Journal of Clinical Periodontology.

1974: 1: 185-196
Key words: niucofiingival sur\ievy - attached aiii
Accepted for piiblicatiot\: October 2, 1974.

/ - free connective tissue grafts.

Clinical evaluation of free connective

tissue grafts used to increase the
width of keratinised gingiva
ALAN EDEL

University College Hospital Dental School, Mortimer Market, London, England

Abstract. Fourteen sites were chosen in eight subjects where pre-operatively less than 2 mm
of keratinised gingiva was present and associated with pocketing of less than 1.0 mm
Three methods were used to provide gingival connective tissue for grafting which facilitated primary closure at the donor site. The pre-operative width of keratinised gingiva was
measured by means of a Williams probe from the gingival margin to the mucogingival
junction to the nearest 0.5 mm. This was repeated immediately post-operatively, and at
1, 2, 5, 10, and 12 weeks, and at 6 months. The results showed that a statistically significant increase in width of keratinised attached gingiva could be achieved with this method
and the resultant tissue was histologically normal.

I t is generally accepted that the presence

of an adequate zone of keratinised attached
gingiva is important for the maintenance
of a healthy dento-gingival junction. The
characteristics of attached gingiva enable it
t o withstand the frictional forces encountered during mastication, and to dissipate
t h e pull of the circum-alveolar musculature.
Lang & Loe (1971) have demonstrated
that a crevicular exudate can always be
detected from a gingival sulcus with less
than 2 mm of attached gingiva, and this
amount would appear to be essential for
gingival health in young adults.
An inadequate width of attached gingiva
is commonly found together with a shallow
vestibular depth, and various methods have
been employed and modified for increasing
the width of keratinised gingiva and/or for
deepening the vestibular sulcus. (Ariaudo
& Tyrell 1957, Bohannan 1962 a and b.

Robinson & Agnew 1963, Corn 1962,

Freedman & Levine 1964, Staffileno et al.
1966).
In recent years the use of free gingival
autografts has become popular (Nabers
1966 a and b, Haggerty 1966, Becker 1967,
Bressman & Chasens 1968, Sullivan &
Atkins 1969, Snyder 1969, Hawley &
Staffileno 1970) since they can be relied
upon to produce more predictable results
(Karring et al. 1971).
Free gingival grafts may be defined as
"partial thickness" when they consist of
epithelium and varying amounts of lamina
propria, or "full thickness" when all the
lamina propria but no glandular tissue or
submucosa is included. Sullivan & Atkins
(1968) have outlined the principles of successful grafting; they state that for the first
few days the graft vitality is maintained by
a plasmatic circulation; and only after the

186

EDEL

third day does a normal vascular circulation become re-established.

Their studies also showed that the epithelial cells of a thick graft tend to desquamate, but that this is not important to
the final result, as the surface will re-epithelialise from cells deeper in the epithelial
ridges.
Oliver et al. (1968) have confirmed these
findings in a series of grafts in seven Rhesus
monkeys. The histological findings showed
that virtually all the epithelium degenerated
and desquamated by the fifth day, though
some cells deep in the epithelial ridges may
have persisted and may have contributed
to the re-epithelialisation of the graft. More
important however, was the contribution of
proliferating epithelial cells from the adjacent tissue, and by the eleventh day epithelial cells covered the entire surface but
showed no keratinisation until the twentyeighth day.
Lange & Bernimoulin (1974) have suggested, on the basis of cytological studies,
that the basal epithelial cells of free gingival grafts probably do not degenerate
and contribute to the re-epithelialisation of
the graft.
In their study, Karring et al. (1971) attempted to determine whether it is some
inherent factor in the tissues or whether it
is functional adaptation that is responsible
for the maintenance of tissue specificity.
They performed a series of heterotropic
gingival and alveolar mucosal transplants
in eight adult monkeys (Cerco pitheous).
The findings that the transplanted tissues
always retained their original structure,
even after 1 year, gave no support to the
theory of functional adaptation (Ivancie
1957, Bradley et al. 1959, Pfeifer 1963).
Most studies on epithelial mesenchymal
interactions favour the concept that histodifferentiation occurs as a response to
moqjhogenetic stimuli from the underlying
connective tissue, and that the epithelial

cells do not possess any predetermined regional specificity (Cairns & Saunders 1954,
McLoughlin 1961, Rawles 1963. Billingham & Silvers 1968, Dodson ]967, Plagmann et al. 1974). It is, however, also possible that histodifferentiation is controlled
by mutual interaction of epithelium and
the underlying connective tissue (Wessles
1962, Cohen 1965).
The present study was undertaken to
determine the predictability of using free
gingival connective tissue grafts without
epithelium, in an attempt to increase the
width of keratinised gingiva.
Materials and Method

Fourteen areas were chosen for treatment

in eight subjects. The criterion for inclusion
in the study was a width of keratinised
gingiva of less than 2.0 mm, associated
with pocketing of no more than 1.0 mm on
the buccal aspect. If more than one tooth
was included in an area, then the results
lor all the teeth were combined, and the
mean taken as representative for the total
area. The age-range of the subjects was
27.-55 years, with a mean age of 39 years.
Prior to surgery, scaling and polishing were
completed, and oral hygiene instruction
was given to ensure good post-operative
control.
The width of attached gingiva, measured
from the free gingival margin to the mucogingival junction, was recorded pre- and
post-operatively (by means of a Williams
probe) to the nearest 0.5 mm; this measurement was repeated at 1,2, 5, 10, 12 weeks,
and at 6 months. The recipient site was
prepared by making two vertical incisions
into the alveolar mucosa, at the buccal line
angles of the teeth adjacent to the area to
be treated. By sharp dissection, a periosteal
bed, which was free of all muscle attachments, and was of sufficient size to take
the graft was left covering the underlying

FREE CONNECTIVE TISSUE GINGIVAL GRAFTS

187

Fiii- I- Diagrammatic illustration of Method 1. A partial thickness flap is raised and the connective tissue graft is taken from below the palatal surface. The flap is then sutured back.
F i g . 1- Schetiutlische
gewebs-Traitsplantat
gelegt.
Hig. 1. Scht/tria du
souleve el ht greffe

DarsteUtmg der Methode 1. Ein Spctlthtppeti wird gebildet utid ein Bindcwird int Gitumcnbcreich entnonttncn. Der Loppen wird darauf zuriickprocede chirurgical de hi tttethode 1. Utt lattibeatt tttuquettx palatin est
cotijottctive est prelcvee dtt tissus sousjacettt; le httitbeau est ensuite suture.

bone. Haemostasis was aehieved by applying pressure with a piece of cotton gauze
soaked in warm saline. The remaining partial thickness flap was displaced apically,
b u t was not sutured.
Donor Site
Method I: The palatal region opposite the
molar teeth served as the donor site in six
cases. Using a number 15 Swann Morton
blade, a primary partial thickness gingival
pedicle flap was raised with its base wider
than its free end. This primary flap was
then displaced by means of a retractor, and
a portion of the underlying mucosa (approximately the size of the recipient bed),
was dissected out with a fresh number 15
blade. Care was taken not to go too deep
in order to avoid the inclusion of any
palatal mucosal glands (Fig. 1). If this did
occur the graft was trimmed before being
placed on the recipient site. The primary
flap was replaced and pressure applied for
2 min to prevent any void under the flap.
The flap was sutured in the conventional
manner with interrupted sutures; these re-

mained in place for 1 week. No dressing

was applied.
Method 2: The undersurface of a full
thickness flap was used as the donor site
in six cases. A primary incision was made
to the crest of the bone along the axis of
the teeth close to the gingival margin. A
full thickness flap was raised, and a second
incision was made to thin this flap internally. The resultant portion of tissue was
tritnmed and used as the graft tissue. The
palatal flap was then replaced, sutured and
left for 1 week (Fig. 2); a dressing was
provided if necessary.
Method 3: The undersurface of a saddle
region between standing teeth was dissected out and used for grafting in two cases.
(Fig. 3). In all cases the donor site was left
without a dressing as primary closure could
always be achieved.
The graft was placed on the prepared
recipient bed and anchored to the adjacent
tissues with 6.0 atraumatic silk sutures
(Ethicon Mersutures). The principles of

188

EDEL

Fig. 2. Diagrammatic illustration of Method 2. Graft material is obtained by the thinning of a

full thickness palatal flap. The first incision is made to the crest of the bone and when the flap
is reflected a second incision thins the flap internally and provides the connective tissue for
grafting.
Fig. 2. Schetnatische Darslcllung der Methode 2, Das Transplantat wird dureh das Verdiitmett
eines palatinalen Schieitnhautperiostlappetis gcwontien. Die erstc Inzisiott erfoigt his auf den
Alveolurknochcnkatnnt, Am zuriickgeschobctteti Lappeti wird dureh cine 2, Inzision auf der
Lappetiititictiseite das Bindegewcbc-Tratisplantat erhalten. Lappetireposition.
Fig. 2. Schetna du procede chirurgical de la methode 2. Le materiel a greffer est obtenti eti atiiincissant le lambeau palatin enticr. La premiere iticision s'etetid fusqu'a la crete osseuse, la scconde
cree un latnbeau au seiti duquel on preleve la greffe conjotictivc.

B
Fig, 3. Diagrammatic illustration of Method 3. A partial thickness flap is raised at the saddle
area and graft material is taken from the underlying connective tissue. The flap is then sutured
back.
Fig. 3. Schetnatische Darsteilung der Methode 3. Ein Spaltlappen wird itn Gebiet des Kieferkatntnsatlels gebildct. Das Transplantat wird detn darutiter liegenden Bittdegewebe etittiomtnen.
Der Spalllappen wird darauf mit Nahten reponiert.
Fig. 3. Schema du procede cliirugical de la tnethode 3. Meme principe que datis la tnethode 1,
tnais au tiiveau d'utie zone edentie.

FREE CONNECTIVE TISSUE GINGIVAL

GRAFTS

189

Fig. 4. Healing pattern of a free gingival connective tissue graft, a) Pre-operative photograph
showing an inadequate width of attached gingiva on the buccal surface of |4. b) The connective
tissue graft sutured in place, c) 1 week post-operatively. d) 6 months post-operatively.
F i g . 4. Die Einheilungsphasen eines Bltidegewebe-Transplantates: a) Prae-operativ ungeniigende
Breite der kercttitiisierten angewachsenen Gingiva btikkal von \4. b) Mit Ndhten fixiertes Bindegewebe-Tritnsplatitat. c) 1 Woclie nach der Operation, d) 6 Monate tmch der Operation.
Fig. 4. Phases succcssives de la guerison d'une greffe de tissus conjonctif gingival. a) Aspect
cliniqtie preoperatoirc motttrant la largeur inadequate de la gencive adheretite vestibtdaire au
niveau de \4. b) Greffe de tissus conjottctif sutttree en place, c) 1 semaitie apres I'operation.
d) 6 tnois apres I'operation.
t r e e gingival grafts, as outlined by Sullivan
& Atkins (1968), were employed, and the
displaced flap was checked to ensure it did
n o t interfere with the graft. A non-eugenol
dressing (Coepak) was applied to the
area. The dressing and sutures were removed after 1 week; then the teeth were
polished and a dressing was replaced for a
further week.

A biopsy specimen was taken of the

muco-gingival junction from one area at
6 months; it was fixed in 10 % formol
saline for 8 h, and processed to wax over
a period of 24 h. Five micron sections were
cut and stained with haematoxylin and
eosin, and Verhoff's van Gieson stain for
elastic fibres.

EDEL

190

Fig. 5, a) Pre-operative view showing inadequate width of attached gingiva on the buccal surface of |345. b) Connective tissue graft sutured in place, c) 1 week post-operatively. d) 6 weeks
post-operatively.
Fig. 5. a) Prae-operativ ungeniigende Breite der keratinisierten, angewachseneii Gingiva, bukkal
von \345, b) Mit Ndhten fixiertes Bindegewebe-Transplantat. c) 1 Woche nach der Operation,
d) 6 Wochen nach der Operation.
Fig. 5. a) Aspect cUnique preoperatoire inontrant la largeur inadequate de la gencive adherante
vestibulaire au niveau de \345, b) Greffe de tisstts conjonetif suturee en place, c) 1 seinaine
apres /' operation, d) 6 semaines apres I'operation.

Results

In all cases the graft area and the donor

site healed uneventfully when both methods
2 and 3 were employed (Figs. 4a-d and
Figs. 5 a-d). In all six cases where method 1
was used the primary flaps degenerated to
a varying degree (Figs. 6a and 6b), and
were associated with marked discomfort

for 712 d, as no dressings were applied to

protect this region during healing.
Table 1 shows the width of attached gingiva recorded at various intervals during the
study. The results were stable at 12 weeks
and remained so over a further period of
3 months. At the end of the 6-month period
the pocket depths were still no more than
1.0 mm, and when a paired t-test was ap-

FREE CONNECTIVE TISSUE GINGIVAL GRAFTS

191

Table 1, Width of keratinised attached gingiva in millimeters

Tabelle 1. Breite der angewachsenen, verliornten Gingiva, tntn
Tableau 1. Largeur de la geticive adherente mtn

Subject

Method 1
1.
2.
3.
4.
5.
6.
Method 2
7.
8.
9.
10.
11.
12.
Method 3
13.
14.

Immediately
Preoperative

Immediately
Postoperative

1.5

weeks (wochen, setnaities)

1

5.

10

12

24

7.0
6.0
5.0

6.0
6.5
7.0
5.0
5.0

4.5
6.0
5.0
4.5
5.0
5.0

4.0
5.5
5.0
4.0
5.0

1.0

5.0
5.0
5.0

5.5
6.5
6.0
5.0
5.0
5.0

3.5
5.0
4.5
3.5
5.0
5.0

3.5
5.0
4.5
3.5
5.0
5.0

1.5
2.0
2.0
1.0
1.5
1.5

5.5
9.0
5.0
4.0
4.5
5.0

5.5
9.0
7.0
3.5
4.5
5.0

5.0
6.5
6.0
3.5
4.0
4.5

4.0
6.0
5.0
3.0
3.5
5.0

5.5
4.5
3.0
3.5
5.0

4.0
5.0
4.0
3.0
3.5
5.0

4.0
5.0
4.0
3.0
3.5
5.0

1.5
1.5

4.5
5.0

7.0
5.0

4.5
4.5

3.5
4.0

3.5
4.0

3.5
3.5

3.5
3.5

1.5

1.5
1.5

. 1.0

5.0

Fig. 6a. Donor area (Method 1); the flap is

sutured back (mirror view).
Fig. 6a. Spetidergegend bei Methode 1, Der
Lappett ist tnit Ndhtett repotiiert.
Pig. 6a. L'ettdroit donnettr (tnethode 1) ttiotitrant le latnbeati tnttqueu.K suture.

5.0
4.0

Fig. 6b. 1 week post-operatively, showing degeneration of the flap (mirror view).
Fig. 6b. 1 Woelie tiach der Operation. Degeneration des Lappens (Bild itn Spiegel).
Fig. 6b. 1 sermine apres I'operaiion le latnbeau
a degenere.

EDEL

192

MGJ

:\

< ' ' , '

'

F/g. 7. Biopsy section of the newly-created muco-gingival junction after

6 months, stained H + E (X40). MGJ = mucogingival junction; AM = alveolar
mucosa; C = connective tissue.
Fig. 7. Histologisches Bild der neuen inukogingivalen Grenze 6 Monate
postoperativ. Haeinatoxylin-Eosin-Fdrbung, X40, MGJ Mukogingivalgrenze;
AM = Alveolarmukosa: C = Biiidegewebe.
Fig. 7. Coupe histologlque de la nouvelle jonction mucogingivale apres 6 mois.
Coloration a I'heinatoxylineeosine, X 40, MGJ = jonction mucogingivale;
AM = muqueuse alveolaire; C = tissus conjonetif.

plied to the results it showed that a significant increase of attached gingiva had been
achieved ( P < 0.001). The width of graft
tissue was recorded immediately prior to
the application of the dressing. The mean
width of the graft being 5.54 1.29 mm
(S.D.) with a range of 4.0-9.0 mm. At 6
months the mean width of keratinised gingiva was 4.58 1.04 mm, with a range of
3.5-5.0 mm. Therefore, at 6 months the
mean contraction was 28 % with a range
of 0 to 50 per cent.
At 1 week the surface of the graft appeared red and shiny, and was covered in
parts with a greyish slough (Fig. 5c). The
base of the defect between the graft and
the displaced flap was filled with a fibriti
clot. At 2 weeks the surface was completely
cpithelialised; by 4 weeks keratinisation

was evident as the graft surface became

progressively paler; and by 6 weeks it had
blended in normally with the surrounding
tissues.
Histology
The histological sectiotis stained with
haematoxylin and eosin showed a clear
demarcation between the keratinised and
non-keratinised epithelium at the newlycreated muco-gingival junction (Fig. 7).
The keratinised epithelium showed welldeveloped rete pegs in contrast to the nonkeratinised alveolar mucosa epithelium. The
collagen bundles in the connective tissue
were predominantly oriented at right angles
to the surface; and the sections stained with
van Gieson (Fig. 8) showed that the presence of elastic fibres corresponded to the

FREE CONNECTIVE TISSUE GINGIVAL

GRAFTS

193

Fig, 8. Biopsy section of the newly-created muco-gingival junction after

6 months stained with Verhoff's van Gieson, X 40. Elastic fibres are found in
the connective tissue below the non-keratinised epithelium. MGI = mucogingival junction; AM = alveolar mucosa; C = connective tissue; E = elastic fibres.
Fig. 8. Histologisches Bild der netten tnukogitigivalen Grenze 6 Motiate postoperativ. Verhoff's Vatt Giesoti-Fdrbutig, X40. Elastische Fasertt itn Bitidegewebe unter detn tiichtkeratinisierten Epilhel. MGJ = Mukogingivalgre}ize;
AM Alveolartnukosa; C = Bitidegewebe; E = Elastische Fasern.
Fig. 8. Coupe de la nouvelle jonction tnuco-gitigivale apres 6 mois. Coloration
de Verhoff-vati Gieson, X 40. Des fibres elastiques sottt trouvees datis le tissus
conjonctif sous I'epitheliutn non-keratitiise, E = fibres elastiques.

region of non-keratinised mucosa, as shown

b y Lozden & Sqiiier (1969).
Discussion
The results show that a signilicent increase
fn attached gingiva can be achieved by
grafting gingival connective tissue alone.
Clinically, the present study tends to confirm the concept that it is the information
i n the connective tissue that ultimately
determines the character of the surface "epithelium. This then raises the question as to
whether the thickness of connective tissue
is important in achieving this result. The
present study can shed no light on this
problem. It is a clinical observation, how-

ewer, that the cases that were associated

with the most "creep back" of the mucogingival junction were those where only a
very thin graft was used. This may also explain the histological findings of Stambaugh
& Gordon (1973) that only 75 per cetit of
palatal connective tissue grafts produced a
keratinised surface; and the cytological investigation of Bernimoulin & Lange (1974),
who found only two-thirds of grafts to he
covered with keratinised epithelium.
The method has certain advantages over
the use of free gingival grafts, providing an
adaquate donor site exists. In this study,
three donor sites were utilised according to
availability, and in most cases primary closure could be achieved, which obviated the

194

EDEL

need for a periodontal dressing. In those

cases where palatal pocketing was present,
pocket elimination was performed, and the
tissue normally discarded after thinning
of the palatal flap was used as grafting
material.
The results suggest that the method can
be relied upon to produce a predictable increase in the width of keratinised attached
gingiva. The average amount of shrinkage
that occurred at 6 months was 28 % (as
compared with 47 % quoted by Ward
(1974) for free gingival grafts, and 87.5 %
quoted by Bohannan (1962 b) for the periosteal retention operation), and in this study
no periosteal fenestration was performed.
During the observation period of the
present study, no increase in pocket depth
occurred, and thus a significant increase in
width of attached gingiva was achieved.
Histologically the healed tissues showed all
the normal characteristics of a fully keratinised tissue in contrast to the results
achieved by the periosteal retention procedure, demonstrated by Pennel et al. (1965).
Recently, Fagan & Freeman (1974) have
shown that both free gingival grafting and
the periosteum retention procedure can produce a predictable increase in the width of
attached gingiva, but no mention was made
as to the character of the healed tissues. In
addition there was a significant difference
in the width of attached gingiva created by
the two methods, although there was no
significant difference in the amount of
periosteum exposed at the surgical site.
This was explained by the inadequate protection of marginal bone afforded by the
periosteum retention procedure which caused an apical shift of the gingival margin as
a result of marginal bone loss.
The degeneration of the palatal flap
when the donor site in Method 1 was used
was probably due to the design of the flap.
Possibly a thicker, more extended envelope
flap would not compromise the blood

supply so much, and would enable grafting

material to be taken without a full palatal
flap procedure. Care was taken to prevent
a void forming under the flap by maintaining pressure over the flap for 2 min,
and so this is unlikely to have been the
cause of the degeneration.
Acknowledgment

The author wishes to express his gratitude

to Dr. R. N. Powell for his encouragement
during this study, and to Mr. C. R. Day of
the Photographic Department of the Dental
School for the illustrations.
Zusammenfassung

Klittisclie Untersuchutig der Verbreitertittg

einer schmaleti angewacliseneti Gingiva tnit
freien BitidegewebsitnpIatUateti.
Bei acht Personen wurden 14 Stellen mit
schmaler ( < 2.0 mm) keratinisierter angewachsener Gingiva und mit Sulci gingivae
kleiner als 1.0 mm ausgewiihlt. Mit drei Methoden wurden am Gaumen oder auf dem
Kieferkamm Bindegewebe-Transplantate entnommen. Dies ermoglichte den Primiirverschluss im Spendergebiet. Die Breite der angewachsenen Gingiva wurde prae- und postoperativ ], 2, 5, 10, 12 und 24 Wochen mit
der Parodontalsonde auf 0.5 mm genau gemessen.
Die Ergebnisse zeigen eine statistisch signifikante Verbreilerung der angewachsenen
Gingiva, die in Biopsien strukturell wie eine
normale Gingiva propria erschien.

Evaluatioti clinique de I'etnplol de greffes

libres de tissu conjonctif pour augtnenter la
largeur de la gencive adherente.
Quatorze sites operatoires furent choisis chez
huit patients presentant une gencive adherente
de moins de 2 mm de largeur associee a un
sillon gingivo-dentaire de moins de 1 mm. Du
cote donneur (palais ou crete alveolaire), les
greffons conjonctifs furent preleves selon trois
methodes differentes permettant une fermeture
de la plaie par premi6re intention. La largeur
de la gencive adherente fut mesuree avec une

FREE CONNECTIVE TISSUE GINGIVAL

sonde parodontale au demi millimetre pres
pre - et 1, 2, 5, 10, 12 et 24 semaines postoperatoirement. Les resultats montrcrent un
elargissemcnt gingival statistiquement significatif; les biopsies livrcrent un tissu de structure normale.

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GRAFTS

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