Annals of Anatomy 204 (2016) 6370

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Annals of Anatomy
journal homepage: www.elsevier.com/locate/aanat

Research Article

Multiple gingival recession coverage with an allogeneic biostatic

fascia lata graft using the tunnel techniqueA histological
assessment
a

Jacek Zurek
, Marzena Dominiak b , Krzysztof Tomaszek c , Ute Botzenhart d, ,
Tomasz Gedrange b,d , Wojciech Bednarz e
a

Special Medical Practis Stomatologia, Srebrna 48 Street, Pl-42-612 Tarnowskie Gry, Poland
Dental Surgery Department, Silesian Piast Medical University of Wroclaw, Krakowska 26 Street, Pl-50-425 Wrocaw, Poland
c
Special Medical Practice, Pawia 12 Street, Pl-42-612 Tarnowskie Gry, Poland
d
Department of Orthodontics, Carl Gustav Carus Campus, Technische Universitt Dresden, Fetscherstr. 74, D-01309 Dresden, Germany
e
Specialistic Outpatient Medical Clinic MEDIDENT, Okulickiego 19 Street, Pl-38-300 Gorlice, Poland
b

a r t i c l e

i n f o

Article history:
Received 5 August 2015
Received in revised form 14 October 2015
Accepted 10 November 2015
Keywords:
Allograft
Fascia lata
Connective tissue
Gingival recession
Fibroblasts

a b s t r a c t
Background: Autogenous connective tissue graft (CTG) that can be safely harvested from the palatal
mucosa is limited. Often a multi-stage surgical procedure is needed to cover multiple gingival recessions (MGR). To address this problem, efforts are being made to explore substitutes suitable in size to
ensure surgical treatment in a single visit.The objective of the present study was the histological evaluation of tissue in the recipient site after augmentation with a hydrated biostatic Fascia Lata Allograft (FLA)
in conjunction with MGR coverage at different healing stages.
Material and methods: Twelve patients needing bilateral multiple gingival recession coverage participated
in this study. On the test side, the tunnel technique with FLA was used, while CTG, harvested from the
palatal mucosa, was used to cover MGR on the control side. Histological assessment was performed 3, 6,
9 and 12 months after augmentation.
Results: FLA was well tolerated by the host tissue. During all investigation periods histological images of
all patients in the test side revealed a slow process of incorporation of the material grafted in the host
connective tissue, showing a colonization of the graft with host broblasts and formation of new blood
vessels. After 12 months, the graft had fully remodeled into connective tissue of the host gingiva.
Conclusion: Apart from the limitations of the present study, we conclude that the FLA may serve as a
substitute for autogenous CTG harvested from the palatal mucosa and can be applied as a technique for
covering MGR in a single visit.
2015 Elsevier GmbH. All rights reserved.

1. Introduction
Gingival recession is a problematic issue in modern periodontology and also an important topic for orthodontic treatment planning
considering critical values of bone-soft tissue morphology and
direction of tooth movement (Warmuz et al., 2014, 2015). It is

The work was performed in the Department of Periodontal Disease and Oral
Mucosal, the Department of Conservative Dentistry with Endodontics University of
Silesia, the Periodontal Disease Clinic and Oral Mucosal in Zabrze and the Department of Oral Surgery Wroclaw, Medical University. Own founding was source of
nancial support.
Corresponding author. Tel.: +0049 351 4582718; fax: +0049 351 4585318.
E-mail address: ute.botzenhart@uniklinikum-dresden.de (U. Botzenhart).
http://dx.doi.org/10.1016/j.aanat.2015.11.002
0940-9602/ 2015 Elsevier GmbH. All rights reserved.

characterized by partially exposed root surfaces of one or more

teeth in a clear form without accompanying features of inammation (Dominiak and Gedrange, 2014). The pathogenesis of gingival
recession is complex and the effectiveness of therapeutic procedures largely depends on the identication of those etiological
factors. However, the most signicant causative factors appear to
be traumatic tooth brushing techniques and an accumulation of
plaque as a result of inadequate dental hygiene (Dominiak and
Gedrange, 2014), but also the direction of orthodontic tooth movement seems to have a signicant inuence on the development and
progression of gingival recession, especially in the front section of
the mandible. Warmuz et al. (2015), for example, could demonstrate that, in patients with skeletal class III malocclusion, gingival
recession of the lower incisor teeth occurred signicantly more frequently in cases in which a camouage treatment with retrusion of

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et al. / Annals of Anatomy 204 (2016) 6370

the front teeth instead of a surgical correction, with more vertical

positioning of the front teeth in the alveolar ridge, was chosen.
Prior to periodontal surgery, conservative treatment should be
undertaken in order to eliminate potential causative factors. The
positive long-term effect of treatment depends on close and effective cooperation between the patient and the attending physician,
who should monitor the course of tissue healing and prevent the
recurrence or formation of any new gingival defects.
Surgical management can involve a number of techniques. The
most commonly applied methods involve the use of coronal and lateral repositioned aps, combined with free gingival or connective
tissue grafts in tandem with GTR procedures (Harris, 2000; McGuire
and Cochran, 2003; Nelson, 1987; Nickles et al., 2010; Zucchelli
et al., 2014). In regenerative periodontal therapy in severe cases,
autogenous transplantation is considered the gold standard (Zietek
et al., 2008) and subepithelial connective tissue has been proven
to have the highest clinical effectiveness and the best aesthetic
results (Nickles et al., 2010; Zucchelli et al., 2014). However, autogenous connective tissue procedures entail a second operating eld,
a longer operating time, patient discomfort, and a larger amount
of analgesics (Fickl et al., 2014; Fletcher et al., 2011; Zucchelli
et al., 2010). To eliminate these inconveniences, attempts are being
made to utilize substitutes of autogenous connective tissue; i.e.
xenogenous or allogeneic grafts (Barker et al., 2010; Hodde et al.,
2007; McGuire and Cochran, 2003; Wang et al., 2014).
The only allogeneic material used for surgical covering of gingival recessions, broadening the keratinized gingiva zone, and for
gingival augmentation, is the acellular human dermal matrix allograft. Although a number of papers discuss the use of human fascia
lata fermoris allografts in dental surgery, there are no studies that
describe its role in gingival recession coverage (Callan, 1993; Sezer
et al., 2004). The histological advantage of autogenous connective
tissue compared to acellular dermal allografts (Alloderm), is the
presence of cells and a network of blood vessels that considerably
promotes the incorporation in the recipient site. As a result, Alloderm is used in combination with keratinocytes, broblasts and
growth factors to further accelerate the healing and to improve
clinical effects (Novaes et al., 2007; Zurek et al., 2015). According to
Chaussain Miller et al. (2002), gingival broblasts are more effective in remodeling connective tissue and ensuring faster healing
than dermal broblasts. Fibroblasts are the main cellular component of brous connective tissue. They are spindle-shaped with an
oval nucleus and with one or several nucleoli. The cytoplasm contains numerous ribosomes and polysomes, extended mitochondria,
an endoplasmic reticulum and single vacuoles. Light microscopy
also revealed evenly distributed bundles of microbers in the cytoplasm. The broblasts are arranged parallel to one another in weak
concentrations inside the tissue (Poggi et al., 2000). Allograft-type
materials in the recipient site act on the basis of a barrier membrane that forms a place for gingival broblasts, which are mainly
responsible for the production and construction of the connective
tissue of the gingiva and the root cementum (acellular, extrinsic
ber cementum). In addition, there is no need to re-perform the
procedure to remove material due to the resorption of the collagen,
contained in the implanted allogeneic material (Sezer et al., 2004).
Femoral Fascia lata is biocompatible and well tolerated by the tissue
in donor sites. Immune system cells directed against foreign bodies
were not shown to be present. Choe and Bell (2001) demonstrated
the presence of intact DNA in freeze-dried gamma irradiated cadaveric fascia lata and acellular cadaveric dermis in comparison to fresh
human rectus fascia. Hathaway and Choe (2002) demonstrated
the presence of intact DNA that had not been completely eliminated when preparing 4 different commercial human allografts
assessed in their study. Fitzgerald et al. (2000) did not observe the
presence of any HLA donor antigens 1 year after the grafts had
been implanted, using both freeze-dried fascia lata allografts and

Tutoplast fascia lata allografts, and additionally stressed that they

had been replaced by host antigens.
The purpose of this study has been to provide a histological assessment of tissue in the recipient site at different healing
stages of a hydrated biostatic femoral fascia lata graft (Fascia Lata
AllograftFLA) in augmentation and multiple gingival recession
coverage procedures.
2. Material and methods
A total of 12 generally healthy patients with an average age of
27 years, who had given their informed consent prior to treatment,
including 7 women, took part in the study. Power analysis was performed with the software R (version 3.2.2; The R Foundation of
statistical computing) giving a power of 86% (n = 12; alpha = 0.05).
The study was carried out in accordance with the recommendations
of the Helsinki Convention of 1975, updated in 2000, and approved
by the Bioethics Committee of the Medical University of Silesia in
Katowice (No. KNW/0022/KB1/107/12) as well as by the Bioethics
Committee of the Wrocaw Medical University (No. KB-104/2014).
Patients with bilateral gingival recession over 2 mm in height on
the facial aspect of their maxillary teeth were included in the study.
The subjects were registered and prepared for gingival recession
coverage in accordance with accepted dental practice guidelines,
which included an informed consent form. Initial periodontal therapy, including recommended oral hygiene measures and adult
prophylaxis, was performed prior to surgery.
The test side underwent multiple gingival recession coverage
using a tunnel technique combined with a Fascia Lata Allograft
(FLA). FLA is a highly cross-linked, hydrated collagen matrix built
from type I and type III collagen, prepared, preserved and stored,
respectively, in the Katowice (Poland) Tissue Bank in a way
described earlier (Zurek et al., 2015). The same procedure was
observed for the control-side, although with autogenous connective tissue graft, harvested from the palatal mucosa, being used
instead. The recipient sites of the test side were histologically
assessed in all patients. Biopsies were obtained from each patient, at
4 observation intervals: 3, 6, 9 and 12 months after the procedures,
respectively. By reason of multiple recession coverage, a different
interdental space was chosen for the biopsies at the different observation periods, respectively, so that a total of 12 biopsies could be
obtained from each time point. Due to the widely known literature
about the histology of autogenous connective tissue graft (Roman
et al., 2010), histological samples had only been collected from the
test side.
2.1. Surgical procedure
Prior to treatment professional oral hygiene instruction was
provided to the patients. In case of dental calculus, it was removed
with ultrasound scaler. The gingival augmentation and recession
coverage procedures were performed in outpatient conditions
under local anesthesia of 4% articaine with 1:100000 ephinephrine
(Ubistesin forte 3M ESPE, Seefeld, Germany). The test and control
treatments were performed during the same surgical appointment (split-mouth study). During the treatment, root planning
was carried out with Gracey curettes (American Eagle instruments
Inc., Missoula, Montana USA). Autogenous connective tissue was
harvested from the palatal mucosa via single incision technique
devised by Hurzeler and Weng (1999). A collagen sponge (Antema ,
Molteni Corlo, Italy) was applied to the wound in the donor site and
the wound was closed with surgical sutures. In both procedures
the preparation on the recipient side was identical and consisted of
the forming of supraperiosteal envelopes at each of the affected
teeth, which were then combined with each other to create a


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65

Table 1
Overview of the course of the treatment including pre- and postsurgical applications.
Observation time

Treatment

Before treatment

Professional oral hygiene instruction of the patients and how to behave after surgery
Removement of calculus (in case) with ultrasound scaler and polishing of the tooth surfaces with rubber polisher
500 mg Amoxicillin orally 24 h before the treatment, three times a day

Surgical process and post-surgical

treatment

Local anaesthesia of 4% articaine with 1:100,000 ephinephrine

Root planning with Gracey curettes
Surgical procedure with CTG and FLA, respectively, using the tunnel technique and mattress sutures
Instructions how to behave in the operation sides:
Prohibition of tooth brushing for 7 days and interdental oss for 2 month, chemical plaque control instead using 0.1% CHX
mouth rinse 3 times a day
Dietary instructions:
Liquid diet for the rst day, followed by a semi-liquid diet for the following 3 days, and a soft diet up to the 14th day after
surgery

Up to 7 days after surgery

500 mg Amoxicillin orally three times a day up to 7 days after surgery and oral pain killers if necessary
Prohibition of tooth brushing in the operation sides
CHX mouth rinse (chemical plaque control)

7 Days after surgery

Tooth brushing with a ultra-soft postoperative tooth brush and uoride toothpaste

2 weeks after surgery

Removal of the sutures (CTG) control-side (with scissors and tweezers)

Professional tooth cleaning with professional toothbrush, rubber polisher and clinic paste

3 weeks after surgery

Removal of the sutures (FLA) test-side (with scissors and tweezers)

Professional tooth cleaning with professional toothbrush, rubber polisher and clinic paste
Normal dental care with a soft toothbrush and uoride toothpaste

5 and 7 weeks after surgery

Professional tooth cleaning with professional toothbrush, rubber polisher and clinic paste

single spacea tunnel. Thereafter, autogenous or suitably trimmed

allogeneic connective tissue was inserted in the tunnel, under the
partial thickness ap. After positioning, the grafts were xed in
place with mattress sutures (Seralene 6/0 Dss-13 Serag, Wiessner Naila, Germany). Then the ap together with the grafts was
advanced coronally and stabilized with suspension sutures on each
tooth, with the aim of totally covering the denuded surfaces of their
roots. A dose of 500 mg amoxicillin orally was applied three times a
day for 7 days, starting 24 h before surgery. After surgery, oral pain
killers were applied if necessary. The patients were instructed not
to clean the teeth with customary toothbrushes on the operation
sides over a period of 7 days and to refrain from dental oss for 2
months. Instead, chemical plaque control using a mouth rinse containing 0.1% chlorhexidine 3 times a day was prescribed. Dietary
instructions included a liquid diet on the rst day, followed by
a semi-liquid diet for the following three days and a soft diet up
to the 14th day after surgery. After 7 days of healing time, dental
care with an ultra-soft post-operative brush was performed and,
after 3 weeks, normal dental care was performed with a soft toothbrush and uoride toothpaste. According to the literature (Allen,
2010; Alves et al., 2012; Ayub et al., 2012; Barros et al., 2005; Felipe
et al., 2007; Shepherd et al., 2009), the sutures were removed 14
days post-surgery in the CTG-side and 3 weeks post-surgery in the
FLA-side. Initially, every 7 days up to the third week and every 14
days between the 4th and 8th weeks after surgery, a professional
tooth cleaning was also performed (W&HR Proxeo Set for Prophylaxis; W&H Dentalwerk Brmoos GmbH, Brmoos, Austria). Table 1
illustrates the treatment at each time point, respectively.

2.2. Biopsy method

After local anesthesia with 4% articaine solution plus an
adrenaline dilution of 1:100,000 (Ubistesin Forte 3M ESPE, Neuss,
Germany), the biopsy material, 2 mm2 in size, was harvested from
the interdental space lying between the covered gingival recessions. Two wedge-shaped incisions were made with scalpel blade
no. 15c (Swann Morton, UK). After harvesting, the material was
placed in a sterile test tube lled with a 5% formalin solution. A

hemostatic sponge (Antema , Molteni Corlo, Italy) was applied to

the wound, which was stabilized with a knot suture (Seralon , 5/0
Ds-12 Serag, Wiessner Naila, Germany).
2.3. Histological preparation
Following xation, the material was put through a Cytadel
Thermo tissue (Thermo Scientic Cytadel) processor using a
standard processor program (rinsing in 50, 90 and 98% alcohol series in turns for 1 h each, rinsing three times with xylene
and embedding in parafn). After being embedded in parafn blocks and cut with a semi-automatic ShandonTM FinesseTM
325 microtome to a thickness of 7 m, the material was dyed
with Bio-Optica Milano S.p.a. Mayers hematoxylin and Bio-Optica
Milano S.p.a. Eosin Y solution using a Thermo ScienticTM Gemini
AS Automated Slide Stainer.
Histological examination was performed by descriptive analysis
under light microscopy with Olympus BX43 microscope.
3. Results
The histological images from all tested patients were similar,
showing the same histological course of healing in each patient,
with slight intersubjective variability (Table 2). Three months after
the gingival recession tunnel coverage procedure using FLA, a
biopsy of keratinized tissue was harvested from one of the interdental spaces adjacent to the augmentation side and prepared
for histological examination. Microscopic images revealed the
implanted FLA, which was clearly delimited and separated from the
tissue of the patients host mucous membrane (Fig. 1). All the histological images included autologous and augmentation connective
tissue. At 300 magnication no foreign body reaction or characteristics of graft rejection were observed at the contact between the
connective gingival tissue and the FLA. Only minor blood extravasation was visible. No inammatory inltration was observed in
the mucous membrane above the implanted fascia fragment. Only
lymphocytic-plasmocyte inltration, which was physiological, was
present under the epithelium (Fig. 2a). The grafted fascia fragment


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Table 2
Overview of the histological assessment of each healing stage.
Observation period

Biopsies

Healing stage

3 months

First

Weak connection between fascia lata allograft and mucosa

Mild lymphocytic inltration
Fibroblast colonization visible

6 months

Second

Firm connection between allograft and mucosa

Prominent broblast colonization and production of new collagen bundles in the allograft
Vascularization of the allograft

9 months

Third

Strong connection between allograft and mucosa

Identical broblast distribution in both: mucosa and allograft
Numerous capillaries in the allograft

12 months

Fourth

Connection between mucosa and allograft almost indistinguishable

Total incorporation of the allograft

Fig. 1. Section from the gingiva 3 months after the procedure without any contact
between the Fascia Lata Allograft and the host mucous membrane (100). Hmalaun
eosin (HE) staining. MM = mucous membrane, FLA = Fascia Lata Allograft.

differed from the brous connective tissue of the host mucous

membrane in terms of having thinner collagen bers with a more
undulating arrangement and of lesser density, which was reected
in the weaker staining of the bers. In turn, visible at 600 magnication, individual broblasts were lying between the collagen bers
and colonizing the graft (Fig. 2b). Features of angiogenesis, both in
the mucous membrane and in the grafted fascia fragment were also

noticeable. A small number of lymphocytes, but no inammatory

inltrations could be seen in the implanted tissue area (Fig. 2c).
Six months after the procedure, the border between the allograft and the host connective tissue was still visible in form of a
line of collagen bundles (Fig. 3a). Histological images revealed a
similar number of broblasts in both tissue fragments and sprouting vessels linking the host connective tissue with the implanted
fascia fragment. Single lymphocytes, but no inammatory inltration was also visible. At 700 magnication, two types of collagen
bers could be distinguished in the fascia regionmore slightly
stained, constricted and degenerated bers originating from the
grafted fascia, colonized by individual broblasts, as well as newly
formed bers, that were more intensely stained, thicker, with a
more regular arrangement and a larger number of broblasts.
Many capillaries were visible throughout the entire fascia fragment
(Fig. 3b).
After 9 months, the grafted fascia fragment had strongly connected with the host mucous membrane. The implantation site was
only distinguishable due to the slightly different arrangement of the
collagen bers. At 200 magnication the collagen bundles in the
host connective tissue and the graft became stained with the same
intensity, and the distribution of broblasts in bers was identical
(Fig. 4a). At 700 magnication, numerous capillaries, penetrating
the graft, were visible at the border of the two areas (Fig. 4b).

Fig. 2. Section from the gingiva 3 months after the procedure with contact between the Fascia Lata Allograft and the host mucous membrane (a; 300). Higher magnication
of the highlighted parts of Fig. 2a with features of angiogenesis, small numbers of lymphocytes (marked by black arrows) but no inammatory inltration (b, c; 600).
Hmalaun eosin (HE) staining. MM = mucous membrane, FLA = Fascia Lata Allograft.


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67

Twelve months after the procedure, histological images showed

a strong connection between the collagen bers of the host connective tissue and the bers in the area of the grafted fascia fragment
(Fig. 5a and b). The majority of the collagen bers were thick and
intensely stained (Fig. 5c). Numerous vessels originating from the
vascular bundle were also visible. No features that may indicate
inammation and foreign body reaction in the grafted fascia fragment could be detected. The architecture of the connective tissue
from the biopsy indicated total incorporation of the FL Allograft
after 12 month of healing (Fig. 5ac).

4. Discussion

Fig. 3. Section from the gingiva 6 months after the procedure. The border between
the allograft and the host connective tissue is seen in from of a line of collagen
bundles (a; 100). Single lymphocytes, but no inammatory inltration are visible
(marked by black arrows). Newly formed collagen bers, lined by a large number of
broblasts, are more intensely stained (marked by red arrows) (b; 700). Hmalaun
eosin (HE) staining. MM = mucous membrane, FLA = Fascia Lata Allograft. (For interpretation of the references to color in this gure legend, the reader is referred to the
web version of this article.)

Fig. 4. Section from the gingiva 9 months after the procedure. Only the slightly
different arrangement of collagen bers still indicates the border between the
host connective tissue and the implantation side, illustrating a strong connection between both tissues (a; 200 and b; 700). Hmalaun eosin (HE) staining.
MM = mucous membrane, FLA = Fascia Lata Allograft.

Human Fascia Lata Allograft (FLA) is a biodegradable natural tissue with high elasticity and exibility and therefore exhibits tensile
strength and is easy to t; furthermore it is biologically compatible,
has a minimal risk of infection, immunological response and is safe
to use (Detorakis et al., 2005; Dufrane et al., 2003; Sezer et al., 2004).
Due to stimulative effects on connective tissue formation, it supports a rapid wound healing and is nally replaced by connective
tissue with no immunological or foreign-body reactions (Burres,
1999; Groutz et al., 2001; Sezer et al., 2004).
So far FLA was used for several indications, mainly in human
medicine, as for example ligament reconstruction in orthopedics
(Dong et al., 2012; Yamakado et al., 2001), as dura mater substitute
(Dufrane et al., 2003), for reconstruction of the orbital oor (Celikoz
et al., 1997) as well as in urology (Dong et al., 2012). In dentistry FLA
was used for vestibuloplasty (Sezer et al., 2004), rehabilitation of
oral mucosal defects (Papakosta et al., 2007), adjacent to implants
(Silverstein et al., 1992) or as natural material for augmentation of
soft tissue prior to implant placement in the edentulous jaw (Callan,
1993).
The use of FLA for gingival recession coverage is a highly new
scope of application and has to the best of our knowledge rarely
been described in the literature. Limited clinical data of the use of
FLA in dentistry are available, which are mainly case series (Callan,
1993; Papakosta et al., 2007). Only a few studies have histologically
assessed the remodeling of gingival tissue following augmentation
and gingival recession coverage procedures using both connective
tissue and its substitutes (Cummings et al., 2005; Goldstein et al.,
2001; Harris, 1998, 1999, 2000; Majzoub et al., 2001; Richardson
and Maynard, 2002), but reports are highly promising.
Harris, for example, performed a punch biopsy three months
after a gingival recession coverage procedure using an allograft
acellular dermal matrix, which revealed the presence of elastin
bers and in turn demonstrated the incorporation of the graft in
the host tissue (Harris, 2000). Luczyszyn et al. (2007) also conrmed
the full incorporation of ADMA (Acellular Dermal Matrix) in connective tissue 12 weeks following surgery in dogs and Al Hezaimi
et al. (2014) assessed the histological results of periodontal tissue
remodeling in baboons 16 weeks after a procedure that involved the
use of an extracellular matrix membraneECM (Dynamatrix, Cook
Biotech) in the coverage of surgically induced gingival recessions.
ECM is the submucosa of the small intestine of pigs, containing
type I, III, IV and VI collagen (Hodde et al., 2007). Compared to our
study this material comes close to the FLA used in our setting. The
authors also noted new collagen bers forming a new periodontal
ligament as well as ECM remnants (Al Hezaimi et al., 2014). New
collagen bers could also be detected in our study, which were thinner, of lesser density and had a more undulated arrangement after
3 months, but with increasing time became thicker and had a more
regular arrangement (after 6 months) until nally, after 9 and 12
months, they were no longer distinguishable from the host tissue.
In a randomized study in mongrel dogs, Novaes et al. (2007)
placed alloderm alone on one side of earlier formed supraperiosteal

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Fig. 5. Section from the gingiva 12 months after the procedure indicating full integration of the FLA in the host connective tissue (a; 200 and b; 400). Numerous broblasts
(marked by blue arrows) are indicative of a high activity of new ber production. Well-organized new bers are thick and intensely stained (marked by red arrows) and
numerous vessels are originating from the vascular bundle (marked by green arrow) (c; 700). Hmalaun eosin (HE) staining. MM = mucous membrane, FLA = Fascia Lata
Allograft. (For interpretation of the references to color in this gure legend, the reader is referred to the web version of this article.)

beds around premolars, applied alloderm with autogenous broblasts on the other side, and then covered and sutured them with
a partial thickness ap. Histological assessment was performed 2,
4 and 8 weeks after the procedure. After 2 weeks, light microscopy
at 40 magnication revealed a zone of dense collagen bers that
was arranged similarly to those in the surrounding connective tissue. In both groups (alloderm plus broblasts and alloderm alone)
thinner blood vessels than in the surrounding connective tissue
were observed, although they were signicantly larger than in the
samples with broblasts. Further incorporation into the surrounding tissue was noted after 4 weeks. In both groups, after that time,
the difference between the quantities of blood vessels faded. Likewise, inammatory inltration decreased. After 8 weeks, alloderm
showed even better vascularization, a large amount of collagen
bers and a decreased inammatory inltration compared to the
histological images after 2 and 4 weeks (Novaes et al., 2007).
Our histological images also showed features of angiogenesis
both in the mucous membrane and in the grafted fascia fragment
3 month after surgery. With increasing time, the number of blood
vessels also increased, linking the host connective tissue with the
implanted fascia fragment. No foreign body reaction, inammatory
inltration or characteristics of graft rejection could be observed at
the contact between the connective gingival tissue and the FLA,
which nally, after 12 month, became indistinguishable from the
host tissue.
Dominiak et al. (2012) covered gingival recessions with a culture
of primary human broblasts on a xenogenous collagen membrane,
and also widened and augmented the gingiva of 34 anterior teeth in
10 patients. Saczko et al. (2008) described a process that involved
taking biopsies from masticatory mucosa, mechanically isolating
and culturing the sections. For nal growth, the broblasts were
placed in a restorable collagen membrane on which they remained
for 3 days. The total cultivation time was 710 days. In the recipient sites a partial thickness ap with an intact periosteum was
formed, a collagen carrier with broblasts was inserted, and the
ap was coronally advanced and stabilized with surgical sutures.
The sutures were removed after 14 days. Twelve weeks after the

procedure a biopsy was extracted from each patient for histological assessment. Each section contained mature connective tissue
covered by epithelium with a basal membrane. The amount of
broblasts and collagen matrix located in the connective tissue
was moderate. However, no inammatory inltration and also no
remnants of collagen membrane were found to be present. In the
present study, 3 months after multiple gingival recession coverage
using a tunnel technique combined with FL Allograft, biopsies were
extracted. Histological images revealed the graft colonized by the
host broblasts, the fascia was clearly visible and had undergone
vascularization. Neither inammatory inltrates nor any foreign
body reaction was visible. In their study, Dominiak et al. (2012)
similarly noted the absence of inammatory inltration and foreign
body reaction and Callan (1993) as well as Papakosta et al. (2007)
also did not clinically observe any graft rejection or infections after
implantation of fascia lata femoralis or human FL Allograft as coverage after bone grafting or as coverage of oral mucosal defects in
humans, respectively.
On the other hand, Richardson and Maynard (2002) reported
that 16 days after implantation of an acellular dermal allograft during ap surgery in humans, the histological specimens revealed
incomplete incorporation of the graft in the recipient site. The procedure was performed on a 44-year old woman and concerned a
canine with a healthy periodontium, on which a full thickness ap
was formed and an ADMA was implanted in a typical position in
contact with the root of the tooth and the bone of the alveolar ridge.
Due to extensive dental caries, the tooth was to be extracted. After
tooth extraction and histological preparation, sections containing
soft tissue, tooth and bone were assessed under light microscopy.
The most coronal regions in which the ADMA came into contact
with the root were free of blood vessels and no histological attachment was found. Only that part located on the surface of the alveolar
ridge displayed resorption and had been replaced by host connective tissue (Richardson and Maynard, 2002). In a histological study
in humans, Cummings et al. (2005) showed that ADMA used for
gingival augmentation procedure formed an attachment in form
of a combination of long junctional epithelium and connective


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tissue adhesion six months after surgery. The ADMA implanted area
was colonized by broblasts and possessed new collagen bers, but
also sustained its own remaining plastic bers. The course of the
new bers was regular with the majority running parallel to the
root surface. Compared to a human block section assessed at the
same time, that is after connective tissue gingival augmentation,
the histological image following ADMA implantation was similar
(Cummings et al., 2005).
In our study an assessment of the structure of the clinical
attachment was not included. After 6 months, the histological
images in the FL Allograft area and at the border of the host
soft tissue were similar to those described by Cummings et al.
(2005). The FL Allograft was also incompletely incorporated 6
months after the procedure. Angiogenesis and new vessels spreading toward the implanted fascia were evident at the interface
between the fascia and the host connective tissue. After a further
healing period, histological images showed an increase of the connection between the implanted fascia fragment and the mucous
membrane by the production of new collagen bers originating
from the grafted fascia. A specimen of gingiva assessed 12 months
after the augmentation procedure contained brous connective
tissue of typical architecture with correctly formed, cigar-shaped
broblasts, indicating a full integration and remodeling of the
graft.
5. Conclusions
The Fascia Lata Allograft used in multiple gingival recession
coverage procedures did not trigger any inammatory reaction
or foreign body reaction in the host tissue. Fascia Lata Allograft was easily colonized by host broblasts, which were slowly
remodeled into gingival connective tissue. Bearing in mind the
limitations of the present study, we conclude that Fascia Lata Allograft may serve as a substitute for autogenous connective tissue,
harvested from the masticatory mucosa, which can be used to
cover multiple gingival recessions. Histopathological examination
revealed that it is well tolerated by the host tissue in the recipient
site.
Conict of interest statement
The authors claim that there are no conicts of interest.
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