CONNECTIVE TISSUE GRAFT

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Journal of Clinical Periodontology. 1974: 1: 185-196

Key words : niucofiingival sur\ievy - attached aiii

Accepted for piiblicatiot\: October 2, 1974.

/ - free connective tissue grafts.

Clinical evaluation of free connective

tissue grafts used to increase the

width of keratinised gingiva

ALAN EDEL

University College Hospital Dental School, Mortimer Market, London, England

Abstract.

Fourteen sites were chosen in eight subjects where pre-operatively less than2mm

of keratinised gingiva was present and associated with pocketing of less than 1.0 mm

Three methods were used to provide gingival connective tissue for grafting which facili-

tated primary closure at the donor site. The pre-operative width of keratinised gingiva was

measured by means of a Williams probe from the gingival margin to the mucogingival

junction to the nearest 0.5 mm. This was repeated immediately post-operatively, and at

1,2, 5, 10, and 12 weeks, and at 6 months. The results showed that a statistically signifi-

cant increase in width of keratinised attached gingiva could be achieved with this method

and the resultant tissue was histologically normal.

It is generally accepted that the presence

of an adequate zone of keratinised attached

gingiva is important for the maintenance

of a healthy dento-gingival junction. The

characteristics of attached gingiva enable it

t o w ithstand the frictional forces encoun-

tered during mastication, and to dissipate

the pull of the circum-alveolar musculature.

Lang & Loe (1971) have demonstrated

that a crevicular exudate can always be

detected from a gingival sulcus with less

t h a n 2 mm of attached gingiva, and this

amount would appear to be essential for

gingival health in young adults.

An inadequate width of attached gingiva

is commonly found together with a shallow

vestibular depth, and various methods have

Robinson & Agnew 1963, Corn 1962,

Freedman & Levine 1964, Staffileno et al.

1966).

In recent years the use of free gingival

autografts has become popular (Nabers

1966 a and b, Haggerty 1966, Becker 1967,

Bressman & Chasens 1968, Sullivan &

Atkins 1969, Snyder 1969, Hawley &

Staffileno 1970) since they can be relied

upon to produce more predictable results

(Karring et al. 1971).

Free gingival grafts may be defined as

partia l thickn ess when they consist of

epithelium and varying amounts of lamina

propria, or full thickness when all the

lamina propria but no glandular tissue or

submucosa is included. Sullivan & Atkins


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186 E D E L

third day does a normal vascular circula-

tion become re-established.

Their studies also showed that the epi-

thelial cells of a thick graft tend to des-

quamate, but that this is not important to

the final result, as the surface will re-epi-

thelialise from cells deeper in the epithelial

ridges.

Oliver et al. (1968) have confirmed these

findings in a series of grafts in seven Rhesus

monkeys. The histological findings showed

that virtually all the epithelium degenerated

and desquamated by the fifth day, though

some cells deep in the epithelial ridges may

have persisted and may have contributed

to the re-epithelialisation of the graft. More

important however, was the contribution of

proliferating epithelial cells from the ad-

jacent tissue, and by the eleventh day epi-

thelial cells covered the entire surface but

showed no keratinisation until the twenty-

eighth day.

Lange & Bernimoulin (1974) have sug-

gested, on the basis of cytological studies,

that the basal epithelial cells of free gin-

gival grafts probably do not degenerate

and contribute to the re-epithelialisation of

the graft.

In their study, Karring et al. (1971) at-

tempted to determine whether it is some

inherent factor in the tissues or whether it

is functional adaptation that is responsible

for the maintenance of tissue specificity.

They performed a series of heterotropic

gingival and alveolar mucosal transplants

in eight adult monkeys (Cerco pitheous).

The findings that the transplanted tissues

always retained their original structure,

even after 1 year, gave no support to the

theory of functional adaptation (Ivancie

1957, Bradley et al. 1959 , Pfeifer 1963).

Most studies on epithelial mesenchymal

interactions favour the concept that histo-

cells do not possess any predetermined re-

gional specificity (Cairns & Saunders 1954,

McLoughlin 1961, Rawles 1963. Billing-

ham & Silvers 1968, Dodson ]967, Plag-

mann et al. 1974). It is, however, also pos-

sible tha t histodifferentiation is con trolled

by mutual interaction of epithelium and

the underlying connective tissue (Wessles

1962, Cohen 1965).

The present study was undertaken to

determine the predictability of using free

gingival connective tissue grafts without

epithelium, in an attempt to increase the

width of keratinised gingiva.

Materials and Method

Fourteen areas were chosen for treatment

in eight subjects. The criterion for inclusion

in the study was a width of keratinised

gingiva of less than 2.0 mm, associated

with pocketing of no more than 1.0 mm on

the buccal aspect. If more than one tooth

was included in an area, then the results

lor all the teeth were combined, and the

mean taken as representative for the tota

area. The age-range of the subjects wa

27.-55 years, with a mean age of 39 years

Prior to surgery, scaling and polishing were

completed, and oral hygiene instruction

was given to ensure good post-operativ

control.

The width of attached gingiva, measured

from the free gingival margin to the muco

gingival junction, was recorded pre- an

post-operatively (by means of a William

probe) to the nearest 0.5 mm; this measure

men t was repeated at 1,2, 5, 10, 12 weeks

and at 6 months. The recipient site wa

prepared by making two vertical incision

into the alveolar mucosa, at the buccal lin

angles of the teeth adjacent to the area t

be treated. By sharp dissection, a periostea

bed, which was free of all muscle attach


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F R E E C O N N E C T I V E T I S S U E G I N G I V A L G R A F T S

18 7

Fiii- I- Diagrammatic illustration of Method 1. A partial thickness flap is raised and the connec-

tive tissue graft is taken from below the palatal surface. The flap is then sutured back.

Fig . 1 -Schetiutlische DarsteUtmg der Methode 1. Ein Spctlthtppeti wird gebildet utid ein Bindc-

gewebs-Traitsplantat wird int Gitumcnbcreich entnonttncn. Der Loppen wird darauf zuriick-

gelegt.

Hig. 1. Scht/tria du procede chirurgical de hi tttethode 1. Utt lattibeatt tttuquettx pa latin est

souleve el ht greffe cotijottctive est prelcvee dtt tissus sousja cettt; le httitbeau est ensuite suture.

bone. Haemostasis was aehieved by apply-

ing pressure with a piece of cotton gauze

soaked in warm saline. The remaining par-

tial thickness flap was displaced apically,

but was not sutured.

Donor Site

Method I: The palatal region opposite the

molar teeth served as the donor site in six

cases. Using a number 15 Swann Morton

blade, a primary partial thickness gingival

pedicle flap was raised with its base wider

than its free end. This primary flap was

then displaced by means of a retractor, and

a portion of the underlying mucosa (ap-

proximately the size of the recipient bed),

was dissected out with a fresh number 15

blade. Care was taken not to go too deep

in order to avoid the inclusion of any

p al a ta l mucosal glands (Fig. 1). If this did

occur the graft was trimmed before being

placed on the recipient site. The primary

flap was replaced and pressure applied for

2 min to preven t any void und er the flap.

mained in place for 1 week. No dressing

was applied.

Method 2: The undersurface of a full

thickness flap was used as the donor site

in six cases. A primary incision was made

to the crest of the bone along the axis of

the teeth close to the gingival margin. A

full thickness flap was raised, and a second

incision was made to thin this flap in-

ternally. The resultant portion of tissue was

tritnmed and used as the graft tissue. The

palatal flap was then replaced, sutured and

left for 1 week (Fig. 2); a dressing was

provided if necessary.

Method 3: The undersurface of a saddle

region between standing teeth was dissect-

ed out and used for grafting in two cases.

(Fig. 3). In all cases the donor site was left

without a dressing as primary closure could

always be achieved.

The graft was placed on the prepared


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18 8

L

Fig. 2.

Diagrammatic illustration of Method 2. Graft material is obtained by the thinning of

full thickness palatal flap. The first incision is made to the crest of the bone and when the fla

is reflected a second incision thins the flap internally and provides the connective tissue f

grafting.

Fig. 2.

Schetnatische Darslcllung der Methode 2, Das Transplantat wird du reh das Verdiitm

eines palatinalen Schieitnhautperiostlappetis gcwontien. Die erstc Inzisiott erfoigt his auf d

Alveolurknochcnkatnnt, Am zuriickgeschobctteti Lappeti wird dureh cine 2, Inzision auf d

Lappetiititictiseite das Bindegewcbc-Tratisplantat erhalten. Lappetireposition.

Fig. 2. Schetna du procede chirurgical de la methode 2. Le materiel a greffer est obtenti eti ati

cissant le lambeau palatin enticr. La premiere iticision s'etetid fusqu'a la crete osseuse, la sccon

cree un latnbeau au seiti duquel on preleve la greffe conjotictivc.

Fig, 3.

Diagrammatic illustration of Method 3. A partial thickness flap is raised at the sad

area and graft material is taken from the underlying connective tissue. The flap is then sutu

back.

Fig. 3.

Schetnatische Darsteilung der Methode 3. Ein Sp altlappen wird itn G ebiet des Ki

katntnsatlels gebildct. Das Transplantat wird detn darutiter liegenden Bittdegewebe etittiomtn

Der Spalllappen w ird darauf mit Nahten reponiert.

Fig. 3. Schema du procede cliirugical de la tnethode 3. Meme principe que d atis la tnethod


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189

Fig. 4. Healing pattern of a free gingival con nec tive tissue graft, a) Pre-operative photograph

s h o wi n g an inadequate width of attached gingiva on the buccal surface of |4. b) The connective

tissue graft sutured in place, c) 1 week post-operatively. d) 6 months post-operatively.

F i g . 4. Die Einheilungsphasen eines Bltidegewebe-Transplantates: a Prae-operativ ungeniigende

Breite

der

kercttitiisierten angewa chsenen Gingiva btikkal

von \4. b Mit

Ndhten fixiertes Binde-

gewebe-Tritnsplatitat. c 1 Woclie nach der Operation, d 6Monate tmchder Operation.

F i g . 4. Phases succcssives de la guerison d'une greffe de tissus conjonctif gingival. a Aspect

cliniqtie preoperatoirc motttrant la largeur inadequate de la gencive adheretite vestibtdaire au

niveau

de \4. b

Greffe

de

tissus conjottctif sutttree

en

place,

c 1

semaitie ap res I'operation.

d) 6 tnois apres I'operation.

tree gingival grafts, as outlined by Sullivan

& Atkins (1968), were employed, and the

displaced flap was checked to ensure it did

not interfere with the graft. A non-eugenol

dressing (Coepak) was applied to the

area. The dressing and sutures were re-

moved after 1 week; then the teeth were

polished and a dressing was replaced for a

A biopsy specimen was taken of the

muco-gingival junction from one area at

6 months; it was fixed in 10 formol

saline for 8 h, and processed to wax over

a period of 24 h. Five micron sections were

cut and stained with haematoxylin and

eosin, and Verhoff's van Gieson stain for

elastic fibres.


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190

E D E L

Fig. 5,

a) Pre-operative view showing inadequate width of attached

gingiva on the

buccal sur-

face of |345. b) Connective tissue graft sutured in place, c) 1 week post-operatively. d) 6 weeks

post-operatively.

Fig. 5. a) Prae-operativ ungeniigende Breite der keratinisierten, angewachseneii Gingiva, bukkal

von \345, b) Mit Ndhten fixiertes Bindegewebe-Transplantat. c) 1 Woche nach der Operation

d) 6 Wochen nach der Operation.

Fig. 5. a) Aspect cUnique preoperatoire inontrant la largeur inadequate de la gencive adherante

vestibulaire au niveau de \345, b) Greffe de tisstts conjonetif suturee en place, c) 1 seinaine

apres

/

operation, d) 6 semaines apres I operation.

esults

In all cases the graft area and the donor

site healed uneventfully when both methods

2 and 3 were employed (Figs. 4a-d and

Figs.

5 a-d). In all six cases where method 1

was used the primary flaps degenerated to

a varying degree (Figs. 6a and 6b), and

were associated with marked discomfort

for 712 d, as no dressings were applied to

protect this region during healing.

Table 1 shows the width of attached ging-

iva recorded at various intervals during the

study. The results were stable at 12 weeks

and remained so over a further period of

3 months. At the end of the 6-month period

the pocket depths were still no more than

1.0 mm, and when a paired t-test was ap-


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FREE CONNE CTI VE TISSUE GIN GIV AL GRAFTS

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Table 1,Width of keratinised attached gingiva in millimeters

T a b e l l e 1.

Breite

der

angewachsenen, verliornten Gingiva, tntn

Tab leau 1.

Largeur

de la

geticive adherente

mtn

Subject

Method 1

1.

2.

3.

4.

5.

6.

Method 2

7.

8.

9.

10.

11.

12.

Method

3

13.

14.

Imme-

diately

Pre-

opera-

tive

1.5

1.5

1.5

1.5

.

1.0

1.0

1.5

2.0

2.0

1.0

1.5

1.5

1.5

1.5

Imme-

diately

Post-

opera-

tive

7.0

6.0

5.0

5.0

5.0

5.0

5.5

9.0

5.0

4.0

4.5

5.0

4.5

5.0

1

6.0

6.5

7.0

5.0

5.0

5.0

5.5

9.0

7.0

3.5

4.5

5.0

7.0

5.0

2

5.5

6.5

6.0

5.0

5.0

5.0

5.0

6.5

6.0

3.5

4.0

4.5

4.5

4.5

weeks

(wochen,

5.

4.5

6.0

5.0

4.5

5.0

5.0

4.0

6.0

5.0

3.0

3.5

5.0

3.5

4.0

setnaities)

10

4.0

5.5

5.0

4.0

5.0

5.0

4.0

5.5

4.5

3.0

3.5

5.0

3.5

4 .0

12

3.5

5.0

4.5

3.5

5.0

5.0

4.0

5.0

4.0

3.0

3.5

5.0

3.5

3.5

24

3.5

5.0

4.5

3.5

5.0

5.0

4.0

5.0

4.0

3.0

3.5

5.0

3.5

3.5

Fig. 6a.

Don or area (Method

1); the

flap

is

sutured back (mirror view).

F i g .

6a.

Spetidergegend

bei

Methode

1, Der

Lappett isttnit Ndhtett repotiiert.

Fig. 6b.1

week p ost-operatively, showing

de-

generation

of the

flap (mirror view).

Fig.

6b. 1

Woelie tiach

der

Operation.

De-

generation desLap pens (Bild itn Spiegel).


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192

L

M

^

<

F/g. 7. Biopsy section of the newly-created muco-gingival junction after

6 m onths, stained H + E (X4 0). M GJ = mucogingival junc tion; AM = alveolar

mucosa; C = connective tissue.

Fig. 7.

Histologisches Bild der neuen inukogingivalen Grenze 6 Monate

postoperativ. Haeinatoxylin-Eosin-Fdrbung, X40, MG JM ukogingivalgrenze;

AM =Alveolarmukosa: C = Biiidegewebe.

Fig. 7.

Coupe histologlque de la nouvelle jonction mucogingivale apres 6 mois.

Coloration a I'heinatoxylineeosine,

X

40, MGJ

=

jonction mucogingivale;

AM = muqueuse alveolaire; C

=

tissus

conjonetif.

plied to the results it showed that a signif-

icant increase of attached gingiva had been

achieved ( P < 0.001). The width of graft

tissue was recorded immediately prior to

the application of the dressing. The mean

width of the graft being 5.54 1 .2 9 mm

(S.D.) with a range of 4.0-9.0 mm. At 6

months the mean width of keratinised ging-

iva was 4.58 1 .0 4 mm , with a range of

3.5-5.0 mm. Therefore, at 6 months the

mean contraction was 28 % with a range

of 0 to 50 per cent.

A t 1 week the surface of the graft a p-

peared red and shiny, and was covered in

parts with a greyish slough (Fig. 5c). The

base of the defect between the graft and

the displaced flap was filled with a fibriti

clot. At 2 weeks the surface was completely

was evident as the graft surface became

progressively paler; and by 6 weeks it had

blended in normally with the surrounding

tissues.

Histology

The histological sectiotis stained with

haematoxylin and eosin showed a clear

demarcation between the keratinised and

non-keratinised epithelium at the newly-

created muco-gingival junction (Fig. 7).

The keratinised epithelium showed well-

developed rete pegs in contrast to the non-

keratinised alveolar mucosa epithelium. The

collagen bundles in the connective tissue

were predominantly oriented at right angles

to the surface; and the sections stained with

van Gieson (Fig. 8) showed that the pres-


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19 3

Fig, 8. Biopsy section of the newly-created muco-gingival junction after

6 months stained with Verhoff's van Gieson, X 40. Elastic fibres are found in

the connective tissue below the no n-keratinised epithelium . M G I = mucogin-

gival junction; AM = alveolar mucosa; C= connective tissue; E = elastic fibres.

Fig. 8. Histologisches Bild der netten tnukogitigivalen Grenze 6 Motiate post-

operativ. Verhoff's Vatt Giesoti-Fdrbutig, X 40. Elastische Fasertt itn Bitide-

gewebe unter detn tiichtkeratinisierten Epilhel. MG J = Muko gingivalgre}ize;

AM Alveolartnukosa; C = Bitidegewebe; E =Elastische Fasern.

Fig. 8.

Coupe de la nouvelle jonction tnuco-gitigivale apres 6 mois. Coloration

de Verhoff-vati Gieson, X 40. Des fibres elastiques sottt trouvees datis le tissus

conjonctif sous I'epitheliutn non-keratitiise, E = fibres elastiques.

region of non-keratinised mucosa, as shown

b y Lozden & Sqiiier (1969).

Discussion

T h e results show that a signilicent increase

fn attached gingiva can be achieved by

grafting gingival connective tissue alone.

Clinically, the present study tends to con-

firm the concept that it is the information

in the connective tissue that ultimately

de ter m ine s the chara cter of the surface epi-

thelium. This then raises the question as to

whether the thickness of connective tissue

is important in achieving this result. The

ewer, that the cases that were associated

with the most creep back of the mu co-

gingival junction were those where only a

very thin graft was used. This may also ex-

plain the histological findings of Stambaugh

& Gordon (1973) that only 75 per cetit of

palatal connective tissue grafts produced a

keratinised surface; and the cytological in-

vestigation of Bernimoulin & Lange (1974),

who found only two-thirds of grafts to he

covered with keratinised epithelium.

The method has certain advantages over

the use of free gingival grafts, providing an

adaquate donor site exists. In this study,

three donor sites were utilised according to


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194

E D E L

need for a periodon tal dressing. In those

cases where palatal pocketing was present,

pocket elimination was performed, and the

tissue normally discarded after thinning

of the palatal flap was used as grafting

material.

The results suggest that the method can

be relied upon to produce a predictable in-

crease in the width of keratinised attached

gingiva. The average amount of shrinkage

that occurred at 6 months was 28 % (as

compared with 47 % quoted by W ard

(1974) for free gingival grafts, and 87.5

quoted by Bohannan (1962

b)

for the peri-

osteal retention operation), and in this study

no periosteal fenestration was performed.

During the observation period of the

present study, no increase in pocket depth

occurred, and thus a significant increase in

width of attached gingiva was achieved.

Histologically the healed tissues showed all

the normal characteristics of a fully kera-

tinised tissue in contrast to the results

achieved by the periosteal retention proce-

dure, demonstrated by Pennel et al. (1965).

Recently, Fagan & Freeman (1974) have

shown that both free gingival grafting and

the periosteum retention procedure can pro-

duce a predictable increase in the width of

attached gingiva, but no mention was made

as to the character of the healed tissues. In

addition there was a significant difference

in the width of attached gingiva created by

the two methods, although there was no

significant difference in the amount of

periosteum exposed at the surgical site.

This was explained by the inadequate pro-

tection of marginal bone afforded by the

periosteum retention procedure which caus-

ed an apical shift of the gingival margin as

a result of marginal bone loss.

The degeneration of the palatal flap

when the donor site in Method 1 was used

was probably due to the design of the flap.

Possibly a thicker, more extended envelope

flap would not compromise the blood

supply so much, and would enable grafting

material to be taken without a full palatal

flap procedure. Care was taken to prevent

a void forming under the flap by main-

taining pressure over the flap for 2 min,

and so this is unlikely to have been the

cause of the degeneration.

Acknowledgment

The author wishes to express his gratitude

to Dr. R. N. Powell for his encouragement

during this study, and to Mr. C. R. Day of

the Photographic Department of the Dental

School for the illustrations.

Zusammenfassung

Klittisclie Untersuchutig der Verbreitertittg

einer schmaleti angewacliseneti Gingiva tnit

freien BitidegewebsitnpIatUateti.

Bei acht Personen wurden 14 Stellen mit

schmaler ( < 2.0 mm ) keratinisierter ange-

wachsener Gingiva und mit Sulci gingivae

kleiner als 1.0 mm ausgewiihlt. Mit drei Me-

thoden wurden am Gaumen oder auf dem

Kieferkamm Bindegewebe-Transplantate ent-

nommen. Dies ermoglichte den Primiirver-

schluss im Spendergebiet. Die Breite der an-

gewachsenen Gingiva wurde prae- und post-

operativ ], 2, 5, 10, 12 und 24 Wochen mit

der Parodontalsonde auf 0.5 mm genau ge-

messen.

Die Ergebnisse zeigen eine statistisch sig-

nifikante Verbreilerung der angewachsenen

Gingiva, die in Biopsien strukturell wie eine

normale Gingiva propria erschien.

Evaluatioti clinique de I'etnplol de greffes

libres de tissu conjonctif pour augtnenter la

largeur de la gencive adherente.

Quatorze sites operatoires furent choisis chez

huit patients presentant une gencive adherente

de moins de 2 mm de largeur associee a un

sillon gingivo-dentaire de moins de 1 m m. D u

cote donneur (palais ou crete alveolaire), les

greffons conjonctifs furent preleves selon trois

methodes differentes permettant une fermeture

de la plaie par premi6re intention. La largeur


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FREE CONN ECT IV E TISSUE GI NGI VAL GRAFTS

195

sonde parodontale au demi millimetre pres

pre - et 1, 2, 5, 10, 12 et 24 semaines post-

operatoirement. Les resultats montrcrent un

elargissemcnt gingival statistiquement signifi-

catif; les biopsies livrcrent un tissu de struc-

ture normale.

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and increasing the zone of attached gingiva.

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D. E.

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