5
of noxious substances. Orban and Archer studied the
Visualization of the
Microvascularization of the
Healing Periodontal Wound
III. Gingivectomy
by
A R T H U R B . NOVAES*
SIMAO K O N * *
M . P. R U B E N * * *
H. M . GOLDMAN****
THIS STUDY REPRESENTS a portion of an extensive i n -
vestigation which utilized the intra-arterial perfusion of
substances (Pelikan ink-Gunther Wagner; Patent Blue
V ) designed to study the distribution and perviousness
of the gingival and periodontal microcirculation with
normalcy, and during the various phases of healing fol-
1,2
lowing the creation of a variety of surgical w o u n d s ,
ie, curettage, gingivectomy, periosteal retention format
of mucogingival surgery, and the full thickness muco-
periosteal flap.
3
In the case of open wounds, as in the gingivectomy
procedure, many gingival vessels are severed and ex-
posed. Their postoperative regeneration is a fundamental
aspect of the healing process and thus deserves investi-
4
gation. Klingsberg and Butcher demonstrated that the
simple removal of the epithelium causes relatively deep
alterations in the oral or periodontal structures. They
produced three different wounds on the palate of rats.
The first one was a bone denudation procedure, the sec-
ond an exposure of connective tissue by peeling off the
epithelium and the third was a full mucoperiosteal flap.
The authors felt that ". . . removal of the epithelium con-
stituted as severe a periodontal insult as removal of the
entire mucoperiosteum." Accordingly, they concluded
that the connective tissue without an epithelium covering
would allow the escape of tissue fluid and the entrance
This project represents a portion of the requirements for the
Master of Science in Dentistry Degree, awarded by Boston Uni-
versity, School of Graduate Dentistry.
This investigation was supported in part by a grant from the
United States Public Health Service National Institute of Dental
Research, Grant No. DE-02569-01, -02.
*C.A.P.E.S. (Brazil) fellowship; School of Dentistry, Ribeirao
Preto, Ribeirao Preto-SP, Brazil; graduate student, Boston Uni-
versity, School of Graduate Dentistry.
**O.A.S. fellowship; School of Dentistry, Sao Paulo Univer-
sity, Sao Paulo, Brazil; graduate student, Boston University,
School of Graduate Dentistry.
***Professor of Stomatology, Boston University, School of
Graduate Dentistry.
****Dean and Professor of Stomatology. Boston University,
School of Graduate Dentistry.
Present address: A. B. Novaes, Faculdade de Odontologia de
Ribeirao Preto, Ribeirao-SP, Brazil.
Page 53/359
dynamics of wound healing following gingivectomy in
patients by the histological examination of biopsies
which were taken after two days of the postoperative
period. The outer layer of the blood clot was necrotic at
two days and a large number of neutrophils formed a
"defense" mechanism. After the epithelium proliferated
and migrated to cover the wound, healing progressed for
14 days, during which period there is a thickening of the
epithelium, a better organization of connective tissue,
and the replacement of the acute inflammatory state
(leukocytes) by a chronic reaction (lymphocytes, histio-
cytes and plasma cells).
Regeneration of the epithelium after gingivectomy was
6
observed by Persson; he noted that on the second day
the basal layer of the " o l d " contiguous epithelium fur-
nished the first cells, which migrated into the blood clot.
H e related the downgrowth of the epithelium and the
inflammatory infiltration, during the later stage of heal-
ing, to the grooves (notches in tooth structure) which
were made to facilitate the measurements.
Recently the literature has described the healing proc-
79
ess after gingivectomy, as well as after many other sur-
gical periodontal procedures, 10-13
but these studies do
not emphasize the vascularization either in the immedi-
ate postoperative state or at various times after the ap-
plication of the surgical procedure. It is important to
delineate such aspects of the microcirculation as ( 1 ) the
initial hemorrhagic event, (2) the formation of the sur-
face blood clot and its structure, (3) the generation of
blood vessels from the exposed gingival corium as a
phase of wound repair, (4) the influence of reepitheliza-
tion of the wound on the type and degree of vascularity
of the subjacent lamina propria and the gingival corium,
(5) the return to relative vascular normalcy when heal-
ing is complete.
14
Stahl, Witkin, Cantor and B r o w n studied the heal-
ing of gingivectomies on humans from several different
aspects; one of their conclusions relative to the micro-
circulation was that the vascularization at the newly-
formed gingival margin had not returned in the 28-day
specimen to the preoperative level.
M A T E R I A L S AND M E T H O D S
Eight mongrel dogs, approximately two years old,
weighing an average of 12 kilograms were anesthetized
intravenously with 0.5 cc of pentobarbital sodium ( D i -
abutal) per kilogram of body weight. Kodachromes were
taken before and after surgery, during healing and at
the time of sacrifice. Local anesthetic (lidocaine 2 % -
epinephrine 1/50.000) was infiltrated into attached gin-
giva at basal aspect of each interdental papilla in the
same manner as is employed when such a surgical pro-
cedure is performed in humans.
Page 5 4 / 3 6 0 NOVAES, K O N , R U B E N , G O L D M A N

FIGURE 1. Control specimen: (a) area used for gingivectomy;

(b) incipient inflammation at the marginal gingiva, epithelial
attachment at CEJ (Mallory, magnification X35), (c) sulcular
epithelium. Higher magnification of (b). (Mallory, magnifi-
cation XI00).

Gingivectomy was carried out on the labial side of

the lower incisors. The sulci about the teeth were meas-
ured and marked preoperatively and were found to have
an average depth of 2.5 mm. The initial incision was
bevelled and the final surface contour was achieved with
the use of soft tissue nippers in order to establish physio-
15 16
logic architecture. According to Waerhaug and L ö e ,
surgical packs appear to have no discernible influence
on the healing of periodontal wounds of dogs and there-
fore were not applied i n this work. Immediately after
surgery and on the following day, 600,000 units of peni-
cillin were given intramuscularly to the animals. Once
daily, each dog was fed a puree of Purina chow ration
with full vitamin and mineral (Wessen salt mixture)
supplementation, having water for consumption ad libi-
tum. F o r the first three weeks after the surgery, the ani-
mals were fed this soft diet, later being returned to a
standard laboratory chow (hard) diet i n order to mini-
mize the possibility of debris and plaque accumulation
17, 1 8
at the gingiva. The animals were sacrificed with 5%
sodium pentobarbital (Veterinary) at zero hour, and at
2, 4, 6, 7, 12, 16, 23, 31, 38, 55 and 85 days postopera-
tively.

Intra-arterial injection with filtered Pelikan carbon

black suspension (Gunther Wagner) was performed
prior to the sacrifice of the animals. The sites of instilla-
tion of the carbon suspension were the common carotid
arteries bilaterally with venous return monitored via
cannulation of the external jugular veins. The details of
this procedure were described i n the first article of this
19
series. In one of the animals a silicone latex suspension
(Microfil) was used to permit comparison of perfusion
techniques and media.
The jaws were removed, cut i n blocks with a water-
cooled rotary saw and kept for two weeks i n a solution
 MlCROVASCULARIZATION OF PERIODONTAL W O U N D Page 55/361

of 10 percent neutral buffered formalin. Five percent
nitric acid was used for decalcification; the acid was
changed daily. Generally, the time required for demin-
er alization ranged from three to five weeks. The blocks
were then embedded i n paraffin and cut into sections 8
microns thick. The sections were stained by Hematoxy-
lin-Eosin and Mallory techniques (Goldman Bloom
modification). Some of the specimens were not decalci-
fied so that they could be studied as cleared sections
(400 microns thick). The findings related to the exami-
nation of these latter specimens will be reported i n a
forthcoming publication.
Although the wound of the gingivectomy was well per-
fused, the carbon black did not reach the red or "ne-
crotic" areas, suggesting obstruction of some vessels.
This could be observed particularly well in the perfused
two-day animal. A t seven days the avascular sites were
still present, although to a lesser degree; they were not
well perfused. The 31-day-healing specimens showed the
sulcular parallel lines as they existed before surgery.
Now, however, they were darkened linearly by the per-
fusing substance (carbon black), demonstrating that the
lines were capillaries. A s healing progressed, these dark
lines were more readily observed.

Histological
RESULTS
Control. The marginal gingiva was composed of dense
Clinical
connective tissue, well collagenated and covered by a
The gingivectomy wounds varied i n width in individ- thick squamous stratified oral epithelium (Fig. l a , b ) .
ual animals; the width of the available zone of attached Complete surface keratinization was present to a point
gingiva was the prime guiding factor. A m o n g the various where it formed the sulcular epithelium. F r o m this point
animals, therefore, the average occlusoapical diameter on it was not keratinized but was formed by squamous
of the wound was felt to be 2 mm i n the first and 3.5 m m cells arranged i n layers (Fig. l c ) . A n incipient inflam-
in the second and third incisors. The incision was started matory state was present at the coronal portion of the
circa 1 m m coronal to the mucogingival junction and sulcular wall.
was extended coronally so as to bevel the connective
The vessels which had been perfused with carbon
tissue bed. The buccal peak of each interdental papilla
black appeared as variably large black spots scattered in
was removed retaining the lingual peak, the buccal phase
the corium. The smallest dark dots (capillaries) were
of which became a wound bed; bleeding appeared to be
present in greater number between rete pegs, at the gin-
marked at this site ( F i g . 2 ) .
gival margin, and subjacent and parallel to the sulcular
In the two and four-day specimens the apical margin epithelium and epithelial attachment.
of the wound was slightly rolled. It was shiny, and the
Zero Hour. The surface of the wound showed connec-
entire surface of the wound was smooth and pink, but
tive tissue covered by a blood clot. When the incision
with isolated reddish spots.
was made the bottom of the epithelial attachment was
A t five days a thin epithelium covered part of the preserved i n some specimens. However, this cannot be
wound leaving small portions in the central aspect of the depended upon since, i n some specimens, the epithelial
wound still uncovered. A t seven days the wound ap- attachment was removed in its entirety and nicks on the
peared completely covered, but small reddish areas were tooth were observed.
noticed which corresponded to the portions that were
uncovered at five days. There was a difference i n color
between the wounds at five and at seven days, indicating
that possibly the epithelium was thicker or the vasculari-
zation decreased. I n some animals, the papillary area
was still friable, shiny and red, suggesting that it was not
completely protected by epithelium.

In close examination of the many kodachromes which

were taken, the tip of the sulcular gingiva appeared
transparent and some lines could be observed parallel to
the long axes of the teeth. In this investigation, they will
be referred to as sulcular parallel lines. The lines dis-
appeared i n consequence of the gingivectomy; however,
some of them could be observed again in the three-week
specimen, when a portion of the sulcular wall had re-
formed. A s was explained earlier, each animal was per-
fused shortly before it was sacrificed. After the perfusion, FIGURE 2. Immediately after gingivectomy. Clinical aspect
the gingiva of the control side turned completely dark. of the wound.
Page 56/362 NOVAES, K O N , R U B E N , G O L D M A N

Inasmuch as we were dealing with vessels which had

been cut, the perfused material could not remain within
the vessels. It was observed subjacent to and on the sur-
face of the wound and admixed with the blood clot of
some of the specimens (Fig. 3 ) .

The connective tissue was dense and well collagen-

ated, and revealed an irregular surface caused by the
incision. The area was well vascularized, as shown by
the perfused material. A slight hemorrhage was present
in some areas of the cut surface where the perfused ves-
sels were close to the hemorrhagic areas. Large vessels
(periosteal) could be identified in a position parallel to
the root bone and the cut surface ( F i g . 4a, b, c ) .

Two Days. This specimen showed a thick clot cover-

ing the entire wound. It is interesting to note that the
blood clot is instrumental in correcting the irregularities
of the connective tissue which had been cut and bringing
about an outer smooth surface. Precisely from the ce-
mentum-enamel junction at which the incision was
made, the blood clot assumes the configuration of the
gingival wall (Fig. 5a, b, c, d ) .

In general, the connective tissue was dense, quite cel-

FIGURE 3. Immediately after gingivectomy. Perfused
material within vessels and on thin blood clot. (H-E,
magnification XI00).
lular, but there was little inflammation. Many dilated
vessels containing carbon black could be seen in this
area. I n some areas the connective tissue close to the
blood clot was disorganized. It appears that there is a
slight epithelial migration at the apical margin of the

FIGURE 4. Immediately after gingivectomy. (a) The surgical wound and the perfused vessels. (Mallory, magnification X35). (b)
The perfused material flowed out of the cut vessels and remain on the wound surface. Higher magnification of (a). (Mallory,
original magnification XI00). (c) Perfused vessels extending parallel to the tooth in the dentogingival junction area. Higher mag-
nification of (a). (Mallory, original magnification XI00).
 MlCROVASCULARIZATION OF PERIODONTAL W O U N D Page 57/363

FIGURE 5. Two-day specimen, (a) Clinical aspect, (b) Blood clot instrumental in correcting irregularities of cut
connective tissue (H-E, magnification X35). (c) Higher magnification of (b) perfused vessel in contact with
blood clot, carbon black on clot. (H-E, magnification X100). (d) Higher magnification of (b) perfused material
on surface of blood clot. (H-E, magnification XI00).

wound as evidenced by the fact that the clot margin is
raised and epithelium appears subjacent to the detached
portion of the clot (Fig. 6 ) . Some blood vessels which
had been perfused with carbon black were leaking and
the carbon black suspension was flowing in the direction
of the blood clot (Fig. 7 ) . In some places it was possible
to see the cut ends of the vessels i n direct contact with
the blood clot (Fig. 8a, b ) . The perfused carbon black
flowed from the vessels and remained either between
the connective tissue and the blood clot or on the clot
surface itself.
Four Days. Blood clot still covers the major part of
the wound surface. Epithelium is proliferating from oral
epithelium and epithelial attachment cells. Dilated and
perfused vessels are observed beneath the blood clot;
Page 58/364 NOVAES, K O N , R U B E N , G O L D M A N
FIGURE 6. Two-day specimen. Apical margin of the
wound; oral epithelium beneath the blood clot. (H-E,
original magnification XI00).
there is an intense cellular activity i n this area (Fig.
9a, b ) .
Six Days. This specimen was almost completely epi-
thelized but some inflammation caused by debris was
noticeable. The epithelium which proliferated from the
oral and sulcular epithelium had not yet joined and there
remained a small blood clot between them. The area
underneath the sulcular and the oral epithelium was dis-
organized and inflamed; the blood vessels were dilated
and contained carbon black evidencing their patency
(Fig. 1 0 ) .
The epithelium of attached gingiva had no rete pegs,
nor was it keratinized (Fig. 11). Its basal layer shows
oval rather than the normal columnar cells.
On the surface of the blood clot and the epithelium
close to it the presence of a dark black line suggested
that some of the perfusion material could be flowing
from a leaking vessel. A n area of bone resorption and
the presence of osteoclasts could be observed at the buc-
cal side of the septum near the crest.
Seven Days. The wound surface is now completely
epithelized and the sulcus is being formed. The new con-
FIGURE 7. Two-day specimen. Vessel is leaking; car-
bon black suspension is flowing in the direction of
blood clot. (H-E, magnification X430).
nective tissue subjacently located is quite vascular, with
the vessels containing a large quantity of India Ink (Fig.
12).
The new oral epithelium is devoid of keratin and rete
pegs. The connective tissue (the future lamina propria)
close to the epithelium contained a large number of
fibroblasts. Many of these cells tended to be plump and
ovoid suggesting that they were either undifferentiated
cells or newly formed fibroblasts. New vessels have been
formed, most of which contain carbon black.
Twelve Days. A t this period the outer gingival epithe-
lium is thicker than i n earlier specimens, but the rete
pegs are still absent. It does not have as yet the appear-
ance of the epithelium of a true attached gingiva. The
connective tissue is more organized and is less inflamed,
but it is quite vascular, particularly at the margin and
at the newly-formed lamina propria. When nicks were
made unintentionally on the teeth during instrumenta-
tion, the sulcular epithelium migrated to cover the nick
closest to the cementum-enamel junction. There was
bone resorption at the buccal side of the septum, but it
was closer to the crest than it was in the seven-day
specimen.
 MlCROVASCULARIZATION OF PERIODONTAL W O U N D Page 59/365

FIGURE 8. Two-day specimen, (a) Carbon black within the vessels and on the surface of blooa'clot (H-E, mag-
nification XI00); (b) Perfused vessel in direct contact with blood clot. (H-E, magnification XI00).

FIGURE 9. Four-day specimen, (a) Clinical aspect, blood clot covers the major part of the wound surface; (b) Dilated and per-
fused vessels, intense cellular activity beneath the blood clot. (H-E, magnification XI00).

Sixteen Days. The area is healed and no inflammatory
reaction is evident. The gingival epithelium is keratinized
and has rete pegs, suggesting the formation of a true
attached gingiva (Fig. 13a, b ) . The sulcular epithelium
is well formed and did not migrate beyond the cemen-
tum-enamel junction. Connective tissue is well organized
and there has been a decrease i n the number of patent
vessels.
Flattened epithelial cells appear to desquamate from
the sulcular epithelium to form an acquired cuticle simi-
lar histologically to the secondary cuticle (Fig. 14). One
Page 60/366 NOVAES, K O N , R U B E N , G O L D M A N
FIGURE 10. Six-day specimen. Dilated vessels contain
the perfused material. (H-E, magnification XI00).
group of vessels could be observed running parallel to
the sulcular epithelium and proceeding to the gingival
margin. Another group was observed between the rete
pegs where they formed a loop-type of arrangement (Fig.
15).
Twenty-three Days. The gingiva is entirely healed,
well collagenated, and covered by squamous stratified
keratinized epithelium with rete pegs. The sulcular epi-
thelium is normal and retains its position on the enamel.
When nicks were made inadvertently, the sulcular epi-
thelium did not consistently proliferate into them.
In sections where more than one notch was present,
connective tissue filled the more apical nicks. It is pos-
sible to see two notches into which connective tissue has
grown but appears to be poorly and indifferently at-
tached to the hard structure. New blood vessels can be
seen in the notches; they have not been labelled by the
perfusing medium. The presence of heavy bundles of
connective tissue fibers, attached at the border of the
nicks, and the insertion of new fibers coronal to the
original fiber attachment, suggest that the connective
tissue prevented the migration of sulcular epithelium.
The crest of bone which had been partially resorbed is
being reformed, as indicated by the alignment of osteo-
blasts on the osseous surface.
FIGURE 11. Six-day specimen. Great cellular activity
and increase in vascularization beneath the newly-
formed epithelium. (H-E, magnification X100).
Thirty-one Days. A t this period there is an increase
in vascularization possibly as a phase of a localized i n -
flammatory reaction. A subsulcular dilated vessel, run-
ning parallel to the epithelium, is clearly discernible.
Surprisingly, there was a great deal of resorption at
the alveolar crest and at its periodontal ligament side.
Since an inflammatory exudate is not associated with the
bone resorption, one may assume that the resorptive
effect is associated with an occlusal traumatic factor.
Thirty-eight Days. The gingivectomy area is com-
pletely healed, with the gingival margin being returned
to its normal shape. The gingival epithelium is well ker-
atinized, contains rete pegs and protects the newly-formed
lamina propria (Fig. 16a, b ) . The dentogingival junc-
tion is normal and the sulcular epithelium remains at
the cementum-enamel junction. Some of the vessels
which are parallel to this epithelium are seen to have
plenty of carbon black.
Fifty-five Days. The appearance of the area is quite
normal, with the epithelial attachment remaining at the
cementum-enamel junction. N o inflammation could be
observed i n the subsulcular area and the remainder of
the gingival corium; there is a slight increase in vascu-
larization however. The sulcular epithelium is normal
 Page 61/367

and the cells which have been flattened against the

enamel form the cuticle that is loose in the enamel space,
thus identifying the bottom of the sulcus. Bone again
takes on its normal shape, suggesting that it is com-
pletely repaired.

Eighty-five Days. There was no significant change

from that of the 55-day animal. Although an incipient
inflammatory reaction could be observed, the epithelial
attachment is still at the cementum-enamel junction,
similar to the control specimens.

DISCUSSION

In this investigation gingivectomies were performed

15
with a bevelled incision, as advocated by Goldman.
A n attempt was made to end the incision at the bottom
of the measurable sulcus, according to Ramf jord's tech-
7
nique. The histologic sections demonstrated that the
exact end of the incision could not be predicted. The
epithelial attachment was completely or partially re-
moved, and i n some cases the incision ended in the con-
nective tissue subjacent to the epithelial attachment.
FIGURE 12. Seven-day specimen. The subepithelial
There are different opinions regarding the depth of
area is quite vascular; vessels contain a large quan- 15

tity of carbon black suspension. (H-E, magnification

the incision. G o l d m a n recommended it at the apical
7
X100). end of the epithelial attachment; Ramfjord stated that

FIGURE 13. Sixteen-day specimen, (a) Marginal gingiva is healed (Mallory, magnification X35). (b) Higher
magnification of (a), thick and keratinized oral epithelium covers the regenerated connective tissue (Mallory,
magnification XI00).
Page 62/368 NOVAES, K O N , R U B E N , G O L D M A N
FIGURE 14. Sixteen-day specimen. Flattened epithelial
cells desquamate to form a new cuticle (Mallory, mag-
nification X100).
the incision must be performed at the bottom of the
measurable sulcus to prevent any damage to the connec-
tive tissue " in order to avoid permanent loss of perio-
20
dontal attachment;" Waerhaug, to prevent apical m i -
gration, advised "that a gingivectomy should not be car-
ried out further than to approximately 1.0 mm from the
bottom of the clinical pocket."
In this investigation, apical migration of the epithelial
attachment occurred only when notches were made close
to the bottom of the sulcus. When notches were located
apically to the prior epithelial attachment, connective
tissue filled them thus inhibiting epithelial migration. In
6
this study on gingivectomies, Persson observed this
apical epithelial migration when a groove was made i n -
tentionally on the root surface.
Immediately after surgery, large vessels which had
been cut are observed in direct contact with the surface
of the wound, where the perfused material was released.
In this area the vessels were dilated; large amounts of
intravascular carbon black identified them.
The blood clot fills the irregularities of the wound
surface and outlines its surface simulating a sulcular wall
and the preoperative surface of attached gingiva. Some
FIGURE 15. Sixteen-day specimen. Capillary loop be-
tween rete pegs is reformed in the healed gingiva.
Higher magnification of Figure 13 (a) (Mallory, mag-
nification X430).
leaking vessels are in contact with the clot and the car-
bon black which flowed from them remains either on
the clot surface or between the clot and the connective
tissue. This suggests that in some areas the blood clot
retains and contains the perfused material on the con-
nective tissue. Occasionally the blood clot apparently is
so permeable that the carbon black passes through it
and remains on its surface. Considerable time is required
for a variation i n the new epithelization of a wound.
When the incision eliminates the entire epithelial attach-
ment, the only source for new epithelium to cover the
wound surface is the oral epithelium which travels from
the margins of the wound over the connective tissue
wound to the cementum-enamel junction. However, if a
portion of the epithelial attachment remains, the epithe-
lial migration can occur from both sides, thus there may
be dual epithelial sources. Consequently, in the latter
situation the epithelization of the wound is presumed to
be faster.
The appearance of the epithelium in the 16-day speci-
men was reminiscent of the control animal. Rete pegs
were forming, the gingival epithelium begun to evidence
keratinization, the sulcular area was healed, and the epi-
thelial attachment was reestablished at the cementum-
 MlCROVASCULARIZATION OF PERIODONTAL W O U N D
FIGURE 16. 38-day specimen, (a) Gingival epithelium is well keratinized, contain rete pegs and protects the
newly-formed lamina propria (Mallory, magnification X35); (b) Higher magnification of (a).
enamel junction. This condition was maintained until the
end of the experiment.
In the two-day specimen the connective tissue close
to the surface of the wound was disorganized. A t this
time the vessels were dilated and were leaking. A n i m -
provement i n this condition could be observed after the
epithelization of the wound. The subepithelial area was
comprised of young connective tissue with many mesen-
chymal cells and fibroblasts.
Although the vasodilation diminished in approximate-
ly 16 days, the vessels did not acquire their preoperative
or normal appearance. A t the same time, the collagen
fibers were being rearranged; however, the progress of
the healing process continued for a few weeks longer.
Therefore, a more favorable stage of healing was
achieved i n the 38-day animal. The greatest number of
patent vessels appeared to be present i n those areas of
connective tissue manifesting a minimum of collagena-
tion, suggesting that vascularization is inversely related
to the degree of collagenation. Bone resorption occurred
in a few animals, i n different areas and at different times,
which could not be correlated with the gingivectomies.
It is interesting to note that after seven days when a new
sulcus is formed, it is possible to observe a newly ac-
quired cuticle adjacent to the enamel space. This cuticle
Page 63/369
is formed of flattened cells in similar fashion as the sec-
ondary cuticle of the control specimens. However, this
new cuticle probably is not of odontogenic origin, but is
rather a by-product of the new epithelial attachment and
the sulcular epithelium.
The results of this experiment suggest strongly that
healing after gingivectomy involves the formation of a
linear zone of granulation tissue over the cut surface of
the gingival corium. This zone of granulation tissue is
overlaid by new epithelium derived from the epithelium
peripheral and contiguous to the wound surface. This
layer of granulation tissue, i n essence, is converted into
a new lamina propria which lies in contiguity with the
outer aspect of the " o l d " gingival corium remaining after
the gingivectomy excision. This connective tissue bed
appears histologically to be comprised of a stable, rela-
tively insoluble collagen; this state may substantiate the
often observed success of gingivectomy-gingivoplasty not
only i n the resection of diseased tissue, but also in the
attainment of stable physiologic tissue from after surgery.
S U M M A R Y AND CONCLUSION
A study was carried out for the purpose of observing
the wound healing process and the behavior of the blood
vessels when gingivectomy was performed. Pelikan car-
Page 64/370 NOVAES, K O N , R U B E N , G O L D M A N
bon black suspension (Gunther Wagner) was filtered
and injected into the common carotid arteries of young
adult mongrel dogs. The perfusion technique was per­
formed shortly before the animals were sacrificed, ie,
immediately after and at 2, 4, 6, 7, 12, 16, 23, 31, 38,
55 and 85 days after gingivectomy.
The macroscopic aspect of the wound was evaluated
clinically and by means of kodachromes. Histologic sec­
tions (8 microns of thickness) were stained by the M a l ­
lory technique (Goldman Bloom modification) and
Hematoxylin-Eosin.
The filtered carbon black solution was a valid means
of demonstrating the presence of vessels and the modi­
fications which occurred in them immediately after the
incision and during the healing process. The presence of
the perfused material intravascularly made it simpler to
follow, to localize and to identify the vessels. The extra-
vascular localization of the carbon black suspension
served to demonstrate the leakage of blood from pre­
existing cut vessels, as well as the perviousness of both
the damaged and regenerating capillary system within
the gingival corium and the newly established lamina
propria. The solution labelled the blood vessels in situa­
tions such as (1) vasodilation, (2) leakage, (3) cut
ends of the vessels at the wound surface, (4) the rela­
tionship between the vessels and the blood clot, (5) the
increase in the number of vessels and (6) the return of
the vessels to normalcy following healing.
It may also be concluded that healing after gingival
resection constitutes the formation of a new lamina pro­
pria over the cut surface of the gingival corium. The
lamina propria is derived from a very vascular layer of
granulation tissue. Epithelial renewal of the wound oc­
curs superficially to the granulation tissue. A s this granu­
lation tissue is transformed into a new gingival lamina
propria, it not only reflects a decrease in vascularity and
a more organized pattern of its connective elements, but
also a conversion of its epithelial cover into an epithe­
lium markedly similar in structure configuration, and
keratinization to that of normal attached gingiva. This
process of gingiva healing appears to be rapid and un­
complicated, essentially maintaining the desirable tissue
topography produced in the gingivoplastic phase of the
gingivectomy operation.
1. A thick blood clot covered the wound. The thick­
ness and surface morphology of the clot resembled that
of the excised tissue.
2. The perfused material flowed from the vessels and
remained between the blood clot and connective tissue
as well as within and on the surface of the clot itself.
3. The vasodilation and increase in vascularization,
identified by the presence of carbon black in the two and
four-day specimen, decreased as the healing progressed,
thereby achieving a near normal appearance at sixteen
days.
4. Also at sixteen days the epithelium manifested rete
pegs formation and a keratinizing surface. The wound,
however, revealed a complete epithelial cover in the
seven-day specimen.
5. A t the two and four-day healing specimen, carbon
black was leaking from some vessels suggesting that
either the damaged vessels were not repaired or that
there was an increase in the permeability.
6. The capillaries observed in the transparent tip of
the sulcular gingiva were recognized in the kodachromes
as sulcular parallel lines.
7. The sulcular parallel lines disappeared as a conse­
quence of the surgery. They were, however, observed
again in the 7-day specimen, but could be observed more
closely in the 12-day specimen. When carbon black was
injected, the lines turned dark, signifying that they were
sulcular parallel capillaries.
8. V i t a l perfusion techniques have been demonstrated
to be of much value in studying the vascularization dur­
ing the healing process of periodontal wounds.
9. A new cuticle, histologically similar to the secon­
dary cuticle considered of odontogenic origin, is ob­
served bordering the enamel space after a new sulcular
well and epithelial attachment are formed during the
healing process.
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