Techniques for the Protection
Palatal donor sites, however are
and Coverage of the Donor
Sites in Free Soft Tissue
Grafts
by
A L I F A R N O U S H , D.M.D., M.S.*
T H E F R E E SOFT TISSUE (gingival) graft was introduced
1 2
by Bjorn in 1963 and King and Pennel in 1964 de­
scribed its clinical applications to correct mucogingival
problems. The technique is now widely used to treat a
variety of periodontal mucogingival problems such as
insufficiency or lack of attached gingiva, the presence of
high frenum attachments, shallow fornix and denuded
3-6
roots following gingival recession.
The donor tissue is most frequently taken from the
palate, although the use of the mucosa of the edentulous
ridge, the tuberosities and the attached gingiva also has
7
been advocated. Numerous attempts have been made to
protect and stabilize the graft and the recipient sites
using such means as suturing, tissue adhesives, various
surgical dressings, rubber dam, telfa or combinations of
these methods. However, little attention has been given
to covering or protecting the donor sites.
The healing process at the donor site proceeds by
secondary intention or "granulating in" and takes about
2 to 4 weeks depending on the width and thickness of
the tissue removed. Although the postoperative response
at the donor site is generally uneventful, many patients
suffer traumatic and postoperative discomfort with oc­
casional bleeding and delayed healing especially if the
graft involves multiple sites on the palate. It is sug­
8-11
gested that the gingival wounds which heal by sec­
ondary intention should be sheltered during the period
of epithelialization and early recollaginization so as to
offer protection against topical irritants, rough, acidic or
highly seasoned foods and toothbrush abrasion. A dress­
ing also can reduce the tendency for over granulation of
9
the wound.
Though the exact value of such a surgical dressing has
12,13
been questioned, the general concensus is that if an
exposed excised wound is protected during the early
phase of healing there is a minimum of topical irritation
with less postoperative discomfort and apparent im­
9
proved healing. As the healing process of a gingivectomy
wound and the wound of the donor site are basically the
same, the rationale for protecting the gingivectomy
wound by a surgical dressing should also be applied to
* Department of Periodontics, University o f Iowa, College of Den­
tistry, Iowa City, Iowa 52242.
403
the palatal donor site.
commonly left exposed because of the difficulty in main­
taining a dressing in position.
This paper illustrates and discusses a number of tech­
niques which can be utilized to protect and cover palatal
donor sites during healing.
INTRAORAL B A N D A G E *
An intraoral bandage or oral adhesive (e.g. Orabasef)
may be used to protect the donor site for a few hours.
However, they do not provide adequate protection over
a long period of time, as they rapidly disintegrate when
8
in contact with saliva.
U S E O F INTERPROXIMAL W I R E L I G A T I O N
Wire ligation around the teeth of the maxillary quad­
rant adjacent to the area which is used as a donor site
can provide the support or retention to keep a surgical
dressing in place. Stainless steel wire ligature, commonly
used for temporary splinting, can be utilized either as
two strands of 0.008 or a single 0.01 gauge wire. One end
of a small section of the wire is passed through mesial
and the other end through distal embrasure spaces
around each tooth to form a loop on the buccal surface,
just below the contact points. The loop is then adapted
closely and twisted with a hemostat in such a way that
both ends of the loop form a single strand about 1 cm
long palatally (Fig. 1). This procedure can be repeated
for a number of teeth in the quadrant and various
combinations may be utilized, e.g., 2 premolars and 2
molars, 1 premolar and 2 molars, or only 2 molars (Figs.
2 and 3). The ends of the wire twisted around each tooth
and forming a single strand can be bent and directed
over the surgical dressing to keep the dressing in the
position.
STABILIZATION O F T H E S U R G I C A L D R E S S I N G BY
"MATTRESS" SUTURES
The dressing can be kept in a desired position by two
mattress sutures, one in the mesial and the other in the
distal portion of the donor site in such a way that each
suture forms a loop over the dressing. The donor site is
first covered by a dressing and a layer of dry foil may be
placed over the dressing for added protection. A number
3-0 or 4-0 atraumatic needle may be used to form two
mattress sutures, 4 to 5 mm from the margin of the
wound or 2 to 3 mm away from the boundary of the
dressing. The sutures are then passed over the dressing
and through the interproximal areas of the adjacent teeth
to be tied (Fig. 4).
U S E OF A MODIFIED H A W L E Y APPLIANCE
A modified Hawley retainer may be used to stabilize
the dressing in its position. The retainer is especially
helpful when multiple donor sites are present in the
* E. R. Squibb & Sons, New York,
† Hoyt Laboratories, Needham, Mass.

404 Farnoush
palate. The retainer consists of a thin acrylic base with
clasps on the anchor teeth. The clasp designs may include
Adam's clasps or interproximal ball clasps (Fig. 5). The
retainer should be made prior to the surgery from an
accurate stone model (Fig. 5).
DISCUSSION
The value of a postsurgical dressing and the therapeu­
tic effects of its constituents on gingival healing have
FIGURE 1. The use of stainless steel wire ligatures is illustrated in
a patient to protect the graft donor site by keeping the surgical
dressing in place.
FIGURE 2. Variation of the wire ligation technique on a model.
Here three ligatures are used on a large donor site.
FIGURE 3. See Figure 2. Here a layer of dry foil is placed
the surgical dressing for added protection.
J. Periodontol.
August, 1978
FIGURE 4. "Mattress" sutures have been used to stabilize the
surgical dressing over the donor site in a patient.
FIGURE 5. In this case, a modified Hawley retainer with two
interproximal ball clasps was used to protect multiple graft donor
sites in the palate by keeping the surgical dressings in their
positions.
10
been the subjects of controversy. Bernier and Kaplan
in 1947 suggested that surgical dressings facilitate the
healing process, primarily by their physical protective
14-17
effects. Subsequent studies have indicated that the
ingredients of some surgical dressings also could have
potential therapeutic benefit on healing from their anti­
septic and antibacterial properties. These studies have
suggested that the antibiotic containing dressings reduce
postoperative complications and patient discomfort. Baer
18
and Wertheimer suggested that the dressings containing
eugenol elicit a greater inflammatory response and have
a detrimental effect on the denuded bone when com­
pared to dressings without eugenol. However, clinical
19-22
and histological observations by other investigators,
in contrast, have indicated no differences in the healing
process of the denuded bone adjacent to eugenol-free
and eugenol containing surgical dressings.
over
Contrary to the numerous studies which support the
Volume 49
Number 8
multibeneficial effects of surgical dressings, the value
and need for such a dressing has been questioned, in that
gingival healing may be equally uneventful without a
dressing provided the cleanliness of the wound is main­
12, 1 3
tained. Comparable healing has been reported fol­
12
lowing gingivectomy with or without a dressing. In fact,
subdermal connective tissue implants of both eugenol
and noneugenol containing dressings in rats resulted in
a mild to moderate inflammatory response during the
initial phase of healing irrespective of the type of dressing
19
used.
The chemical tissue adhesive, N-butyl cyanoacrylate
also has been used experimentally as a periodontal dress­
23
ing. The advantages of the cyanoacrylate as a peri­
23,24
odontal dressing have been listed as such that (1) it
can be applied with great ease, (2) it can act as a tissue
covering by adhering to moist, living tissues, (3) it is a
hemostatic agent, (4) it is not bulky and therefore does
not interfere with the use of prostheses, (5) it can be used
around single teeth, (6) it reduces postoperative pain, (7)
it does not induce overgrowth of granulation tissue, and
(8) it accelerates the healing processes. It appears from
these reports 23-25
that N-butyl-cyanoacrylate can fulfill
most of the criteria required for an ideal periodontal
dressing. However some of the attributed therapeutic
properties of this material such as more rapid healing,
less granulation tissue and less postoperative pain have
been based only on clinical and subjective findings. In
21
fact, the histological analysis failed to reveal improved
healing with the cyanoacrylate adhesive when compared
with other periodontal dressings. Furthermore, the cy­
anoacrylate may delay healing, if it seeps under a peri­
odontal flap or is embedded within the tissue thereby
26
producing a foreign body granuloma. The use of this
chemical adhesive as a periodontal dressing is still in the
experimental state and has not been approved by the
Food and Drug Administration.
Despite the controversy on the rationale for the appli­
cation of postsurgical dressings or the superiority of one
material over another, the general consensus is that a
surgical dressing at least can provide patient comfort and
protect the wound from further injury during the early
phase of healing. 8,9
The methods for coverage of the palatal donor site
described in this article are easy to utilize, are inexpen­
sive, and can help to eliminate postoperative discomfort
by protecting the wound from further injury during
healing of the donor sites.
SUMMARY AND CONCLUSION
Palatal donor sites used for free soft tissue grafts are
commonly left exposed during healing which occurs by
secondary intention. This often results in postoperative
discomfort and pain and in some cases apparent delayed
healing of the donor sites. Various techniques for the
protection and coverage of donor sites have been pre­
sented and the rationale, advantages and disadvantages
of coverage of gingival wounds have been discussed.
Protection and Coverage of Donor Sites 405
REFERENCES
1. Bjorn, H.: Free transplantation of gingiva propria. Odon-
tolRevyU: 323, 1963.
2. Pennel, B. M., Tabor, J. C , King, K. O., Towner, J. D.,
Fritz, B. D., and Higgason, J. D.: Free masticatory mucosa
graft. J Periodontol 40: 162, 1969.
3. Nabers, J. M.: Free gingival grafts. Periodontics 4: 243,
1966.
4. Nabers, J. M : Extension of the vestibular fornix utilizing
a gingival graft. Periodontics 4: 77, 1966.
5. Sullivan, H . C , and Atkins, J. H.: Free autogenous
gingival grafts. Principles of successful grafting. Periodontics 6:
121, 1968.
6. Sullivan, H . C , and Atkins, J. H.: Free autogenous
gingival grafts. III. Utilization of grafts in the treatment of
gingival recession. Periodontics 6: 152, 1968.
7. Goldman, H., and Cohen, D. W.: Periodontal Therapy.
ed 5, p 727. St. Louis, C. V. Mosby Co., 1973.
8. Baer, P. R , Sumner, C. F., III, and Miller, G.: Periodontal
dressings. Dent Clin North Am 13: 181, 1969.
9. Goldman, H., and Cohen, D. W.: Periodontal Therapy.
ed 5, p. 879. St. Louis, C. V. Mosby Co., 1973.
10. Bernier, J. L., and Kaplan, H.: The repair of gingival
tissues after surgical intervention. J Am Dent Assoc 35: 697,
1947.
11. Linghorne, W. J., and O'Connell, D. C : The therapeutic
properties of periodontal cement packs. J Can Dent Assoc 15:
199, 1949.
12. Stahl, S. S., et al.: Gingival healing. III. The effects of
periodontal dressings on gingivectomy repair. J Periodontol 40:
34, 1969.
13. Loe, H., and Sillness, J.: Tissue reactions to a new
gingivectomy pack. O r a l Surg 14: 1305, 1961.
14. Fraleigh, C. M.: An evaluation of topical terramycin in
postgingivectomy pack. J Periodontol 27: 201-208, 1956.
15. Waerhaug, J., and Löe, H.: Tissue reaction to gingivec­
tomy pack. O r a l Surg 10: 923, 1957.
16. Eberle, P., and Muhlemann, H. R.: Ein Neuer Paraden­
tal Verband. Schweiz Monatsschr Zahnheilkd 69: 1095, 1959.
17. Baer, P. N., Sumner, C. F., and Seigliano, J.: Studies on
a hydrogenated fat-zinc bacitracin periodontal dressing. Oral
Surg 13:494, 1960.
18. Baer, P. N., and Wertheimer, F. W.: A histologic study
of the effects of several periodontal dressings on periosteal-
covered and denuded bone. J Dent Res 40: 858, 1961.
19. Guglani, L. M., and Allen, E. F.: Connective tissue
reaction to implants of periodontal packs. J Periodontol 36:
279, 1965.
20. Frisch, J. E., and Bhaskar, S. N.: Response of rat tissue
to eugenol-containing and eugenol-free periodontal packs.
I A D R Abstracts, 507, 1967.
21. Ochstein, A. J., Hansen, N . M., and Swenson, H. M.: A
comparative study of cyanoacrylate and other periodontal
dressing on gingival surgical wound healing. J Periodontol 40:
515, 1969.
22. Oliver, W. M., and Neaney, T. G.: Sequelae following
the use of eugenol or non-eugenol dressings after gingivectomy
and subgingival curettage. Dent Pract (Bristol), 21: 49, 1970.
23. Bhaskar, S. N., Frisch, J., Margetis, P. M., and Leonard,
F.: Oral Surgery-Oral Pathology Conference No. 18, Walter
Reed Army Medical Center. O r a l Surg 22: 526, 1966.
24. Bhaskar, S. N., Cutwright, D. E., Jacoway, J. R., Mar­
getis, P. M., and Leonard, F.: Use of chemical adhesives in the
management of bone fractures. I A D R Abstracts No. 47, 1967.
25. Meyler, L.: Side Effects of Drugs. Excerpta Medica
Foundation, 1966.
26. Woodward, S. C , et al.: Histotoxicity of cyanoacrylate
tissue adhesive in the rat. Ann Surg 162: 113, 1965.