J Periodontol • May 2006

Case Series
Connective Tissue Graft for Gingival Recession Treatment:
Assessment of the Maximum Graft Dimensions at the
Palatal Vault as a Donor Site
Virginie Monnet-Corti,*† Alain Santini,*† Jean-Marc Glise,*† Caroline Fouque-Deruelle,*†
Francxois-Laurent Dillier,† Marie-Franc
xoise Liébart,*† and Alain Borghetti*†

Background: The palatal masticatory mucosa is widely used as a

T
he palatal masticatory mucosa
connective tissue donor site in gingival recession treatment. However, is widely used as a connective
concern has been raised regarding the potential risk of damaging the tissue donor site in periodontal
greater palatine artery (GPA) due to anatomical variations in the pal- plastic surgery and particularly in gin-
atal vault. The anatomy of the palatal vault in terms of size and shape gival recession treatment, with reported
may affect the maximum dimensions of the graft that can be safely high success rates.1-5 However, con-
taken from the palatal vault. In a cohort of patients free of periodontal cern has been raised regarding the
disease, the purpose of this study was to assess the maximum dimen- potential risk of damaging the greater
sions of the graft, particularly the height and length, that could palatine artery (GPA) due to variation in
be safely taken from the palatal vault. the anatomy of the palatal vault. Reiser
Methods: Plaster impressions were made from 198 patients free of et al.6 suggested that variation in terms
periodontal disease. Because the connective tissue graft is usually of size and shape of the palatal vault
taken from an area extending from the mid-palatal aspect of the ca- may affect the dimensions of the donor
nine to the mid-palatal aspect of the second molar, this interval tissue harvested. Therefore, it was of
was measured and represented the maximum length dimension. interest to study the maximum dimen-
The emergence of the GPA was assumed to be localized at the junc- sions that can be taken from the palatal
tion of the vertical and horizontal palatal walls of vault, and its course vault in terms of height and length in
was marked on the plaster casts. The maximum height of the graft relation to the usual course of the
corresponded to the distances measured from the gingival margin greater palatine artery in an unselected
to the marked course of the GPA of each tooth at its interproximal population of patients free of periodon-
and mid-palatal aspects. tal disease.
Results: The length of the maximum available tissue graft was
31.7 – 4.0 mm. The distance extending from the gingival margin to
the greater palatine artery ranged from 12.07 – 2.9 mm at the canine MATERIALS AND METHODS
level to 14.7 – 2.9 mm at the mid-palatal aspect of the second molar Patients
level. Therefore, in the premolar area, it was possible to harvest a con- Our patient population consisted of
nective tissue graft measuring 5 mm in height in all cases and 8 mm consecutive outpatients from March
in height in 93% of cases. 2002 to March 2003 of the Dental Clinic
Conclusion: Our findings suggest that the maximum available of the University of Marseille, Faculty of
tissue graft as measured in the palatal vault was large enough to Odontology, who met the following in-
allow a safe withdrawal from this donor site in a high percentage clusion criteria: older than 21 years of
of our patient population free of periodontal disease. J Periodontol age, a healthy periodontium, a complete
2006;77:899-902. dentition, and absence of pathologic oc-
clusion or prosthesis in the upper jaw.
KEY WORDS The study was conducted in accordance
Connective tissue graft; gingival recession/surgery; with the Helsinki Declaration of 1975, as
gingival recession/therapy; mouth mucosa. revised in 2000. Informed consent to ob-
tain impressions of the upper jaw was
obtained from all patients.

* Department of Periodontology, University of Marseille, Faculty of Odontology,

Marseille, France.
† Parodontia Study Group, Marseille, France. doi: 10.1902/jop.2006.050047

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Connective Tissue Graft From the Palatal Vault Volume 77 • Number 5

Method of Measurement
Impressions of the upper jaw were taken using ir-
reversible hydrocolloid impression material‡ poured
by a type IV dental stone.§ All measurements were
made with a Boley gauge (Fig. 1) to the nearest mil-
limeter by the same investigator based on the
schemes proposed by Reiser et al.6 and Reiser and
Bruno.7 The emergence of the greater palatine artery
has been located midway between the gingival margin
of the second molar and the midline raphae.8
The greater palatine artery was assumed to be
located at the junction of the vertical and horizontal
walls of the palatal vault, and its supposed course
was marked with a pencil on the maxillary dental casts Figure 2.
(Fig. 1). The length of the palatal vault donor site was Mean heights of palatal vault donor site (distance from the gingival
measured from the mid-palatal aspect of the canine to margin [black line] to the greater palatine artery [green line]). From
left to right, arrows correspond to the following teeth numbers and
the mid-palatal aspect of the second molar at the GPA zones: 3 = canine zone; 3 to 4 = proximal zone between canine and
level (Fig. 1). The height of the palatal vault donor site first premolar; 4 = first premolar zone; 4 to 5 = proximal zone
was measured from the gingival margin to the level of between first premolar and second premolar; 5 = second premolar
the GPA (Fig. 2) at the interproximal aspect and at zone; 5 to 6 = proximal zone between second premolar and first
the mid-palatal aspect of each tooth from the canine molar; 6 = first molar; 6 to 7 = proximal zone between first molar
and second molar; and 7 = second molar. N = 198. The Universal
to the second molar (Fig. 2). Safety margins of 3 mm System was used for numbering teeth.
from the GPA and 2 mm from the gingival margin
(Fig. 3) were subtracted from previous measurements.
In this area, the ability to harvest a connective tissue
graft with a height of 5 or 8 mm was assessed.

Data Analysis
The height and length of the palatal donor sites were
expressed as mean – SD.
Comparison of the measurements between men
and women was analyzed using a two-way analysis

Figure 3.
To delineate the safe harvesting zone coronally and apically, safety
distances of 3 mm from the greater palatine artery and 2 mm
from the gingival margin were subtracted from the measurements.

of variance. A probability of P <0.05 was accepted

to reject the null hypothesis.

Figure 1.
On the maxillary plaster model, a pencil marked the level of the GPA.
With a Boley gauge, palatal vault length (from canine to second
molar) and palatal vault heights (from the gingival margin to the level
of the GPA at the interproximal aspect and at the mid-palatal aspect
of each tooth from canine to second molar) were measured.
RESULTS
A total of 198 maxillary plaster models were obtained
from consecutive patients who met the inclusion
criteria. There were 136 women and 62 men, with a
mean age of 42.0 – 12.8 years. According to the mea-
surement technique defined in the Materials and
‡ Xantalgin, Bayer, Leverkusen, Germany.
§ Fuji Rock, GC International, Scottsdale, AZ.

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J Periodontol • May 2006
Table 1.
Heights (mm) of the Palatal Vault Donor Site (mean – SD) in Men and Women
Tooth #† 3 3-4 4 4-5
All patients 12.07 – 2.9 13.61 – 2.62 13.8 – 1.92 15.43 – 1.97 15.38 – 2.14
Men 11.97 – 3.12 13.65 – 2.9 14.13 – 2.12 15.84 – 2.15
Women 12.11 – 2.75 13.6 – 2.5 13.65 – 1.8 15.25* – 1.86 15.05* – 1.84 15.83* – 2.06 14.63* – 2.4 15.1* – 2.46 14.1* – 2.64
* Differences between men and women were statistically significant at P <0.05.
† According to the Universal System.
Methods, the mean length of the harvesting area for all
patients was 31.7 – 4.0 mm, ranging from 24 to 46
mm. The mean length of the harvesting area was
31.1 – 4.0 mm, ranging from 24 to 45 mm, for women
and 33.0 – 3.8 mm, ranging from 26 to 46 mm, for
men. The difference between measurements made
from plaster models of men and women was statisti-
cally significant (P = 0.001). The mean height is pre-
sented in Table 1. It ranged from 12.07 – 2.9 mm at
the mid-palatal aspect of the canine to 16.2 – 2.2
mm at the interproximal aspect between the second
premolar and the first molar. The second premolar
to the second molar areas showed the greatest
heights. The mean height measured from the second
premolar area to the second molar area was signifi-
cantly greater in men than in women (Table 1). It ap-
peared possible to harvest in the premolar area a
connective tissue graft measuring 5 mm in height in
all cases. It was still possible to harvest an 8-mm-high
graft from the interproximal aspect between the first
premolar and the second premolar in 94% of cases,
from the mid-palatal aspect of the second premolar
in 93% of cases, and from the interproximal aspect
between the second premolar and the first molar in
96% of cases. There was a statistical difference be-
tween men (32.98 – 3.82 mm) and women (31.15 –
3.99 mm), but the smallest length measured (24
mm) was still compatible with safe harvesting. The
mean heights ranged from 12.07 – 2.9 mm (canine
area) to 16.2 – 2.2 mm (second premolar-first molar
area). Heights £7 mm were measured in only 11
women (N = 136) in the canine area. In the canine-first
premolar interproximal area, only two women ex-
hibited heights £7 mm.
DISCUSSION
Main Findings
In a cohort of patients older than 21 years and free of
periodontal disease, this study showed that the avail-
able connective tissue graft dimensions that could be
obtained from the palatal donor site are large enough
to allow a safe withdrawal in a high percentage of pa-
tients. Our results are concordant with those reported
Monnet-Corti, Santini, Glise, et al.
5 5-6 6 6-7 7
16.2 – 2.2 15.16 – 2.47 15.7 – 2.62 14.7 – 2.9
16.1 – 2.57 17.02 – 2.28 16.15 – 2.57 17.02 – 2.5 16.02 – 3.0
by Redman et al.,9 who found a mean height of 14.9 –
2.93 mm in men and 12.7 – 2.45 mm in women, but
differ from those of other studies.10,11 These discrep-
ancies may be explained by differences in location at
which the measurements were performed.
There is some concern regarding variations in the
anatomy of the palatal vault that may interfere with
the graft dimensions that can be harvested. Reiser
et al.6 proposed to subdivide the palatal vault into
three groups, high, average, and shallow, and sug-
gested that caution should be observed not to endan-
ger the GPA when dealing with a shallow palatal vault.
However, we were unable to find data in the literature
supporting the relationship between the palatal vault
anatomy and the resulting risk for the GPA. Despite
using the landmarks proposed by Reiser et al.6 for lo-
calizing the GPA at the junction of the vertical and hor-
izontal walls of the hard palatal vault, we concluded
that it is still possible to withdraw a 5-mm-high con-
nective tissue graft in 100% of the cases and an
8-mm-high connective tissue graft in 93% of the cases
in the premolar area. Previous studies8,11-13 investi-
gating masticatory mucosal thickness had shown that
the palatal root of the first molar represented an ana-
tomic barrier in graft harvesting. In our study, the ca-
nine exhibited the smallest height. Therefore, in terms
of height, thickness, and length, the useful donor site
is located between the distal aspects of the canine to
the mid-palatal aspect of the first molar.
Limitations of the Study
Our study was performed on cast impressions of the
upper jaw in patients free of periodontal disease and
does not obviate the need for a careful clinical exam-
ination. From a clinical viewpoint, palpation and ob-
servation of the groove traversed by the GPA should
be done to evaluate the available thickness, height,
and length of the palatal mucosa harvesting zone. This
attentive clinical examination and these measure-
ments are necessary to avoid accidental damage to
the GPA or its branches or to obtain sufficient free
connective tissue graft. Our study on casts did not
evaluate tissue thickness, which is an important con-
sideration.
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Connective Tissue Graft From the Palatal Vault
The choice of the height of the graft (5 and 8 mm)
may seem arbitrary. It has been advocated4 that to
achieve full coverage of gingival recessions with sub-
epithelial connective tissue grafts, the latter should lie
at least over 3 mm of bone apical to the gingival reces-
sion. Therefore, we estimated that 5 mm is a mini-
mum dimension required to cover shallow recessions,
and 8 mm is the appropriate height to cover deep
recessions.3
The emergence of the GPA and its course were
assumed. We could have attempted to locate the
emergence by palpation in each patient, but this
would have complicated our study.
CONCLUSION
Based on measurements done on cast impressions of
the upper jaw in patients free of periodontal disease,
our study suggests that the maximum available tissue
graft in the palatal vault is large enough to allow a safe
connective tissue graft from this donor site.
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Volume 77 • Number 5
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Correspondence: Dr. Virginie Monnet-Corti, 44 Bd. Tristan
Corbière, 13012 Marseille, France. E-mail: gebetgini@free.fr.
Accepted for publication October 28, 2005.