Case Series

A Histologic Evaluation of Various Stages of Palatal

Healing Following Subepithelial Connective Tissue
Grafting Procedures: A Comparison of Eight Cases
Kristi M. Soileau* and Robert B. Brannon

Background: It is often necessary to procure tissue

from the same area of the palate in cases where con-
nective autogenous grafting procedures are war-
ranted due to limitations caused by anatomical
features. The purpose of this study was to determine
whether the length of time between a rst procure-
ment and a second would have any bearing on the
quality of tissue available for recipient sites.
Methods: Eight patients requiring more than one
grafting procedure underwent surgery at baseline
and again at various intervals ranging from 6 weeks
to 11 months. Specimens were taken from the palate
and evaluated microscopically, and photographs
were taken for purposes of visual comparison.
Results: The 6.9- to 7.7-week specimens exhibited
complete reepithelialization. The lamina propriae were
composed of a cellular proliferation of broblasts
with loosely arranged collagen deposition and an oc-
casional thin vascular channel. However, remodeling
of the wound appeared complete in the specimens
removed at the 9-week interval and beyond. The lam-
ina propria was, in general, composed of thick, dense,
interlacing bundles of collagen. Small-caliber blood
vessels were interspersed throughout the brous
element.
Conclusion: Reharvesting of tissue performed ear-
lier than at 9 weeks may result in poorer autogenous
graft quality due to indications that remodeling of the
connective tissue is still progressing andnot as mature
as specimens noted at weeks 9 to 47. J Periodontol
2006;77:1267-1273.
KEY WORDS
Grafts; healing; histology; palate; tissue.
I
n recent decades, reconstruction of damaged
periodontal tissue has taken on an increasingly
important role in surgical periodontics. It is be-
cause of the similarity of reconstructive periodontal
surgery to the medical specialty that many clinicians
have referred to these rened approaches as peri-
odontal plastic surgery.
Recent emphasis onperiodontal reconstructionco-
incides with restorative dentistrys emphasis on es-
thetics, and although the emergence of excellent
bonding agents has amplied restorative possibilities,
bonding alone cannot address mucogingival defects.
The restorative dentist should consider reconstructing
damaged periodontal structures before recommend-
ing cosmetic bonding or altering pontic design.
1
Ex-
clusive use of dentin bonding cannot reproduce the
functional and esthetic characteristics of soft tissue.
This is particularly true in cases of single tooth reces-
sion where contour and harmony are essential for
optimal esthetics. Once a restoration has been placed
on the root, soft tissue grafting becomes difcult with-
out extensive root preparation. Also, in cases of pro-
gressive recession, additional loss of attachment can
negate the esthetic results of the restorative therapy.
Therefore, it is in the patients best interest to include
reconstructive periodontal surgery as a principal op-
tion in cases of recession. Connective tissue grafting
has expanded our options in this area. In cases of gin-
gival recession, periodontal root coverage procedures
can create a naturally esthetic result that will blend
with the adjacent tissue. Ideal results can be obtained
with the replacement of lost periodontal tissues fol-
lowed by bonding of any residual defects. The two
go hand and hand, enhancing our ability to restore
form and function in a manner not possible previ-
ously. The development of the connective tissue graft
has signicantly improved treatment options and
predictability.
Autogenous subepithelial connective tissue graft-
ing has been used in the eld of periodontics since rst
described by Edel
2
as a technique for increasing
* Private practice, New Orleans, LA.
Department of Oral andMaxillofacial Pathology, Louisiana State University
School of Dentistry, New Orleans, LA. doi: 10.1902/jop.2006.050129
J Periodontol July 2006
1267
attached tissue in areas of inadequate gingival width
and for root coverage. More recently, with the intro-
duction of the subepithelial connective tissue graft
performed by Langer and Calagna
3
to build edentu-
lous ridges and by Langer and Langer
4
to cover roots,
procedures have become more successful, esthetic,
and predictable. Several modications in the surgical
procedure have been and are currently being made.
5-9
The principal applications of the connective tissue
graft include the following: 1) root coverage with spe-
cic applications in cases of esthetic concern, pro-
gressive recession, and recession where marginal
tissue inhibits hygiene, causes root sensitivity, and
increases risk of root caries; 2) edentulous ridge aug-
mentation or recontouring before restorative therapy;
3) gingival augmentation in conjunction with ortho-
dontics or restorative dentistry; and 4) tissue buildup
around implants to enhance esthetics.
1
Although the option of donor grafting is a viable
alternative for some clinicians, many, and perhaps
the majority, still choose to procure tissue directly
from the patient undergoing surgical therapy.
Regardless of the nal destination, the palate is the
most commonly useddonor site whenconsideringau-
togenous soft tissue grafting. The hard palate is com-
posed of the palatal process of the maxillary bone and
the horizontal process of the palatine bone. It is cov-
ered with masticatory mucosa. The soft tissue extend-
ing superiorly from the cemento-enamel junction
(CEJ) of the maxillary posterior teeth for ;2 to 4 mm
is composed of dense lamina propria. The connec-
tive tissue continuing on to the midline of the palate
contains loosely organized glandular and adipose
tissue. The height, length, and thickness of donor
tissue that can be obtained varies with the different
anatomic dimensions of the palatal vault. The greatest
height (inferior-superior dimension) can be found in
the high (U-shaped) palatal vault. The greatest length
(anterior-posterior dimension) can be found in a large
palate. The thickest tissue can be found in that area
fromthe mesial line angle of the palatal root of the rst
molar to the distal line angle of the canine. A thick al-
veolar process and/or exostosis is oftenencounteredin
the molar region, which limits the length and thickness
of tissue that may be obtained. The clinician can deter-
minethethickness of thedonor tissuebyneedlesound-
ings following the administration of local anesthesia.
The greater and lesser palatine nerves and blood
vessels gain entrance into the palate by passing
through the greater and lesser palatine foramina.
The foramina locations vary, but generally can be
identied apical to the third molar at the junction of
the vertical and horizontal parts of the palatine bone.
These nerves and vessels course anteriorly within a
bony groove. The neurovascular bundle may be lo-
cated 7 to 17 mm from the CEJs of the maxillary pre-
molars and molars. Prior to making the initial incision
to procure the donor tissue from the palate, the sur-
geon should attempt to palpate the bony groove. This
palpation allows the surgeon to determine the maxi-
mum apical placement of the incision that is possible
before violating the neurovascular bundle. When the
palatal vault is shallow, the neurovascular structures
will be located more proximally to the CEJ. When
the palatal vault is high (Ushaped), the structures will
be located at a greater distance from the CEJ. The
retrieval of donor tissue from the premolar region in
the high and average palates offers a greater margin
of safety than retrieval from the shallow palatal vault.
The mean height of the palatal vault in an adult male is
14.90 mm with a SD of 2.93 mm. The mean height in
an adult female is 12.70 mm with a SD of 2.45 mm.
Caution must always be exercised not to violate the
neurovascular bundle when obtaining the donor tis-
sue, but extreme caution must be exercised when
the palate is shallow.
10
The area of procurement gen-
erally occurs a minimum of 2 mm from the gingival
margin in the region located between the distal of
the cuspid and mesial to the midpoint of the maxillary
rst molar in an effort to stay away from the greater
palatine artery and nerve. In the hard palate, mucosal
thickness increases with greater distances from the
marginal gingiva. The mucosa over the palatal root
of the maxillary rst molar is signicantly thinner than
at all other positions in the hard palate.
11
The desired thickness of the tissue procured de-
pends on the intended use. For root coverage, 1.5 to
2 mm is typically adequate, whereas ridge augmen-
tation procedures require a much thicker graft. Some
fatty or glandular tissue may be inadvertently in-
cluded in the graft, which generally is not considered
a problem.
1
Predictable root coverage can be anticipated on
roots without signicant interproximal loss of attach-
ment, as in those labeled as Class I and II in Millers
classication.
12
Root coverage becomes increasingly
less predictable in areas with greater interproximal
bone loss, as in Classes III and IV in Millers system.
12
In obtaining autogenous donor tissue, the subepi-
thelial graft technique typically involves the making
of two parallel palatal incisions ;2 mm apart, with
the incisions carried along to the free gingival margin
of the teeth adjacent to the site selected for procure-
ment of donor tissue.
Oftentimes, it is necessary to repeatedly use the
same area of a patients palate for consecutive graft-
ing procedures due to limitations caused by inade-
quate tissue or vascular anatomy. Therefore, if there
is a shortage of tissue necessary for treating all of
the sites, a patient may ultimately need grafting, un-
less the same palatal donor site is often used on more
than one occasion. The purpose of this study was to
Histologic Evaluation of Stages of Donor Site Palatal Healing Volume 77 Number 7
1268
determine whether the length of time between two
separate surgical procedures, both using the same
palatal donor site, would have any bearing on palatal
healing and readiness for a second surgical take.
Thus, should there be a minimal healing time prior
to reinvading the palate so as to maximize donor
tissue value and function? Therefore, the issue is
whether or not there should be a 9-week minimal
healing time prior to reinvading the palate so as to
maximize donor tissue value and function, according
to the histologic ndings presented in this study.
MATERIALS AND METHODS
Patient Population and Study Design
Eight patients from a private periodontal practice in
New Orleans, Louisiana, were selected to participate
in the study (age range: 31 to 62 years; seven females
and one male). Subjects were made aware of the case
presentation submitted, and the study was conducted
in accordance with the Helsinki Declaration of 1975,
as revised in 2000. It was necessary that none of the
patients were smokers and that their medical histories
were unremarkable.
Additionally, all patients required grafting of sev-
eral teeth such that a one-stage procedure would
not have been adequate to achieve an increased gin-
gival width for all of the teeth scheduled for treatment.
Two patients underwent surgery at baseline and be-
tween 6.9 and 7.7 weeks; one patient had surgery
at baseline and at 9.0 weeks; two patients had surgery
at baseline and between 12.4 and 13.4 weeks; two pa-
tients had surgery at baseline and between 22.9 and
26.3 weeks; and one patient had surgery at baseline
and at 47.3 weeks. Therefore, these eight patients
were divided into ve groups according to healing in-
tervals (Table 1). All surgeries were completed be-
tween 2003 and 2004.
Surgical Procedure
The presurgical workup included review of allergies,
medications being taken, and medical history
changes since the patients last visit. All patients were
instructed as to the discontinuation of aspirin and
aspirin-likeproducts, vitaminE, andalcohol consump-
tion for the 10 days prior to surgery in an effort to
prevent bleeding problems at or following surgery.
An impression was taken so that a palatal stent could
be used postoperatively, and patients were generally
given prescriptions for propoxyphene with acetamin-
ophen, alprazolam 0.5 mg, valdecoxib 20 mg, and
doxycycline 100 mg, the latter of which was to be
taken daily for 2 weeks. At the time of surgery, med-
ical history was again reviewed and monitoring of
blood pressure, SaO
2
, and electrocardiogram
(EKG) was performed on all patients throughout the
procedure. One hour prior to surgery, patients re-
ceived 0.5 mg alprazolam and 20 mg valdecoxib. A
general polishing was performed on all teeth, and
the patients were given a 0.12% chlorhexidine gluco-
nate solution to swish with for 30 seconds. Marcaine
0.5% with 1:200,000 epinephrine was administered
in the recipient surgery site, whereas xylocaine 2%
with 1:50,000 epinephrine was administered in the
palatal donor site. The donor site received a total of
;0.9 to 1.2 ml per surgery, with some being adminis-
tered following surgery when deemed necessary for
postoperative bleeding control.
After preparing the recipient site for accepting the
graft, the palatal donor tissue was procured. Adouble-
bladed scalpel was employed, using 1.5 mm of width
between the two blades, and an incision was made be-
tween the mesial of the rst molar and the distal of the
cuspid and ;3 mm from the free gingival margin of
the nearby teeth. The incision was made until resis-
tance was felt on the osseous tissue, and the incision
was carried horizontally through an amount of tissue
necessary to fulll that length of tissue required at
the recipient site. The ends of the graft were released
by using a 15Cblade, and the graft was lifted fromthe
palate. Photographs were taken of each donor graft
site, and the last 2 mm of each piece of donor tissue
taken from each patient was submitted for histologic
evaluation of collagen organization and maturation.
The area fromwhich the piece sent for histologic test-
ing came was also measured with a probe and docu-
mented so that, with photographs, it would be certain
that the same area would be procured at the rehar-
vesting for a comparative histologic evaluation. As
stated in Table 1, reharvesting occurred at ;6 weeks
and at 2, 3, 6, and 11 months. All of the surgically
Table 1.
Time Intervals Between
Surgical Procedures
Group/Case
Time Interval (days/weeks) Between
First and Second Surgery
I/1 48/6.9
I/2 54/7.7
II/3 63/9.0
III/4 87/12.4
III/5 94/13.4
IV/6 160/22.9
IV/7 184/26.3
V/8 331/47.3
J Periodontol July 2006 Soileau, Brannon
1269
removed specimens were submitted to the Depart-
ment of Oral and Maxillofacial Pathology, Louisiana
State University School of Dentistry, to ensure that
an ofcial pathology report was issued. All cases were
evaluated microscopically using the standard hema-
toxylin and eosin (H&E) stain.
Following surgery, the palatal site was covered by a
surgical acrylic stent, as did Rossmann and Rees
13
for
bleeding control and minimization of discomfort,
which had been fabricated prior to surgery. However,
sutures, acrylates, or dressings were not employed on
the palatal donor sites in this study.
RESULTS
Clinical Findings
All eight patients healed as expected with no unfore-
seen adverse occurrences. Discomfort was typically
diminished by day 10, at which time wound closure
appeared to be clinically complete in all eight cases.
An area of slight redness persisted for up to 4 weeks,
at which time color began to blend with surrounding
palatal tissue, as did tissue contour. Recovery of sen-
sation did not occur for months in some cases. Addi-
tionally, a certain shrinkage of all grafts was noted at
the recipient sites as maturing occurred.
Histologic Findings
The histologic ndings of the eight hard palate spec-
imens at the time of the initial surgery (baseline)
showed normal palatal mucosa and submucosa.
The specimens were composed of orthokeratinized
or parakeratinized stratied squamous epithelium
with well-formed rete ridges (Figs. 1 and 2). The lam-
ina propria possessed thick dense bundles of collagen
with small-caliber blood vessels scattered throughout
(Figs. 3 and 4).
The group I specimens that were removed at the
6.9-week (48 days) to 7.7-week (54 days) intervals
Figure 1.
Normal (baseline) palate from case 5 showing keratinized stratied
squamous epithelium overlying dense collagenous tissue (H&E;
original magnication 40).
Figure 2.
Normal (baseline) palate from case 8 showing keratinized stratied
squamous epithelium overlying dense collagenous tissue. Adipose
tissue and small-caliber blood vessels are in the lower one-third of
the specimen (H&E; original magnication 40).
Figure 3.
Normal (baseline) palate lamina propria from case 5 composed of
dense interlacing collagen bundles (H&E; original magnication
100).
Figure 4.
Normal (baseline) palate lamina propria from case 8 composed of
dense interlacing collagen bundles (H&E; original magnication
100).
Histologic Evaluation of Stages of Donor Site Palatal Healing Volume 77 Number 7
1270
showed that reepithelialization of the wound was com-
plete. The lamina propria was composed of a cellular
proliferation of broblasts with a loosely arranged
deposition of collagen bers and an occasional thin
vascular channel (Figs. 5 and 6). These ndings indi-
cated that remodeling of the connective tissues was
still in progress.
Remodelingof the woundappearedcomplete inthe
specimens removed at the 9-week (63 days) interval
and beyond. Reepithelialization was complete, and
the lamina propria was composed of thick, dense, in-
terlacing bundles of collagen. Small-caliber blood
vessels were interspersed throughout the brous
element (Figs. 7 through 9).
DISCUSSION
Regarding the recipient site, Rossmann and Rees
13
followed patients an average of 10 months and found
Figure 6.
At 54 days, numerous spindle-shaped brocytic nuclei amid loosely
woven collagen bers are noted in the lamina propria of case 2
(H&E; original magnication 100).
Figure 7.
Reepithelialized wound of case 6 at 160 days. The lamina propria is
composed of dense collagenous tissue with several small-caliber blood
vessels interspersed throughout (H&E; original magnication 40).
Figure 8.
The lamina propria of case 6 at 160 days exhibiting interlacing
bundles of dense collagen. There is a capillary in the center and lower
left of the photograph (H&E; original magnication 100).
Figure 5.
At 48 days, note the loosely woven collagen bers in the lamina
propria of case 1. A thin-walled blood vessel is at the far left of the
photograph (H&E; original magnication 100).
Figure 9.
Case 7 at 184 days reveals a densely collagenous lamina propria.
A capillary is at the far left of the photograph, and the tip of a rete
ridge is at the top left (H&E; original magnication 100).
J Periodontol July 2006 Soileau, Brannon
1271
a mean shrinkage of recipient grafts of 24% in total
surfacearea. Inthepalatal donor site, healingismainly
by primary intention, and postoperative discomfort
is dramatically decreased compared to the free gin-
gival graft (FGG). In beagle dogs, Squier et al.
14
found that actin-containing cells with the ultrastruc-
tural characteristics of myobroblasts (contractile
broblasts) are present in the granulation tissue
of healing skin and oral muscosal wounds and
may be responsible for the wound contraction ob-
served clinically in the healing palatal mucoperios-
teum. Cornelissen et al.
15
found myobroblasts in
rat palatal wound tissue between days 4 and 22,
with the highest density at 8 days postwounding.
The number of collagen type I and type II bers
gradually increased until about 8 days postwound-
ing, and thereafter the staining intensity of collagen
type III bers decreased. At 60 days postwounding,
there were more transversely oriented collagen type
I bers and fewer type III bers and elastin present in
the submucosa than in normal tissue. This suggests
that wound contraction occurs in the mucosa mainly
between 4 and 22 days.
15
The parallel single incision (PSI) method was used
in expectation of a more rapid surface healing/epithe-
lialization due to proposed earlier advanced healing
with this technique. In a comparative study of clinical
healing in the donor site between patients treated with
a trap door (TD) technique or with a PSI, which uses a
scalpel with parallel blades, Harris
16
recorded a high
rate of sloughing of the supercial ap (11 out of
13 cases) for the TD group. Del Pizzo et al.
17
showed
faster reepithelialization in the SI group than in the TD
or FGG groups they studied. However, Del Pizzo et
al.
17
showed no statistically signicant differences re-
garding the return of sensibility among the SI, TD, or
FGG groups they studied; complete recovery of sen-
sation occurred in at least 8 weeks in a number of pa-
tients. Discomfort was absent or minimal in the TD
and SI groups, whereas the FGGgroup reported more
problems postoperatively in the rst 2weeks after sur-
gery. Clinically, eating habits showeda faster return to
normal by the second week, whereas 25% of the TD
and 34% of the FGG groups still followed a soft food
diet.
17
Interestingly, Pedlar
18
demonstrated that a rugae
does not regenerate if it is removed; thus, a return
to normality does not occur.
18
In the Kahnberg and
Thilander study
19
on palatal healing in rats, epithelial-
ization was noted to have progressed from the wound
borders, and reduction of the wound surface pro-
ceeded by contraction of the wound margins and by
epithelial cell migration. After 3 weeks, the defects
were completely covered with epithelium, although
epithelial rete pegs had not yet developed in the cen-
tral part of the former defect.
19
Squier and
Kremenak
20
looked at healing of mucoperiosteal
wounds in beagle dogs by use of ultrastructural ster-
eology. When the quantitative data from healing
wounds was compared to values from normal, un-
wounded control tissue, values for the periosteum
and submucosa returned close to control values 13
days following wounding, whereas those values for
the subepithelial layer andlamina propriawere still sig-
nicantly different from the controls at 18 days. Thus,
Squier and Kremenak
20
concluded that there is a gra-
dient of healing between the bone and the surface ep-
ithelium, and complete repair and remodeling of the
tissue is likely to take longer than 18 days. Donn
21
studied three submerged connective tissue autografts
that wereevaluatedat 4, 7, 10, 14, 20, 30, and90days,
and at 1.5 and 4 years for similarities in a wound-
healingstudy. One wound-healingsequence was actu-
ally presented to evaluate the role of the specicity of
connective tissue in the creation of a new gingival at-
tachment procedure. In Donns study,
21
he admits that
difculty often exists in obtaining adequate amounts of
donor tissue. He also notes that healing of the palate
after 1 month will not leave any depression at the site,
and thus the area can usually be entered again for ad-
ditional connective tissue material.
21
It is for this particular reason that this research
bears clinical relevance. Should there be a 9-week
minimal healing time prior to reinvading the palate
so as to maximize donor tissue and function?
Because maturation of tissue was notably better at
63 days versus the 48- and 54-day specimens, an ad-
ditional study following biopsies daily from the 6- to
9-week intervals may further elucidate that particular
point at which an acceptable collagen maturation is
truly reached.
ACKNOWLEDGMENTS
The authors thank Dr. James Weir, Department of
Oral and Maxillofacial Pathology, Louisiana State
University School of Dentistry, for his assistance in
photographing the histologic specimens and Dr.
David DeGenova (spouse of Dr. Soileau) for contribu-
tions toward the layout and design of electronic im-
ages. This paper is dedicated to Dr. Roland Meffert,
postdoctoral professor and mentor of Dr. Soileau at
the Louisiana State University School of Dentistry.
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Correspondence: Dr. Kristi M. Soileau, 2820 Napoleon
Ave., Ste. 470, New Orleans, LA 70115. Fax: 504/899-
1237; e-mail: kmsperio@earthlink.net.
Accepted for publication January 6, 2006.
J Periodontol July 2006 Soileau, Brannon
1273