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Zuhr O, B aumer D, H urzeler M. The addition of soft tissue replacement grafts in
plastic periodontal and implant surgery: critical elements in design and execution. J
Clin Periodontol 2014; 41 (Suppl. 15): S123S142. doi: 10.1111/jcpe.12185.
Abstract
Soft tissue replacement grafts have become a substantial element to increase tissue
volume in plastic periodontal and implant surgery. Autogenous subepithelial con-
nective tissue grafts are increasingly applied in aesthetic indications like soft tissue
thickening, recession treatment, ridge preservation, soft tissue ridge augmentation
and papilla re-construction. For the clinical performance of connective tissue
graft harvesting and transplantation, a fundamental understanding of the anat-
omy at the donor sites and a sound knowledge of tissue integration and re-vascu-
larization processes are required. Possible donor sites are the anterior and
posterior palate including the maxillary tuberosity, providing grafts of distinct
geometric shape and histologic composition. The selective clinical application of
different grafts depends on the amount of required tissue, the indication and the
personal preference of the treating surgeon. One of the main future challenges is
to volumetrically evaluate and compare the efficacy and long-term stability of soft
tissue autografts and their prospective substitutes. The aim of this review was to
Key words: donor sites; graft harvesting; soft
discuss the advantages and shortfalls of different donor sites, substitute materials
tissue augmentation; soft tissue replacement
and harvesting techniques. Although standardized recommendations regarding graft; soft tissue substitute; subepithelial
treatment choice and execution can hardly be given, guidelines for predictable connective tissue graft
and successful treatment outcomes are provided based on clinical experience and
the available scientific data. Accepted for publication 16 October 2013
The use of soft tissue replacement soft tissue autografts has character- on the belief that a minimal width of
grafts has become a substantial ele- ized the last 50 years of clinical peri- keratinized gingiva would be
ment in plastic periodontal and odontology, and till today more required to maintain the periodontal
implant surgery. The application of than ever a variety of soft tissue tissues healthy and stable (Nabers
grafting interventions is carried out 1954, Ochsenbein 1960, Friedman &
Conflict of interest and source of with two different targets being pur- Levine 1964, Sullivan & Atkins
funding statement sued: increasing the width of kerati- 1969, Carranza & Carraro 1970,
nized tissue and increasing soft tissue Hall 1981, Matter 1982). A mini-
The authors declare that they have no
volume. In the beginning of the era mum of 1 mm to 3 mm of kerati-
conflict of interest. This review article
has been self-funded by the authors.
of mucogingival surgery, surgical nized gingiva was believed to be
interventions were performed based mandatory (Corn 1962, Bowers
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S123
S124 Zuhr et al.
1963, Lang & Loe 1972). In the thetic indications. In search of better ing soft tissue grafting techniques
1960s, it was assumed that the tissue alternatives it soon became clear that in plastic periodontal and implant
around teeth adapts to functional the predictability regarding the aes- surgery and to provide clinical
requirements when subjected to thetic outcome was much higher strategies for soft tissue replacement
physical impacts during mastication when using a subepithelial connec- graft procedures. Based on scientific
(Ivancie 1957, Orban 1957, Bradley tive tissue graft (SCTG) (Langer & evidence and clinical experience it
et al. 1959, Pfeifer 1963). As a conse- Calagna 1980, Langer & Langer is supposed to (I) analyse and dis-
quence, denudation techniques (Och- 1985, Raetzke 1985, Nelson 1987, cuss the advantages and shortfalls
senbein 1960, Bohannan 1962, Corn Harris 1992, Allen 1994, Bruno of different donor sites and har-
1962, Wilderman 1964), periosteal 1994). The further development of vesting techniques as related to
retention procedures (Staffileno et al. soft tissue autografts from the FGG autogenous soft tissue grafts and
1962) and apical repositioned flaps to the SCTG represents a paradigm (II) to provide clinical guidelines
(Friedman 1962) were recommended shift, which is conceptually anchored for predictable and successful treat-
to increase the width of the kerati- in the literature by the transition ment outcomes and (III) give a
nized gingiva. As the role of inherent from classical mucogingival surgery global perspective on current and
factors regarding genetic determina- to plastic periodontal surgery. Today future possibilities with soft tissue
tion of gingival tissues became clear soft tissue augmentation only occa- substitutes.
later on (Karring et al. 1971, 1974, sionally means widening of the gin-
1975), the use of pedicle grafts and giva or peri-implant mucosa in the
Anatomical landmarks
in particular free epithelialized context of plastic periodontal and
grafts, usually referred to as free gin- implant surgery. It is rather indi- The oral mucosa can be divided into
gival grafts (FGG), was proposed cated for soft tissue recession treat- three portions: the specialized sen-
instead (Haggerty 1966, Nabers ment at teeth (Cairo et al. 2008, sory mucosa (taste buds on dorsum
1966, Sullivan & Atkins 1968, Edel Chambrone et al. 2010, 2012, Cortel- of the tongue), the lining mucosa
1974). lini & Pini Prato 2012) or implants (lips, cheeks, vestibule, floor of the
When it was subsequently real- (Burkhardt et al. 2008, Roccuzzo mouth, base of the tongue and soft
ized that the biological significance et al. 2013, Zucchelli et al. 2013), for palate) and the masticatory mucosa
of a sufficient wide keratinized gin- ridge preservation procedures with (gingiva and hard palate) (Orban &
giva was doubtlessly overrated in the immediate implants or fixed partial Sicher 1945). The masticatory
past (Miyasato et al. 1977, Hangor- dentures (Esposito et al. 2012, Lang mucosa of the hard palate is com-
sky & Bissada 1980, Lindhe & et al. 2012), for soft tissue ridge aug- posed of three histologic layers: the
Nyman 1980, de Trey & Bernimou- mentation associated with implants epithelium, and the subepithelial
lin 1980, Dorfman et al. 1982, Schoo or fixed partial dentures (Thoma connective tissue with the lamina
& van der Velden 1985, Kisch et al. et al. 2009, Schneider et al. 2011, propria and the submucosa (Fig. 1).
1986, Salkin et al. 1987), the clinical Sanz et al. 2012) and for papilla The epithelium is characterized by
importance of FGGs to increase the reconstruction (Nemcovsky 2001, orthokeratinization and about
width of the keratinized gingiva Nordland et al. 2008). Furthermore, 300 lm thick, its structure basically
more and more decreased. Instead it might be recommended for soft corresponding to that of the gingival
periodontists started to use the FGG tissue thickening to stabilize the gin- epithelium. The lamina propria
for aesthetic corrections like soft tis- giva, for example. before orthodon- below the palatal epithelium is very
sue recession coverage (Bernimoulin tic (Steiner et al. 1981, Wennstrom coarse tissue. It contains a high pro-
et al. 1975, Miller 1982) and soft tis- et al. 1987) or restorative (Ericsson portion of inter-cellular substance,
sue ridge augmentation (Seibert & Lindhe 1984) treatment and to which is produced by fibroblasts.
1983) as well as for socket preserva- mask discoloured roots or shining This extracellular matrix is responsi-
tion in aesthetically relevant areas through implant components (Jung
(Landsberg & Bichacho 1994). These et al. 2007).
advancements of soft tissue augmen- Considering the challenges of
tation procedures were marked by a soft tissue augmentation procedures
sense of aesthetics among patients, in plastic periodontal and implant
which had not been present in the surgery today, the FGG has conse-
dental community in this form quently disappeared from the aes-
before. This meant a fundamental thetic zone and its scope of
change regarding the indications of application has been limited to pro-
soft tissue autografts in periodontol- cedures increasing the keratinized
ogy. However, as much as the FGG tissue around teeth and implants in
had proven for increase in the width aesthetically irrelevant zones. For
of keratinized gingiva, as much its that reason, this review dispenses
Fig. 1. Clinical view of a thick free epi-
limitations, both regarding the quan- FGGs and concentrates on SCTGs
thelialized graft without periosteum har-
titative (volume augmentation) and and their potential substitutes for vested from the lateral palate to illustrate
qualitative outcomes (aesthetic inte- soft tissue recession treatment and the histological composition of the pala-
gration, surface, colour, scarring), soft tissue volume increase. The tal masticatory mucosa: covering epithe-
were obvious when it was applied aim of this review was therefore to lium and subepithelial connective tissue
for soft tissue re-construction in aes- analyse the dental literature regard- including lamina propria and submucosa.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Soft tissue replacement grafts S125
ble for the mechanical properties of age (Song et al. 2008). Furthermore, sek and Rungruang found that the
the tissue layer. It consists predomi- there was a tendency for an increase GPF was most frequently found in
nantly of collagen fibrils mainly with from the canine to the second pre- the region near the apices of the
type I and II and few type V and VI molar, a decrease at the first molar second and third molars, in the area
collagen. Elastic fibres are hardly and an increase again at the second where the vertical and horizontal
present. The lamina propria is molar. The second pre-molar region segments of the palatine bone come
divided into the papillary portion showed to be thickest with a mean together (Klosek & Rungruang
and the reticular portion. The papil- of 3.81 0.75 mm and the first 2009). Ikuta and coworkers found
lary portion shows finger-like projec- molar region the thinnest with in a cone beam computed tomogra-
tions that inter-lock with the 3.13 0.69 mm. In a cadaver study phy study that the GPF was located
overlying epithelium whereas the by Gapski and coworkers, the soft in 92 of 100 cases in the third molar
reticular portion consists of thick tissue thickness at the tuberosity region and in an average distance of
and dense reticular fibres. The sub- came out to be 2.54 mm (Gapski 7.9 mm from the alveolar ridge (Ik-
mucosa is a connective tissue layer, et al. 2006). Apparently, the subepi- uta et al. 2013), whereas a study in
which attaches the lamina propria to thelial connective tissue from the Indian skulls observed the GPF to
the periosteum of the underlying tuberosity area is a very dense, be in the third molar region in only
bone. Numerous glands, nerves and coarse and collagen-rich tissue that 73% of the cases (Sharma & Garud
adipose tissue are present in this tis- seems to contain less fat and glandu- 2013). Monnet-Corti and coworkers,
sue layer. Its thickness can vary lar tissue, but much more collagen who measured the distance of the
between patients and within the than that from the anterior lateral main branches of the GPA from the
same individual (Muller et al. 2000). palate. palatal gingival margin in 198 plas-
The submucosa is characterized by a The arterial blood supply of the ter models of periodontally healthy
rather fatty zone in the anterior and palate is provided by the greater pal- patients, found that the average dis-
copious glands (Gll. Palatinae) in the atine artery (GPA), a branch of the tance from the gingival margin to
posterior area whereas it is in gen- maxillary artery, which emerges the GPA ranged from approxi-
eral less pronounced in the posterior from the greater palatine foramen. It mately 12 mm in the canine area to
than in the anterior part of the pal- runs through a groove lateral to the roughly 14 mm at the second molar
ate. In a histologic evaluation of greater palatine nerve (GPN) and level (Monnet-Corti et al. 2006).
human SCTGs from the anterior submits branches to the palatal The authors concluded that it
palate by Harris, large differences in mucosa and the gingiva, continu- should be possible to harvest a
the histologic composition were ously decreasing its diameter and SCTG measuring 5 mm in height in
found: some grafts consisted almost ends at the incisive canal, where it all patients and 8 mm in height in
only of lamina propria and in some anastomoses with the sphenopalatine 93% of patients without a risk of
grafts the greatest proportion was artery. The innervation of the damaging the GPA. However, a
submucosa with mainly adipose tis- mucosa and gingiva at the hard pal- cadaver study by Fu and coworkers
sue (Harris 2003). The portion of the ate is provided by the GPN, which revealed that the predicted location
lamina propria varied between 21.1 emerges also through the greater pal- of the GPA based on the aforemen-
and 100% of the graft (mean atine foramen and traverses medial tioned study cast measurements
65.2%). These results confirm the to the GPA, subdividing into several tended to be inaccurate and that the
clinical observation that the dimen- branches, which are becoming thin- predicted distance between the GPA
sions of the different subepithelial ner towards the epithelial layer. and the cementoenamel junction of
connective tissue layers vary substan- Between the GPA and the GPN, a the first molars and pre-molars
tially from patient to patient. crest is present, which can in most tended to be underestimated (Fu
The thickness of the masticatory cases be palpated clinically (Bennin- et al. 2011). This is in correspon-
mucosa at the palate has been evalu- ger et al. 2012). dence to findings by Benninger and
ated in different studies. Eger and With respect to potential compli- coworkers, who measured an aver-
M uller determined the thickness with cations of harvesting SCTGs from age distance of 12 mm (range 9
ultrasonic devices (Eger et al. 1996, the palate, the palatine neurovascu- 16 mm) between the first molar and
Muller et al. 2000). They found that lar bundle is a very important and the GPA (Benninger et al. 2012). To
the soft tissue thickness at the tuber- clinically relevant anatomical struc- establish a guideline for clinicians to
osity area was highest with more ture to be protected. Therefore, hav- localize the GPA, the authors
than 4 mm, followed by the palatal ing a general idea of the possible assumed that in most cases the
masticatory mucosa at the second course of the palatine artery is GPA would be found at a distance
molars and pre-molars with an aver- essential. For this reason, different of 76% of the palatal height mea-
age of 3 mm. In general, the thick- anatomical studies were set up with suring from the cementoenamel
ness was found to be higher in men the objective to work out reliable junction of the first molar. Other
than in women. In a computertomo- reference points and guidelines that evidence suggests that the height of
graphic study by Song and cowork- can be used by clinicians to prevent the palatal vault is related to the
ers, it was found to be damage to the GPA during SCTG course of the greater palatine artery:
3.83 0.58 mm with females having harvesting in a given clinical situa- The shallower the palatal vault, the
a thinner (3.66 0.52 mm) mucosa tion. In an anatomical study of the closer the palatine artery gets to the
than men (3.95 0.60 mm) and an GPA and related bony structures of palatal gingival margin (Reiser et al.
increasing thickness with increasing the hard palate in 41 cadavers, Klo- 1996) (Fig. 2).
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S126 Zuhr et al.
lar ridge augmentation is rather per- as good with the requirements for
formed with a voluminous graft from graft survival in the course of plas-
the tuberosity area whereas a reces- matic circulation and re-vasculariza-
sion coverage can also be done with a tion during the early postoperative
thin and small dimensioned graft phase. As a clinical consequence
from the posterior lateral palate. SCTGs from the posterior palate
Should the clinical situation require seem in contrast to SCTGs from
changing the geometry of a given the anterior area to need being
graft, the transplant can be modified fully covered by a flap to ensure
by folding and suturing grafts from healing by primary intention. It is
the lateral palate or by slicing and presently unclear to what extent it
unfolding grafts from the tuberosity might play an additional role in this
area. As the dimensions of the masti- context if, depending on the
catory mucosa at the palate vary sub- employed harvesting technique, the
stantially from patient to patient periosteum covering the palatal bone
(Eger et al. 1996, Muller et al. 2000, is included in the graft or not.
Harris 2003, Gapski et al. 2006, Song SCTGs can also be harvested
et al. 2008), it is important for the cli- from the palate with covering epithe-
nician to quickly overview the lium according to FGGs, provided
Fig. 2. The blood vessels that supply the
amount of available tissue at the pos- that they are deepithelialized extrao-
lateral palate region can be seen in this
anatomical specimen. The greater pala- sible donor sites. To do so, a good rally. This approach has the advan-
tine artery emerges from the greater pala- and simple option is using an end- tage that SCTGs can also be taken
tine foramen and extends along the odontic needle with a silicon disc in situations with a very thin masti-
lateral palate in an anterior direction. applied to it (Studer et al. 1997, Pao- catory mucosa and that the graft
Due to its size, injury to the greater pala- lantonio et al. 2002, da Silva et al. preparation itself can be performed
tine artery, particularly in its distal seg- 2004, Joly et al. 2007). In this con- more superficially, thereby not vio-
ment, can be expected to result in text, Zucchelli and coworkers lating blood vessels and nerve fibres
massive bleeding. It is therefore crucial to assumed that in addition to measur- running in deeper layers. In this
take precautions to prevent damage to ing soft tissue thickness at the palate way, transplants with more extensive
the artery when subepithelial connective
tissue grafts are harvested from the
endodontic needles might also be surfaces can be gained in a short
palate. used to estimate the composition of amount of time and the allegedly
the subepithelial connective tissue. high-quality tissue layer of the lam-
The authors believed that due to dif- ina propria can be used to full
ferent penetration resistances towards extent as no parts of it remain in the
the needle the transition between lam- flap at the donor site like in under-
Donor site selection
ina propria and the adipose submu- mining harvesting techniques. On
It is beyond all question that among cosa could be felt in many situations the other hand, this procedure might
suitable donor sites for intra-oral (Zucchelli et al. 2010). adversely affect patient morbidity:
SCTG harvesting only those come Besides their geometry, grafts In several clinical studies it could be
into consideration that promise an from different donor sites vary in demonstrated that a more painful
adequate amount of obtainable tis- their histologic composition (Harris post-operative course could be
sue. They should not be associated 2003). It may be speculated that observed in FGG patients with a
with major health risks and go along these differences not only account palatal wound healing by secondary
with acceptable patient morbidity. for variable volume stability but also intention in contrast to SCTG
Under these requirements and in influence the physiologic process of patients where a flap was raised, the
consequence of the anatomical soft graft re-vascularization. From clini- graft harvested internally and the
tissue conditions in the oral cavity cal experience, it seems in this con- wound allowed to heal by primary
two areas of interest for autograft text as if subepithelial connective intention (Farnoush 1978, Jahnke
harvesting have emerged as the areas tissue from the tuberosity and the et al. 1993, Del Pizzo et al. 2002,
of choice: the anterior and the posterior lateral palate was denser Griffin et al. 2006, Wessel & Tatakis
posterior palate, whereas in the pos- and firmer than that from the ante- 2008). However, these results are
terior area the tuberosity and the lat- rior palate. It can be assumed that it contrary to a recent clinical study
eral palate can be distinguished. is therefore less susceptible to post- identifying influencing factors for
In general, the grafts from the dif- operative shrinkage. On the other pain sensation after FGG removal
ferent eligible sites differ in their geo- hand, this very dense and coarse (Burkhardt et al. in preparation)
metric shape: grafts from the connective tissue appears to undergo and a randomized controlled clinical
tuberosity are more voluminous, necrosis more easily than that from trial (RCT) comparing patient mor-
those from the posterior lateral palate the anterior palate. It may be bidity after FGG and SCTG har-
rather thin, whereas those from the hypothesized that compared to the vesting procedures (Zucchelli et al.
anterior palate can often be extensive rather loose formation of the subepi- 2010). In both studies it could be
with a large surface. This has an influ- thelial connective tissue from the demonstrated that post-operative
ence on the indication they are anterior palate, the dense tissue from pain was rather influenced by the
intended for. For example, an alveo- the posterior area does not comply thickness of the graft and the
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Soft tissue replacement grafts S127
remaining soft tissue at the palate, from different donor sites seem to basically in the particular position
but by primary or secondary wound have different characteristics that of the donor site, the number and
healing at the donor site. It can be might require selective clinical appli- type of surface incisions and in the
mentioned as an aside that in the cation and well thought out surgical flap design for gaining access to the
latter study, the deepithelialized protocols. The clinical decision graft. In principle, they can be sub-
autografts consisting of lamina pro- where to harvest soft tissue auto- divided into techniques that provide
pria only led to a statistically signifi- grafts from is presently hardly based SCTGs with or without a remaining
cant higher increase in buccal on written evidence, but rather relies collar of keratinized epithelium.
gingival thickness following reces- on clinical experience and depends Relating to the group of SCTGs
sion coverage (Zucchelli et al. 2010). on the amount of available tissue at with epithelium, Langer and Cala-
These findings support the afore- the eligible donor sites, the indica- gna as well as Langer and Langer
mentioned clinical observation that tion in which the transplant is sup- introduced a harvesting method
SCTGs containing presumed denser posed to be used and last, but not based on a rectangular incision
subepithelial connective tissue are least on the personal preference of design with two horizontal and two
comparatively less prone to postop- the treating surgeon. vertical incisions resulting in SCTGs
erative shrinkage. The clinical expe-
rience that using SCTGs that are
harvested with epithelium and deepi-
thelialized outside the oral cavity
seem to bear an increased risk for
postoperative scar tissue formation
at the recipient site should not be
neglected, though. At this point of
time any attempted explanation
would be speculative in nature,
although it would be possible that in
(a) (b)
contrast to SCTGs from deep sub-
epithelial connective tissue zones
SCTGs consisting mainly of a super-
ficial layer of subepithelial connec-
tive tissue behave more similar to
FGGs with all the negative conse-
quences for the qualitative treatment
outcomes outlined above (aesthetic
integration, surface, colour, scar-
ring). This might potentially be
caused by isolated fragments of epi- (c) (d)
thelium that are left in the graft
Fig. 3. Clinical view of soft tissue grafts harvested from the different possible donor
after deepithelialization, especially
sites with varying geometric shape and histologic composition: from the anterior lat-
due to the papillary inter-locking eral palate (a), from the posterior lateral palate (b), from the lateral palate, deepitheli-
between the epithelium and the lam- alized extraorally (c) and from the maxillary tuberosity (d).
ina propria. In a study by Harris,
SCTGs were manually deepithelial-
ized at the best optical control by with an epithelial collar of about
Harvesting techniques
the surgeon (Harris 2003). The 2 mm width (Langer & Calagna
subsequent histological analysis, The clinical procedure of SCTG har- 1980, 1982, Langer & Langer 1985).
though, could demonstrate remain- vesting from the palate is often char- Subsequently, Harris used a very
ing epithelium in 80% of the grafts. acterized by the remarkable similar approach and modified the
In addition, more aggressive mor- challenge of obtaining the largest technique by limiting the vertical
phogenetic stimuli regarding the dif- volume of tissue possible on one side incisions to a minimal dimension,
ferentiation of the covering while minimizing post-operative pain barely enough to get access to the
epithelium at the recipient site could and reducing the risk of complica- underlying donor tissue (Harris
be suspected in more superficial lay- tions on the other side. To meet 1992). Raetzke, finally, abstained
ers of subepithelial connective tissue these requirements, various proce- from vertical incisions completely
(Ouhayoun et al. 1988). If it would dures for soft tissue autograft har- and used two converging horizontal
make a difference for this reason to vesting in plastic periodontal and crescent-shaped incisions resulting in
position the superficial side of the implant surgery have been developed a wedge-shaped SCTG with an epi-
graft inwards or outwards in the and described in the literature: thelial collar (Raetzke 1985). How-
recipient bed could be an interesting ever, the disadvantage of all these
field of future research (Fig. 3). techniques obtaining SCTGs includ-
SCTG harvesting from the lateral palate
In summary, it can be stated that ing parts of the epithelium was
although the actual reasons are The different SCTG harvesting tech- beside the aforementioned negative
largely unknown up to date grafts niques from the lateral palate vary consequences for the qualitative-aes-
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S128 Zuhr et al.
thetic treatment outcomes that the given in two recently published text- face instead of on bone or perios-
donor site could not be completely books (Zuhr & H urzeler 2012, Zuc- teum after surgery, which might
covered with the flap and was there- chelli 2013). improve the predictability to achieve
fore partially healing by secondary healing by primary intention.
intention. Due to the rigidity of the SCTG harvesting from the anterior palate
Depending on the clinical indication
palatal masticatory mucosa this and how much tissue is available,
could only be avoided if SCTGs The procedure starts according to SCTGs can be obtained with or
were harvested without epithelium. the single-incision technique with a without periosteum. Grafts with
In consequence, Edel introduced a horizontal incision along the row of periosteum are harvested by blunt
trap-door approach without remov- teeth starting from the mesial border dissection using a periosteal elevator.
ing epithelium from the donor site of the first molar to the lateral inci- For graft removal without perios-
(Edel 1974). By undertaking one sor, 2.0 mm apical to the gingival teum, an additional offset incision is
horizontal and two vertical inci- margin, 1.01.5 mm deep. All the carried out above the periosteum by
sions, an access flap could be remaining incisions are undermining sharp dissection with a scalpel blade.
raised, the graft removed and com- below the mucosal surface. With Although leaving periosteum on the
plete wound closure achieved. How- regard to post-operative pain, it bone has probably positive conse-
ever, particularly in cases with seems to be the main challenge from quences in terms of post-operative
unfavourable relations between flap a surgical point of view to achieve wound healing, clinical experience
base and pedicle length flap slough- primary wound healing at the palatal has shown that SCTGs with perios-
ing could be observed causing donor site. In this context, it appears teum have superior mechanical sta-
unnecessary discomfort for the to be essential to guarantee an ade- bility, which might be an advantage
patient (Edel 1974, Harris 1994, quate postoperative blood supply for relating to the clinical handling of
1997). This is why H urzeler and the access flap and therefore prepare those grafts in certain situations. For
Weng proposed a single-incision a partial-thickness flap of uniform the following wound closure parallel
technique for SCTG harvesting thickness and proper dimension. For and crossed horizontal sling sutures
from the lateral palate later on this reason, it is mandatory to per- are recommended. The placement of
(Hurzeler & Weng 1999). The exe- form the initial horizontal incision this type of sutures around the max-
cution of only one horizontal sur- with a scalpel held strictly perpendic- illary posterior teeth has a wound
face incision followed by an ular to the palatal surface. To ensure compressing effect that might be
undermining flap preparation that the following split-thickness flap beneficial particularly in terms of
seemed to positively affect post- preparation will provide a flap of promoting hemostasis and primary
operative healing and patient mor- sufficient dimension throughout, it is adaptation of the wound margins
bidity compared with the trap-door important to gradually increase the (Zuhr & H urzeler 2012) (Fig. 4).
technique (Del Pizzo et al. 2002, angle of the blade until it is parallel
Wessel & Tatakis 2008). In the fol- to the palatal surface by making
SCTG harvesting from the posterior
lowing, three distinct and obviously repeated distal to mesial movements, lateral palate
frequently applied techniques to mainly with the tip of the scalpel.
harvest SCTGs from the lateral pal- Care must be taken to ensure that The harvesting procedure is carried
ate will be proposed: SCTG har- the flap preparation is not substan- out at the first and second maxillary
vesting from the anterior palate, tially extended more than 10 mm molars and usually contains one hor-
SCTG harvesting from the posterior apical from the cementoenamel junc- izontal and two vertical incisions
lateral palate and SCTG harvesting tion of the maxillary posterior teeth. according to the trap-door approach.
from the lateral palate by obtaining If placed roughly 2 mm from the ce- Depending on the soft tissue thick-
a graft with epithelium correspond- mentoenamel junction, the initial ness at the donor site and the size of
ing to a FGG that is deepithelial- incision can be safely extended api- the graft to be harvested one or in
ized extraorally. In this respect cally to a depth of approximately individual cases even both vertical
ideally those surgical protocols 8 mm without a risk of damaging incisions can be omitted. While the
should be picked out that have sci- the great palatine artery. As the cut- horizontal incision is performed 1
entifically proven to be the presently ting portion of a No. 15 scalpel 2 mm apical of the gingival margin,
best possible treatment options. blade is approximately 8 mm in the two vertical incisions should
However, at the time being it is in length, it can serve as a gauge for extend 1 mm further than the
this context hardly possible to safe graft harvesting on this occa- intended apicocoronal dimension of
choose one approach over the other sion. After that the size of the graft the graft offering access to the apical
one based on scientific evidence. is defined by executing two horizon- incision line in the connective tissue
For this reason, those clinical proce- tal and two vertical incisions inside later on. A split-thickness flap is
dures were selected that seem to the created envelope. They should be then prepared parallel to the external
reflect a contemporary mindset and extended to the bone and overlap at mucosal surface by watching the
presently seem to be based upon intersections. It might be advisable blade working from outside under
sound clinical experience if SCTGs to place the coronal internal incision the flap. By doing so, the goal is to
are harvested from the lateral pal- roughly 1.01.5 mm apical to the ini- create a flap of uniform thickness,
ate. The subsequent SCTG harvest- tial horizontal incision. This ensures whereby the releasing incisions can
ing step by step descriptions are that the access flap will rest on a be used as flap thickness guides.
based on clinical recommendations well-perfused connective tissue sur- Now the horizontal incision of the
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Soft tissue replacement grafts S129
with those in the covering connective data from clinical studies could not during the harvesting procedure. In
tissue. However, the results of ani- reveal more pronounced gingival addition, more recessions could be
mal experiments and controlled clini- inflammation and plaque accumula- treated at the same time if necessary
cal trials indicated that chemical tion if class V restorations made of as the required grafts per recession
root surface demineralization cannot different tooth coloured filling mate- could be comparatively small and
improve wound healing outcomes rials were covered with coronally rather thin. Furthermore, the nutri-
and cannot be considered as benefi- advanced pedicle flaps (Lucchesi tional exchange between wound bed,
cial for root coverage procedures et al. 2007, Santamaria et al. 2008). SCTG and covering flap might be
compared to mechanical biofilm Santamaria and coworkers evalu- improved during the early wound
removal only (Roccuzzo et al. 2002, ated in a RCT the treatment of healing period by this type of grafts
Oates et al. 2003, Cortellini & Pini gingival recessions associated with an aspect that might in particular
Prato 2012). Whether the combina- non-carious cervical lesions by play a role if the covering flap is thin
tion of SCTG and root surface SCTGs with a coronally advanced (Hwang & Wang 2006). In this sense
conditioning with ethylenediamine- flap alone or in combination with Zucchelli and coworkers modified
tetraacetic acid before application of the fabrication of resin-modified position, size and thickness of
enamel matrix derivate (EMD) can glass ionomer restorations. Six SCTGs and recommended the use of
influence the type of attachment on months after surgery there was no about 1 mm thick grafts that were
the root surface after gingival reces- statistically significant difference positioned in a distance apical of the
sion treatment is presently unclear between test and control regarding cementoenamel junction that corre-
and needs further scientific verifica- percentage of root coverage. Fur- sponds to the pre-operative width of
tion (Rasperini et al. 2000, Carnio thermore, no clinical signs of keratinized tissue with a mesiodistal
et al. 2002). The clinical observation inflammation could be detected in extension of the recession width plus
of a so-called creeping attachment both groups. The authors credited 6 mm and an apicocoronal dimen-
which refers to a soft tissue matura- the results with the biocompatibility sion calculated as the distance from
tion process with a certain coronal of the filling material, the well fab- the cementoenamel junction to the
migration of the gingival margin at ricated and polished restorations bone crest minus the pre-operative
SCTG-treated sites over time, cannot and the good compliance and oral height of keratinized gingiva. In a
not be explained at present. (Agudio hygiene of the patients (Santamaria RCT using coronally advanced flaps
et al. 2009, Pini Prato et al. 2010). et al. 2009). in combination with SCTGs for
Two clinical case documentations In gingival recession treatment, recession treatment, the authors
reported on external root resorption the combination of coronally compared the conventional type of
after root coverage with SCTGs advanced flaps and SCTGs is pres- graft with the novel approach.
(Hokett et al. 2002, Carnio et al. ently recommended as the treatment Although differences between the
2003). The fact that this is indeed a modality of choice (Cairo et al. two treatment modalities were not
severe but not a common complica- 2008, Chambrone et al. 2012, Cortel- statistically significant regarding per-
tion after gingival recession treat- lini & Pini Prato 2012), whereas on centage of root coverage, aesthetic
ment might be explained by the the other hand uncertainty exists results and patient-centred outcomes
early formation of a root-protective about the real effect of the graft: were superior with the small dimen-
barrier, namely a new connective tis- Cortellini and coworkers compared sioned and apically positioned graft
sue attachment in the most apical in a RCT coronally advanced flaps (Zucchelli et al. 2003). If for any rea-
part and a long junctional epithe- for gingival recession treatment with son the SCTG failed to anchor the
lium in the more coronal part of the and without the additional applica- overlying flap and undesired flap
treated root surfaces. tion of SCTGs (Cortellini et al. retraction occured during the early
It goes without saying that if 2009). The presence of a SCTG wound healing phase the SCTG
instead of natural roots SCTGs are under the flap was associated with a might, on condition that it is posi-
placed against artificial surfaces of reduced soft tissue contraction dur- tioned at the level of the cemento-
implants or restored teeth new con- ing the early phase of healing lead- enamel junction, act as a protector
nective tissue attachment cannot be ing to a significantly greater amount beyond it and still allow healing by
expected. It can be assumed that of sites completely covered at primary intention and successful
the established type of attachment 6 months. These results can be inter- root coverage. This clinical presump-
is slightly different between restored preted in a way that the presence of tion can be supported by the results
tooth and implant and from mate- a SCTG might stabilize the flap in a of a clinical study by Bouchard and
rial to material, and is character- coronal position and therefore serve coworkers comparing coronally
ized by connective tissue adhesion as an anchor for the covering flap advanced and envelope flaps in com-
and primarily by a long junc- during the initial wound healing per- bination with SCTGs for gingival
tional epithelium (Berglundh et al. iod. A variety of clinical conse- recession treatment (Bouchard et al.
1991, Abrahamsson et al. 1998, quences would follow if this 1994). Although treatment outcomes
Gomes et al. 2005, Martins et al. hypothesis was confirmed: SCTG were similar with respect to root
2007). Although subgingival resto- harvesting for gingival recession coverage a significant increase in
ration margins seem to be detri- treatment would be less demanding keratinized tissue height was surpris-
mental to gingival and periodontal for the surgeon in the majority of ingly observed in both groups. These
health over a long period of time the cases and go along with a findings could be expected in the
(Schatzle et al. 2001), short-term decreased risk of damaging the GPA envelope flap group where the most
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S134 Zuhr et al.
ical studies on volumetric changes Thalmair et al. 2013, Zuhr et al. role. Furthermore, it should be kept
after soft tissue ridge augmentation accepted for publication, Rebele in mind that the risk of graft necro-
procedures with a follow-up period et al. submitted for publication) sis might increase with graft thick-
of 3.5 months (Studer et al. 2000) offers new perspectives in this con- ness (Miller 1985, Borghetti &
and 12 months (Schneider et al. nection: If ongoing progress and Gardella 1990). Besides, those care
2011) presently exist. Studer and development regarding soft tissue should be taken that the blood clot
coworkers compared in a controlled augmentation procedures in plastic between wound bed and trans-
clinical study SCTGs and FGGs for periodontal and implant surgery is planted tissue is post-operatively as
soft tissue ridge augmentation by the goal, to volumetrically evaluate thin as possible to minimize diffu-
quantitative volume assessment. and compare the efficacy and long- sion distance and capillary prolifera-
Impressions were made before treat- term stability of eligible soft tissue tion length, and that the graft is
ment and also at 1 and 3.5 months replacement grafts will be one of the embedded stable and immobile in
after surgery to measure the volume main challenges for the future the recipient site by tension-free flaps
changes on dental casts with a vali- (Fig. 10). and appropriate suturing techniques
dated projection Moire system. Vol- The above-mentioned scientific (Allen & Miller 1989, Pini Prato
umetric assessment after 3.5 months investigations give a deep insight et al. 2000). In this context, a gentle
revealed significantly greater volume into the fundamental physiologic wound compression immediately fol-
gain with SCTGs in comparison to processes and the healing chronology lowing surgery might have a positive
FGGs (Studer et al. 2000). Schneider of free autogenous soft tissue grafts. effect and in-depth patient instruc-
and coworkers evaluated the dimen- In this respect, some factors of clini- tions on post-operative physical rest
sional changes of peri-implant tissues cal relevance can be identified that of the intra-oral wound area might
obtained by hard and soft tissue should be respected to accomplish also play a role.
augmentation. Impressions were successful and predictable treatment
taken before treatment, after implant outcomes if SCTGs are used in plas-
Soft tissue substitutes
placement and guided bone regener- tic periodontal and implant surgery.
ation, after soft tissue augmentation In the first place, the best possible Soft tissue augmentation procedures
with SCTGs, immediately after blood supply from the recipient bed with autogenous grafting materials
crown insertion and 1 year later. and the covering flap should be pro- have significant disadvantages. First
After the cast models were scanned vided for graft survival: incision- and foremost, the amount of avail-
and digitally superimposed, a and flap-design (Mormann & Cian- able tissue is limited and in the
mean buccal tissue gain of 1.27 cio 1977), thickness of the flap majority of clinical situations, a sec-
0.67 mm could be determined after (Hwang & Wang 2006), complete ond surgical site is needed to obtain
the surgical procedures. One year graft coverage (Harris 1994, Studer a sufficient quantity of autograft
after crown insertion, a mean loss of et al. 2000) and an atraumatic surgi- material, which increases the burden
0.04 0.31 mm in the labial direc- cal proceeding (Burkhardt & Lang on the patient and the morbidity of
tion was recorded. Guided bone 2005) seem to play an important the surgical procedure considerably
regeneration conducted more to vol- (Farnoush 1978, Del Pizzo et al.
ume gain than soft tissue grafting. 2002, Griffin et al. 2006, Soileau &
Moreover, in one-third of the Brannon 2006). Against this back-
implants, the soft tissue augmenta- ground, it is quite evident that the
tion did not contribute to the search for suitable soft tissue substi-
increased buccal volume at all tutes is currently at the centre of
(Schneider et al. 2011). Besides that enormous efforts by scientists and
long-term data on volumetric stabil- manufacturers, for the good of the
ity of soft tissue augmentations are patient.
missing completely. This might Yet, the development of adequate
partly be explained by the fact that soft tissue substitutes turns out to be
in the past only very complicated complicated: SCTGs are undoubt-
measurement technologies like the edly considered as the gold standard
optical projection Moire method for soft tissue volume augmentations
used by Studer and coworkers were in plastic periodontal and implant
available (Studer et al. 2000). How- surgery to date. However, the term
ever, the introduction of the afore- gold standard suggests a well-
mentioned recently developed new defined, consistent standard of har-
measuring methods employing three- vesting procedure. However, in fact
dimensional optical scanning and there seems to be no standardized
subsequent virtual superimposing protocol for SCTG removal from
procedures with a previously unfore- Fig. 10. For future research it will be
the palate. As elucidated above dif-
seen precision in the quantitative important to generate more three-dimen- ferent available donor sites and har-
evaluation of volumetric changes sional data after soft tissue augmentation vesting techniques result in
(Windisch et al. 2007, Fickl et al. procedures. Innovative methods using inconsistent types of SCTGs that
2008, Strebel et al. 2009, Thoma digital superimposing of models allow vary in their histological composi-
et al. 2010, Schneider et al. 2011, precise volumetric evaluation. tion potentially influencing their clin-
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
S136 Zuhr et al.
ical characteristics. Furthermore, it and was inferior to the combination 2004, Murata et al. 2008, Aroca
is difficult to develop alternatives to of coronally advanced flap and et al. 2009, Griffin & Cheung 2009).
SCTGs as long as their true impact SCTG (Cairo et al. 2008). Even Carney and coworkers investigated
on successful treatment outcomes is though, in addition, sufficient long- the combined effect of recombinant
not entirely clear. In some indica- term data are missing it needs to be human platelet-derived growth factor
tions the actual role of the graft is stated that the application of acellu- (rhPDGF) applied on ADM, with
obviously the volume increasing lar dermal substitutes seems to be the aim to promote faster re-vascu-
effect, for example. in soft tissue presently widespread and accepted larization of the ADM network
ridge augmentation procedures. In by many clinicians as an approved (Carney et al. 2012). After a 6-
other applications like, for example alternative to SCTGs in gingival month healing period, they found no
in soft tissue recession treatment in recession treatment (Gapski et al. statistically significant differences in
contrast the true nature of the 2005, Cairo et al. 2008, Moslemi the clinical outcomes, showing no
SCTG is as mentioned before et al. 2011, Schlee & Esposito 2011). benefit from adding PDGF to
not quite as clear. As long as the As on the other hand, only few ADM. McGuire and coworkers con-
SCTG is not clearly defined and as short-term observations from clinical ducted a RCT to compare coronally
long as important information case series exist, scientific evidence is advanced flap procedures for gingi-
regarding the true effect of the weak if ADM is supposed to be used val recession treatment through a
SCTG is lacking it will be very diffi- for soft tissue ridge augmentation growth factor-mediated approach
cult to develop substitutes that are procedures (Thoma et al. 2009). with either beta-tricalcium phosphate
supposed to measure up with the Care needs to be taken, moreover, if (b-TCP) + 0.3 mg/ml rhPDGF-BB
current gold standard. Not least on bigger dimensioned grafts are with a bioabsorbable collagen
these grounds it needs to be realized required: Folded or layered ADM wound healing dressing or SCTG.
that for the time being the develop- might impede vascularization and Moreover, recession defects were cre-
ment of SCTG substitute materials lead to extensive shrinkage (Batista ated in six teeth, each requiring
is still in its infancy. et al. 2001, Wei et al. 2002). Ethical extraction for orthodontic therapy,
In principal, three basic soft tis- concerns being an allograft from and treated with the same treatment
sue substitute materials of different human cadavers and the pretended modalities. Nine months after surgi-
origin can be distinguished: alloge- risk of disease transmission are cal correction, en bloc resections
neic (of human origin), xenogeneic remarkable counterpoints of the were obtained and examined
(from another species, e.g. of porcine material frequently subjected by histologically and by the use of
or bovine origin), and alloplastic (of patients. micro-CT. In the RCT, statistically
artificial origin) materials. At the Later on tissue-engineered cellu- significant results favouring the
moment a variety of available prod- lar dermal substitutes, including cel- SCTG were found regarding reces-
ucts are on the market, whereby it lular components and tissue-inducing sion depth reduction 6 months after
needs to be mentioned restrictively substances, came to the centre of sci- surgery. Histologic and microcom-
that only a few of them have proved entific attention. Wilson and puted tomography examination
scientifically documented success. coworkers investigated the safety revealed evidence of new cementum,
In the late 1980s acellular dermal and effectiveness of living human fi- PDL with inserting connective tissue
substitutes were introduced to the broblasts cultivated on polymer scaf- fibres and supporting alveolar bone
dental market. The best-researched folds compared with autogenous in all sites treated with rhPDGF-BB
type is the acellular dermal matrix SCTGs for gingival recession treat- + b-TCP, whereas neither SCTG-
(ADM), an allogeneic substitute that ment (Wilson et al. 2005). The treated site exhibited any signs of
consists of a freeze-dried connective 6-month results were promising with periodontal regeneration (McGuire
tissue matrix, without epithelium no statistically significant differences et al. 2009a).
and cellular components, which is between control and test group. Jha- Recently, xenogeneic soft tissue
obtained from tissue banks by a veri and coworkers, who applied substitutes in the shape of bilayered
standardized, controlled manufactur- autologous fibroblasts on ADM porcine-derived collagen-based
ing process. It contains type I- and scaffolds, found similar outcomes matrices were introduced. Although
III- collagen bundles and elastic compared with SCTGs in their these materials were originally intro-
fibres, which seem to be degraded investigation (Jhaveri et al. 2010). duced to promote keratinized tissue
and replaced by host tissues during Despite these promising findings, the regeneration (Sanz et al. 2009, Her-
the wound healing and integration critical cost-benefit ratio seems to ford et al. 2010, Nevins et al. 2011,
process (Wei et al. 2002, Cummings presently interfere with further Lorenzo et al. 2012), they were sub-
et al. 2005, Scarano et al. 2009). investments in this type of substitute sequently adopted for root coverage
With respect to root coverage proce- material. To what extent in the con- procedures. Clinical outcome mea-
dures, a systematic review by Cairo text of tissue-engineered soft tissue sures were promising in short-term
and coworkers revealed considerable substitutes growth factors in the view and a certain potential for soft
heterogeneity in clinical outcome form of platelet-rich fibrin mem- tissue thickening was observed,
measures after 612 months and branes or platelet-concentrated grafts although a lower percentage of root
concluded that adding ADM to cor- could be applied to replace SCTGs coverage was recorded compared
onally advanced pedicle flaps did not for gingival recession treatment is with coronally advanced flaps in
improve clinical results compared also a matter of current scientific combination with SCTGs (Cardaro-
with coronally advanced flaps alone investigations (Cheung & Griffin poli & Cardaropoli 2009, McGuire
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Soft tissue replacement grafts S137
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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S142 Zuhr et al.
Clinical relevance concerning the use of soft tissue Practical implications: The avail-
Scientific rationale: Soft tissue aug- replacement grafts. able donor sites provide grafts of
mentation procedures are increas- Principal findings: Subepithelial con- distinct shape and composition.
ingly performed in plastic nective tissue grafts are considered Which donor site is chosen depends
periodontal and implant surgery. as gold standard. Many questions on the amount of required tissue
Standardized guidelines regarding regarding graft healing and volumet- and the indication. Harvesting and
donor sites and harvesting tech- ric stability are presently unknown. transplantation procedures should
niques can hardly be given to date, The limited amount of grafting tis- follow certain advices to allow the
but recommendations for predict- sue and the increased patient mor- best healing and tissue integration
able treatment outcomes can be bidity make the search for suitable possible.
developed. The aim was to provide soft tissue substitutes an important
a narrative review of the literature field of future research.
2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd