CASE SERIES

Pedicle Connective Tissue Graft With Novel Palatal Tunneling

Alain H. Romanos,*†‡ Nicolaas C. Geurs,* and Ramzi V. Abou-Arraj*

Introduction: Implant esthetics can be compromised with a lack of hard and/or soft tissue in the anterior maxilla. Soft-
tissue augmentation is often a crucial step in optimizing esthetic outcomes. Palatal pedicle soft-tissue grafts present a ver-
satile option and have a high survival potential. This case series presents a pedicle connective tissue graft technique with novel
palatal tunneling as an additional tool for implant site development. It has multiple indications, including complete socket clo-
sure, augmentation of soft-tissue volume, enhancement of gingival papillae, and treatment of peri-implant defects.
Case Series: In the first case, the pedicle graft was performed to achieve soft-tissue closure over a socket preserva-
tion site that was fully dehisced on the facial aspect. This procedure allowed for protecting the bone graft and developing the
soft tissue for implant placement 4 months later. The second case was more challenging because of an ankylosed maxillary
central incisor presenting with a severe gingival discrepancy. After tooth extraction and hard-tissue reconstruction, a pedicle
graft was used at the time of implant placement to augment the soft tissue over the facial dehiscence of the implant in com-
bination with a bone graft.
Conclusions: The novel palatal tunneling in this technique improved the positioning of the pedicle graft at the recip-
ient site. It also preserved the integrity of the mucosa palatal to the defect site by minimizing the protuberance that resulted at
the site of pedicle rotation. Soft-tissue height and volume were found to be increased. Clin Adv Periodontics 2013;3:191-
198.
Key Words: Dental implants; esthetics, dental; maxilla; pedicle flap; tissue grafts.

Background hard-tissue augmentation techniques have been proposed

Hard- and soft-tissue reconstruction of the anterior maxilla
has gained particular interest with the progression of
implant dentistry. To prevent or correct the inevitable
ridge reduction that takes place after tooth extraction,1,2
* Department of Periodontology, University of Alabama School of Dentistry,
Birmingham, AL.
†
Private practice, Beirut, Lebanon.
‡
Department of Periodontology, Lebanese University, Beirut, Lebanon.
Submitted December 5, 2012; accepted for publication February 12,
2013
doi: 10.1902/cap.2013.120125
to reconstruct the integrity and shape of the deficient
ridge.3,4 Simultaneously, various mucogingival procedures
have been described to address the soft-tissue deficiencies
and the increased esthetic concerns. Enhancement of peri-
implant soft tissue can be performed at multiple treatment
stages: 1) socket preservation; 2) immediate or conven-
tional implant placement; 3) second-stage implant surgery;
4) after delivery of implant-supported restoration; and 5)
treatment of peri-implant disease. Numerous techniques
addressing these indications mainly through autogenous
soft-tissue options have been advocated in the literature.5-18
At the time of socket preservation or immediate implant
placement, several treatment options are available to
achieve socket closure and augment the soft-tissue volume

Clinical Advances in Periodontics, Vol. 3, No. 4, November 2013 191

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and contour. Free gingival grafts (FGGs) have been
described as a viable therapy to achieve soft-tissue closure
of extraction sockets after immediate implant placement
or socket grafting procedures.8,11,16 These grafts are
harvested from the palate to fit the custom size of the
socket orifice. FGGs were found to integrate at the
recipient sites in 74% to 92.3% of cases.11,16 Similarly,
free connective tissue grafts (FCTGs) are obtained from
the palate and used to seal socket defects. Their main
differences with FGGs include tucking the graft under the
facial and palatal soft-tissue margins and expecting donor
site wound healing by primary intention. However,
healing of FCTGs at the recipient site is similar to that
of FGGs, relying completely on a socket vascularization
source.7 Conversely, pedicle palatal soft-tissue grafts have
been described as advantageous alternatives to free grafts
in the closure of socket grafting and immediate implant
sites.12,13,15,17 Rotated split- and full-thickness palatal flaps
were found to achieve predictable bone formation around
peri-implant dehiscence defects.12 Meanwhile, the palatal
subepithelial connective tissue (CT) flap technique was
presented with minimal partial flap necrosis. The tech-
nique involved elevating a full-thickness palatal flap after
a paramarginal straight incision from the molar area to
the extraction site, dissecting a CT graft from the coronal,
apical, and distal aspects, and rotating it over the socket
toward the facial aspect.13 A modification of this method
consisted of flipping the pedicle graft over the defect
instead of rotating it.17 Although both techniques showed
improved clinical outcomes, they also resulted in a soft-tissue
protuberance palatal to the defect site, corresponding to the
site of pedicle rotation or flipping. This case series presents
a pedicle CT graft technique with novel palatal tunneling as
an alternative treatment modality to enhance soft-tissue
volume and coverage of socket grafting and implant sites.
Clinical Presentation, Management,
and Outcomes
Patients 1 and 2 presented to a private practice limited to peri-
odontics and implant dentistry in Beirut, Lebanon (AHR).
Their treatment extended from 2007 to 2011. Both patients
provided written informed consent before treatment began.
Case 1
The patient was a healthy 47-year-old male who presented
with a fractured tooth #7. During an apicoectomy attempt,
a root fracture was noted and the patient was referred to
the periodontist (AHR) for tooth extraction and implant
placement. At the time of periodontal evaluation, the patient
presented with moderate edema and erythema of the alveo-
lar mucosa on the facial aspect of tooth #7 and a mucosal
tear over tooth #6 with residual silk sutures (Fig. 1a). A
periapical radiograph revealed adequate bone height on
the adjacent teeth (Fig. 1b).
After local anesthesia and a minimally invasive extrac-
tion of tooth #7, the socket was curetted and inspected.
A complete facial bony dehiscence was encountered,
192 Clinical Advances in Periodontics, Vol. 3, No. 4, November 2013
whereas the other socket walls were intact. The dimensions
of the socket orifice were measured and considered for ped-
icle graft preparation in the following steps. A single pala-
tal incision design19 was placed from the mesial aspect of
tooth #3 to the midpalatal aspect of tooth #6. Care was
taken to stop the incision one tooth distal to the defect site
(tooth #7). The length of this incision was calculated to
achieve complete closure of the palato-facial size of the
socket and to extend at least 3 mm under the facial tissue.
Similar to a subepithelial CT graft, the pedicle graft was
dissected at the coronal, distal, and apical aspects, leaving
the mesial side attached (Fig. 2a). The width of the graft
was calculated to match the mesio-distal size of the socket.
Using an Orban periodontal knife,x a tunnel was created
under the palatal mucosa, connecting the donor site to
the socket orifice. A polyglactin 910‖ 5-0 suture was used
at the distal end of the pedicle graft to aid in sliding it under
the created tunnel and into the socket space (Figs. 2a and
2b). A collagen membrane was trimmed to cover the facial
dehiscence, and a freeze-dried bone allograft was placed
in the socket (Figs. 2c through 2e). The pedicle was then
adapted over the grafting materials and fitted under the
facial mucosa. Using a polyglactin 910 5-0 suture, horizon-
tal mattress and simple interrupted sutures were placed
over the pedicle at the socket orifice and for primary clo-
sure at the donor site (Fig. 2f).
Healing was uneventful in the immediate postoperative
period (Fig. 3). Site reentry was performed at 4 months
postoperatively for implant placement and immediate tem-
porization (Figs. 4a through 4c). Adequate bone and soft
tissue quantity and quality were noted. A dental implant
was placed in an optimal position and immediately tempo-
rized (Figs. 4d through 4f). A permanent restoration was
placed 6 months later. Evaluation of results up to 2 years
postoperatively reveals high gingival esthetic outcomes at
site #7 (Fig. 5).
Case 2
A 19-year-old systemically and periodontally healthy male
presented to the periodontist (AHR) office with an anky-
losed tooth #8 that was retained 4 mm apical to tooth
#9 (Fig. 6a). At time of presentation, the patient was under-
going orthodontic treatment. Dental history revealed an
avulsion of tooth #8 caused by an accident at age 12 years.
The tooth was repositioned back into the socket after the ac-
cident. The tooth became ankylosed and preserved its initial
position within the growing maxilla. At age 19 years, two lat-
eral cephalometric radiographs taken 6 months apart were
superimposed and found to be identical, indicating the end
of growth. The patient was then referred for tooth extraction
and implant placement. Severe gingival discrepancy was noted
between the maxillary central incisors; however, the inter-
proximal bone height was adequate on the adjacent teeth.
The apical position of the tooth imposed an esthetic challenge
that required multiple surgical therapies.
x
Hu-Friedy, Chicago, IL.
‖
VICRYL, Ethicon, Johnson & Johnson, Somerville, NJ.
Novel Pedicle Connective Tissue Graft Technique
 C A S E S E R I E S

FIGURE 1 Case 1. 1a Maxillary right lateral

incisor (tooth #7) at initial presentation after an
aborted apicoectomy attempt. 1b Periapical
radiograph showing apical lesion and normal
crestal bone level.

FIGURE 2 Case 1. 2a Pedicle graft dissected from the palate through a single incision design and channeled through the mucosal tunnel with a suture. 2b
Facial view showing pedicle length. 2c Resorbable barrier shaped to cover the facial bony dehiscence. 2d and 2e Placement of bone particulate graft into
socket defect. 2f Pedicle positioned to cover the graft material and tucked under the facial gingival margin, achieving complete soft-tissue closure; suture
placement at donor site and over the pedicle for stabilization.

FIGURE 3 Case 1. 3a and 3b Uneventful healing at 2 days postoperatively. 3c and 3d Complete clinical healing at 3 weeks postoperatively.

As a first phase of treatment, tooth #8 was extracted,
leaving a severe localized horizontal and vertical ridge de-
fect that was addressed using a ramus block graft (Figs. 6b
through 6f). Four months later, the site was reentered for
implant placement. After the elevation of a trapezoidal fa-
cial flap, the ridge revealed adequate horizontal gain and
limited vertical gain, whereas adequate interproximal bone
height was still encountered on the adjacent teeth (Figs. 7a
through 7c). A pedicle CT graft was dissected from the mid-
palatal aspect of tooth #3 to the distal aspect of tooth #7
and handled in a similar manner as in case 1 (Figs. 7d
through 7f). A dental implant was placed in an optimal

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FIGURE 4 Case 1. 4a through 4c Mature soft-tissue healing at 4 months postoperatively showing adequate soft-tissue height and ridge contour. 4d Papilla-
preservation facial flap and implant placement in an optimal three-dimensional position. 4e Periapical radiograph at time of placement confirming proper
implant positioning. 4f Immediate implant temporization and flap repositioning with 5-0 polyglactin 910 sutures.

FIGURE 5 Case 1. 5a Final outcome at 1 year after implant placement with definitive restoration in place. 5b Periapical radiograph showing stability of crestal
bone 2 years after implant placement. 5c Soft-tissue esthetics maintained at 2 years after implant placement in the anterior maxilla.

three-dimensional position, which created a 4-mm facial
dehiscence (Fig. 8a). Autogenous bone chips, deproteinized
bovine bone mineral, and a resorbable barrier were se-
lected to treat the peri-implant defect (Figs. 8b through
8d). The pedicle graft covered all the grafting materials,
and primary flap closure was obtained at the recipient
and donor sites (Figs. 8e and 8f).
Augmenting the soft-tissue volume allowed for a reso-
lution of the esthetic discrepancy until the implant was
uncovered at 6 months postoperatively (Fig. 9a). After
another 3-month temporary phase (Fig. 9b), a permanent
implant restoration was placed. Although a 0.5-mm dis-
crepancy of the gingival margins of the central incisors
is noted, significant enhancement of gingival esthetics
was achieved in this challenging case using a combi-
nation of hard- and soft-tissue ridge augmentations
(Fig. 9c).
Video 1 demonstrates harvesting and management of
this novel pedicle CT graft technique in a patient whose
informed written consent was obtained.
Postoperative instructions were similar for both pa-
tients. Amoxicillin (500 mg) was prescribed three times
a day for 1 week. Pain control was managed with non-
steroidal anti-inflammatory drugs. Chlorhexidine (0.12%)
was also prescribed twice per day for 2 weeks postopera-
tively. The patients were seen at 1-, 2-, and 3-week follow-
up visits, including removal of sutures and oral hygiene
instructions. Wound healing at the recipient and donor
sites was uneventful.
Discussion
Soft-tissue enhancement has numerous indications in im-
plant therapy. It begins with developing the extraction site,
continues at the time of implant placement and second-stage
implant surgery, and proceeds after implant restoration in
the treatment of peri-implant disease. Various autogenous
soft-tissue options have been described for these purposes in
the literature. Palatal pedicle grafts were successfully used
at time of socket preservation and/or implant place-
ment.12,13,15,17 These pedicle options have improved

194 Clinical Advances in Periodontics, Vol. 3, No. 4, November 2013 Novel Pedicle Connective Tissue Graft Technique
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FIGURE 6 Case 2. 6a Ankylosed maxillary right central incisor (tooth #8) creating an esthetic discrepancy of 4 mm in height. 6b Trapezoidal facial flap and
tooth extraction. 6c Residual bony defect lacking in ridge height and width at site #8. 6d Ramus block fixated at site #8 with two titanium miniscrews. 6e
Autogenous bone chips, deproteinized bovine bone mineral, and acellular dermal matrix allograft placed over the ramus block. 6f Coronally advanced flap
achieving primary closure at site #8.

FIGURE 7 Case 2. 7a Improved clinical situation 4 months postoperatively. 7b Minimal exposure of ramus block at facial aspect of edentulous site. 7c
Trapezoidal flap elevation and debridement of non-integrated part of the block graft. Horizontal bone gain was noted, interproximal bone height was
maintained, and vertical bone gain was minimal. 7d Dissection of pedicle graft after a single palatal incision extending from the mesial aspect of the first molar
to the distal aspect of the tooth distally adjacent (tooth #7) to the implant site (tooth #8). 7e Pedicle graft elevated from the donor site except for the mesial
aspect. 7f Pedicle graft pulled through the created mucosal tunnel into the implant site.

vascular supply and stability at the recipient sites when com-
pared with free grafts. The subepithelial CT pedicle tech-
niques13,17 were shown to provide a greater amount of tissue,
achieve soft-tissue closure at donor and recipient sites, and
cause minimal postoperative morbidity.
This case series presents a novel pedicle CT technique by
incorporating a palatal tunnel through which the pedicle is
channeled to the recipient site. More than 100 patients
were successfully treated by the authors using this
technique. The clinical observation in the present case se-
ries reveals significant gains in soft-tissue height and volume
of treated sites. Several advantages can be attributed to this
novel modification. Although all existing palatal pedicle
options dissect the mucosa directly palatal to the defect
site, the present technique preserves the integrity of that
mucosa by stopping the single incision one tooth distal
to the defect site. This allows for the creation of a tunnel
under the mucosa palatal to the defect area. This tunnel

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FIGURE 8 Case 2. 8a Implant placement according to ideal three-dimensional position leading to a coronal facial dehiscence. 8b Placement of autogenous
bone chips at the peri-implant defect. 8c Deproteinized bovine bone mineral particles used as a contour bone graft. 8d Placement of a resorbable barrier
secured with the implant cover screw. 8e Pedicle graft positioned over barrier at crestal and facial aspects. No sutures were required because of improved
stabilization by the palatal tunnel. 8f Coronally advanced flap and primary soft-tissue closure.

FIGURE 9 Case 2. 9a Patient smile line 6 months after implant placement. 9b Gingival line symmetry restored between central incisors after implant
temporization. 9c Two-year follow-up presentation demonstrating resolution of gingival margin discrepancy with final restoration in place.

contributes to the vascular supply of the pedicle, whereas
the overlying palatal mucosa stabilizes the graft in the de-
sired position over the defect site. Therefore, suturing the
pedicle graft is not required for proper positioning,
although sutures to approximate wound margins over
the pedicle are usually placed. In addition, this novel tun-
nel modification significantly minimizes the formation of
a soft-tissue protuberance at the site of pedicle rotation,
which is normally encountered in other techniques that fully
elevate the palatal flap. Partial necrosis of the pedicle grafts
was noted in only 4% of all treated cases. Nevertheless,
the authors consider this treatment option more time
consuming and technique sensitive than existing pedicle
graft modalities. n

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Summary
Why are these cases new j To the best of our knowledge, this is the first pedicle CT graft
information? technique that describes a palatal tunneling.
j Multiple advantages can be attributed to this novel technique:
1) improved stability of pedicle graft; 2) no need to suture pedicle graft
in position; 3) minimal to no protuberance of the palatal mucosa at the
site of pedicle rotation; and 4) preservation of soft-tissue integrity and
blood supply of palatal mucosa at the defect site.

What are the keys to successful j Refrain from extending the palatal single incision to the defect site.
management of these cases? j Prepare the pedicle graft longer and wider than the actual dimensions
of the defect.
j Use caution when dissecting the pedicle at the curvature of the palate

in the canine region to avoid fenestration of the palatal mucosa.

j Use a suture to help in channeling the pedicle through the tunnel.

What are the primary limitations to j Minimal thickness of the palatal mucosa
success in these cases? j Multiple defect sites in the anterior maxilla
j Underestimating the graft dimensions required to cover the defect site

Acknowledgment CORRESPONDENCE:
Dr. Ramzi V. Abou-Arraj, University of Alabama at Birmingham, SDB 412,
The authors report no conflicts of interest related to this 1919 7th Ave. S., Birmingham, AL 35294-0007. E-mail: rva@uab.edu.
case series.

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