Haemorrhagic risk when harvesting palatal connective tissue grafts: a reality?

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1 CLINICAL REPORT 231 Puliction Sophie-Myrim Dridi, Michel Choustermn, Mrc Dnn, Jen Frnçois Gudy Hemorrhgic risk when hrvesting pltl connective tissue grfts: relity? KEY WORDS connective tissue grft, hemorrhgic risk, humn hrd plte, pltine rtery Sophie-Myrim Dridi Assistnt Professor, DDS MS, Deprtment of Periodontology, University Pris René Descrtes, Frnce When otining good clinicl results using connective tissue sumerged grfts, the vst mjority of uthors plce gret emphsis on the surgicl techniques crried out. However, few studies hve shown the complictions tht my rise during such interventions. Although complictions my not e frequent nd re not life-thretening, these complictions do exist. These complictions generte nxiety prctitioners. Those tht re regrded with most pprehension re peri- nd post-opertive hemorrhge, nd this occurs due to the physiologicl vsculristion density of the pltl mucos. Through study of the humn ntomy, the uthors verified the correltions tht could exist etween the morphology of the hrd plte nd the distriution of the greter pltine pedicle nd, furthermore, if they were determining fctors in choosing therpeutic options. This study comprises two sections relting to pplied ntomy: osteology (prt 1) nd dissection (prt 2). Prt 1 involved 30 mxills presenting vrious ms nd edentitions. Oservtions were crried out to compre the reltionship etween the line of the greter pltine pedicle, the morphology of the plte, nd the effects of osseous remodelling ssocited with extrctions nd the instlltion of removle prosthesis. Prt 2 ws crried out on 12 fresh humn cdver mxills. After injection of the rteril system with coloured ltex, the specimens were dissected to oserve the distriution of the greter pltine pedicle of the plte. Antomicl surgery ws crried out on two pltes with different morphologies nd different tissue hrvesting techniques were permed. This llowed the uthors to first specify the vsculr distriution pttern of the plte, nd to evlute the reltion etween the smple zones nd the rnches of the greter pltine pedicle, to finlly estlish rules to help prevent hemorrhge from occurring. Michel Choustermn Clinicl Instructor, Deprtment of Periodontology, University Pris René Descrtes, Frnce Mrc Dnn Assistnt Professor, DDS MS, Deprtment of Periodontology, University Pris René Descrtes, Frnce Jen Frnçois Gudy Professor, Deprtment of Antomy, University Pris René Descrtes, Frnce Correspondence to: Professeur Jen Frnçois Gudy, Université Pris René Descrtes, Lortoire d Antomie Fonctionnelle, 1 rue Murice Arnoux, Montrouge, Frnce Introduction In the present dy, periodontists recognise connective tissue sumerged grft techniques s relile nd reproducile opertive techniques. These techniques re indicted numer of procedures nd re pplied to oth dentulous nd edentulous sectors; in periodontl plstic surgery to cover denuded root surfces nd in preprosthetic surgery to thicken gingivl site or improve the crestl volume 1,2. They re lso indicted to crete fvourle mucosl peri-implnt environment 3.

2 232 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts Different surgicl protocols re well documented, s re pulictions recording clinicl results nd longterm esthetic outcomes. Hence, connective tissue sumerged grft techniques cn e considered s stndrd interventions in periodontics. Nevertheless, these opertive techniques re difficult to perm nd present certin numer of complictions, prticulrly on the pltl donor site tht remins s the privileged region tissue hrvesting. Griffin et l 4 reported the possiility of pronounced pin, delyed heling situtions, necrosis of the hrvested zone nd sensitivity disorders. However, the compliction tht is regrded s the most serious is hemorrhgic ccident due to injury of vsculr trunk 5. When this occurs periopertive leeding is undnt, stressful the ptient nd difficult to rrest the prctitioner. Further complictions rise with the risk of sumucosl hemtom tht cn ecome secondrily infected. To etter preserve the vsculristion nd innervtion of the hrd plte, the hrvesting procedure hs ecome more ccurte over the yers 6-9 nd clssifiction of incisions hs een recently proposed 10. The detiled nd meticulous nlysis of the hrd plte ntomy is crucil in the choice of the opertive technique. With regrd to the loction of the principl vsculr rnches, two fundmentl notions seem to e drwn from ville ntomicl studies The first notion determines the existence of the plte t risk, ccording to the depth of the hrd plte, which vries mong individuls nd in reltion to the degree of lveolr resorption 15. The second notion emphsises the presence of risk zones ccording to the thickness of the pltine firomucos. This vries mong individuls nd depends upon individul pltl regions 12. It is thicker t the premolr nd cnine re, finer compred with the mesio-pltl root of the first molr nd it ecomes thinner with ge 15. Through this study, the uthors verified whether or not the dt were pertinent, ntomiclly sed nd could relly serve s sis reflection the clinicin. Severl recommendtions were lso suggested to decrese the risk of peri- nd post-opertive hemorrhge. Mterils nd methods Antomicl study Puliction Osteology study Thirty mxillry pltl ones from freshly prepred smples in the ntomy lortory were exmined. Two smples were completely dentulous, wheres the other smples generlly presented prtil or complete edentitions. The loction of the greter pltine men, extent nd importnce of the indenttion of the greter pltine pedicle on the pltl one nd morphologicl pltl modifictions in edentulous sujects who wore prosthesis were oserved. Antomicl dissection Twelve mxillry locks from fresh humn cdvers whose vsculr network ws injected with coloured ltex were isolted. A curved mucosl incision ws crried out from the posterior order of one mxillry tuerosity to the other, crossing the posterior nsl spine. This incision ws completed crestl incision on edentulous sites nd on the pltl mucos tngentil to the cementoenmel junction (CEJ) from one tuerosity to nother. The superficil outline of the mucos ws retrcted nteroposteriorly leving the neurovsculr pedicle in plce. The sumucosl connective tissue ws then scrped off using Wlkmn curette to visulise the loction nd distriution of the pedicle. Antomicl surgicl protocol Two mxillry locks from fresh humn cdvers whose rteril network ws injected with coloured ltex were selected. Two pltes of different depths using the Reiser clssifiction were chosen 14. In this clssifiction, the hrd plte is considered high in depth if the distnce etween the neurovsculr elements nd the CEJ of teeth 15 nd 16 is 17mm. It is sid to e verge in depth if the distnce is 12 mm nd shllow or flt if the distnce is just 7 mm. Plte numer 1 ws considered verge in depth. Teeth 17 to 27 were present. Plte numer 2 ws flt nd presented lterl edentulous zones. To evlute the depth of the plte, the greter

3 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts 233 c c Puliction Fig 2 Prtilly edentulous mxill with minimlly resored lrge crests. The plte is deep. Identified lndmrks: () greter pltine men, () descending pltine rtery groove, (c) incisive men. Fig 1 Pltl view of dentulous suject showing the loction of the greter pltine men nd the osseous line of the greter pltine pedicle. Identified lndmrks: () greter pltine men, () descending pltine rtery groove, (c) incisive men. pltine men were first loclised ee virtully plotting stright line until the inter-incisive point. The numer of millimetres etween the stright lines nd the CEJ ws then estimted. From 17 to 12mm, the plte ws considered to e high, from 12 to 7mm s verge nd <7mm s flt. For ech plte, t the level of the lterl section tht ws est preserved, two connective tissue hrvests were permed ccording to the Bruno technique 8 ; first in the nterior region of the hrd plte (distl to the centrl incisor, distl to the first premolr), nd second in the posterior pltl region (mesil to the second premolr, distl to the first molr). Numerous uthors prctise the Bruno technique, ecuse it prevents the lifting of mucosl flp, nd this minimises post-opertive complictions. Severl incisions were necessry; two horizontl incisions defined the length of the grft. They were prllel to ech other, prt 1 to 2mm nd t distnce of round 1 mm from the gingivl mrgin order. For the incision closest to the CEJ, the surgicl lde ws positioned perpendiculrly to the tooth xis up to the one. For the most picl incision, the lde ws inserted prllel to the pltl firomucos nd dissected severl millimetres ee regining one contct. Two verticl incisions on the mesil nd distl s well s n picl horizontl incision completed the grft hrvesting, which ws previously seprted from the one using surgicl lde. A delicte dissection of ech hlf of the hrd plte ws then permed to verify the dimension nd loction of the principl trunk of the descending pltine rtery in reltion to the incision lines. For the other lterl section of the dentulous plte, n epithelil connective tissue grft ws hrvested in the re of the premolrs nd the first molr. Four incision lines using surgicl lde, delineted rectngle (the most coronl incision must e t 1.5 to 2mm from the CEJ). The depth of the incisions ws determined the lde evel tht entirely penetrted into the firomucos. The dissection of the grft ws lwys prllel to the mucosl surfce. For plte numer 2, due to the poor qulity of the pltl firomucos on the second lterl prt, n epithelil connective tissue grft ws not hrvested. Results From the ntomicl study On one smples (Figs 1 to 5) the greter pltine men presented very stle loction: 12 to 13mm from the mxillry tuerosity crest nd 3mm in front of the posterior order of the hrd plte. The indenttion of the greter pltine pedicle on the osseous plte is lwys present nd disppers progressively t the level of the second premolrs even in edentulous sujects (ll removle denture werers). The disppernce of the pltl osseous contours ws oserved in sujects presenting dvnced crestl resorptions. On dissections (Figs 6 to 12) the sme reproducile loction of the greter pltine men ws

4 234 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts Puliction Fig 3 Completely edentulous mxill, complete denture werer. The plte is less deep. Despite of the resorption, the osseous pedicle groove is quite visile. Identified lndmrks: () greter pltine men, () descending pltine rtery groove. Fig 4 Completely edentulous mxill, complete denture werer. Advnce resorption of the crests, ut the osseous pedicle groove is quite visile. Identified lndmrks: () greter pltine men, () descending pltine rtery groove. c Fig 5 Pltl view of n edentulous suject wherein the pltl contours hve een smoothed due to wering temporry prosthesis. Fig 6 Medil view of hemi-mxillry lock showing the greter pltine pedicle in the greter pltine cnl nd its pltl distriution. Identified lndmrks: () pedicle in the cnl, () medil wing of the pterygoid process, (c) hitus of the mxillry sinus. oserved. On the 3 sujects the descending pltine rtery ws med t its emergence of the men principl trunk of 0.7mm 2 to 3cm, supported much more slender trunk tht then projected numerous mucosl rmifictions. On ll other sujects, from its emergence, the descending pltine rtery divides in severl terminl rnches of diverse clires (etween 0.2 nd 0.4mm). The rteril rnches re lwys prllel to the xis of the lveolr crest. The voluminous rnches, protected the overhnging one, re lwys in contct with the one.

5 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts 235 Puliction Fig 7 Pltl dissection of the greter pltine pedicle in totlly dentulous suject. Identified lndmrks: () here the pedicle is divided into three rnches t the exit of the men, () the medin rnch is the lrgest nd t distnce from the CEJs of the teeth. Fig 8 Dissection of the greter pltine pedicle in prtilly edentulous suject. Identified lndmrks: () here the pedicle is divided into two trunks, one of which is voluminous nd prllel to the dentl rch, () the other is much more slender. nterior nterior nterior lterl lterl posterior posterior posterior Fig 9 View of the mxill fter erosion showing the greter pltine pedicle. Here igger principl trunk (0.8mm) exists with the ccessory rnch rpidly rmifying. Fig 10 Dissection of left greter pltine pedicle, which presents t its emergence severl rnches of neighouring clire. Fig 11 Dissection of left greter pltine pedicle presenting pltl network consisting of severl very fine rnches.

6 236 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts Fig 12 Dissection of greter pltine pedicle from the incisive region showing the density of the vsculr network t this level. up Puliction nterior down Fig 13 Plte numer 1, teeth 17 to 27. Incision lines the two hrvested connective tissue grfts. Hrvesting ws done in the posterior section of the hrd plte (mesil of 25, distl of 26). The other ws done in the nterior region (distl of 21, distl of 24). Fig 14 Plte numer 1. Connective tissue grfts fter removl of the coronl epithelil section. The grft originting from the nterior section of the plte () hs less dipose nd presented lrger vessels thn the grft from () the posterior section. Fig 15 Plte numer 2. Incision lines the posterior connective tissue hrvest. From the ntomicl surgicl protocol For ech plte, two connective tissue grfts of out 15mm x 6mm, were otined, one in the nterior prt nd the other in the posterior prt of the plte (see ntomicl surgery protocol). These comprised numerous vsculr rmifictions (Figs 13 to 15). From the initil dissection of the pltl lterl sections, it ws clerly oserved tht n importnt quntity of dipose tissue overextends to the picl limits of the hrvested grfts. The dipose mss is more undnt in the posterior zones (Figs 16 to 17). However, if these oservtions re vlid the two pltes, it must e emphsised tht plte numer 2 presented firomucos much finer thn plte numer 1. As the picl limit of the posterior hrvested grfts, it ws situted t the extension of the greter pltine min. Once the pltl dissection ws concluded, vsculr pthwys were esily detectle. For plte numer 1, the principl trunk of the descending pltine rtery emerged in the posterior lterl section of the greter pltine men, it continued its pthwy in liner fshion into n osseous groove until it reched the retroincisive zone. It then rmified into numerous collterl rnches tht covered the entire region of the hemi-plte. With regrd to the loction of the greter pltine men, the trunk ws locted more piclly towrds the centre of the plte. Its verge clire ws

7 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts 237 Puliction Fig 16 Plte numer 1. Beginning of the dissection of the lterl hlf of the plte. At the picl limits of the two tissue hrvests, n importnt quntity of dipose tissue ws oserved especilly on the posterior region. Fig 17 Plte numer 2. Beginning of the dissection of the lterl hlf of the plte reveling the picl limits of the tissue hrvests. Fig 18 Plte numer 1. End of the dissection of the lterl hlf of the plte. The descending pltine rtery is clerly visile. It is situted 12mm from the CEJ of tooth 26 nd 4mm from the picl limit of the posterior hrvest. The greter pltine nerve is situted just ove the rtery. Fig 19 Plte numer 2. End of the dissection of the lterl hlf of the plte. The descending pltine rtery presents lrger clire thn tht of the pltine rtery of plte numer 1 nd its pthwy is more convoluted. It is situted 9mm from the CEJ of the molr present in the rch. 0.6mm in the premolr-molr zones, slightly decresing in the nterior pltl zone. It ws 12mm wy from the CEJ of the first molr nd 4mm from the picl incision line of the posterior hrvest (Fig 18). For the nterior hrvest, the mesiopicl limit ws djcent to the nterior endings of the descending pltine rtery. The greter pltine nerve ws lso clerly visile. It emerged like the descending pltine rtery to the greter pltine men to distriute itself into severl nterior rnches. The principl rnch ws situted more coronlly to tht of the pltine rtery. Thus, it ws closer to the picl limit of the posterior hrvest. For plte numer 2, the principl trunk of the descending pltine rtery presents different pthwy nd clire in comprison with the rtery of plte numer 1. Once it emerged from the greter pltine men, it rn towrds the incisive region in convoluted mnner, nd ws positioned slightly more piclly compred with the loction of the greter pltine men. Its clire ws more significnt s it pproched 0.8mm nd its collterl rnches were less numerous nd finer. Moreover, the trunk ws not locted in n osseous groove. The minimum distnce etween the trunk nd the CEJ orders ws 9mm (Fig 19). For hlf of the posterior hrvest zone, the picl limit is very close to the principl trunk of the pltine rtery. Collterl rnches, on the other hnd, line the nterior hrvest zone.

8 238 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts On the second lterl section of plte numer 1, 15mm x 6mm epithelil connective tissue grft ws hrvested. It ws less vsculrised thn connective tissue grfts nd did not include dipose tissue. The incision lines were superficil, thus very fr from the trunk nd principl collterl rnches of the descending pltine rtery. Discussion Connective tissue grfts The size of the grft tken from the two sujects ws predetermined to void lesion to the descending pltine rtery, which would hve prevented the uthors from dissecting correctly. Theree, the dimensions of the tissue hrvests were reduced. However, it remined cceptle. Cliniclly, it would e possile to cover denuded root without ny prolem. For ll grfts, dipose tissue ws found in the picl section. This oservtion ws comptile with the histologicl studies, which reveled the frequent presence of dipose tissue in the deep connective tissue 16. In periodontl plstic surgery, the extent of the picl hrvest is of less interest s the dipose tissue must e removed or it will prevent the neovsculristion during heling of the recipient site. The thickness of the grfts were thin. However, good section of the connective tissue ws hrvested. From the eginning of the dissection of the hrd plte, the osseous surfce ws lredy distinctly visile. The poor thickness of the firomucos is in reltion with the ntomicl smples origin nd its conservtion process. In humn cdvers, retrction of the mucous ws oserved. Moreover, the thickness of the firomucos of plte numer 2 ws much less thn tht of plte numer 1. Given the presence of edentitions, the uthors thought tht plte numer 2 elonged to much older individul thn the individul with dentulous plte. Furthermore, it ws thought tht the individul proly wore removle prosthesis, which compressed the mucos. The dilttion of the osti of the ccessory slivry glnds of the plte indicted tht the individul ws smoker. Puliction Concerning the loction of the principl vessels supplying the plte The uthors oservtions concerning the descending pltine rteries of plte numer 1 nd 2 concurred with the results of the pplied osteology nd ntomicl studies. The descending pltine rteries ensure the totlity of the pltl vsculristion. Collterl rnches of the descending mxillry rteries emerge from the posterolterl sections of the plte t the greter pltine min. In generl, their verge clire ws from 0.6 to 0.8mm 15. The uthors lso otined the sme mesurement. Ech rtery rmifies into numerous collterl rnches, which supply eyond the lterl sections of the plte. The two rteril regions principlly overlp ech other nd stretch wrd until the retroincisive zone. The possiility of rmifictions, on the contrry, ws vried. The pltine rtery dvnces in most cses into shllow groove in the one, which provides protective role, ut is not stndrdised nd my sometimes e sent (s ws oserved in plte numer 2). This sitution is more risky. Untuntely, there is no vile clinicl mens of identifying if the rtery is protected ee strting n intervention. Whtever their size, the principl vsculr trunks dvnce in more picl position thn the greter pltine men. The innervtion of the hrd plte follows the rteril pthwys. It is essentilly supplied the greter pltine nerves, which emerge like the descending pltine rteries in the greter pltine min, to e distriuted into severl nterior rnches. For the two pltes tht were chosen, the nerves dvnced prllel to the pltine rteries in more coronl position. Theree, the risk of dmge occurring is higher. The hemorrhgic risk During hrvesting of connective tissue grft, the opertive risk tht is most dreded clinicins is the occurrence of hemorrhge 5. In reltion to the ntomicl dt, it is resonle to sy tht the hemorrhge involves mostly the collterl rnches. The lesion of principl trunk of pltine rtery is ctully rre, ecuse the trunk is generlly found in the groove, which is frequently lined overhnging osseous projections tht constitute rel nturl

9 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts 239 Puliction c Fig 20 to c Connective tissue grft hrvesting in ptient: () clinicl view of incisions situted etween the lterl incisor nd the cnine, () completely dissected grft hrvest, c) suture of donor site to ensure hemostsis. Fig 21 to Recommendtions in cse of sudden hemorrhge: () compression of the greter pltine men, () ntomicl connection of the compressed zone (instrument rtificilly dded on the imge). protection. However, n ccidentl injury cusing necrosis to the pltine mucos is possile, especilly if the rtery is not protected or if the plte is flt. The fter-effects re often very limited though, given the interpenetrtion of the rteril regions nd the existence of complementry vsculristion supplied oth the scending phryngel rtery (rnch of the externl crotid) nd the scending pltine rtery (rnch of the fcil rtery). However, to prevent ny risk of injury to the rteril trunk during tissue hrvesting in the postero-lterl section of the plte, the uthors propose simple procedure: ee strting the incisions, imgine line from the greter pltine men towrds the interincisive point, which will e the virtul picl limit nd the tissue will not e hrvested eyond this line. This clinicl precution is prticulrly vlid verge nd flt pltes. It is simple to pply s the men cn e esily plpted. Similrly, it is suitle to hrvest in the premolr regions ecuse their CEJs re fr from the rteril trunk in comprison with those of the molrs. Hrvesting in the nterior section of the plte is lso solution (Figs 20 nd ). By pplying these rules to the ntomicl smples, it ws verified tht the picl limits of the incision lines of ll the connective tissue hrvest zones were clerly t distnce to the principl rteril trunks. The collterl section of the descending pltine rtery cn nevertheless provoke mjor peri-opertive leeding. The risk incurred in this sitution is the mtion of sumucosl hemtom, which cn ecome secondrily infected. If undnt leeding occurs, it is recommended tht pressure is put on the greter pltine men re with the id of lunt instrument. This will significntly reduce the flow of leeding nd enle the clinicin to view the hemorrhgic origin (Fig 21). It is then necessry to perm suture points to ring the incision lines closer (Fig 20c). Suspending sutures

10 240 Dridi et l Hemorrhgic risk when hrvesting pltl connective tissue grfts round teeth re sometimes useful. Sutures llow the olitertion of the vessels compression of the region where it is locted. It is, in fct, impossile to individully loclise the pltine vessels ligtion. The operted zone must e compressed firmly nd persistently. The plcement of periodontl dressing round teeth will ssure compression severl dys. A preopertive fricted plstic stent covering the hrd plte should lso e plnned to ensure durle pltine compression fter the surgery. Some uthors recommend the use of hemosttic sustnces such s oxidised regenerted cellulose or geltine sponge 5 the hrvest sites. The prescription of trnexmic cid mouthwsh is eqully recommended. In the cse of n epithelil connective tissue grft, the hemorrhgic risk is lmost nil s the wound is superficil. Conclusions The hemorrhgic complictions following pltl hrvest of the connective tissue re infrequent, ut re lwys difficult to mnge. Severl precutions llow these complictions to e voided. During the preopertive phse, the exmintion of the site is fundmentl ecuse the neurovsculr elements must e respected. Knowledge of the pltl ntomy nd its vsculristion is compulsory. Flt pltes cn e considered t higher risk hemorrhgic complictions thn verge or high pltes. During the peri-opertive phse, it is importnt to work in good conditions (e.g. efficient suction, good visiility) nd to perfectly mster the opertive technique in order to perm good hrvest. To void injury to the principl trunk of the descending pltine rtery, it is recommended to hrvest in zone coronlly situted from the line pssing from the greter pltine men nd the inter-incisive point. Under this line, the risk of hemorrhge is eqully s importnt s the quntity of the dipose tissue. Likewise, the choice of hrvest sites must fvour the premolr or incisive-cnine regions. Molr regions re more dngerous. In the cse of undnt nd persistent leeding, it is impertive to suture the wound to void the occurrence of sumucous hemtom nd to ensure compression of the operted zone. Puliction Finlly, during the post-opertive phse, it is importnt the clinicin to e ville, ecuse leeding cn occur hours or dys following the intervention. This leeding suggests incorrect hemostsis, moilistion of the wound tongue movements, erly nd repeted rinsing of the mouth, or the existence of n undignosed hemosttic nomly during the preopertive phse. Respecting these sfety precutions is importnt the prctitioner so s to ensure tht the clinicl oligtions re fulfilled. References 1. Bouchrd P, Mlet J, Borguetti A. Decision-mking in esthetics: root coverge revisited. Periodontol ;27: Buser D, Dul K, Hess D, Hirt HP, Belser UC. Loclized ridge ugmenttion with utogrfts nd rrier memrnes. Periodontol ;19: Zetu L, Wng HL. Mngement of interdentl/inter-implnt ppill. J Clin Periodontol 2005;32: Griffin TJ, Cheung WS, Zvrs AI, Dmoulis PD. Postopertive complictions following gingivl ugmenttion procedures. J Periodontol 2006;77: Rossmnn J, Rees TD. A comprtive evlution of hemosttic gents in the mngement of soft tissue grft donor site leeding. J Periodontol 1999;70: Nelson SW. The supedicle connective tissue grft. A ilminr reconstructive procedure the coverge of denuded root surfces. J Periodontol 1987;58: Hrris RJ. The connective tissue nd prtil thickness doule pedicle grft. A preditle method of otining root coverge. J Periodontol 1992;63: Bruno JF. Connective tissue grft technique ssuring wide root coverge. Int J Periodontics Restortive Dent 1994;14: Bosco AF, Bosco JMD. An lterntive technique to the hrvesting of connective tissue grft from thin plte: enhnced wound heling. Int J Periodontics Restortive Dent 2007;27: Liu CL, Weisgold AS. Connective tissue grft: clssifiction incision design from the plte site nd clinicl reports. Int J Periodontics Restortive Dent 2002;22: Müller HP, Eger T. Mstictory mucos nd periodontl phenotype. A review. Int J Periodontics Restortive Dent 2002; 22: Müller HP, Schller N, Eger T, Heinecke A. Thickness of mstictory mucos. J Clin Periodontol 2000;27: Studer SP, Allen EP, Rees TC, Koud A. The thickness of mstictory mucos in the humn hrd plte nd tuerosity s potentil donor sites ridge ugmenttion procedures. J Periodontol 1997;68: Reiser GM, Bruno JF, Mhn PE, Lrkin LH. The suepithelil connective tissue grft pltl donor site: ntomic considertion surgeons. Int J Periodontics Restortive Dent 1996; 16: Gudy J-F. Antomie clinique. Collection JPIO. Ed CdP Groupe Liisons. Frnce: Rueil Mlmison 2003; Hrris RJ. Histologic evlution of connective tissue grfts in humns. Int J Periodontics Restortive Dent 2003;23:

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