CLINICAL REPORT  231

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Sophie-Myriam Dridi, Michel Chousterman, Marc Danan, Jean Franois Gaudy

Haemorrhagic risk when harvesting palatal

connective tissue grafts: a reality?

Sophie-Myriam Dridi
Assistant Professor,
DDS MS, Department of
Periodontology,
University
Paris Ren Descartes,
KEY WORDS connective tissue graft, haemorrhagic risk, human hard palate, palatine artery France

Michel Chousterman
Clinical Instructor,
Department of
When obtaining good clinical results using connective tissue submerged grafts, the vast majority of Periodontology,
authors place great emphasis on the surgical techniques carried out. However, few studies have shown University Paris Ren
Descartes,
the complications that may arise during such interventions. Although complications may not be frequent France
and are not life-threatening, these complications do exist. These complications generate anxiety for prac-
Marc Danan
titioners. Those that are regarded with most apprehension are peri- and post-operative haemorrhage, Assistant Professor,
and this occurs due to the physiological vascularisation density of the palatal mucosa. DDS MS,
Department of
Through a study of the human anatomy, the authors verified the correlations that could exist Periodontology,
University Paris Ren
between the morphology of the hard palate and the distribution of the greater palatine pedicle and,
Descartes,
furthermore, if they were determining factors in choosing therapeutic options. France
This study comprises two sections relating to applied anatomy: osteology (part 1) and dissection Jean Franois Gaudy
(part 2). Part 1 involved 30 maxillas presenting various forms and edentitions. Observations were car- Professor, Department of
Anatomy,
ried out to compare the relationship between the line of the greater palatine pedicle, the morphology University Paris Ren
of the palate, and the effects of osseous remodelling associated with extractions and the installation Descartes,
France
of removable prosthesis. Part 2 was carried out on 12 fresh human cadaver maxillas. After injection
of the arterial system with coloured latex, the specimens were dissected to observe the distribution of Correspondence to:
Professeur Jean Franois
the greater palatine pedicle of the palate. Gaudy,
Anatomical surgery was carried out on two palates with different morphologies and different tissue Universit Paris Ren
Descartes,
harvesting techniques were performed. This allowed the authors to first specify the vascular distribution Laboratoire dAnatomie
Fonctionnelle,
pattern of the palate, and to evaluate the relation between the sample zones and the branches of the
1 rue Maurice Arnoux,
greater palatine pedicle, to finally establish rules to help prevent haemorrhage from occurring. 92100 Montrouge,
France

 Introduction are applied to both dentulous and edentulous sec-

tors; in periodontal plastic surgery to cover denuded
In the present day, periodontists recognise connec- root surfaces and in preprosthetic surgery to thicken
tive tissue submerged graft techniques as reliable a gingival site or improve the crestal volume1,2. They
and reproducible operative techniques. These tech- are also indicated to create a favourable mucosal
niques are indicated for a number of procedures and peri-implant environment3.

PERIO 2008;5(4):231240
 232 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts
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Different surgical protocols are well documented,  Materials and methods ub

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as are publications recording clinical results and long- tio
 Anatomical study te n ot

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term aesthetic outcomes. ss e n c e fo r
Hence, connective tissue submerged graft tech- Osteology study
niques can be considered as standard interventions Thirty maxillary palatal bones from freshly prepared
in periodontics. Nevertheless, these operative tech- samples in the anatomy laboratory were examined.
niques are difficult to perform and present a certain Two samples were completely dentulous, whereas
number of complications, particularly on the palatal the other samples generally presented partial or
donor site that remains as the privileged region for complete edentitions. The location of the greater
tissue harvesting. Griffin et al4 reported the possibil- palatine foramen, extent and importance of the
ity of pronounced pain, delayed healing situations, indentation of the greater palatine pedicle on the
necrosis of the harvested zone and sensitivity disor- palatal bone and morphological palatal modifica-
ders. However, the complication that is regarded as tions in edentulous subjects who wore a prosthesis
the most serious is haemorrhagic accident due to were observed.
injury of a vascular trunk5. When this occurs peri-
operative bleeding is abundant, stressful for the Anatomical dissection
patient and difficult to arrest by the practitioner. Fur- Twelve maxillary blocks from fresh human cadavers
ther complications arise with the risk of submucosal whose vascular network was injected with coloured
haematoma that can become secondarily infected. latex were isolated.
To better preserve the vascularisation and inner- A curved mucosal incision was carried out from
vation of the hard palate, the harvesting procedure the posterior border of one maxillary tuberosity to
has become more accurate over the years6-9 and a the other, crossing the posterior nasal spine. This
classification of incisions has been recently pro- incision was completed by a crestal incision on eden-
posed10. tulous sites and on the palatal mucosa tangential to
The detailed and meticulous analysis of the hard the cementoenamel junction (CEJ) from one tuber-
palate anatomy is crucial in the choice of the opera- osity to another.
tive technique. With regard to the location of the The superficial outline of the mucosa was
principal vascular branches, two fundamental retracted anteroposteriorly leaving the neurovascu-
notions seem to be drawn from available anatomical lar pedicle in place.
studies11-14. The submucosal connective tissue was then
The first notion determines the existence of the scraped off using a Walkman curette to visualise the
palate at risk, according to the depth of the hard location and distribution of the pedicle.
palate, which varies among individuals and in rela-
tion to the degree of alveolar resorption15.
The second notion emphasises the presence of  Anatomical surgical protocol
risk zones according to the thickness of the palatine Two maxillary blocks from fresh human cadavers
fibromucosa. This varies among individuals and whose arterial network was injected with coloured
depends upon individual palatal regions12. It is thicker latex were selected. Two palates of different depths
at the premolar and canine area, finer compared with using the Reiser classification were chosen14. In this
the mesio-palatal root of the first molar and it classification, the hard palate is considered high in
becomes thinner with age15. depth if the distance between the neurovascular ele-
Through this study, the authors verified whether ments and the CEJ of teeth 15 and 16 is 17 mm. It is
or not the data were pertinent, anatomically based said to be average in depth if the distance is 12 mm
and could really serve as a basis for reflection by the and shallow or flat if the distance is just 7 mm.
clinician. Palate number 1 was considered average in
Several recommendations were also suggested to depth. Teeth 17 to 27 were present. Palate number
decrease the risk of peri- and post-operative haem- 2 was flat and presented lateral edentulous zones.
orrhage. To evaluate the depth of the palate, the greater

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 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts  233
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ub edentu-
Fig 2 Partially

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c lous maxilla lwith
ica mini-
ti
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mally resorbed large
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crests.
ss e n c e land-
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deep. Identified
marks: (a) greater pala-
c tine foramen, (b)
b descending palatine
artery groove, (c) inci-
sive foramen.
a b

Fig 1 Palatal view of a dentulous subject showing the loca-

tion of the greater palatine foramen and the osseous line of
the greater palatine pedicle. Identified landmarks: (a) greater
palatine foramen, (b) descending palatine artery groove,
(c) incisive foramen.

palatine foramen were first localised before virtually artery in relation to the incision lines. For the other
plotting a straight line until the inter-incisive point. lateral section of the dentulous palate, an epithelial
The number of millimetres between the straight lines connective tissue graft was harvested in the area of
and the CEJ was then estimated. From 17 to 12 mm, the premolars and the first molar. Four incision lines
the palate was considered to be high, from 12 to using a surgical blade, delineated a rectangle (the
7 mm as average and < 7 mm as flat. most coronal incision must be at 1.5 to 2 mm from
For each palate, at the level of the lateral section the CEJ). The depth of the incisions was determined
that was best preserved, two connective tissue har- by the blade bevel that entirely penetrated into the
vests were performed according to the Bruno tech- fibromucosa. The dissection of the graft was always
nique8; first in the anterior region of the hard palate parallel to the mucosal surface. For palate number 2,
(distal to the central incisor, distal to the first premo- due to the poor quality of the palatal fibromucosa on
lar), and second in the posterior palatal region (mesial the second lateral part, an epithelial connective tissue
to the second premolar, distal to the first molar). graft was not harvested.
Numerous authors practise the Bruno technique,
because it prevents the lifting of a mucosal flap, and
this minimises post-operative complications. Several
incisions were necessary; two horizontal incisions
 Results
defined the length of the graft. They were parallel to  From the anatomical study
each other, apart by 1 to 2 mm and at a distance of
around 1 mm from the gingival margin border. On bone samples (Figs 1 to 5) the greater palatine
For the incision closest to the CEJ, the surgical foramen presented a very stable location: 12 to
blade was positioned perpendicularly to the tooth 13 mm from the maxillary tuberosity crest and 3 mm
axis up to the bone. For the most apical incision, the in front of the posterior border of the hard palate.
blade was inserted parallel to the palatal fibromucosa The indentation of the greater palatine pedicle on
and dissected several millimetres before regaining the osseous palate is always present and disappears
bone contact. Two vertical incisions on the mesial progressively at the level of the second premolars
and distal as well as an apical horizontal incision com- even in edentulous subjects (all removable denture
pleted the graft harvesting, which was previously wearers). The disappearance of the palatal osseous
separated from the bone using a surgical blade. A contours was observed in subjects presenting
delicate dissection of each half of the hard palate was advanced crestal resorptions.
then performed to verify the dimension and location On dissections (Figs 6 to 12) the same repro-
of the principal trunk of the descending palatine ducible location of the greater palatine foramen was

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 234 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts
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Fig 3 Completely edentulous maxilla, complete denture Fig 4 Completely edentulous maxilla, complete denture
wearer. The palate is less deep. Despite of the resorption, the wearer. Advance resorption of the crests, but the osseous
osseous pedicle groove is quite visible. Identified landmarks: pedicle groove is quite visible. Identified landmarks:
(a) greater palatine foramen, (b) descending palatine artery (a) greater palatine foramen, (b) descending palatine artery
groove. groove.

Fig 5 Palatal view of an edentulous subject wherein the Fig 6 Medial view of a hemi-maxillary block showing the
palatal contours have been smoothed due to wearing a tem- greater palatine pedicle in the greater palatine canal and its
porary prosthesis. palatal distribution. Identified landmarks: (a) pedicle in the
canal, (b) medial wing of the pterygoid process, (c) hiatus of
the maxillary sinus.

observed. On the 3 subjects the descending palatine descending palatine artery divides in several terminal
artery was formed at its emergence of the foramen branches of diverse calibres (between 0.2 and
by a principal trunk of 0.7 mm by 2 to 3 cm, sup- 0.4 mm). The arterial branches are always parallel to
ported by a much more slender trunk that then pro- the axis of the alveolar crest. The voluminous
jected numerous mucosal ramifications. branches, protected by the overhanging bone, are
On all other subjects, from its emergence, the always in contact with the bone.

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b
a

Fig 7 Palatal dissection of the greater palatine Fig 8 Dissection of the greater palatine pedicle in a partially edentulous subject. Identified land-
pedicle in a totally dentulous subject. Identified marks: (a) here the pedicle is divided into two trunks, one of which is voluminous and parallel to the
landmarks: (a) here the pedicle is divided into dental arch, (b) the other is much more slender.
three branches at the exit of the foramen,
(b) the median branch is the largest and at a dis-
tance from the CEJs of the teeth.

anterior anterior anterior

lateral

lateral

posterior

posterior posterior

Fig 9 View of the maxilla after erosion showing Fig 10 Dissection of a left greater palatine pedi- Fig 11 Dissection of a left greater palatine pedi-
the greater palatine pedicle. Here a bigger prin- cle, which presents at its emergence several cle presenting a palatal network consisting of
cipal trunk (0.8 mm) exists with the accessory branches of neighbouring calibre. several very fine branches.
branch rapidly ramifying.

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 236 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts
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Fig 12 Dissection of a ub

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greater palatine pedicle lica
from the incisive region tio
te otn

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showing the density of up
the vascular network at
ss e n c e
fo r
this level.

anterior

down

Fig 13 Palate number 1, teeth 17 to 27. Incision lines for

the two harvested connective tissue grafts. Harvesting was
done in the posterior section of the hard palate (mesial of 25,
distal of 26). The other was done in the anterior region
(distal of 21, distal of 24).

Fig 14 Palate number 1. Connective tissue grafts after Fig 15 Palate number 2. Incision lines for the posterior con-
removal of the coronal epithelial section. The graft originat- nective tissue harvest.
ing from the anterior section of the palate (a) has less adi-
pose and presented larger vessels than the graft from (b) the
posterior section.

 From the anatomical surgical protocol As for the apical limit of the posterior harvested
grafts, it was situated at the extension of the greater
For each palate, two connective tissue grafts of about palatine foramina. Once the palatal dissection
15 mm x 6 mm, were obtained, one in the anterior was concluded, vascular pathways were easily
part and the other in the posterior part of the palate detectable.
(see anatomical surgery protocol). These comprised For palate number 1, the principal trunk of the
numerous vascular ramifications (Figs 13 to 15). descending palatine artery emerged in the posterior
From the initial dissection of the palatal lateral sec- lateral section of the greater palatine foramen, it con-
tions, it was clearly observed that an important quan- tinued its pathway in a linear fashion into an osseous
tity of adipose tissue overextends to the apical limits groove until it reached the retroincisive zone. It then
of the harvested grafts. The adipose mass is more ramified into numerous collateral branches that cov-
abundant in the posterior zones (Figs 16 to 17). How- ered the entire region of the hemi-palate. With
ever, if these observations are valid for the two palates, regard to the location of the greater palatine fora-
it must be emphasised that palate number 2 presented men, the trunk was located more apically towards
a fibromucosa much finer than palate number 1. the centre of the palate. Its average calibre was

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 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts  237
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Fig 16 Palate number 1. Beginning of the dissection of the Fig 17 Palate number 2. Beginning of the dissection of the
lateral half of the palate. At the apical limits of the two tissue lateral half of the palate revealing the apical limits of the
harvests, an important quantity of adipose tissue was tissue harvests.
observed especially on the posterior region.

Fig 18 Palate number 1. End of the dissection of the lateral Fig 19 Palate number 2. End of the dissection of the lateral
half of the palate. The descending palatine artery is clearly half of the palate. The descending palatine artery presents a
visible. It is situated 12 mm from the CEJ of tooth 26 and larger calibre than that of the palatine artery of palate
4 mm from the apical limit of the posterior harvest. The number 1 and its pathway is more convoluted. It is situated
greater palatine nerve is situated just above the artery. 9 mm from the CEJ of the molar present in the arch.

0.6 mm in the premolar-molar zones, slightly de- way and calibre in comparison with the artery of
creasing in the anterior palatal zone. It was 12 mm palate number 1. Once it emerged from the greater
away from the CEJ of the first molar and 4 mm from palatine foramen, it ran towards the incisive region
the apical incision line of the posterior harvest (Fig in a convoluted manner, and was positioned slightly
18). For the anterior harvest, the mesioapical limit more apically compared with the location of the
was adjacent to the anterior endings of the descend- greater palatine foramen. Its calibre was more sig-
ing palatine artery. nificant as it approached 0.8 mm and its collateral
The greater palatine nerve was also clearly visible. branches were less numerous and finer. Moreover,
It emerged like the descending palatine artery to the the trunk was not located in an osseous groove. The
greater palatine foramen to distribute itself into several minimum distance between the trunk and the CEJ
anterior branches. The principal branch was situated borders was 9 mm (Fig 19). For half of the posterior
more coronally to that of the palatine artery. Thus, it harvest zone, the apical limit is very close to the prin-
was closer to the apical limit of the posterior harvest. cipal trunk of the palatine artery. Collateral
For palate number 2, the principal trunk of the branches, on the other hand, line the anterior har-
descending palatine artery presents a different path- vest zone.

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 238 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts
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On the second lateral section of palate number 1, Concerning the location of the principal P ub
vessels

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a 15 mm x 6 mm epithelial connective tissue graft supplying the palate tio
The authors observations concerning tthe
n
ot

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was harvested. It was less vascularised than connec- essdescend-
e nc e
fo r
tive tissue grafts and did not include adipose tissue. ing palatine arteries of palate number 1 and 2 con-
The incision lines were superficial, thus very far from curred with the results of the applied osteology and
the trunk and principal collateral branches of the anatomical studies.
descending palatine artery. The descending palatine arteries ensure the total-
ity of the palatal vascularisation. Collateral branches
of the descending maxillary arteries emerge from the
 Discussion posterolateral sections of the palate at the greater
palatine foramina. In general, their average calibre
 Connective tissue grafts was from 0.6 to 0.8 mm15. The authors also obtained
the same measurement. Each artery ramifies into
The size of the graft taken from the two subjects was numerous collateral branches, which supply beyond
predetermined to avoid lesion to the descending pala- the lateral sections of the palate. The two arterial
tine artery, which would have prevented the authors regions principally overlap each other and stretch
from dissecting correctly. Therefore, the dimensions of forward until the retroincisive zone. The possibility of
the tissue harvests were reduced. However, it ramifications, on the contrary, was varied.
remained acceptable. Clinically, it would be possible to The palatine artery advances in most cases into a
cover a denuded root without any problem. shallow groove in the bone, which provides a protec-
For all grafts, adipose tissue was found in the tive role, but is not standardised and may sometimes
apical section. This observation was compatible with be absent (as was observed in palate number 2). This
the histological studies, which revealed the frequent situation is more risky. Unfortunately, there is no viable
presence of adipose tissue in the deep connective clinical means of identifying if the artery is protected
tissue16. before starting an intervention. Whatever their size,
In periodontal plastic surgery, the extent of the the principal vascular trunks advance in a more apical
apical harvest is of less interest as the adipose tissue position than the greater palatine foramen.
must be removed or it will prevent the neovascular- The innervation of the hard palate follows the
isation during healing of the recipient site. arterial pathways. It is essentially supplied by the
The thickness of the grafts were thin. However, a greater palatine nerves, which emerge like the
good section of the connective tissue was harvested. descending palatine arteries in the greater palatine
From the beginning of the dissection of the hard foramina, to be distributed into several anterior
palate, the osseous surface was already distinctly vis- branches. For the two palates that were chosen, the
ible. The poor thickness of the fibromucosa is in rela- nerves advanced parallel to the palatine arteries in a
tion with the anatomical samples origin and its con- more coronal position. Therefore, the risk of damage
servation process. In human cadavers, a retraction of occurring is higher.
the mucous was observed.
Moreover, the thickness of the fibromucosa of The haemorrhagic risk
palate number 2 was much less than that of palate During harvesting of a connective tissue graft, the
number 1. Given the presence of edentitions, the operative risk that is most dreaded by clinicians is the
authors thought that palate number 2 belonged to a occurrence of a haemorrhage5.
much older individual than the individual with a den- In relation to the anatomical data, it is reasonable
tulous palate. to say that the haemorrhage involves mostly the col-
Furthermore, it was thought that the individual lateral branches.
probably wore a removable prosthesis, which com- The lesion of a principal trunk of a palatine artery
pressed the mucosa. The dilatation of the ostia of the is actually rare, because the trunk is generally found
accessory salivary glands of the palate indicated that in the groove, which is frequently lined by overhang-
the individual was a smoker. ing osseous projections that constitute a real natural

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 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts  239
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a b c
Fig 20a to c Connective tissue graft harvesting in a patient: (a) clinical view of incisions situated between the lateral incisor and the canine, (b) completely
dissected graft harvest, c) suture of donor site to ensure haemostasis.

Fig 21a to b Recom-

mendations in case of
sudden haemorrhage:
(a) compression of the
greater palatine fora-
men, (b) anatomical
connection of the com-
pressed zone (instru-
ment artificially added
on the image).

a b

protection. However, an accidental injury causing are far from the arterial trunk in comparison with
necrosis to the palatine mucosa is possible, especially those of the molars.
if the artery is not protected or if the palate is flat. The Harvesting in the anterior section of the palate is
after-effects are often very limited though, given the also a solution (Figs 20a and b).
interpenetration of the arterial regions and the exis- By applying these rules to the anatomical sam-
tence of a complementary vascularisation supplied ples, it was verified that the apical limits of the inci-
by both the ascending pharyngeal artery (branch of sion lines of all the connective tissue harvest zones
the external carotid) and the ascending palatine were clearly at a distance to the principal arterial
artery (branch of the facial artery). trunks. The collateral section of the descending pala-
However, to prevent any risk of injury to the arte- tine artery can nevertheless provoke major peri-oper-
rial trunk during tissue harvesting in the postero-lateral ative bleeding. The risk incurred in this situation is the
section of the palate, the authors propose a simple formation of a submucosal haematoma, which can
procedure: before starting the incisions, imagine a line become secondarily infected.
from the greater palatine foramen towards the inter- If abundant bleeding occurs, it is recommended
incisive point, which will be the virtual apical limit and that pressure is put on the greater palatine foramen
the tissue will not be harvested beyond this line. area with the aid of a blunt instrument. This will sig-
This clinical precaution is particularly valid for nificantly reduce the flow of bleeding and enable the
average and flat palates. It is simple to apply as the clinician to view the haemorrhagic origin (Fig 21). It
foramen can be easily palpated. Similarly, it is suitable is then necessary to perform suture points to bring
to harvest in the premolar regions because their CEJs the incision lines closer (Fig 20c). Suspending sutures

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 240 Dridi et al Haemorrhagic risk when harvesting palatal connective tissue grafts
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around teeth are sometimes useful. Sutures allow the Finally, during the post-operative phase, ubit is

Q ui
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obliteration of the vessels by compression of the important for the clinician to be available, because ti
te the inter- on ot

n
region where it is located. It is, in fact, impossible to bleeding can occur hours or days followingss e n c e fo r
individually localise the palatine vessels for ligation. vention.
The operated zone must be compressed firmly and This bleeding suggests incorrect haemostasis,
persistently. The placement of a periodontal dressing mobilisation of the wound by tongue movements, by
around teeth will assure compression for several days. early and repeated rinsing of the mouth, or the exis-
A preoperative fabricated plastic stent covering the tence of an undiagnosed haemostatic anomaly
hard palate should also be planned to ensure a durable during the preoperative phase.
palatine compression after the surgery. Respecting these safety precautions is important
Some authors recommend the use of haemo- for the practitioner so as to ensure that the clinical
static substances such as oxidised regenerated cellu- obligations are fulfilled.
lose or gelatine sponge5 for the harvest sites. The
prescription of tranexamic acid mouthwash is equally
recommended. In the case of an epithelial connective
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