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The International Journal of Periodontics & Restorative Dentistry

COPYRIGHT 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE
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Connective Tissue Graft:


A Classification for Incision Design
from the Palatal Site and Clinical
Case Reports

Chiun-Lin Liu, DDS* The connective tissue graft is a com-


Arnold S. Weisgold, DDS** mon and popular procedure for root
coverage,13 soft tissue augmenta-
tion for the edentulous area, 4,5
A classification system for connective tissue graft incisions is proposed. It catego- implant dentistry,6 and cosmetic pro-
rizes the design of the palatal incision into three classes. In addition to the basic cedures.7 The requirements of the
classification, two subclasses are mentioned in this article. Additional descriptions anatomic or pathologic condition
are included to further define the incision design. The use of such a classification ultimately relate to the donor site
should assist future communication among clinicians and researchers. This article flap design. The authors classify the
presents representative clinical cases to aid the clinician in applying the classifica- incisions related to the palatal donor
tion for incision design from the palatal site. (Int J Periodontics Restorative Dent
site. The purpose of this article is to
2002;22:373379.)
describe a classification for incision
design relative to the donor site
preparation for subepithelial con-
nective tissue grafting.
The classification of incision
design from the palatal site is based
upon:

1. The graft size required by the


recipient site
2. The anatomy of the palatal vault,
which is divided into high, aver-
age, and shallow8
3. The possibility of an exostosis9
**Clinical Assistant Professor, Periodontal Prostheses, and Primary Care Unit
Leader, Restorative Dentistry, University of Pennsylvania School of Dental 4. Wound healing from the donor
Medicine, Philadelphia. site (primary or secondary inten-
**Clinical Professor of Periodontics, and Director of Postdoctoral Periodontal tion healing)10
Prostheses, University of Pennsylvania School of Dental Medicine, Philadelphia.
5. Blood supply for the overlying
**Reprint requests: Dr Chiun-Lin Liu, University of Pennsylvania School of Dental flap
Medicine, 4001 Spruce Street, Philadelphia, Pennsylvania 19104-6003. 6. Postoperative discomfort

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7. Whether sutures, stents, or


hemostatic agents are required
8. Visibility of the procedure

The classification will help to


determine the most effective inci-
sion/flap design to harvest the donor
tissue. The incision design is as fol-
Fig 1a Class I type A incision design. Fig 1b Class I type B incision design.
lows.

Liu classification

Class I: one incision line (Figs 1a


and 1b)
Class II: two incision lines (L
shape; Figs 1c and 1d)
Class III: three incision lines (U
shape; Figs 1e and 1f)
Fig 1d Class II type B incision design.
Subclassification (horizontal inci-
Fig 1c Class II type A incision design.
sion)
Type A: one horizontal inci-
sion (Fig 2a)
Type B: two horizontal inci-
sions (Fig 2b)

Class I: One incision line

This classification can be used in any


connective tissue graft from the
Fig 1e Class III type A incision design. Fig 1f Class III type B incision design.
palatal site. Its advantages include:

1. Only one incision line.


2. Postoperative stent is not nec-
essary.
3. Sutures or hemostatic agents
may not be necessary.
4. The incision can be applied to
varying palatal forms, including
high, average, and shallow .
5. Less patient discomfort (a
smaller wound at 1 week post-
operative).

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Fig 2a Subclass type A incision design. Fig 2b Subclass type B incision design.

6. More blood supply for the over- Advantages are: 2. Need for larger amount of tissue
lying flap.
7. Primary intention healing (in 1. Smaller incision, but sufficient vis- Advantages are:
Class I type A) . ibility
2. Moderate blood supply for the 1. Graft size similar to the incision
Disadvantages of this type of overlying flap design
incision are: 3. Relatively easy to execute 2. Greater visibility
3. Easiest to execute
1. Reduced visibility of the donor A disadvantage of this type of
site during graft preparation incision is that two incision lines may Disadvantages of this type of
2. Quite difficult to execute compromise the blood supply from incision are:
the donor site.
1. More incision lines; possible
Class II: Two incision lines compromise of the blood sup-
(L shape) Class III: Three incision lines ply from the donor site
(U shape) 2. More postoperative pain; a
Indications for a Class II incision are: larger wound at 1 week postop-
Indications for a Class III incision are: erative10
1. Avoidance of the greater pala- 3. More sutures or stent required
tine artery and nerve 1. Concern for underlying anatomy
2. When third incision line is not (such as exostosis, vessels,
necessary nerves)

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Fig 3a Subclass type A incision design is Fig 3b Subclass type B incision design is
applied to an area with an exostosis. applied to an area with an exostosis.

Subclassification (horizontal molars or greater than normal tissue surgical expertise is required. (Larger
incision) depth, the use of one incision line incisions may compromise the blood
allows harvesting of the full amount supply.)
Indications for a type A (one hori- of connective tissue beneath the First, subclass types A and B are
zontal incision11) design are: undermined masticatory mucosa. dependent on the recipient site. If
Indications for a type B (two hor- the connective tissue graft is going
1. The connective tissue graft with- izontal incisions) design are: to expose the epithelial area at the
out epithelium covering recipient site, the type B design (two
2. Can be applied to different 1. The tissue from the palatal site horizontal incisions) is used. If the
palatal forms, including high, has sufficient thickness. connective tissue graft is going to be
average, and shallow8 2. The connective tissue graft with buried underneath the recipient site,
3. Can be used in areas of minimal its epithelial covering. the type A design (one horizontal
tissue depth (the thickness of 3. The recipient site will expose the incision) is used.
donor site tissue is 3 mm or less, epithelial side of the graft. The second concern is the thick-
which is the average tissue depth ness,12 width, and length of the
in molar areas) graft. The anatomy of the palatal
4. When a graft length (anteropos- Discussion vault8 is divided into:
terior) larger than two premolars
is needed8 (average tissue depth This proposed classification system Average palate: The average dis-
in premolar region is 5 mm; in should allow for ease of communi- tance from the cementoenamel
molar region average depth is 3 cation with clinicians and offer a junction (CEJ) to the neurovas-
mm) presurgical outline of the required cular bundle is 12 mm.
flap design. The greater the inci- High palate: The average dis-
For a connective tissue graft that sions, the lower the blood supply; tance from the CEJ to the neu-
has a length greater than two pre- the smaller the incision(s), the more rovascular bundle is 17 mm.

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Fig 4a Gingival recession on the facial Fig 4b Class I type A incision design is Fig 4c At 10 months, note complete root
surfaces of the maxillary right canine and used at a donor site without epithelium. coverage.
first premolar. Note that an orthodontic
appliance is being used to erupt the lateral
incisor.

Shallow palate: The average dis- Clinical Case Reports Case 2


tance from the CEJ to the neu-
rovascular bundle is 7 mm. Case 1 This 32-year-old woman had the
maxillary right central incisor miss-
For example, in the shallow This 36-year-old man had gingival ing. She was not satisfied with her
palate situation, a 10 mm  5 mm  recession on the facial surfaces of restorative dentistry. After removing
2 mm connective tissue graft is the maxillary right canine and first the old restorations, the pontic area
planned for harvesting. With the premolar (Fig 4a). The premolar had revealed a Class I ridge defect15,16
subclass type B incision, it is possible endodontic treatment previously (buccolingual loss of tissue; Fig 5a).
to cut the neurovascular bundle, so completed. A complete crown was The Class I type B incision design
a subclass type A incision will be the to be fabricated in the future. The was applied at the donor site with
choice in this situation. gingival margin of the right first pre- epithelium on the outer layer of the
The third concern is the possi- molar was at the same level as that connective tissue graft (Fig 5b). The
bility of an exostosis at the palatal of the left first premolar. Root cov- pouch procedure17,18 was used at
site, especially in the molar area. If erage was planned to be attempted the recipient site. The connective tis-
the sounding reveals an exostosis on the canine. A Class I type A inci- sue graft was sutured beneath the
and there is not enough tissue thick- sion design was applied at the donor flap with epithelium exposed.4 At 5
ness, the type A incision design is site without epithelium (Fig 4b). The months, a depression was created in
the better choice to gain more tissue supraperiosteal envelope tech- the edentulous area for an ovate
(Fig 3). nique13,14 was applied to achieve pontic.19 The occlusal view showed
root coverage. At 10 months, there the success of the soft tissue aug-
was complete root coverage (Fig 4c). mentation (Fig 5c).

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Fig 5a Pontic area (maxillary right central Fig 5b Class I type B incision design is Fig 5c At 5 months, a depression is cre-
incisor) reveals a Class I ridge defect (buc- used at the donor site, with epithelium on ated in the edentulous area for an ovate
colingual loss of tissue). the outer layer of the connective tissue pontic. Occlusal view shows the success of
graft. the soft tissue augmentation.

Fig 6a This 45-year-old man had lost the Fig 6b Class II type A incision design is Fig 6c At 3 months, the ridge defect is
maxillary right central and lateral incisors. used at the donor site, without epithelium significantly improved.
A Class III ridge defect is noted. on the outer surface of the connective tis-
sue graft.

Case 3 neath the flap. A coronally posi- ing larger wounds. The following
tioned flap was used to cover the factors should be evaluated:
This 45-year-old man had lost the graft. At 3 months, the ridge defect
maxillary right central and lateral was improved a great deal (Fig 6c). The graft size required by the
incisors (Fig 6a). A Class III ridge recipient site
defect20 was noted. A connective tis- The anatomy of the palatal vault
sue graft with a coronally positioned Conclusions The possibility of an exostosis
flap21 was to be attempted before Wound healing from the donor
the final fixed restoration. The Class The Liu classification of incision site (primary or secondary inten-
II type A incision design was applied design from the palatal site should tion)
at the donor site without epithelium aid clinicians to decide which kind Blood supply for the overlying
on the outer aspect of the connec- of incision design is best for the flap
tive tissue graft (Fig 6b). A crestal patient and to achieve the most Postoperative patient discomfort
incision was made at the edentulous effective incision/flap design to Whether sutures, stents, or
area, and a sulcular incision was harvest the donor tissue. Accord- hemostatic agents are required
made around the right first premolar ing to this classification, clinicians Visibility of the procedure
and left central incisor. The connec- can harvest properly sized con-
tive tissue graft was placed under- nective tissue grafts, thus avoid-

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