Palatal graft harvesting techniques: A narrative review

OBJECTIVES According to the American Acade my of Periodontology, soft tissue grafting consists of harvesting soft tissue that is completely detached from the donor site and placed in a properly prepared recipient bed. The harvesting of soft tissue from the palate is a technique used in periodontics for over fifty years and still in continuous evolution. From free gingival grafting to bilaminar techniques with connective tissue only or free gingival grafts disepithelized extra-orally, several techniques have been proposed over the years, some of which are now part of today’s periodontal plastic surgery. These techniques are designed to increase periodontal soft tissue thickness, restore a proper keratinized tissue width, correct muco-gingival deformities, improve aesthetics, allow correction of peri-implant de hiscences, soft tissue augmenta tion and ridge preservation, in or der to limit post-extraction bone crest alteration in aesthetically rel evant areas. MATERIALS AND METHODS This narrative review considers the main techniques of soft tissue harvesting from the palate as described in the literature, from the trap-door proposed by Edel in 1974 to the free gingival graft disepithelialized extra-orally proposed by Zucchelli, through a series of single incision techniques introduced over the years. The examination of the grafting techniques is followed by the analysis of the donor area (lateral palate or maxillary tuber) in terms of tissue quality, composition and thickness, difficulties and complications of the surgery. Wound healing and post-operative discomfort are also explored, evaluating the main differences between techniques involving an epi thelial-connective graft and techniques involving only a connective graft. In particular, the use of donor site protectors, such as cyanoacrylate adhesives and PRF (Platelet-Rich Fibrin), is considered. Finally, possible complications are considered − from intra-operative and post-operative bleeding, treatable by compression with wet gauze and tranexamic acid − to less frequent complications such as flap laceration and donor site infection. RESULTS AND CONCLUSIONS The most indicated technique seems to be the harvesting of an extra-orally disepithelized free gingival graft. This bilaminar technique, besides having shown the best clinical results, is also easier to perform, in a reduced operative time and with a lower risk of damaging vascular structures; moreover, the graft composition is richer in connective tissue, without contamination of adipose or glan dular tissue of lower quality. On the other hand, its harvesting technique implies second inten tion healing at the donor site, which may be less comfortable for the patient, but without increasing post-operative pain. In addition, the use of a donor site protection appears to further reduce possibile post-operative patient morbidity. CLINICAL SIGNIFICANCE The use of an extra-orally disepithelized free gingival graft as part of a bilaminar technique can be considered the gold standard among the soft tissue augmentation techniques, possibly accompanied by the use of donor site protections.