gested eradication of postoperative graft mobility with­
Placement of Free Gingival
Grafts on Denuded Alveolar
Bone
Part I: Clinical Evaluations*
by
WILLIAM C. JAMES, D.D.S., M.s.†
WALTER T . MCFALL, JR. D.D.S., MS.‡
T H E MUCOGINGIVAL aspect of periodontal therapy i n ­
volves a reconstructive plastic surgery of diseased tissues
which i f untreated will complicate periodontal disease
and compromise successful therapeutic results. The ra­
tionale for mucogingival procedures and techniques have
been developed to supplement periodontal pocket elim­
ination by (1) relocation of frena and muscle attach­
1-4
ments, (2) eliminations of pockets extending to or
1-6
beyond the mucogingival l i n e , (3) establishment of an
1-4
adequate zone of attached gingiva, ' (4) provision of a
tissue layer to speed epithelialization of broad
8-13
wounds, (5) adjunctive therapy i n ridge extension
procedures to create a more functional prosthesis.
and (6) prevention of food impaction against a gingival
1 4
margin. "
Free autografts, derived from masticatory mucosa,
have been used successfully i n periodontal therapy since
the introduction of the free gingival grafts into periodon­
17
tics i n Europe i n 1963 by Bjorn. Numerous reports
were published between 1964 and 1968 expounding upon
the feasibility and advantages of intraoral gingival graft-
18 23
ing. "
7,25
Sullivan and A t k i n s and Gordon, Sullivan and
24
A t k i n s presented i n 1968 the principles of free gingival
grafting i n a three part investigation that included his­
tological and clinical assays. Other clinical accounts have
been reported by Gargiulo and Arrocha, Calandriello,
27
Oliver et a l . , Brackett and Gargiulo, and Bhaskar et
28 29 32
al., and others. " Other investigations have explored
variable sources of donor tissue to free gingival grafts. "
Some studies have been directed to the unpredicability
51
of root coverage with these grafts. "
57
Dordick and Rabinowitz, Klewansky et a l . and
59
Dordick et a l . have evaluated the placement of free
grafts on denuded bone. These investigations have sug­
* This research was supported by grant No. RR05333, Division of
Research Resources, National Institute of Health, Bethesda, Md 20014.
Submitted in partial fulfillment of the requirement for the degree of
Master of Science in Dentistry, UNC School of Dentistry, Chapel Hill,
NC 27514.
† Address: 130 Providence Road, Charlotte, NC 28201.
‡ Professor, Department of Periodontics, University of North Car­
olina School of Dentistry, Chapel Hill, NC 27514.
out deleterious effects to osseous structures.
The present study of placement of free grafts on
denuded bone was conducted to evaluate the extent o f
bone alterations following bone denudation and cover­
age by a split partial thickness free palatal graft. Clinical
and histologic evaluations were conducted.
MATERIALS A N D METHODS
Fourteen patients who were classified as needing six
or more extractions and removable protheses were se­
lected for this study.The patients were i n good health.
Their age varied from 27 to 56 years. Dental records,
roentgenograms, and clinical pictures o f the patients
were available. A l l patients were instructed i n the mod­
ified Stillman and Bass brushing techniques and i n the
use of dental floss, interdental stimulators, and interden­
tal brushes. Oral hygiene effectiveness was monitored by
1
60
a plaque index. A l l patients were required to achieve
oral physiotherapy success at or below the 20% level of
efficiency before surgical therapy was instigated. A l l
patients received a thorough scaling, curettage, and root
planing prior to surgical therapy.
7
SURGICAL PROCEDURE
Local anesthesia was obtained by vestibular buccal
14-16
injections o f 2% lidocaine with 1/100,000 epinephrine
and 2% lidocaine with 1/50,000 epinephrine for hemor­
rhage control (Fig. 1).
A split thickness bed was prepared by sharp dissection
at the mucogingival junction with a N o . 15 scalpel. The
incision was made to bevel the superior border o f the
recipient site to allow a more esthetic blending of the
graft. The extent of the bed incision was the mesial line
angle o f the mandibular canines. The dissection was
extended apically to provide a deeper vestibular depth
and a fenestration created at the depth of the extension.
Then a N o . 15 blade was used to incise the soft
connective tissue components of the bed from the distal
line angle of the left lateral incisor to the midline of the
central incisors extending superiorly from the previous
22 26
level of the mucogingival junction to a point approxi­
8
mately 5 m m apical to the superior margin of the surgical
33 50
site. A thin split thickness recipient bed of lamina propria
and immobile periosteum covered the alveolar bone from
66
distal aspect of the left lateral incisor to the distal aspect
58
of the right lateral incisor.
To insure total and complete removal of all remaining
periosteal fibers from the bone surface on the left side of
the mandible adjacent to the central and lateral incisors,
the alveolar cortical bone was thoroughly scraped with
a back action chisel producing a bleeding response from
the subjacent marrow spaces.
A carbide round bur was used to create grooves o n
each mandibular incisor at the cementoenamel junction
on the lingual to produce a standardized point from
which to obtain preoperative measurements o f alveolar
283
 J. Periodontal.
284 James, McFall June, 1978

FIGURE 1. Preoperative gingival grafting site. G — g i n g i v a ,

M C J — m u c o g i n g i v a l junction, Fr—frenum, L M — l a b i a l mucosa.

bone thickness relative to tooth position. This measure­

ment was accomplished with a Boley gauge 5 mm below
the buccal cementoenamel junction (Fig. 2). These mea­
surements were repeated postoperatively just prior to a
block section procedure.
Measurements were taken with a Michigan 0 peri­
odontal probe to determine the dimensions of the free
grafts to be secured from the hard palate. In one case the
entire surgical area was denuded of periosteum through­
out and free grafts were placed only upon the left half of
the recipient site to allow healing by granulation on the
right side. A second case was prepared leaving perios­
teum without a free graft on the right side to permit FIGURE 2.
histologic evaluation of the healing process i n this con­
dition.
The split-thickness graft tissue was secured from the
palate utilizing a N o . 10-A scalpel blade. The average
measured graft thickness was 0.9 mm. The graft tissue
was carefully examined on a surgical gauze dampened
with sterile water and all fat deposits were carefully
scraped from the connective tissue side of the graft (Fig.
3).
The graft was divided into two sections of correspond­
ing size to the prepared recipient bed. Each piece of graft
tissue was tatooed with india ink* i n each corner of the
graft with 0.05 m m of dye solution using a 27-gauge
tuberculin syringe. The dimensions of each graft were
carefully measured with a Boley gauge and recorded.
Grafts were placed against the prepared recipient bed
and secured with resorbable gut sutures. Sutures were
designed to pass through periosteum inferior to the graft
FIGURE 3. Dissected free palatal graft tissue prior to tatooing.
site, then cross over the graft avoiding graft tissue pene­
tration and finally passing through the interdental pa­
pillae of each tooth or i n a sling design around each tissue which might result i n hematoma formation. A l l
tooth. Graft tissue penetration was avoided to minimize operative sites were covered with a noneugenol peri­
graft trauma which subsequently might influence graft odontal dressing.† A l l patients were given a prescription
healing and dimensional changes (Fig. 4). to be filled as needed for postoperative pain, and Tetra­
F i r m pressure was maintained against each graft for cycline capsules (250 mg)‡ to be taken every 6 hours for
5 minutes, following suturing, using a damp gauze and
finger pressure to prevent dead space under the grafted
† COE-PAK periodontal paste, Coe Laboratories, Incorporated,
Chicago, 111. 60658
* Faber-Castell Corporation, Newark, N.J. 07103 ‡ Panmycin, Upjohn Company, Kalamazoo, Mich. 49001
 Volume 49
Number 6 Placement of F r e e G i n g i v a l Grafts on Deruded Alveolar Bone 285

border of the graft signifying healing by secondary i n ­

tention. M i l d swelling and cyanosis of the marginal
tissues was noted.
A l l grafts on periosteum the third postoperative week
were covered with mature appearing epithelium. Graft
margins demonstrated a blending of the transplanted
graft tissue with the adjacent gingival tissues. A l l grafts,
however, were easily recognized by their grayish surface,
observable tatoo markings, and distinct graft borders.
These control grafts appeared to lack clinical mobility.
M i l d redness was noted i n the free gingiva and at the
inferior borders of the grafts were newly formed tissue
was apparent.
FIGURE 4. Control graft (C) and experimental graft (E) sutured At the 6 week interval all control grafts clinically
into place with resorbable gut suture (S). Note tatoo markings exhibited complete healing. Though grafts were distin­
(T). Observe that the sutures do not penetrate the grafted tissue. guishable from the adjacent recipient tissue, they blended
well into their new environment. A distinct red line
superior to each graft differentiated the graft from the
the first 3 postoperative days. The antibiotic was given
recipient attached gingiva. Cicatrization was complete at
to minimize postoperative infection as well as provide a
marker for histologic evaluation of bone.
It was determined to maintain the grafts for a period
of 24 weeks i n three patients. In two patients grafts were
evaluated at 1 week postoperatively. The remaining
grafts were maintained for intervals of 2, 3, 6, 12, 15,
and 18 weeks.
At 1 week postoperatively all sutures that remained
were withdrawn and the graft area was carefully de-
brided and residual dressing on teeth removed. Gentle
cleansing of the area was accomplished with glycerin-
peroxide rinse (Fig. 5).
Patients were recalled i n accordance with the estab­
lished time sequence for clinical evaluation and mea­
surement of dimensional graft change. A t the designated
time interval the bone-tissue thickness measurements
were repeated using the previously prepared lingual FIGURE 5. Control (C) and experimental (E) grafts at 1 week.
notch (Fig. 6). Observe disintegration (D) of the keratinized tissue over thefacial
of tooth No. 23. Note the tatoos (T) and the loss of inferior tatoo
RESULTS markings. Also, note the rolled wound edges at the vestibular
margins (V).
Patients were evaluated clinically at each recall ap­
pointment, clinical measurements and photographs were
taken, and differences i n graft healing were recorded.

C o n t r o l Site—Grafts Placed on Periosteum

At 1 week, grafts which had been placed over retained
periosteum were observed for surface changes. A l l grafts
appeared to be firmly bound down and adherent to their
recipient beds, demonstrating a graft "take". These grafts
displayed a gray surface composed of desquamated epi­
thelial cells, periodontal dressing remnants, and plaque
debris interspersed with small red zones of exposed
connective tissue. Graft margins were distinct and a mild
to moderate redness was noted at the junction of the
inferior border of the graft with the alveolar mucosa.
Grafts at 2 weeks appeared covered by epithelium
which lacked stippling. A l l transplants to periosteum FIGURE 6. Control (C) and experimental (E) grafts at 6 weeks.
were well delineated from the adjacent tissues and were M a r g i n a l inflammation (I) is associated with gingival recession
(R) on the facial of tooth N o . 23. Observe the lack of stippling on
bound firmly to the underlying connective tissue. There the transplanted graft surface i n contrast to the stippling (St) seen
was a rolled margin of granulation tissue at the inferior on the attached gingiva. Note the faded appearance of tatoos (T).

286 James, McFall
the vestibular extension margin and oftentimes coincided
with the inferior margin of the graft. Stippling was not
evident.
Control grafts lacked a nonstippled surface and
slightly raised distinguishable margins which delineated
them from adjacent attached gingiva at 12 weeks. Most
tatoo markings were also recognizable and the red line
was still noted superior to the grafts. Increased graft
shrinkage was evident on the controlled areas when
compared with the experimental grafts.
Little definitive variation was noted at 18 or 24 weeks
postoperatively when compared with 12 week specimens.
A more profound degree of graft shrinkage was noted
than that i n experimental grafts. A distinct red line
superior to one of two grafts evaluated at 24 weeks
accentuated the superior extent of the control specimen.
E x p e r i m e n t a l Site Grafts Place on Denuded Bone
Experimental grafts characteristically demonstrated
delayed wound healing at 1 week. The epithelial surface
possessed a "ghostly" white appearance composed of
masses of necrotic epithelial cells, periodontal dressing
remnants, and accumulated plaque debris. Surface con­
tinuity was disrupted by zones of frank connective tissue
exposure and multiple ulcer formations. Graft margins
were identifiable only by color differences as most of the
tatooing agent was recognizable. N o graft mobility was
observed.
Experimental grafts had lost all clinical evidence of
tatooing by the 2 week interval. Graft margins were
distinguishable by raised reddened margins and pre­
sented a patchwork appearance of red on white with
some ulceration of the wound surface. Slow healing was
evident at inferior margins of the experimental grafts i n
association with vestibular margins.
At the 3 week interval all grafts were covered by
nonstippled epithelial surface. M i l d redness was noted
only near the gingival sulcus tissue or at the level of the
vestibular extension. There was a distinct visual improve­
ment i n adaptation of experimental grafts with their
recipient tissues when compared with the control sites.
Marginal blending was so complete i n some cases that
the grafts were hardly distinguishable from the adjacent
attached gingiva. Tatoo markings were faint. Experimen­
tal grafts lacked mobility.
By 6 weeks the grafts on bone had blended entirely
into their new environment. A visible red line was ob­
servable superior to the grafts next to the attached gin­
giva. Cicatrization was complete between the inferior
graft margins and the vestibular extension tissue. A more
esthetic blending of experimental graft and scar tissue
occurs than i n control tissues.
Experimental grafts were clinically essentially identi­
cal at each 12, 15, 18, and 24 week postoperative evalu­
ation. A l l grafts were covered with mature epithelium
exhibiting variable degrees of stippling and were undif-
ferentiable from adjacent attached gingiva. There was a
gradual diminution i n the intensity of the red line supe­
J. Periodontol.
June, 1978
rior to the free graft on denuded bone. Graft shrinkage
was evident, but to a lesser degree than i n the controls.
No mobility was noted and significantly increased
amounts of attached gingival tissue were evident.
Alterations were made on the controlled graft site i n
two surgical instances to allow for variations i n the
surgical procedure.
The surgical procedure for one patient was altered to
provide a graft recipient bed with periosteal retention on
the right mandibular incisor region without placement
of a free graft. A t 1 week the periosteum lacked an
epithelial covering. It was covered with a cyanotic mass
of granulation tissue. Wound margins bled easily.
At 3 weeks the wound was covered with a surface
layer of epithelium. The wound margins had a cyanotic
appearance but exhibited a blending with the adjacent
tissues without raised borders or tissue discontinuity.
Another patient was treated on the mandibular right
incisor area by alveolar bone denudation without graft
coverage. A t 1 week the bone surface was covered by
young granulation tissue without an epithelial surface
layer. The wound margins exhibited an intense inflam­
matory response. Adjacent tissues were highly edema­
tous and cyanotic.
By 3 weeks there was a partial epithelialization of the
denuded wound area with an immature epithelial layer.
The central area of the wound was ulcerated and wound
margins were quite swollen.
By 15 weeks the original surgical site was indetermin­
able. Clinical redness had disappeared and no distin­
guishable scar tissue was present. N o red line superior to
the surgical wound was noted as i n previous control
grafts.
C l i n i c a l Measurement of V a r i a t i o n of Tissue Thickness
Buccal tissue thicknesses over each tooth were mea­
sured from standardized lingual grooves preoperatively
and postoperatively at a level 5 m m buccally below the
cementoenamel junction. The results of a matched pair
/ test showed a significance between preoperative and
postoperative tissue thickness when grafts were placed
on denuded bone at the 0.02 level of significance and
between preoperative and postoperative tissue thickness
when grafts were placed on periosteum at the 0.01 level
of significance.
Graft shrinkage data was obtained by measurement of
the linear distance between tatoo marks located at the
four corners of each graft or between the margins o f the
four sides of each graft as indentified by the raised
borders of the healing graft tissue and/or tissue color
differences between the grafted tissue and the adjacent
gingival recipient tissue. The linear distance of each side
of the palatal graft tissue was measured prior to final
graft placement over the donor site and the graft area
covering bone and periosteum calculated i n square m i l ­
limeters.
Graft shrinkages were averaged and evaluated for
statistical correlation with a sign test for significance for
Volume 49
Number 6 Placement of F r e e G i n g i v a l Grafts on Denuded Alveolar Bone 287

each time interval and are reported in Table 1. This table

provides a mechanism for comparing the degree of graft
shrinkage between the two surgical methods. The results
revealed the percentage of graft shrinkage at each time
interval and the degree of difference between the control
and the test surgical areas to be significant as determined
by a sign test i n respect to the number of patients
analyzed between the 0.001 and 0.05 levels o f signifi­
cance between the 1 week and 12 week time intervals.
Table 2 was prepared to analyze the ratio of the slopes
from linear regressions of log area on both control and
experimental sites. A l l slopes were negative with the
exception of one patient which had been disregarded
previously because of suspected clinical measurement
error. The results of this table indicated a consistent FIGURE 7. Six week postoperative specimen. Control (C) and
periosteum/bone slope ratio greater than 1. This indi­ experimental (E) grafts. Note the degree of control graft shrink­
age when compared with the experimental graft. G—graft mar­
cates a greater degree of shringage on the control site. gins.
The degree of control graft shrinkage was significantly
greater than the experimental graft shrinkage for the
time intervals studied at the 0.001 level of significance.
Grafts placed over periosteum demonstrated a pro-

TABLE 1. Average Percentage of Graft Shrinkage

Time Grafts on
Grafts on Sign test
period denuded
periosteum significance
(weeks) bone
1 11.782 20.723 0.001
2 18.410* 26.550* 0.01
3 18.924 32.004 0.01
6 23.246 36.670 0.05
12 24.315 39.893 NA†
18 24.235 44.690 NA
24 24.850 48.310
* Results of only one clinical patient.
FIGURE 8. Twenty four week postoperative specimen. Control
† NA—Not applicable because of sample size attrition.
(C) and experimental (E) grafts. Note the degree of control graft
shrinkage when compared with the experimental graft. Note the
TABLE 2. Slopes from Linear Regression of Log Area Over Time in retained tatoo markings (arrows). Ca—calculus, GI—gingival
Weeks for Bone and Periosteum Sites inflammation. W—vestibular wound margin, GM—graft mar­
Paired t statistic (11 df) = -4.39, a = 0.001. gins.
Ratio of
Number slopes
Patient
of time Bone Periosteum peri­ gressively greater percentage of shrinkage than those
initials
points osteum/ grafts placed over denuded bone. Control grafts dem­
bone onstrated between 1½ and 2 times more shrinkage than
JA(1) 6 0.00154 -0.01810 *
the experimental areas (Figs. 7 and 8).
SB (2) 7 -0.01167 -0.02041 1.749
KB (3) 5 -0.02670 -0.03868 1.449
DISCUSSION
JB(4) 5 -0.01854 -0.02552 1.376
EC (5) 4 -0.04836 -0.07409 1.532 The present investigation was conducted to evaluate
SC (6) 2 -0.16889 -0.22893 1.355 clinical characteristics of free grafts placed on denuded
AD (7) 3 -0.09228 † bone. Also, graft shrinkage and differences i n tissue
MK (8) 5 -0.02719 -0.03948 1.452
EM (9) 4 -0.03652 -0.07154 1.959 thickness were analyzed i n comparison to placement of
LS (10) 6 -0.01317 † free grafts on retained periosteum.
PS (11) 7 -0.00801 -0.02193 2.738 A l l control and experimental grafts were evaluated at
LSp (12) 4 -0.04737 -0.06443 1.360 1 week and observed to cover their respective recipient
ST (13) 2 -0.10214 -0.17491 1.712
beds. This observation was verified by identification of
WW (14) 3 -0.10173 -0.15427 1.516
tatoo markings within each graft when present and de­
* Ratio not calculated due to suspected clinical error in measure­
termination of the increased graft thickness is i n accord­
ment of graft placed over denuded bone. 57 59

† Surgical area left denuded (LS) or covered only with periosteum ance with reports by Dordick et a l . ' and Klewansky
58
(AD). et a l . W i t h prolonged observation up to 24 weeks

288 James, McFall
postoperatively, it was noted that all test grafts exempli­
fied a lack o f clinical mobility and establishment of an
adequate zone of masticatory mucosa. Control grafts on
retained periosteum were also observed for up to 24
weeks and were noted to lack clinical graft mobility and
to establish an adequate bone of attached gingiva. In
59
contrast Dordick et a l . reported postoperative graft
mobility i n over one-half of the grafts placed on retained
periosteal beds. None of their grafts placed on denuded
bone exhibited mobility.
A lack of mobility was anticipated i n grafts on de­
nuded bone because of wound healing studies by Pfei-
61
fer and Costich and Ramfjord. ' Their evaluations of 62 63
healing with denudation demonstrated the repair of the
wound by proliferation of granulation tissue from adja­
cent wound margins and marrow spaces which became
exposed following resorption of the cortical plate of
7
alveolar bone. Also, Sullivan and Atkins pointed out
that apical and lateral fenestrations may eliminate graft
64
mobility. Bressman and Chasens noted minimal
chances of postoperative graft mobility when periosteal
fenestration was performed at the apical level of the
recipient bed. The results of this study demonstrated
attachment of grafts to the recipient denuded bone by
proliferation of collagen fibers adjacent to the osseous
tissue and entrapment of the collagen bundles within
new osteoid tissue.
The clinical measurements recorded for up to 24 weeks
of reduction i n graft areas have demonstrated 25%
shrinkage of grafts on denuded bone with the greatest
amount of shrinkage occurring within the first 6 weeks.
Recordings of grafts on retained periosteum for the same
time interval revealed a 50% shrinkage of control grafts.
Also, control grafts were observed to shrink by propor­
tionate increments throughout the entire observation
interval.
65
Staffileno and L e v y reported a 20% decrease i n graft
size within the first 12 hours, but failed to elaborate on
total graft shrinkage over a set period of time. Zingale
published results demonstrating a reduction i n average
graft width from 3.8 m m to 2.7 m m after 6 months,
however, this approximate 25% decrease i n width is
incomparable to the total decrease in area as calculated
42
i n this investigation. Zingale also noted the greatest
contraction to occur between 1 week and 1 month post­
operatively with no dimensional variations after the 3rd
month.
66
Rose and Sullivan noted a 55% decrease in surface
area with full thickness wounds at 10 to 12 weeks and
35% reduction of surface area at 3 to 5 weeks. They
correlated this tissue shrinkage with the amount of gran­
51
ulation tissue formed. W a r d analyzed clinical changes
in the width of grafts used to correct localized recession
in association with a frenal pull and reported 45% con­
traction at 3 months and 47% contraction at 6 months
when periosteum was maintained. He attributed the
severe degree of tissue shrinkage to either loss of tissue
during the initial healing phase or contraction during
58
healing. Klewansky et a l . evaluated the placement of
J. Periodontal.
June, 1978
free grafts on denuded bone i n two cases and noted a
35% shrinkage of the grafted tissue at 1 month.
The determination of a significant statistical variability
between the two surgical methods at the 0.001 to 0.05
levels of significance indicate a definite advantage in the
placement of grafts on denuded bone to minimize loss of
a surgically established zone of attached gingiva.
7 45 67 68
Previous investigators ' ' ' have evaluated free graft
healing from the standpoint of differences i n graft thick­
ness and the influence of full and partial thickness grafts
on the wound healing phenomenon. This investigation
maintained a partial thickness transplant of 0.9 m m
average to minimize variations i n the wound healing.
Remarkably, the average increase i n tissue thickness on
both graft sites is 0.9 m m ± 0.01 mm. Thus, it seems that
the repair process attempts to reestablish a tissue thick­
ness equivalent to the thickness of the grafted tissue.
Wound healing was evaluated at each time interval
between 1 week and 24 weeks and compared. It was
observed that at 1 week the experimental grafts were
covered with desquamated cells and debris. This loss of
surface protection may be attributable to the lack of an
entirely adequate blood supply or to the normal matu­
ration pattern of epithelium at this early period of eval­
uation. Later time intervals demonstrated a total blend­
ing of the graft into the recipient site with the exception
of a red line superior to the graft. This delineation is
suggestive of nonkeratinized epithelium superior to the
prepared recipient site. Another possible explanation of
the red zone would be an increase i n vascularity to
provide an adequate blood supply to the graft on de­
nuded bone. This is a likely consideration and is sup­
ported by the gradual diminution of the line with time.
Evaluation of clinical wound healing and graft shrink­
age suggest that the majority of control graft shrinkage
69
is attributable to loss of vestibular depth. Bohannon
showed that after an observation period o f 26 weeks,
only 16% of the accomplished vestibular extension pro­
42
cedure was retained. This loss of surgically produced
vestibular extension was attributed to cicatricial contrac­
tion. In the present study, no attempts were made to
fenestrate periosteum apical to the prepared bed site to
avoid jeopardization of graft blood supply. The control
results tend to confirm Bohannon's observations.
Color differences between recipient and grafted tissue
were observed to be much less with the placement of
grafts on denuded bone. This camouflage effect is due
possibly to the thickness of the epithelial surface tissue
on the experimental side accomplishing a closer prox­
imity of vascular connective tissue with the surface rather
than a pale white color often seen with free grafts on
45
periosteum. Brasher et a l . noted greater color discrep­
ancies in control grafts with thicknesses greater than 1.25
m m and i n individuals with physiologic pigmentation of
the attached gingiva.
SUMMARY
Fourteen patients were examined and determined to
lack an adequate zone of attached gingiva i n the man-
 Volume 49
Number 6 Placement
dibular incisor region. Each patient was treated on the
left side of the mandible by placement of a free gingival
graft on denuded bone and 12 of the 14 patients received
a free gingival graft on retained periosteum i n the right
mandibular anterior region. Two patients were treated
on the right side by either bone denudation or periosteal
bed preparation without graft placement to permit his­
tological evaluation of wound healing under these cir­
cumstances.
Grafts were retained for time intervals from 1 week to
24 weeks. A l l patients were evaluated clinically for graft
"take", graft healing, graft shrinkage, and graft mobility.
CONCLUSIONS
1. Evaluation of all surgical sites for up to 24 weeks
postoperatively demonstrated graft "take" and lack of
clinical graft mobility on both control and experimental
graft sites.
2. Clinical measurements suggested a IV2 to 2 fold
increase i n shrinkage of grafts placed over periosteum
when compared to grafts placed over denuded bone. The
comparison of the percentage of graft shrinkage between
the control and the experimental sites was significant
between the 0.005 and 0.01 levels of significance relative
to the 1 to 12 week postoperative healing interval.
3. Control and experimental grafts tended to increase
the postoperative tissue thickness at the 0.01 and 0.02
levels of statistical significance.
4. The use of india ink as a tatooing agent was unsat­
isfactory for highly accurate clinical measurements i n
oral grafting evaluation.
5. Subjective evaluation of postoperative pain sug­
gested that no differences exist between the two surgical
techniques.
6. The success of alveolar bone retention under free
grafts on bone depended on the thickness of the preop­
erative bone, the height of the bone level as it relates to
the location of the mucogingival junction, and the buc­
cal-Ungual position of the tooth within the arch.
7. A t no time was bone sequestration observed clini­
cally with placement of grafts on denuded bone.
8. F r o m a clinical standpoint the free graft on de­
nuded bone procedure is a reliable and feasible method
for treatment of a lack of attached gingiva i n selected
cases with a sufficient thickness of preoperative alveolar
bone.
ACKNOWLEDGMENTS
Appreciation is expressed to Dr. Walter T. McFall, Jr., Dr.
E. Jeff Burkes, Dr. Myron S. Silverman, Dr. Luther H. Hutch-
ens, Jr., Carolyn Blackwood, Peggy Davis, Linda Kilgo, Bill
Blanton and Jerry Quinn whose cooperation helped make these
studies possible.
REFERENCES
1. Glickman, I.: Clinical Periodontology, ed 4, pp 531-547.
Philadelphia, W. B. Saunders Co., 1972.
2. Goldman, H. M., and Cohen D. W.: Periodontal Therapy,
ed 4, pp 1-20, 40-45, 694-702, 857, 859, 875, 937. St. Louis, C.
V. Mosby Co., 1968.
3. Goldman, H. M.: Periodontia, ed 3, pp 552-568. St. Louis,
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