Artéria Palatina
Artéria Palatina
Artéria Palatina
Free gingival graft (FGG) harvesting from the palate approach for re-establishing or increasing the kerati-
was initially proposed by Nabers1 for increasing the nized tissue width around teeth and implants, aug-
vestibular depth. This technique was later modified menting gingival thickness, treating single or
by Sullivan and Atkins2 for treating gingival recessions multiple GRs, and deepening the vestibulum.3 FGGs
(GRs). The introduction of FGG has provided a reliable have been extensively investigated, not only for their
Received from Department of Periodontics and Oral Medicine, Address correspondence and reprint requests to Dr Tavelli:
University of Michigan School of Dentistry, Ann Arbor, MI. Department of Periodontics and Oral Medicine, University of Michi-
*Resident. gan School of Dentistry, 1011 N University Ave, Ann Arbor, MI
yResident. 48109-1078; e-mail: tavelli@umich.edu
zResident. Received June 8 2018
xProfessor. Accepted October 1 2018
kProfessor and Director of Graduate Periodontics. Ó 2018 American Association of Oral and Maxillofacial Surgeons
This article was partially supported by the University of Michigan 0278-2391/18/31114-5
Periodontal Graduate Student Research Fund. https://doi.org/10.1016/j.joms.2018.10.002
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
1.e1
1.e2 SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING
clinical outcomes but also regarding their healing. measurements from cadavers and cone beam
Clinical and histologic studies have been conducted computed tomography (CBCT) or computed
to explain the mechanisms related to the revasculariza- tomography (CT) studies on the position of the GPF
tion and integration of the recipient bed, as well as fac- and the course of the GPA in relation to the teeth.
tors that can influence its success or shrinkage, such as
thickness, the amount of connective tissue, and the
nature of the recipient site (whether periosteum or
Materials and Methods
denuded bone).4-6 STUDY DESIGN
In the past few decades, there has been an upward To address the research purpose, we designed and
trend in replacing the FGG with the connective tissue implemented a systematic review modeled after The
graft (CTG) for treating GRs; increasing soft tissue vol- Cochrane Collaboration’s recommendations for sys-
ume; and masking discolored roots, crown margins, or tematic reviews. The focused question was as follows:
implants.3 Indeed, better esthetic results, complete ‘‘Is it possible to define a safety zone for palatal harvest-
flap closure, and healing of the donor site by primary ing based on the location of the greater palatine artery
intention are among the advantages that can been and foramen?’’
attributed to a CTG.3
Besides the advantages provided by soft tissue
grafts, either FGG or CTG, palatal harvesting tech- SAMPLE IDENTIFICATION AND SELECTION
niques present a crucial part of a procedure, as they The study population was composed of all publica-
are soundly correlated to patient morbidity, graft qual- tions on GPF and/or GPA anatomy from 1980 to
ity, and bleeding control. Thus, several harvesting January 2018. Electronic and manual literature
approaches have been proposed: trap-door, parallel- searches, conducted by 2 independent reviewers
incision, single-incision, and epithelialized gingival (L.T. and S.B.), covered studies across the National Li-
graft techniques and many others. The superiority of brary of Medicine (MEDLINE by PubMed), Embase,
any approach over the others remains controversial, and the Cochrane Oral Health Group Trials Register
as it has been shown that the postoperative morbidity (Fig 1).
accompanied by secondary intention healing (typical The MEDLINE (PubMed) search was performed on
of the epithelialized gingival graft harvesting January 13, 2018, using the following strategy:
approach) can be efficiently minimized.7 (greater[All Fields] AND palatine[All Fields] AND
However, regardless of the palatal harvesting (‘‘arteries’’[MeSH Terms] OR ‘‘arteries’’[All Fields] OR
approach, prolonged intraoperative and postoperative ‘‘artery’’[All Fields])) OR (greater[All Fields] AND
bleeding caused by injury to the palatal vessels is one palatine[All Fields] AND foramen[All Fields]) AND
of the most common complications of this proced- English[lang].
ure.8 Hence, a thorough knowledge of the anatomy The Embase search was completed on January 13,
is necessary for reducing the risk of complications. 2018, using the following strategy: (greater AND pala-
Indeed, it has been reported that the anatomy of the tine AND (‘artery’/exp OR artery) OR greater) AND
palatal vault strongly influences the risk of damaging palatine AND foramen.
the greater palatine artery (GPA), being on average 7, The search on the Cochrane Oral Health Group Tri-
12, and 17 mm from the cementoenamel junction als Register was performed on October 3, 2017, using
(CEJ) of the maxillary teeth when the palatal vault is the following strategy: ‘‘Greater palatine artery’’
shallow, average, and high, respectively.9 Monnet- [Search All Text] OR ‘‘Greater palatine foramen’’
Corti et al10 found that the average distance from the [Search All Text].
GPA to the canines and second molars was In addition, a manual search of related journals,
12.07 2.9 mm and 14.7 2.9 mm, respectively. including a complete search of the Journal of Clinical
However, gathering data from fabricated casts and Periodontology, Journal of Periodontology, and Inter-
assuming the course of the GPA are the major draw- national Journal of Periodontics and Restorative
backs of this study design. Although the position of Dentistry, was performed.
the greater palatine foramen (GPF) and the course of Cadaveric and CBCT or CT studies were included if
the GPA, as well as its distance from the CEJ of the they analyzed at least 1 of the following outcomes: 1)
teeth, have been assessed in several cadaveric distance between the CEJ of the maxillary teeth and
studies,11-13 there is still no agreement on the the GPA, 2) distance from the GPF to the midsagittal
definition of a safety zone for palatal harvesting suture, 3) distance between the GPF and the interinci-
based on anatomic landmarks that can guide sive foramen, 4) distance between the GPF and the
clinicians during this procedure. Therefore, the posterior border of the hard palate, 5) position of
purpose of this study was to define a safety zone for the GPF in relation to the maxillary molars, and 6)
soft tissue graft harvesting by comparing diameter of the GPF and GPA.
TAVELLI ET AL 1.e3
FIGURE 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. Abbreviations: CEJ, cementoenamel
junction; GPA, greater palatine artery; GPF, greater palatine foramen; IF, interincisive foramen; MSS, midsagittal suture; PB, posterior border
of hard palate.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2018.
Contrarily, articles were excluded if they were 1) The tertiary variables were age, gender, and study
cadaveric or CBCT or CT studies not reporting mea- design (skulls vs CBCT or CT) and their effect on
surements on the GPA or GPF or 2) case reports. the outcomes.
Studies were initially screened by reading titles and
abstracts. The definitive stage of screening involved
DATA COLLECTION, MANAGEMENT, AND
full-text examination using a predetermined data
ANALYSES
extraction form to confirm the eligibility of each study.
In all of the mentioned steps, data were independently Studies were excluded by screening of titles and ab-
extracted by 2 review authors (L.T. and S.B.). When stracts and full-text reading by 2 investigators (L.T. and
clinical data were lacking, the study’s authors were S.B.) using a predetermined data extraction form to
contacted. At each stage, disagreement between re- confirm the eligibility of each study based on the afore-
viewers was resolved through discussion and mentioned criteria. The same 2 authors independently
consensus. If a disagreement persisted, the judgment extracted data from the included articles. At each
of a third reviewer (A.R.) was decisive. stage, disagreement between reviewers was resolved
through discussion and consensus. If a disagreement
persisted, the judgment of a third reviewer (A.R.)
STUDY VARIABLES was decisive.
The primary variables were the location of the GPF Weighted means and standard deviations were
in relation to the teeth and the apico-coronal distance calculated based on the sample size (number of hemi-
from the path of the GPA to the CEJ of the teeth. palates) of each included study. Differences between
The secondary variables were 1) the distance be- the computed values for male and female individuals,
tween the GPF and the interincisive foramen, poste- measurements from CBCT scans, or direct cadaveric
rior border of the mandible, and midsagittal suture measurements were compared by use of t tests, at a
and 2) the diameters of the GPF and GPA. significance level of .05. All statistical analyses were
1.e4 SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING
performed using RStudio software (version 1.1.383; 4 reported the distance between the GPA and the
RStudio, Boston, MA). CEJ of the maxillary teeth,11-13,36 and 8 assessed the
distance between the GPF and the interincisive
foramen.16,17,19,23,28,29,31,32 The distance between
Results the GPF and the posterior border of the hard palate
was evaluated by 14 studies14,16,17,19,23,25-29,31-34 and
STUDY SELECTION AND CHARACTERISTICS
the position of the GPF itself was investigated by 19
The search results based on the PRISMA (Preferred articles,12,14-18,20,22-30,33-35 whereas the diameter of
Reporting Items for Systematic Reviews and Meta- the GPF and the GPA was described in 7
Analyses) guidelines are depicted in Figure 1. This sys- studies.13,16,21,22,26,27,29
tematic review included 26 studies, investigating
5,768 hemipalates.11-36 In 22 studies, direct
measurements were performed on cadavers or LOCATION OF GPF
skulls11-14,16-20,22-30,32-34,36; 3 studies were based on The location of the GPF was estimated to be on the
CBCT or CT scans15,21,35; and in 1 study, data from midpalatal side of the third molar in 57.1% of cases, be-
cadaveric measurements and CT scans were tween the second and third molars in 21.3%, and distal
combined.31 Among the investigated palates, most be- to the third molar in 13.5%. Table 2 depicts the fre-
longed to white individuals (35.4%), followed by In- quency of the position of the GPF in relation to the
dian (28.6%) and Asian (11.1%) individuals (Table 1). maxillary teeth.
Among the studies, 19 described the distance be- On average, the distance between the GPF and the
tween the GPF and the midsagittal suture,14-19,21,23-34 interincisive foramen was 35.8 3.4 mm, whereas
Abbreviations: GPF, greater palatine foramen; 1M, first maxillary molar; 2M, second maxillary molar; 3M, third maxillary molar.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2018.
the GPF was 3.8 1.2 mm and 15.2 1.3 mm from the 13.8 2.1 mm to the second premolar,
posterior border of the hard palate and the midsagittal 11.8 2.2 mm to the first premolar, and
suture, respectively (Fig 2). No significant differences 9.9 2.9 mm to the canine (Fig 3).
were found between male and female individuals for
the distance between the GPF and the midsagittal su-
ture (16.1 mm vs 15.5 mm) and the study design
(skulls vs CBCT or CT) (14.6 mm vs 15.4 mm) (P > .05). DIAMETER OF GPF AND GPA
The mean anteroposterior opening of the GPF was
4.1 1.2 mm, whereas its mediolateral diameter was
COURSE OF GPA estimated at 2.8 0.8 mm. The diameter of the GPA
The distance from the GPA to the CEJ of the maxil- was approximately 1.2 0.3 mm and 1.3 0.4 mm
lary teeth was calculated as follows: 13.9 1 mm to in the second and first molars, respectively, and
the second molar, 13.0 2.4 mm to the first molar, 1.2 0.4 mm, 0.8 1.1 mm, and 0.8 0.4 mm in
FIGURE 2. Schematic drawing representing the location of the greater palatine foramen (GPF) (red dot) and its distance from the interincisive
foramen (IF), midsagittal suture (MSS), and posterior border of the hard palate (PB).
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2018.
1.e6 SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING
FIGURE 3. Schematic drawing representing the distance between the cementoenamel junction of the maxillary teeth (second molar [M2], first
molar [M1], second premolar [P2], first premolar [P1], and canine [C]) and the greater palatine artery.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2018.
relation to the second premolar, first premolar, and deviation as well was to reduce the possibility of injury
canine teeth, respectively. to the vessel as much as possible, hence the term
safety zone (SZ):
DEFINITION OF SAFETY ZONE
SZðmmÞ ¼ weighted mean distance from the GPA
If a distance of 2 mm from the CEJ (which corre-
sponds to the gingival margin in the healthy periodon- SD 2
tium) is considered the physiological biological
width,37 a safety zone for harvesting an FGG or CTG
is determined by subtracting the standard deviation
Discussion
(SD) of the mean from the mean value itself (average
distance from the CEJ to the GPA for each tooth) Bleeding and paresthesia are the most common
(Fig 4). The reason for subtraction of the standard complications described after palatal soft tissue graft
FIGURE 4. Schematic representation of safety zone in healthy periodontium. The safety zone was determined with respect to the average dis-
tance between the cementoenamel junction of each tooth and the greater palatine artery, as well as its standard deviation and 2 mm for the
gingival margin.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2018.
TAVELLI ET AL 1.e7
harvesting.38,39 The best precaution for minimizing the maxillary alveolar ridge.12 In addition, in a cadav-
the risk of complications is to be aware of anatomic eric study, Benninger et al11 showed that the GPA
structures.9 Guidelines for palatal harvesting to avoid runs in close proximity to the greater palatine crest,
the neurovascular structures have previously been which is prominent and can be palpated in most cases.
proposed; however, because of the limited sample Fu et al,12 on the basis of fabricated study models,
size,22 the assumption of the course of the palatal reported that the location of the GPF was underesti-
artery,10 and the nature of the article itself (expert mated by up to 4 mm when 20 examiners were asked
opinion),9 a strong evidence-based definition of a to estimate this anatomic landmark. This could reduce
safety zone for palatal harvesting is lacking. Therefore, the chances of injury to the vessel but also limit the
the purpose of the present article was to provide a amount of CTG that can be harvested.12 This finding
definition of a safe area for soft tissue graft harvesting highlights the flaw in the study design of Monnet-
based on the position of the GPF and GPA. Corti et al,10 who estimated the mean distance of the
Our results showed that the GPA traverses the palate GPA from the CEJ of the second molar and the canines
anteriorly while approximating the maxillary teeth, using only cast models.
except in the first molar region, where its distance Recently, the use of ultrasound or magnetic reso-
(13 2.4 mm) is smaller than the distance to the nance imaging for identifying the position of the GPF
second molar and to the second premolar has been proposed.42,43 However, these methods do
(13.9 1 mm and 13.8 2.1 mm, respectively). It is not seem practical in daily practice. By using the
interesting to note that a similar pattern has been CEJs of the maxillary teeth as landmarks, our study
described in the literature for palatal mucosal provides a safety zone that should minimize the risk
thickness.40,41 of damaging the GPA during the harvesting
Age, gender, and population characteristics have procedures. Indeed, the safety zone takes into
been reported as factors that can affect the thickness account not only the mean distance from the GPA to
of the palatal mucosa.40 However, in our study, we the CEJ of the teeth but also the calculated standard
found a lack of a statistically significant correlation be- deviation. According to our results, the safety zone is
tween these parameters and the distance of the GPF greater at the second molar and second premolar
from the landmark structures (midsagittal suture, in- area whereas it is considerably smaller at the first
terincisive foramen, and posterior border of the hard premolar and canine area. In agreement with our
palate). Nevertheless, these results should be inter- findings, harvesting anterior to the distal region of
preted with caution because the samples included in the canines is generally discouraged.10
this review were not homogeneous among the popula- Despite traditional beliefs of the palatal root of the
tions and only a few studies reported results specific first molar being the distal limit for harvesting an
for male and female individuals.15,19,21,24,25,31 In FGG or CTG,10,40 our study shows that extending
addition, in agreement with a previous study, no the harvesting zone to the second molar can be safe
differences were found when direct measurements if the graft height is within the proposed safety zone.
in cadavers and CBCT or CT results were compared.31 However, it should be noted that the diameter of the
As reported by Tomaszewska et al,31 anatomic land- GPA was found to be widest at the molar areas while
marks are essential tools for identifying the position of gradually reducing in width when reaching the
the GPF. In this view, our study contributes to the liter- anterior areas. This may explain why several authors
ature by providing the approximate location of the have suggested limiting the harvesting sites to the
GPF based on its distance from the midsagittal suture, mesial aspect of the first molars,10,22 where
interincisive foramen, and posterior border of the hard the palatal mucosa is also thinner and less suited for
palate. Although anatomic variability among patients the harvesting.41
must be considered, the results of this study are sup- According to Monnet-Corti et al,10 a palatal harvest-
ported by a total sample size of 5,768 hemipalates. ing of 8 mm in height, without damaging the GPA, was
In agreement with a previous systematic review,31 possible in almost all cases (93%); however, our study
our results confirmed that the most common location showed that this statement is valid only for the poste-
of the GPF is in the midpalatal aspect of the third molar rior palate (from the second premolars to the
(57.1%), followed by locations between the second second molars), not in the anterior region of the palate
and third molars (21.3%) and distal to the third molars where the graft height is reduced (7.6 and 5 mm for
(13.5%). first premolar and canine, respectively).
Nevertheless, palpation of the posterior palate Regardless of the precautions for avoiding injury to
should always be performed for identifying the posi- the palatal vessels, hemorrhages do occur. A possible
tion of the GPF and the course of the GPA. It has explanation is the different patterns of the GPA; types
been reported that the artery is commonly at the junc- III and IV, as defined by Yu et al,36 run closer to the CEJ
tion between the horizontal plate of the maxilla and and thus are associated with a higher risk of GPA injury
1.e8 SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING
and bleeding than the most common pattern (type I), Revascularization and shrinkage—A one year clinical study. J
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