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Connective Tissue Grafts in se nz
Periodontal Surgery
Sonja Böhm, Dietmar Weng, Jörg Meyle

The application of connective tissue grafts has become a widely accepted therapeutic option in
aesthetically oriented periodontal plastic surgery. The harvesting techniques as well as the fields
of application have changed and further developed since the first description of a free connec-
tive tissue graft three decades ago. This article will provide an overview of techniques for graft
harvesting and its therapeutic use as well as future developments.

Key words: connective tissue graft, periodontal plastic surgery, recession coverage, soft tissue
augmentation

INTRODUCTION HARVESTING TECHNIQUES

The autologous connective tissue graft (CTG) is an The original publication by Edel (1974) not only
indispensable therapeutic tool in mucogingival pe- described the possibility of harvesting a free CTG
riodontal surgery and implantology from the func- but also presented three different harvesting tech-
tional and aesthetic point of view. Since it was first niques:
described by Edel in 1974, the technique has • the palate using a three-sided 'trapdoor' incision
continued to develop steadily in terms of its indica- • from the underside of a mucoperiosteal flap and
tions, usage and harvesting methods. While it • from the crestal area of an edentulous maxillo-
was originally used only to increase the width of mandibular saddle
the keratinised gingiva, its current range of uses
has now expanded to include coverage of gingi- Palatal harvesting in the region between canine
val recessions, soft tissue augmentation in edentu- and first molar has now become established as
lous areas, tissue thickening around teeth and im- the standard procedure and, to enhance postop-
plants and cosmetic measures (papilla reconstruc- erative patient comfort, the graft is usually harvest-
tion, scar correction, etc.). ed from the same side as the recipient area.
With the aid of clinical examples, this article will Periodontal prophylaxis in relation to the teeth ad-
provide an overview of techniques for graft har- jacent to the harvesting area demands a distance
vesting, indications and success rates as well as of 3–4 mm between gingival margin and the first
future prospects relating to possible alternatives to incision along the palatal course of the dental
the free CTG. arch. Other anatomical limitations to connective
tissue harvesting are the area of the palatine ru-
gae (anteriorly), the palatal root of the first molar
(posteriorly) and the neurovascular bundle emerg-

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Fig 1 An incision is made along
the palatal course of the dental
se nz
arch.

Fig 2 The layers of connective

tissue are undermined and sharply
separated from each other.

ing from the greater palatine foramen (medially). publications or as in harvesting techniques involv-
With respect to the form of the palate and the as- ing special scalpels (Langer and Calagna, 1980,
sociated position of the palatine artery, Reiser et al 1982; Langer and Langer, 1985; Raetzke,
(1996) identify three possible anatomical variants 1985; Harris, 1992). Primary wound healing in
of the palatal arch: flat, normal or high. Based on the donor area is no longer possible after harvest-
measurements of the arch, the neurovascular bun- ing of a CTG with an epithelial strip because of
dle is located at a distance of 7, 12 or 17 mm the rigidity of the palatal tissue, which means
from the adjacent teeth according to this classifica- greater postoperative discomfort (re-bleeds, pain)
tion. An adequate distance from these structures for the patient. Attempts are often made to relieve
should be maintained in order to avoid intra-oper- this discomfort with additional measures, such as
ative bleeding. This is easier to do because the wound plates or haemostatics (Seibert, 1983;
neurovascular bundle lies in a shallow channel. Langer and Langer, 1985; Harris, 1997).
Once the harvesting area is decided, there are If an epithelial strip is not harvested with the graft,
various possible types of incision that will provide access can be achieved with one (single-incision
access to the subepithelial connective tissue. A de- technique), two (angular-incision technique) or
cisive factor initially is whether or not a strip of ep- three (trapdoor technique) incisions. The more inci-
ithelium is to be removed along with the graft. sions that are made in the particular technique, the
Leaving an epithelial strip on the graft was origi- wider the view of the underlying connective tissue,
nally intended to provide a better transition to the but the more the blood supply to the covering flap
existing epithelial border when treating recessions is reduced, which can lead to postoperative
(Langer and Langer, 1985, 1993). It was found, necrosis of the overlying flap (Edel, 1974;
however, that the presence of a band of epitheli- Mörmann and Ciancio, 1977; Harris, 1994,
um made no difference to the aesthetic end-result 1997).
and the outcome merely depended on the grafted Recent approaches to connective tissue harvesting
connective tissue not necrotising on the root sur- favour a single-incision technique (Hürzeler and
face (Bouchard et al, 1994). As the covering ep- Weng, 1999). The procedure, similar to the har-
ithelium necrotises anyway within the first 5 days vesting of a free mucosal graft, involves starting
(Oliver et al, 1968; Lange and Bernimoulin, from a single incision along the gingival margin
1974), the underlying connective tissue will deter- (Fig 1) to a layer thickness of 1–1.5 mm and un-
mine the nature, shape and colour of the newly dermining to sharply separate the connective tis-
formed epithelium (Karring et al, 1975). For all in- sue layers from each other (Fig 2). After prepara-
dications where the CTG is completely covered tion, the deep-lying connective tissue is separated
by the overlying flap of the recipient bed, the ep- from its surroundings by incisions reaching to the
ithelium included in the graft must already be re- bone and is detached from the bone with a pe-
moved beforehand. In terms of practicability, it riosteal elevator (Fig 3). After removal of the con-
therefore does not make sense to leave an epithe- nective tissue, the harvesting site is closed with
lial strip on the CTG, as recommended in earlier horizontal compression sutures (Fig 4).

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Fig 3 The connective tissue graft
is detached from the bone with a
se nz
periosteal elevator.

Fig 4 Wound closure with

horizontal compression sutures.

The advantages of the single-incision technique lie If a CTG is used to cover the recession and the
in optimal vascularisation of the cover flap, a small gingival flap is positioned over it, this raises the
number of sutures, no necessity for additional question of how much the CTG fixed onto the
haemostatic or compressive measures, primary cleaned root surface will bring about genuine pe-
and hence relatively painless wound healing and riodontal regeneration and will not merely pro-
the possibility of obtaining grafts of variable di- duce a long junctional epithelium. It is known from
mensions. the literature that a long junctional epithelium forms
on recessions that are covered with laterally or
coronally displaced gingival flaps and that any
INDICATIONS AND SCIENTIFIC periodontal regeneration remains confined to the
BACKGROUND apical and lateral defect borders (Wilderman and
Wentz, 1965; Caffesse et al, 1984; Gotlow et
Autologous connective tissue grafts are firmly es- al, 1986). Nevertheless, how does it behave if a
tablished in aesthetically oriented, periodontal connective tissue graft is placed under the gingival
mucogingival plastic surgery. Particularly with re- flap?
gard to coverage of gingival recessions, it has In a study on the beagle dog, Weng et al (1998)
now become the treatment of choice alongside showed that, after a 9.6 mm long, surgically
techniques that use periodontal membranes. produced, chronic recession defect was treated
Depending on the nature of the recession, various with a connective tissue graft over a distance of
techniques are used; the common factors are fix- 5.5 mm, new connective tissue attachment (equiv-
ation of the CTG onto the root surface to be cov- alent to 57% of the defect length) was able to de-
ered and the complete or partial coverage of the velop. In various case reports involving human his-
CTG with a gingival flap displaced from apically tology analysis (Harris, 1999a; Goldstein et al,
or laterally (Figs 5 to 10). 2001), regenerated bone, cement and attach-
However, the decision on whether a CTG or a ment developed under an autologous CTG. On
barrier membrane is used for recession coverage the other hand, Harris (1999b) published a case
should also be based on biological considera- study on a human biopsy after recession coverage
tions: if a membrane is placed over a denuded with a CTG, in which no regeneration occurred
root surface, the aim is not merely to cover the re- on the root surface. Therefore the question arises
cession by means of the coronally displaced gin- of whether the presence of periosteum on the un-
gival flap positioned over it. The biological effect derside of a CTG may have an influence on the
of the membrane is also intended to bring about regenerative outcome.
periodontal regeneration on the formerly exposed While accepted opinion often describes the pe-
root surface. New periodontal connective tissue riosteum as 'the best membrane', studies from as
attachment and, if possible, formation of new buc- early as the 1970s (Melcher, 1969, 1971;
cal alveolar bone are the intended goal of mem- Melcher and Accursi, 1971) show that the perios-
brane application. teum has no regenerative potential after being de-

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Fig 5 Harvested connective tissue graft. Fig 6 Condition before recession coverage on teeth 12
and 13.

Fig 7 View of the recipient bed with periosteum and Fig 8 Fixation of the connective tissue graft onto the sur-
mucosal flap left in place. face to be covered.

Fig 9 Suturing and complete coverage of the connective Fig 10 Situation 3 months after recession coverage on
tissue graft with a gingival flap displaced from apically. teeth 12 and 13.

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buccal side in order to compensate fort eashorizon-

i
tached from the bone surface. The reason is that se nz
the regenerative potential of periosteum lies in tal ridge defect and the creation of support in
what is known as the cambium layer. This layer pontic areas. By means of undermining, sharp
becomes thinner with advancing age and in preparation of the soft tissue, a cavity or pocket is
adults is made up of a single-cell layer of progen- created into which the CTG is placed and fixed
itor cells. The mechanical trauma of detaching the with sutures.
periosteum from the bone already destroys this Whereas in the past a CTG would have been in-
cell layer, calling into question the membrane func- serted after blunt preparation of a mucoperiosteal
tion of the periosteum. In an animal experiment flap between bone and periosteum, nowadays a
(Weng et al, 2000) it was shown in the monkey split-flap preparation in the recipient area is in-
model that the bone regeneration potential of pe- creasingly preferred because the augmented area
riosteum-covered cavities is markedly lower than is more likely to be covered as a result of the
that of membrane-covered cavities. This suggests greater flap mobility. With both techniques, how-
that, once it has been detached from the bone in ever, the CTG can be covered either entirely or
adult patients, periosteum should be regarded as partly by the overlying flap. Early contouring of
a simple connective tissue from the regenerative the grafted connective tissue is advisable in order
point of view. At most, there is likely to be greater to achieve improvements at the periodontal-
regenerative potential in young patients where the restorative interface (Figs 11 to 15). The question
cambium layer comprises several layers of progen- of the long-term stability of this kind of purely soft-
itor cells lying on top of each other. In view of the tissue augmentation is not entirely resolved in the
literature quoted above, whether the periosteum literature. As the newly created soft tissue struc-
layer should be left on the CTG or the periosteum tures are often supported by prosthetic elements,
should be directed towards the tooth or the gingi- reference should be made to two publications
val flap is no longer decisive and is rather second- which show that soft tissue supports under pontics
ary in relation to the regenerative outcome of re- can be kept inflammation-free and volume-stable
cession coverage. in the long term (Studer et al, 2000; Zitzmann,
Bearing in mind the issue of regeneration, it is ac- 2002).
ceptable to use a connective tissue graft to cover a Another application for connective tissue grafts is
gingival recession (distinct from coronal or lateral soft tissue thickening on the buccal side of teeth and
displacement without a CTG). Despite contradicto- implants (Azzi et al, 2002). Where the gingiva is
ry case reports, this is acceptable provided it is at thin or in the case of peri-implant mucosa, avital
least clear that a pure displacement technique with- roots and titanium implants in the marginal area
out CTG would only produce a long area of junc- can be seen through the mucosal covering and im-
tional epithelium on the side of the flap facing the pair the aesthetic end-result around the periodontal-
root surface. If the main focus is turned away from restorative interface. As a simple corrective meas-
the regenerative outcome to the aesthetic end-result ure, a micro-scalpel is used to prepare a subepithe-
in terms of the percentage coverage achieved, lial pocket on the buccal side affected. The CTG
treatment with a CTG proves superior to the mem- harvested from the palate is then drawn into the pre-
brane technique, according to a recent systematic pared pocket with the aid of a guide stitch and
meta-analysis by Roccuzzo et al (2002). fixed in the desired final position (Figs 16 to 18).
The use of connective tissue grafts for soft tissue With this technique, part of the connective tissue
augmentation and contouring of alveolar ridge graft can be left outside the pocket, if required.
defects is indicated if build-up of the deficient
area with hard tissue is not possible or undesir-
able. This mostly concerns ridge defects of small- ALTERNATIVES/FUTURE PROSPECTS:
er dimensions where the amount of surgical work TISSUE ENGINEERING
involved, time spent and financial cost bear no re-
lation to the required end-result (Langer and The harvesting area, as a secondary operation
Calagna, 1980; Garber and Rosenberg, 1981; site, is still the greatest disadvantage of connective
Breault et al, 1999; Gasparini, 2004). Prominent tissue grafting. As the harvesting site is usually
indications are soft tissue augmentation on the more painful than the recipient site postoperative-

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Fig 11 Horizontal ridge defect in the pontic area with Fig 12 Connective tissue graft harvested from the
concave profile. palate.

Fig 13 The connective tissue graft is placed under the Fig 14 Occlusal view of the convex pontic area re-
split-skin flap. shaped by the connective tissue graft, 3 months after
grafting.

ly, a replacement material for a CTG that could do al graft, but not as a volume-producing replace-
without a second operation site would also be de- ment for dense connective tissue from the palatal
sirable from the psychological point of view of the region. However, these approaches are basically
patient. very promising and may be transferable to other
One approach moving in this direction is the cul- types of soft tissue in the future.
turing and in vitro growing of autologous epithelial Another replacement for connective tissue is
cells (BioSeed-S) (Lauer, 1994; Lauer and known from the USA, which is obtained from allo-
Schimming, 2002; Lauer et al, 2003). After mini- geneic skin material (AlloDerm) in a similar way to
mal tissue removal, this involves growing epithelial demineralised, freeze-dried bone. The skin prod-
cells over a period of two to three weeks, which uct originating from burns medicine can be used
can then be inserted into the wound/recipient as a direct volume replacement for connective tis-
area. As the growing of cells has so far concen- sue grafts. The laboratory preparation of the prod-
trated on the epithelial area, such cell cultures are uct guarantees the removal of any cell remnants,
in fact suitable as a replacement for a free mucos- in other words all that remains of the part of skin

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Fig 15 Situation 3 months after
soft tissue augmentation with all- se nz
ceramic bonded bridge inserted.

Fig 16 The thin buccal mucosa in Fig 17 A connective tissue graft is Fig 18 Situation 6 months after
the area of the emergence profile inserted and fixed into the sharply placement of the connective tissue
allows the neck of the implant to prepared pocket. Part of the CTG graft and after final all-ceramic
show through as a dark area. protrudes beyond the mucosal mar- restoration of the single-tooth im-
gin. plant in region 23.

originally incorporating epithelium and dermis are free mucosal graft (widening the keratinised gin-
the basement membrane and all the non-cellular giva/mucosa, vestibuloplasty). Initial case studies
elements of the dermis. As a result, the antigenic and comparative studies are extremely promising
component of the material is removed, so that it as far as the aesthetic and functional end-result is
can be biologically tolerated. The use of this prod- concerned (Callan and Silverstein, 1998; Harris,
uct extends to all the indication areas covered by 1998; Silverstein and Duarte, 1998; Peacock et
connective tissue grafting (recession coverage, soft al, 1999; Silverstein et al, 1999; Tal, 1999;
tissue augmentation) but also to classic uses for a Harris, 2000; Wei et al, 2000; Mahn, 2003).

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