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   Table of Contents    
Year : 2019  |  Volume : 23  |  Issue : 5  |  Page : 395-408  

44-year journey of palatal connective tissue graft harvest: A narrative review

1 Department of Periodontology, Institute of Dental Studies and Technologies, Modinagar, Ghaziabad, Uttar Pradesh, India
2 Department of Periodontology, Aditya Dental College, Beed, Maharashtra, India

Date of Submission27-Apr-2018
Date of Acceptance11-Dec-2018
Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. Komal Puri
AK-93, Shalimar Bagh, Delhi - 110 088
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_288_18

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Connective tissue graft (CTG) is considered the gold standard for soft-tissue correction and augmentation surgeries, but involves a secondary donor area and its associated complications. The techniques to harvest CTG have undergone a large number of modifications over a period of 44 years since the time it was introduced by Edel in 1974 to increase the width of keratinized gingiva. This review compiles all the techniques of graft harvest from the palate and their modifications which have been introduced in the last 44 years till date. This review is based on systematic reviews, comparative human studies, and case reports describing any new technique of graft harvest. Publications till April 2018 were selected and further reviewed. In addition, specific related journals and books were searched upon. In order to minimize the pain, bleeding, and morbidity associated with donor site, several researchers proposed harvesting of the connective tissue by means of different techniques, each precisely different from others in terms of design, incisions, and procedure of harvest. Although the latest techniques are minimally invasive with reduced incision lines, less compromised blood supply, accelerated healing, and no sloughing of the overlying flap, they are technique sensitive which requires higher expertise to execute.

Keywords: Connective tissue, gingival recession, graft, palate, plastic surgery

How to cite this article:
Puri K, Kumar A, Khatri M, Bansal M, Rehan M, Siddeshappa ST. 44-year journey of palatal connective tissue graft harvest: A narrative review. J Indian Soc Periodontol 2019;23:395-408

How to cite this URL:
Puri K, Kumar A, Khatri M, Bansal M, Rehan M, Siddeshappa ST. 44-year journey of palatal connective tissue graft harvest: A narrative review. J Indian Soc Periodontol [serial online] 2019 [cited 2022 Aug 15];23:395-408. Available from:

   Introduction Top

Over the last few years, connective tissue graft (CTG) has become a reliable treatment modality for increasing the width of keratinized gingiva,[1] root coverage,[2],[3],[4] treatment of furcation,[5],[6] alveolar ridge deficiencies,[7],[8],[9],[10] management of peri-implant tissue abnormalities,[11],[12] and papillary loss.[13] In dentistry, Alan Edel first delineated CTG in 1974 for increasing the width of gingiva and since then its functions have increased tremendously.

Currently, for most of the soft-tissue augmentation surgeries, it is still deemed as the gold standard treatment.[14],[15] Contemplating the confronts of soft-tissue augmentation techniques in periodontal plastic and implant surgery presently, free gingival graft has subsequently disappeared from the esthetic region, and its scope of use has been narrowed down to procedures increasing the keratinized tissue around teeth and implants in esthetically insignificant zones.[16] In 2010, a Cochrane systematic review has stated that, in cases where gain in keratinized tissue and root coverage is anticipated, the use of CTGs seems to be more adequate than others, which was also supported by Chambrone and Tatakis in their systematic review who stated that subepithelial CTG provided the best outcomes for clinical practice because of its greater percentages of mean and complete root coverage and also significant increase of keratinized tissue.[17],[18] Buti et al. in a meta-analysis also stated that coronally advanced flap + CTG might be contemplated as the gold standard in root coverage procedures.[19]

This can be attributed to bi-laminar vascular environment created from both the periodontal plexus and the overlying flap that nourishes the graft and after 2 weeks leads to a comprehensive blood supply for the graft.[20] Furthermore, connective tissue provides a morphogenetic stimuli favoring histodifferentiation as it possesses regional specificity.[21],[22]

The procedure of harvesting the CTG from the palate is often associated with the noteworthy challenge of procurement of the largest volume of tissue possible while minimizing associated trauma, postoperative pain, and the risk of complications at the same time.[16] To meet these requirements and overcome the challenges, various modifications of CTG harvest have been proposed till date. Broadly, they can be subdivided into techniques with or without vertical incisions and techniques that provide CTGs with or without a remaining collar of keratinized epithelium, with the first incision being partial thickness or full thickness [Table 1].
Table 1: Connective tissue graft harvest techniques

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The review aims to concise and simplify various CTG harvest techniques and their modifications, each precisely different from others in terms of design, incisions, and procedure of harvest.

   Surgical Considerations and Graft Harvesting Techniques Top

Harvesting of the CTG, though a simple approach, is technique sensitive and requires a thorough knowledge and evaluation of the palatal donor site to avoid any undesired complications.

Anatomical considerations of the palate

Variations in the anatomy (size and shape) of the palate may affect the proportion of graft harvested, and also the position of the greater palatine nerve and vessel must be known before planning any palatal surgery.[40] The entry of greater and lesser palatine nerves and vessels on the palate occurs through their respective palatine foramina and they course anteriorly within a bony groove. The groove depicts the maximum apical (superior) placement of the incision that is possible before violating the neurovascular bundle. Depending on the distance between neurovascular bundle and cementoenamel junction, Reiser et al.[40] classified palatal vault into shallow (flat) (7 mm), average (12 mm), and high (U shaped) (17 mm). The shallower the palatal vault, the closer the palatine artery gets to the palatal gingival margin. Care must be taken not to violate the neurovascular bundle when obtaining the donor tissue, particularly when the palate is shallow. Incisions should be restricted to the distal surface of canine to avoid greater palatine nerve and artery as they descent closer to the cementoenamel junction in the anterior area and persist approximately 2 mm from the margin of the gingiva.[40]

Monnet-Corti et al., 2006,[41] contradicted the relationship between the palatal vault anatomy and the resultant risk for the vessels. They reported that it is feasible to withdraw CTG of 5 mm height in 100% of the cases and 8 mm height in 93% of the cases in the premolar area. Previous authors studying masticatory mucosal thickness had shown that the first molar's palatal root represented as an obstacle in the harvesting of graft.[42],[43] Palatal mucosa of the distal aspect of canine till the mesial aspect of the first molar was agreed upon as the useful donor site, but transgingival probing should be done presurgically to determine the presence of 3 mm of donor tissue thickness.[3]

Apart from these anatomical considerations, there may be other confounding factors that influence the palatal submucosal thickness which need to be considered before harvesting CTG, such as genetic factors, age, and body weight.[44],[45] On investigation, the palatal mucosa of the younger age group was thinner than that of the older group, which might be because the thickness of the ortho keratinized epithelial layer of the hard palate mucosa increases with age, resulting in the palatal mucosa that is seen in older individuals. It might also be due to gingival tissue which is found to become more coarse and dense with age.[46] Furthermore, palatal mucosal thickness was found to be more in males as compared to females,[44],[45] but in contrast, a study done by Schacher et al.[47] stated that females had thicker mucosa than males and reasoned out that thickness depends on body mass. The effect of the body mass index on palatal mucosal thickness was investigated, and it has shown positive results as increase in body weight makes an effect on the amount of adipose tissue present in the palatal submucosal layer, which results in an increased thickness of the palatal mucosa.[48]

Why palate is the routinely used donor site?

CTG can be procured from the edentulous ridges, maxillary tuberosity, and palate, with palate being the most frequently used donor site due to the large dimensions of graft that could be obtained and also the presence of histological similarity between the palatal mucosa and keratinized attached mucosa of alveolar ridge.[40]

Classification of incision design

Liu and Weisgold proposed a categorization of design of incisions on the palatal donor site depending on the anatomy of palatal vault (shallow/average/high), size of graft required, existence of exostosis, postsurgical discomfort, wound healing (primary/secondary intention), blood supply, requirement of sutures/stents/hemostatic agents, and visibility to decide the most appropriate incision design for graft harvest. The classification includes [Figure 1]:[49]
Figure 1: Liu and Weisgold's classification of incision lines. a,b: Class I; c,d: Class II; e,f: Class III

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  1. Class I: One incision line
  2. Class II: Two incision lines (L shape)
  3. Class III: Three incision lines (U shape).

Subclassification includes (horizontal incision):

  1. Type A: One horizontal incision
  2. Type B: Two horizontal incisions.

Connective tissue graft harvesting techniques

[Table 1] and [Table 2] enumerate CTG harvesting techniques till date.
Table 2: Advantages and disadvantages of connective tissue graft harvest techniques

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Edel in 1974 pioneered the use of CTG for increasing the width of keratinized gingiva and described three methods of graft harvesting: two from palatal region opposite to the molar tooth and one from saddle region between teeth.[1]

In Edel's first palatal technique, a number 15 Swann Morton blade was used to give one horizontal and two vertical incisions and raise a partial-thickness trapezoidal flap. Thereafter, a secondary connective tissue flap was reflected and was dissected at its base using a horizontal incision. The primary flap was repositioned, and interrupted sutures were given. No periodontal dressing was applied [Figure 2] and [Figure 3].
Figure 2: Line diagram of Edel's first trapdoor technique. a:Incision; b: partial thickness flap raised; c: underlying graft harvested using full thickness incisions

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Figure 3: Clinical photographs of Edel's first trapdoor technique. a: One horizontal and two vertical incisions; b: Partial thickness flap reflected; c: Harvested graft

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In the second palatal technique, a full-thickness flap was reflected, and a second incision was made internally to obtain graft from this reflected flap. The palatal flap was then replaced and sutured. Periodontal dressing was provided if required [Figure 4].
Figure 4: Line diagram of Edel's second trapdoor technique. a,b: One horizontal and two vertical incisions till crest of bone; c: Full thickness trapezoidal flap reflected and another incision given in reflected flap to obtain graft

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Broome and Taggart in 1976 compared two cases of connective tissue harvest using Brasher–Rees knife [Figure 5].[27]
Figure 5: Line diagram of Broome and Taggart's technique

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In the first case, a similar technique to Edel's first technique [1] was used, but with the base of the flap at the distal aspect of the palate and use of a Brasher–Rees knife to reflect and incise the connective tissue. The primary flap was repositioned and sutured. In the second case, similar to Edel's technique, primary horizontally displaced flap was reflected, but Brasher–Rees knife was used to obtain CTG. The palatal flap was sutured back and no dressing was used.

The authors stated that reflecting a flap with a wider base minimizes the postoperative discomfort and also reduces the healing time due to optimal vascular supply being present. Furthermore, Brasher–Rees knife has a straight handle with a curved blade due to which adequate amount of CTG can be obtained.

Thereafter, Langer and Calagna in 1980/1982 proposed two CTG harvest procedures (depending on the presence or absence of periodontal pockets on palatal donor site) for the correction of depression in the residual alveolar ridge and uneven gingival margins.[7],[8]

In case of the presence of pockets, an internally beveled flap was elevated. Collar of the connective tissue comprising the pocket wall and remaining on the bone after reflection of the internally beveled flap was used as the donor material. The overlying epithelium was removed with tissue rongeurs, scalpel, or electrosurgical tip [Figure 6]a.
Figure 6: Langer and Calagna's technique. a:In case of pockets on palatal aspect, submarginal incisions made for reflection of internal beveled flap; b: In case no pockets are present on palatal aspect, parallel incisions connected by vertical incisions given; c: Sagittal view of palatal incisions to obtain connective tissue graft with island of epithelium

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In cases where no periodontal pockets were present, two vertical and two horizontal parallel incisions were given. The first horizontal incision: 4–5 mm apical to the palatal gingival margin to reflect an internally beveled flap, leaving a layer of the connective tissue on the bone and the second horizontal incision: 1–2 mm coronal to the first incision but at least 1 mm submarginally to prevent recession at donor site. This latter incision was beveled apically toward the bone in order to leave the base of the connective tissue on the coronal margin after graft harvest to act as a base for the margin of original flap. The connective tissue lying over the bone (with epithelial collar) was dissected. The donor site was sutured [Figure 6]b and [Figure 6]c.

Donor tissue taken for root coverage was same as that for augmentation procedure, but the epithelial collar was retained which was placed external to the recipient flap.

Langer and Langer proposed the same procedure for recession coverage.[2]

Raetzke in 1985 proposed an envelope flap in which two convergent horizontal incisions were made at a distance of 1–2 mm such that the length of incisions was double the width of recession. They intersect deep within the palate and converge just short of the bone. CTG with an epithelial collar was dissected. Flap was sutured back [Figure 7].[23]
Figure 7: Raetzke's technique. a,b: Two incisions 1-2mm apart carried to depth of palatal mucosa, where they converge just short of bone; c: A wedge of tissue with epithelium at its edge is dissected

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In 1992, Harris proposed two techniques: Parallel incisions and use of graft knife to procure CTG [Figure 8].[3]
Figure 8: Harris's technique. a: 1) Parallel incisions using scalpel with parallel blades, 2) Trap door with distal base; b) Scalpel with parallel blades; c) Unigraft knife

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In technique using parallel incisions, a scalpel with 1.5 mm apart parallel blades (H and H Company, Ontario, CA, USA) was used to make two parallel horizontal incisions with approximately 2 mm distance from the gingival margin. These incisions were extended 10–12 mm medially into the palate. After that, mesial, distal, and medial edges between the parallel incisions were incised to procure a uniform, thick CTG, with an epithelial border (which was later discarded). Palatal wound was sutured back.

In the second technique, a Unigraft knife from Ace Surgical Supplies (ACE Surgical Supply Co., Inc., Brockton, MA) was used in order to obtain uniform 1.5 mm-thick CTG. This knife can be reassembled to be used in both pulling and pushing directions. For the first incision and elevation of partial-thickness trapdoor flap, knife was assembled with a cutting shoe reversed so that the cutting shoe would cut in a pushing direction, with the base of the flap present at the distal edge. Thereafter, in order to obtain CTG, the knife (assembled again in conventional pulling motion) was pulled mesially starting from the distal edge and was procured by incising the mesial edge of the graft. Primary flap was sutured back.

Bruno in 1994 proposed another technique in which an initial incision was made 2–3 mm apical to gingival margin on the palatal surface, at 90° to the long axis of the teeth till the bone, with its length corresponding to the graft desired. Thereafter, depending on the thickness required, a second incision was made 1–2 mm apical to the first incision, parallel to the long axis of the teeth, and was carried medially depending on the height of graft required. Full-thickness flap was reflected using only periosteal elevator. Sutures were used to approximate palatal wound. Epithelial collar may or may not be retained [Figure 9].[28]
Figure 9: Bruno's technique. a: Double incision technique; b: First incision perpendicular to long axis of teeth. Second incision parallel to long axis of teeth 1-2mm apical to first incision; c: Periosteal elevator used to raise full thickness periosteal connective tissue graft

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In 1999, Hürzeler and Weng gave another technique, according to which, depending on the required graft size, one horizontal incision was made 2 mm away from the gingival margin, perpendicular to the long axis of teeth. Thereafter, through the incision made, blade was angled to approximately 135°, and an undermining dissection toward the median was done. Advancing ahead along the incision line and preventing any tissue perforation, the angle of blade was progressively flattened to nearly parallel position to the bone surface and a split-thickness flap was reflected. The graft was then removed by detaching it from the bony surface with a periosteal elevator and making incisions on the medial, mesial, distal surfaces till the bone. Use of only one incision with no epithelium removed facilitates the readaptation of the separated tissue. The 90° angle of the blade to the bone during the first incision created butt joints. Donor site was sutured and no periodontal dressing was placed [Figure 10].[4]
Figure 10: Hürzeler and Weng's technique. a: Full thickness incision (90 degrees); b: Through first incision undermining preparation towards median (135 degrees); c: Sagittal view of palatal incisions; d: Periosteal elevator used to detach graft from bone surface after making incision to bone on all sides of graft

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Lorenzana and Allen in 2000 in their innovation stated that using a number 15 blade, one horizontal incision was made perpendicular to the bone around 2–3 mm apical to the gingival margin on the palate depending on the desired graft size. Through this incision, a split-thickness flap was then elevated by incising parallel to long axis of teeth. Thereafter, connective tissue along with periosteum was raised using a small Molt or Buser elevator (Hu-Friedy). Careful manipulation of the graft with Corn suture pliers (Hu-Friedy) or other delicate tissue forceps may be required, but compression or tearing of the graft should be avoided. Palatal wound was sutured [Figure 11].[29]
Figure 11: Lorenzana and Allen's technique. a: Full thickness single incision; b: Partial thickness dissection made within the single incision; c: Graft harvested using periosteal elevator

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Del Pizzo et al. in 2002 proposed a technique similar to Lorenzana and Allen.[29] In this, after reflecting split-thickness flap, when the connective tissue is adhered to the bone, a deep sharp dissection through first incision, but parallel to second incision, was made to dissect the graft from the underlying bone. Periosteum was not removed along with connective tissue [Figure 12], as it aids in granulation tissue formation and hastens wound healing.[26]
Figure 12: Del Pizzo et al's. technique. a: Single incision technique; b: First incision perpendicular to long axis and extending completely till bone; c: Through the first incision, second incision parallel to long axis made leaving graft attached to bone surface; d: Through the first incision third incision parallel to second incision made leaving periosteum attached to bone to dissect graft

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Zucchelli et al. in 2003[24] studied about bilaminar techniques for the treatment of recession-type defects in which they used Harris 1992[3] trapdoor technique of graft harvest, but in patients in whom they encountered unfavorable palatal anatomic conditions, an epithelized free gingival graft was obtained from palate which was deepithelized extra orally before securing it at the recipient site. Thereafter, in 2010, Zucchelli et al. compared the patient morbidity and root coverage outcomes of a coronally advanced flap with CTG and de-epithelialized gingival grafts. To obtain de-epithelized graft, two horizontal and two vertical 1.0–1.5 mm-deep incisions were given according to the required size, perpendicular to the surface. Then, the blade was rotated to be almost parallel to the mucosal surface and moved apically as far as required. Free epithelial graft (FGG) of uniform thickness was mobilized being 0.5 mm thicker than actually needed. The graft was then positioned on a sterile gauze, moistened with a saline solution, and de-epithelialized with a sharp scalpel blade held parallel to the external graft surface.[25]

In 2004 Cetiner, Bodur, and Uraz proposed an “expanded mesh CTG technique” to dissolve the drawback of limited supply and avoid another/extensive surgery for obtaining larger graft. Trapdoor technique was used to procure CTG. After harvesting the graft, alternating incisions were given to enlarge the mesh graft up to 1.5 times greater than the one obtained [Figure 13].[37]
Figure 13: Cetiner et al's. technique

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Bosco and Bosco in 2007 proposed yet another technique to harvest graft from “thin” palate. A template of desired size was placed on the palate and an incision approximately 1.5-mm deep was given using a number 15 blade following the outline of template, similar to harvesting a free gingival graft. Keeping the periosteum intact, a uniform thickness graft was obtained. Graft was placed on sterile cloth or gauze soaked in saline and was bisected using number 15 blade into two halves – one containing epithelium and a layer of connective tissue and other containing only connective tissue. The epithelized graft was repositioned at the donor area and compressed with wet gauze to remove any dead space. Sutures may be given or if the graft gets stabilized only periodontal pack can be given [Figure 14].[30]
Figure 14: Bosco and Bosco's technique

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Ribeiro et al. in 2008 also developed a “single-incision technique” to harvest CTG. A thick graft of maximum size was procured, so that it could be split. Thereafter, it was placed on a sterile glass slab and immobilized using a sterile wooden spatula. The graft was split crosssectionally with number 15 blade, but not divided completely into two parts, resulting in the graft almost twice the length of the initial graft and a thickness of 1.5 mm.[35]

Thereafter, McLeod et al., 2009, introduced a graft harvest technique for the treatment of multiple teeth with root exposure. A sharp back-action chisel/gingivectomy knife/surgical bur or stone was used to de-epithelialize palatal donor area, which was confirmed by the appearance of uniform and generalized bleeding. After de-epithelialization, 1 mm-thick CTG was harvested similar to free gingival graft technique [Figure 15]. They advised that width of the CTG should not be > 7–10 mm, as more bulk may make advancement of the primary flap and achieving primary closure difficult. Large grafts can be sectioned into two or three 7-mm pieces to treat multiple areas of gingival recession. They also recommended boundaries for graft removal: 5 mm from the mid-palatal suture, 5 mm apical to the depth of the lingual sulci of the teeth, posteriorly, till the distal aspect of second molar and anteriorly, till the lateral incisor.[34]
Figure 15: McLeod et al's. technique. a: Back action chisel to deepithelialize donor site; b: Removal of graft using no. 15 blade

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Stimmelmayr et al., 2010, proposed an “epithelized-subepithelial CTG” for extraction cases.[50] Stimmelmayr et al., 2011, developed a similar technique to be used in tunnel technique of recession coverage. Template of desired graft size was measured and transferred to the palate. For outlining the epithelialized component of the graft, a 1-mm deep incision perpendicular to palatal surface was made, which was extended horizontally mesially and distally by 1-mm deep releasing incisions. Thereafter, elevation of the split-thickness flap toward the midline was done, and the exposed graft was outlined with incision directed toward the bone. After that, a partial-thickness flap parallel to the palatal bone was raised to harvest the graft without periosteum [Figure 16]. Suturing of the palatal wound was done.[31]
Figure 16: Stimmelmayr et al's. technique. a: 1-mm deep incision perpendicular to palatal surface for outlining epithelialized component of graft, extending it mesially and distally by horizontal releasing incisions; b: Split thickness flap raised and a combined epithelized-subepithelial connective tissue graft harvested

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Ramakrishnan et al. in 2011 proposed an “epithelial embossed CTG” for root coverage. Template of required graft size was placed on the donor site. Incision was made around the template and also extended 3 mm close to the gingival margin on either side. Thereafter, epithelium was undermined 3 mm from the incision made around template on all the sides. Releasing incision was given to separate the connective tissue of the surrounding 3 mm. Then, the graft was harvested which had connective tissue on all the sides, and the center region was embossed with epithelium that matched the defect exactly [Figure 17].[39]
Figure 17: Ramakrishnan et al's. technique (permission obtained to reproduce figure). a: Template placed at donor site and incisions outlined; b: Donor site after graft harvest; c: Epithelium embossed connective tissue graft

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In 2013, Kumar et al. amended Hürzeler and Weng's [4] technique and proposed a “modified single incision technique” for graft harvest. A single horizontal incision (depending on required graft size) was made using number 15 blade to raise a partial-thickness flap by placing the blade parallel to long axis of teeth. Through the first incision made, the blade was positioned at 90° to the palate, and an incision directed to the bone was made. Thereafter, elevation of the connective tissue from the underlying bone was done using periosteal elevator and then to procure graft, incisions on medial, mesial, and distal ends of the graft were made with the help of special blades such as “AVS blade” (medial incision) and “Barraquer cataract knives” (mesial and distal incisions). Donor site was sutured, and periodontal pack was placed [Figure 18] and [Figure 19].[38]
Figure 18: Line diagram of Kumar et al's. technique. a: Partial thickness first incision parallel to long axis of tooth; b: Through the first incision second incision perpendicular to long axis of tooth is given till bone

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Figure 19: Kumar et al's. technique (permission obtained to reproduce figure). a: Three incisions under partial thickness flap to harvest graft; b: Barraquer cataract knife and AVS instrument

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Reino et al. in 2013 proposed another single incision technique for CTG harvest from palate in which periosteum was left on the underlying bone. The purpose was to control the thickness of the harvested graft and decrease patient discomfort or morbidity. On the palatal surface, using number 15 blade, one horizontal incision (depending on the required graft size) was made approximately 3 mm apical to the gingival margin at 90° to the palatal tissue, directed to the bone. A 1–2 mm thick flap was reflected using a periosteal elevator, leaving only a layer of periosteum covering the bone. To procure CTG, raised full-thickness flap was dissected using the blade to separate a partial-thickness connective tissue flap. Donor site was sutured back [Figure 20].[32]
Figure 20: Reino et al's. technique. a: First incision perpendicular to long axis of tooth till bone; b: Full thickness flap reflected; c: Dissect full thickness flap to obtain graft

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Following which in 2017, Aguirre-Zorzano et al. described a new “UPV/EHU technique,” acronym for the name of their university (Universidad del País Vasco/Euskal Herriko Unibertsitatea) for palatal donor tissue harvest. On the palatal surface, using a number 12 blade, intrasulcular incisions were made while preserving the papillae in the interproximal spaces and a full-thickness flap was elevated [Figure 21]. In order to harvest CTG, 15c scalpel was used to dissect the reflected full-thickness flap by holding it with tissue forcep. Epithelium and a thin layer of connective tissue were left in the remaining flap, which were sutured back.[33]
Figure 21: Aguirre-Zorzano et al's. technique

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Lately, Bhatavadekar and Gharpure in 2018 proposed a controlled palatal harvest technique of graft harvest with advantages such as adequate control due to good visibility, good predictability in ensuring adequate graft and flap thickness, and less chance of leaving behind a thin flap for closure at the donor site (which reduces chances of necrosis and sloughing of flap). A number 15 blade was used to make one horizontal incision, 2 mm submarginally, extending anteriorly from the first molar. A vertical L-shaped incision was made at the anterior end of the first incision. A thick split-thickness flap was raised from the edges of the incision leaving behind a thin periosteum covering the palatal bone. Reflected flap was held with a tissue forceps, and the graft was harvested by dissecting it from the raised flap, leaving a 1.5-mm-thick flap for requisite flap healing. Donor site was sutured or secured with collagen tape [Figure 22].[36]
Figure 22: Bhatavadekar and Gharpure's technique. a: L-shaped incision made at anterior end of first incision; b: Thick split thickness flap raised leaving thin periosteum covering bone. Graft harvested from raised flap by dissecting it

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   Clinical Perspectives Top

Connective tissue still remains the most reliable technique for various soft-tissue augmentation surgeries and over the past 44 years have been simplified and become minimally invasive from Edel's momentous trapdoor technique [1] to single-incision minimally invasive techniques.

Edel's “trap-door” technique is the most popular because of its historic importance and simplicity.[1] Thereafter, various techniques were introduced with modified designs, ways to gain access to the graft, reduced number of surface incisions, and increased patient's comfort. The various harvesting techniques that have been suggested result in different graft characters, in terms of both dimension and histologic composition. Clinically, it is sometimes demanding to procure an ample graft, which has necessitated the invention of new or amended harvesting techniques and led to continued research. Each CTG procedure has its own advantages and disadvantages, and the technique selected depends on various considerations, such as the purpose of the procedure, any anatomical limitations, surgeon's expertise, and the expected morbidity.[51]

There are various possible types of flap designs/incisions that will provide access to the subepithelial connective tissue. One such factor is whether or not a band of epithelium is to be removed along with the graft. Langer and Langer reported that epithelium was retained to aid suturing and to provide more rapid epithelialization. The epithelium on the graft was believed to help smoothen the transition of the grafted tissue to the existing epithelium.[2],[52] It was found, however, that both CTG with and without epithelial collar have provided anticipated and successful root coverage, and the outcome merely depended on the grafted connective tissue but not necrotizing on the root surface.[53] The removal of epithelial collar, however, was done so as to attain better stabilization of the graft and its complete coverage by overlying coronally repositioned flap resulting in smooth and esthetic gingival contour.[53] Bouchard et al., 1994, and Byun et al., 2009, reported that retained epithelial collar on the CTG did not provide a significant advantage with regard to the clinical parameters, and only a short-term increase in keratinized tissue width could be expected.[53],[54]

Furthermore, it has been reported that epithelium necrotizes within 5 days,[55] and it is the underlying connective tissue which determines the color, nature, and shape of the newly formed epithelium.[20],[21] Healing by primary intention is not possible after harvesting of a CTG with an epithelial band because of the rigidity of the palatal tissue, which means greater postoperative discomfort for the patient.[4]

Another factor to be determined is the number of incisions. Edel's technique consisted of one horizontal and two vertical incisions.[1] Consequently, Harris modified the technique by reducing the vertical incisions to a minimal dimension, barely enough to get access to the underlying donor tissue.[3] Raetzke,[23] finally, abstained from vertical incisions entirely and used two converging crescent-shaped horizontal incisions to procure a wedge-shaped graft. The latter techniques with no surface vertical incisions were advantageous over the ones with vertical palatal incisions as vertical incisions could interrupt the vascular supply to the overlying flap predisposing it to necrosis or sloughing,[1],[29],[49] but, on the other hand, techniques with parallel incisions may prevent primary closure of the wound at times and also absence of vertical incisions may compromise the accessibility and visibility.[3],[23],[27],[29],[49]

Del Pizzo et al., 2002,[26] compared FGG with trapdoor and single-incision technique and found single-incision technique to be better than the rest two with early epithelializationm which was in accordance to all single-incision techniques,[4],[29],[38] that it is more conservative and leads to primary closure of wound. In addition, Del Pizzo reported early return of sensibility in single-incision group as the unique incision of epithelium contains less sensory receptors. The only disadvantage of single incision is low visibility of the surgical area, which lengthens the harvest time and lowers the predictability of graft size.[26]

In many techniques, first incision was given such that a partial-thickness flap was raised [1],[2],[7],[8],[38] because very negligible bleeding was seen at this initial stage and also the flap was thick enough to minimize the chances of flap tearing or sloughing, hence increased visibility, appropriate control over the incisions, no random blade angulations, and therefore better assessment of the CTG size.[38]

Few researchers harvested graft from the inner surface of freely mobile reflected flap and reported adequate control because of good visibility, good predictability in ensuring sufficient uniform graft and flap thickness, and less chances of leaving behind a thin flap (which might slough or necrose) for closure at the donor site and hence improved graft success.[1],[32],[36]

Furthermore, modifications were attempted to leave a layer of periosteum on the donor bone surface as removal may retard healing, whereas if left may provide nourishment and act as a recipient bed for the flap.[32],[36]

A number of techniques of procuring CTG have been proposed, but the ideal technique should be one that produces an adequate sized graft, is quick, easy to utilize in a wide variety of clinical situations, and result in minimally operative/postoperative discomfort/complications. The best-suited technique would be the one, by which the surgeon/operator could easily accomplish with minimal discomfort to the patient.[54] When anesthetizing the palate, infiltration into the graft tissue should be avoided; otherwise, unwanted vasoconstrictor might be transferred to the recipient site.[4],[40] Every effort should be made to handle the graft carefully and not to keep it without blood supply for long. Transfer of the graft after removal from donor to the recipient site should be achieved as soon as possible, to limit cell necrosis, and Harris [56] stated that goal should be to keep the graft without blood supply for < 60 s. The graft should be sutured to the recipient site before the palate was sutured to decrease the amount of time the graft was without blood supply.[3],[56]

Though various modifications over the decades have made CTG a minimally invasive technique, still numeral phases of graft harvest require surplus exploration. More research is essential to understand the healing characteristics and long-term volume stability of graft when obtained using different techniques and from different areas of the palate. In addition, comparative research should be undertaken to evaluate the results of different techniques with standardized long-term clinical trials.

   Conclusion Top

The unique nature of connective tissue still makes it the most reliable and gold standard technique for various soft-tissue augmentation surgeries, especially for treatment of gingival recession. With the amazing success rates with the use of CTG in treatment of gingival recession, the use of CTG has dramatically increased in periodontal esthetic treatments. With the increase in its use, numerous techniques have been proposed over the last 44 years with the aim of making the procedure of harvesting CTG, easier, less traumatic, and more predictable. From Edel's historic trapdoor technique to single-incision minimally invasive techniques, there have been various advancements seen in the graft harvesting procedures. The latest techniques are minimally invasive with reduced incision lines, less compromised blood supply, accelerated healing, no sloughing of overlying flap, but are technique sensitive which require higher expertise to execute. Therefore, the operator must be well versed with varied aspects of the graft harvesting procedures, including handling of the tissue, involved potential limitations, and complications associated with the technique.

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Conflicts of interest

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]

  [Table 1], [Table 2]


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