only the connective tissue amined vio light microscopy.
was removed and utilized os donor
Orol hygiene instructions were giv- Ultrothin sections with interference
tissue (Figs 4 to 9), The epithelium
en to the patients to ensure excellent colours in the silver ronge ¡approxi-
was then replaced and sutured se-
preoperotive and postoperative mately 700 Â) were cut in Reichert
curely.
plaque control in conjunction with microtomes with glass knives. They
scaling and polishing procedures. were mounted on copper grids,
This regimen was repeated once a stained with uronyl acetate and lead
week for o period of 2 weeks. citrate, and examined with a scan-
ning electron microscope (Zeiss EM-
9S2), Samples of attached gingiva
and hard palote, prepared for the
scanning electron microscope by the
same procedure, served as controls.

The Internalional Journal of Penodonlics & Restoroliue Dentistry


285

fÄ, 1^* Al ¿j ^ ** í7(?

f CT
E

\
i / ^

Fig I The palatal components: (Bl Fig 2 Reflection of the partiol thickness epithelialized graft epithelium as the outer sur-
bone; (CTj connective tissue; ¡E) epithe- face of the flap. The incisions are located at a safe distance from the free gingival
lium. margin to prevent recession in the approximating area.

Figs 1 to 3 Schematic representation of


the free gingñ/ol graft (with epithelium)
procedure.

Fig 3 Removal of the free gingival graft


exposes a large orea of uncovered con-
nective tissue for a delayed healing
phase (healing by secondary intention).

Volume 11, Number 4, 1991


286

Figs 4 ta 9 Schematic representation oí Fig 4 The palatal components: ¡B) Fig 5 Incision ond thin palatal flop
Ihe free gingival gran (wilhou! epithelium) bone. ¡CT) connective iissue; ¡El epithe- reflected, leaving underlying connective
procedure- lium. tissue.

Fig 7 Removal of connective tissue to


Fig 6 Further reflection of palatal ílap to gain easy access to connective tissue. use as a gingival graft.

The Iniemotioriol Joumol of Periodonlics & Restoralive Denhstiy


287

figs 8 and 9 Flap is sutured to palate. This procedure will facilitate the healing af the donor tissue ¡heoling by primory intentian).

Results epithelium ridges that surrounded the basal lamina, wos irregulor be-
fingerlike connective tissue papillae in cause of numerous short projections
Attached gingiva which capillaries were abundant. All that extended into the underlying
Under the light microscope, the ot- of this is in o g ree ment with the results connective tissue, causing the for-
toched gingivo appeared to be com- of previous studies.^''"^'' matian of introflections, in which the
posed of epithelium and lamina pro- Scanning electron microscopic basal lomina were found (Fig 10],
analysis showed that the oral epithe- Desmosomes joined adjacent epi-
priQ, the lotter in close and direct re-
lium wos subdivided into the char- thelial cells.
lationship with the periosteum, A
clearly delineated submucosa was octeristic four loyers of cells: basal,
obsent. The lining epithelium was a spinous, granular, and cornified. The
kerotiniztng stratified squomous epi- basal loyer wos made up of either
cylindrical or cuboidal cells, in a
thelium, while the lamina propria, with
single layer, immediately adjacent to
na glands, was made of dense fi-
the connective tissue from which they
brous connective tissue, with only a
were seporoted by o basal lomina.
few elastic fibers. The bosement
The cytoplosm contained differently
membrane, which separotes the ep-
oriented bundles of microfilaments.
ithelium ond connective tissue, was
The cellular surface, in proximity to
uneven and characterized by deep

Volume I I , Number 4, 1991


The spinous cell layer consisted af
several loyers of large, polyhedral
cells. Numerous cytoplosmic pro-
cesses protruded from the cellular
periphery into o lorge intercellular
space, giving the cell surface a ¡ag-
g e d a p p e a r o n c e (Fig I I ] . The cyta-
plasmatic microfiloment population
was organized into bundles. Melan-
ocytes, with a b u n d a n t cytoplasmic
granules of pigments, were present
in the stratum spinosum.
In the granular layer, the cells be-
c a m e flattened parallel to the gingi-
val surface. Electron-dense keroto-
hyalin granules a n d microfilaments,
more prominent than in the stratum
spinosum, were found in the stratum
granulosum (Fig 12). Numerous des-
Fig 10 Epithelium of ottoched gingivo. Portions of bosal cefis show bundles of microfi-
loments. the basal surface extends Into the underlying connective tissue, mosomes joined the facing mem-
¡b! Microfilaments; ¡et) connective tissue; ¡nj nucleus; ¡bIJ basal lamina. fOriginol magni-
fication X 13,000.) branes of adjacent cells.
The stratum corneum was com-
posed of numerous layers of anu-
clear a n d flattened cells. The cyto-
plasm was densely packed with mi-
Fig 11 Cells of the spinous loyer of the gingivol epithelium. Note the numerous thin crofiloments, oriented along the long
cytoplasmic projections bridging Ihe intercelfufor spoces. ¡n) Nucleus; ¡is) intercellular axis of the cell ¡Fig 13).
space; ¡p) thin cytoplasmic proiections; ¡b) microfilaments. ¡Originol magnification x
5,000.1 The lamina propria was a layer of
dense connective tissue filled with a
network of collagen fibers, some of
which provided the firm attachment
of the lomina proprio to the perios-
teum of the alvealar pracess. Be-
tween bundles of collogen fibers, iso-
loted fibroblasts were present with
long a n d flattened cytoplasmic pra-
lections or lamellae. In the gingival
connective tissue, granular basophil
cells, choracferized by a cytoplasm
rich in electron-dense granules, were
found, while only occasionally were
single myelinated nerve fibers ob-
served. Numerous capillaries, char-
acterized by a small lumen and thin
wall, were present in the papillary
spaces between the projeclions of
the inner epithelial surface (Fig 14).

The Internationol Joumoi of Peiiodonhcs Ä Restorotiue Dentistry


289

Fig 12 Epithelium covering attached gin-


giva. The cytapiosm of the gronulor layer
cells shows electrodense kerotohyalin
granules and bundles of microfilaments.
¡ni Nucleus; ¡k/ keratohyalin granules;
¡b) micrafilaments ¡Original magnification
X 14.000./

Fig 13 Kerotinized epithelium of ot-


toched gingivo. Ciosely packed, flattened
ceils of the cornified layer ¡stratum cor-
neum/ demonstrate numerous cytopiosmic
microfilaments oriented along the major
cellular axes ¡c/ Cells; ¡is/ intercellular
spoce; Ib/ microfilaments. ¡Original mag-
nification xll.OOO./

• 11, Number •!, 199t


290

Mucosa of the hard palate af the


danor site

Under the light microscope, the pal-


atal mucosa was composed of ker-
atinized stratified squamous epithe-
lium ond a lamina propria of con-
nective tissue, folding in irregular pa-
pillae. The lamina propria was firmly
bound to the periosteum of the al-
veolar process.
Examination under the scanning
electron microscope demonstrated
that the lining epithelium of the pal-
atal mucosa appeared to be sub-
divided into severol layers of celts:
basal, spinous, granular, and corni-
fied. The basal layer was made of
only one loyer of isoprismatic cells in
Fig 14 Lamina propnd ol attached gingivo. Capillaries in the connective tissue papillae contact with o continuous basal lam-
provide the nutritional supply to the gingival epithelium. Fibroblasts with thin projections
are also evident, (bv) Capillary; (II fibroblasfs; (be) basal cells. (Original magnification ina anchored to o loyer of microfibrils
X5.400.) (Fig 15). Interdigitating, adjacent cells
were connected to one another via
desmosomes. The cytoplasm con-
tained many microfilaments clustered
Fig 15 Basot orea of the epithelium of the hard palote of the donor site. Note ihe into bundles with various orientations.
lorge nucleus, numerous bundles ol cytophsmic filaments, the basot lamina, and the The large and ovoid nucleus was
anchoring fibnis of the underlying connective tissue, (bl) Basal lamina;
(n) nucleus; (is) intercellular space; (ml) microfibnis; (b) microfilaments. (Original magnifi- charocterized by the peripheral dis-
cation X 12.000.1 tribution of chromatin.

The stratum spinosum consisted of


severol layers of cells equipped with
short cytoplasmic processes, resem-
bling spines, attached to one anoth-
er. The intercellular spaces seemed
to be crossed by narrow intercellular
bridges at regular intervals, which
gave the cell surfaces a prickled op-
peorance. These consisted of des-
mosomic mechanisms, well devel-
oped along the interface of focing
plosmic membrane of adjacent cells.
In the cellular cytoplasm of the stra-
tum spinosum, bundles of microfila-
ments were present in clusters in
proximity to the intercellular bridges
¡Fig 1Ó). The granular layer consisted
of flattened cells with granules and

l of PenodonfrCï & Resforolive


291

Pig 16 Epithelium of the hard palote al


the donor site. Spinous cells show narrow
intercellular bridges across the intercellular
spaces, ¡nj Nucleus; ¡b/ microfitoments;
¡pi thin cyloplasmic projections: I's) inter-
cellular space; ¡d) desmosome. ¡Original
magnification x ¡4,000J

Fig !7 Epithelium of Ihe hard palate at


the donor site. A portion of a ceil oí the
granular layer, which is rich in electro-
dense droplets and bundles of microfila-
ments. ¡bj Microfilaments; ¡k) keratohyolin
granules; ¡nJ nucleus. ¡Original mognifica-
iion x24,000.l

Volume H , Number <t, 1991


292

bundles of microfiloments in their cy-


toplosm (Fig 1 7).
The stratum corneum wos com-
posed of several layers of enucleat-
ed, flattened cells, surrounded by a
morkedly thickened cell membrane.
At the inferior border of the cornified
loyer, the cells were densely packed
together, while in their superficial por-
tions they tended to be forther opart,
but were still ottoched to one another
vio desmosomes ¡Fig 18).
The lamina propria of the palatal
mucoso was characterized by the
presence of large bundles of colla-
gen fibers with random orientations.
With the scanning electron micro-
scope, typicol fibroblasts and only
occasionally blood vessels were ob-
18 Epithelium of the hord polate at the donor site. Flattened cells of the stratum served. The connective tissue of the
carneum ore evident. The plasmatemma of adjacent ond more superficial cells show
desmosomes (c) Cell of the strotum comeum; (is) intercellulor space; fbl microfiloments; palatal mucoso was characterized
(dl desmosomes. (Original mognification x 10,000.)
by a predominance of collagen
fibers aver omorphous ond cellular
constituents (Fig 19),

Fig 19 Lamina propria of the mucosa of ths hard palote at the donor site. Large bun-
dles of coltogen fibers ore rondamly oriented, ¡cfj Collogen fibers. lOriqinol moanifica-
tian x24.000.¡

DI Penodonlics £• Re&ioraiive Denfisfiy


293

Epithelium—connecfive tissue
autograft

Specimens of the free gingival epi-


thelium—connective tissue autograft,
taken 30 days postoperatively. were
abserved under the light microscope.
They consisted of a stratified squa-
mous epithelium, superficially cov-
ered by a keratinized cell layer, and
a lamina propria of dense connective
tissue. The border between the epi-
thelium and the underlying lamina
propria of the cannective tissue wos
uneven and characterized by deep
epithelial ridges that surrounded
fingerlike connective tissue papilloe.
Under the scanning electron mi-
croscope, the lining epithelium pre-
Fig 20 Epithelium of the epithelium-connective tissue outagraft. Bosot cells thot show o
sented v/ith the typicol strotified pat- welf-developed nucleus and a cytaplasmic membrane attached to basal lamina through
tern (ie, basal, spinous, granular, and hemidesmosomes are evident ¡n! Nucleus, ¡is) intercellular space; ¡bt) bosof famina; ¡b)
microfiloments; (h) hemidesmosomes. ¡Original magnificaban x 13,000.)
carnified layers). The shope and di-
mensians of the basal layer cells
were similar to those of "normal " tis-
sues, with connection of one cell to
another dependent on extensive in-
Fig 21 Epithelium of the epilhelium-conneclive tissue outograft. Spinous epithelial cells
terdigitattans and desmosamal at- show a highly vocuolized cytoplasm. Intercellulor spaces ore reduced, ana the desmo-
tachments. The nuclei were lorge, Somic junctions Ore fewer ¡n) Nucleus, (is) intercellular spoce, (d! desmosome; (v) vacu-
oli. (Originol magnificotion x 11,000.)
while cytoplasm was scarce, dem-
onstrating an abundance of microfi-
laments [Fig 20j. Hemidesmosomal
attachments were evident between
the basement membrane and the
cells.
in the spinous layer, there wos o
transition from rounded cells in the
deeper loyers to flattened cells in the
more superficial loyers. The intercel-
lular spoces were much narrower
than were the spaces between spi-
nous cells in the epithelium of the ot-
tached gingiva and in the mucoso of
the hard palate ¡Fig 21). The de-
mosomes joining intercellular bridges
were reduced in number, ond fewer
microfilaments were anchored to
them. Numerous vacuoli, containing

Volume n . Number 4, 1991


294

mitochondrial remnants were present


¡Figs 21 and 22). Cellular organelles
were not detected and microfilamen-
tous structures were rare. The nuclei
demonstroted chromantin that wos
organized in large, high-electron-
dense granules. In short, pathog-
nomic signs of cellular degeneration
were evident.
The strotum granulosum consisted
of a few layers of flattened cells,
characterized by cytoplasmic gran-
ules and microfilaments, often in bun-
dles (Fig 23).
The strotum corneum was com-
posed of several layers of cells, with
fairly thickened plasmalemma, re-
sembling overlapping lamellae (Fig
24), Microfilomentous material in on
fig 22 Higher magnification of Fig 12. ¡n/ Nucleus; ¡v/ vacuoli. ¡Original magnification
electron-dense matrix was abundant
in the cytoplasm. Finely granular ma-
terials were found in the intercellular
space. Desmosomal attachments
were present between cells. Medan-
ocytic and cleor cells were also not-
ed.
Fig 23 Epithelium-connective tissue auiograft. Celts of the granular layer af the epithe- The lomina propria was mode of
lium are choracterized by eiectran-dense draplets and cytoplasmic microfiiament bun-
dles, ¡k/Electron-dense drapiets: ¡b I micro filaments ¡Original magnification x 28.500./ dense connective tissue, consisting of
iiTegularly oriented collagen fibers,
sometimes in bundles. The fibroblosts
of such fibrous connective tissue were
equipped with fanning pro[ections.
Delicate capillaries with walls com-
posed of three to four endothelial
cells were obsen/ed (Fig 25), These
cells demonstrated pyknolic nuclei
and an absence of cellular organ-
elles, once again indicating cellular
degeneration.

The IrlernaHonol Joumol of Penodontics & Restorative Denlistiy


295

Fig 24 Epithelium of the epithelium-con-


nective tissue autograft. Thin parallel enu-
cleate sheets of the stratum corneurn ore
densely pocked with fitoment bundles.
The cell membranes have become thick-
ened and desmosomes are maintained,
(c) Cell; (d) desmosome; (is) intercellulor
space. (Original magnification x24.500.)

Fig 25 Lamina prapria of the epithelium-


connective tissue auiagraft. Nate the col-
lapsed walls of the capillaries and the
vacuolized cytoplosm of the endotheliol
cells. The nucleus is picnofic. (ec) Endoth-
eliol cell; (n) nucleus; (vl vacuoiL (Origi-
nal magnification x 12.000.1

• I I , Number-S, 1991
296

Pree gingival connective tissue


outograft

Under the light microscope, the free


connective tissue autograft, taken 30
doys postoperatively, was histologi-
colly interchangeable with the epithe-
lium-connective tissue graft alreody
described. The connective tissue
outogrott w a s , therefore, compased
of o keratinized stratified squamous
epithelium ond lamina proprio, inter-
digitoting with the epithelial ridges.
Scanning electron microscopic o b -
servations demonstroted that the
basal layer consisted of one cylin-
drical cell layer; each cell was char-
octerized by thin cytoplasmic pro-
cesses on its basal surfoces (Fig 26).
Fig 26 Epithelium oí the connective tissue autogroft. Portion of a basal epithelial cell These fingerlike extensions of the cells
resting on bosal lamina Note the undulating microvilli following Ihe contours of the bas-
al lamina. The cells are attached vio hemiJesmosomes. ¡n) Nucleus; ¡bl¡ basol lamino; protruded into the underlying con-
(bl microfiloments; ¡h) hemidesmosomes; ¡cf¡ collagen fiber. ¡Original magnification nective tissue a n d were connected to
X 26,000.1
o continuous basal lamino via hem-
idesomosomal attachments. The
cytoplasm of the basal cells locked
cellular organelles, but was chorac-
Fig 27 Epithelium of Ihe connective tissue oulograit. Spinous epithelial cells. The inler- terized by numerous microfiloments in
ceiluiar ¡unctions are characterized by increased numbers of desmosomes.
¡n) Nucieus; ¡d) desmosome; ¡b) microfiioments; Inl) nucteotus. ¡Original magnification the basal zone.
X 12.000.)
The spinous cells showed ultra-
structurol characteristics thot resem-
bled those of cells in the strotum spi-
nosum of the attached gingiva ond
the hard palate, but not the chor-
acteristics of cells in the free epithe-
lium tissue outografts. Their cyto-
plasms were filled with a micrafilo-
mentous opporotus that mosked the
cellular orgonelles to a degree (Fig
27). The nuclei of the spinous cells
were round, with the chromotin moin-
ly locoted in proximity to the nuclear
membrane, and contained an evi-
dent nucleolus.

The granular layer consisted of


several layers of cells, whose cyto-
plasm was choracterized by mony
electron-dense droplets a n d micro-

The InternoKonol Journol o( Periodontics S Restoroüve Dentistry


297

Fig 28 Epithelium of connective tissue


autaqraft. A portion of o cell of the gran-
ular layer is shown. Many electran-dense
droplets and microfilaments are present in
the cellular cytoplasm, (n) Nucleus; (b)
microfiloments; ¡k) electron-dense drop-
lets. (Origino! magnification x24,000.)

Fig 29 Epithelium of the connective tis-


sue outagrañ. The ceHs of the stratum
corneum shaw minimal structural detaHs
other than dense!y packed filament bun-
dles, (c) Cell; (is) intercellular spoce.
(Original magnification x24,000.)

• 11, Number 4, 1991


298

Fig 30 Lamina propria of the connective


tissue autagraft. Wide-open waits of o
copilfory blood vessef ore evident The
junctions between adjacent endotheliol
cells show numerous cytaplosmic microfi-
faments in o horizontol cross section.
(n) Nucleus; (ec! endotheliol cell; ¡t! tight
junction, ¡f) lumen; ¡cf) coljagen fiber.
(Originof mognificotian x27,000.)

Fig 31 Lamina propna of the connective


tissue autogroft. A capillary with cof-
lopsed walls is demonstrated, ¡n) Nucfe-
us: ¡ec) endotheliof cell; ¡rbc) red blood
ceJI. ¡Originol mognification x 12,000.)

The International Joumol o( Penodorlics & Restorative Dentistry


299

filaments that were frequently aggre- Discussion and conclusions Both human ond animal studies
gated in bundles (Fig 28). have previously reported degenera-
The stratum comeum was com- Numerous clinical studies have tive epithelial alterations of the graft
posed of flattened, onucleor cells, shown a definitive biologic attach- during the first week.'^'-*^ Histoiogic
whose cytoplasm was filled almost ment and blending of the free gin- studies have also reported a migra-
exclusively by microfilaments running giva autogrofl inio the surrounding tion of epithelial cells from adjacent
parallel to the long axes of the cells periodontal tissues,^'"'^^'^' Attach- wound margins between the second
1F¡9 29). ment of the groft materiol is accom- and the fourth days."'"'" Oliver et
The underlying connective tissue plished by day 10 to 13.'^ al'^ and Lange and Bernimaulin'^
consisted of coarse collagen fibers Light microscopic studies hove mentioned a possible participation of
frequently aggregated in intermin- clorified the healing mechanisms, in- basal cells that remain in the graft in
gling bundles. Immediately below the cluding the cellular changes and vos- re-epithelia!ization.
epithelium, the collogen fibers be- cular development of the free gingi- The presence of nonvital ar un-
come thinner, forming a band to val graft placed in the donor healthy spinaus cells in the speci-
which the cellular projections of the area."-'^''^ mens we examined could signify on
basal layer were anchored (see Fig The ultra structura I observations via incomplete maturation of the epithe-
26). The prime cellular constituents of scanning electron microscope have lium, because of a compromise of
the connective tissue were the fibro- dealt with numerous aspects of the nutritional supply from the blood ves-
blasts, which showed evidence of dentogingival interface of healthy hu- sels of the lamina propria. This hy-
active production. man gingiva ond the normal human pothesis was reinforced by the fact
NumeroLiS capillaries with either periodontium.^"'^^ LJsing the transmis- that the endothelial cells of the cap-
distended ¡Fig 30) or collapsed walls sion electron microscope, Listgarten^^ illories interspersed throughout the
were observed (Fig 31). The long, examined the gingival graft in mon- bundles af collagen fibers in the graft
flattened endothelial cells were par- keys. demonstrated ultra structura I charoc-
allel to the long axes of the vessels. However, an ultra structura I study teristics of degeneration (ie, absence
Tight [unctions were present belween of free gingival epithelium-connec- of cellular organelles, vacuolization
adjacent endothelial cells. The cyto- tive tissue ond connective tissue grafts of the cytoplasm, pyknotic nuclei).
plasm was filled with microfiloments in humans has not been presented Thus, the histoiogic alterations of the
and vescicles of micropinocytosis. before. Ultra structura I obsen/ctions of epithelium were a consequence of in-
The tuminal surfaces of the endo- epithelium-connective tissue grafts, ten-uption of the nutrient supply to the
thelial cells were smooth in some taken 30 days posto peratively, led to grafted material, whose survival must
areas, while, in other regions, folding the conclusion that the lining epithe- initially depend on tissues of the sur-
had resulted in crypt formotion. The lium was composed of four cellular rounding areas for nutrition.
external surfaces were lined with a layers: basol, spinous, granular, and Examination of the connective tis-
continuous basal membrane. cornified. Such cells presented a sue-only graft, 30 days postopera-
morphologic picture resembling the tively, revealed an epithelium similar
cells of the lining epithelium of the to that of both the control and the
attached gingiva and the mucosa of epithelium-connective tissue graft.
the hord palate in the donor site, with
the exception of the spinous cell
layer. Here the trouma and degen-
eration were evidenced by vocuolo-
zation of the cytoplasm, the absence
of cellular organelles, a reduced
number of desmosomes, and nar-
rower intercellular spaces.

VoiLime 11, Number^, 1991


300

The morphologic picture of the spi-


nous cells resembled that of the at- References
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Volume 11, Number 4, 19?1