CASE REPORT

Focus on Epithelialized Palatal Grafts. Part 3: Methods to Enhance Patient

Comfort at Palatal Donor Sites
Joshua P. Berridge,∗ Thomas M. Johnson,† Albert W. Cheng,‡ Dane T. Swenson† and Preston D. Miller Jr.§

Introduction: Postoperative discomfort is a documented complication of the epithelialized palatal graft (EPG)
procedure, and the expectation of an unpleasant patient experience may cause some practitioners to avoid EPG altogether.
However, EPG affords distinct advantages in a variety of clinical situations, and the postoperative discomfort associated
with the procedure can be minimized.
Case Series: Three generally and periodontally healthy patients with gingival recession defects and minimal zones
of attached gingiva received mandibular anterior EPG procedures. In all cases, collagen membranes were trimmed to fit the
palatal donor sites and sutured in place. Two patients reported minimal donor site discomfort at any time point. One patient
with large bilateral donor sites reported moderate palatal discomfort limited to the first postoperative week. All patients
reported overall positive treatment experiences.
Conclusions: Placement of a resorbable collagen membrane at large EPG harvest sites appears to limit topical irrita-
tion of the wound and may substantially improve patient comfort postoperatively. Combining local and systemic measures
to minimize patient discomfort may render EPG procedures very tolerable for patients. Controlled clinical trials comparing
patient-centered outcomes following EPG harvest with and without collagen membrane placement appear warranted.
Clin Adv Periodontics 2019;00:1–8.
Key Words: Autografts; gingiva; palate; pain management; treatment outcome; patient outcome assessment.

Background discomfort and patient distress compared with subepithe-

Limited evidence supports what many practitioners lial connective tissue graft (SCTG)-based procedures.1 – 6
understand from practical experience—the EPG proce- Given this relative tolerability of palatal connective tis-
dure produces more severe and persistent donor site sue harvests, it is fortunate that SCTG procedures have
emerged as the gold standard for root coverage.7 – 9 No
root coverage technique has been found to produce a
∗ Department of Periodontics, US Army Dental Health Activity, Fort higher mean percent root coverage, more frequent com-
Bragg, NC
plete root coverage, or more stable results than SCTG-
† Departmentof Periodontics, Army Postgraduate Dental School, based procedures.7 – 9 Despite SCTG advantages, EPG
Uniformed Services University of the Health Sciences, Fort procedures address factors that commonly contribute to
Gordon, GA gingival recession (GR) and offer practitioners valuable
‡ Department
of Periodontics, US Army Dental Health Activity, Fort flexibility in treatment planning.10 Additionally, it is gen-
Leonard Wood, MO erally acknowledged that a half century after its introduc-
§ Distinguished
tion, EPG remains the gold standard for increasing the
visiting lecturer, New York University, New York, NY
dimensions of attached gingiva.11
Received May 25, 2018; accepted October 8, 2018
Hard palate anatomy and differences between EPG
and SCTG harvest techniques may account for com-
doi: 10.1002/cap.10066 paratively greater discomfort from EPG palatal donor

Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 1

C A S E R E P O R T

sites. Near the palatine raphe and also in the vicinity of

the maxillary teeth, the oral mucosa of the hard palate
lacks a distinct submucosa.12 These areas are character-
ized by presence of a mucoperiosteum—a dense collagen
network anchoring the lamina propria of the mucosa
directly to the periosteum.12 In the area between these
two mucoperiosteal zones, a distinct submucosa con-
tains loose connective tissue, adipose, glands, vessels, and
nerves.12,13 Afferent fibers from the maxillary division of
the trigeminal nerve (V2 ) are distributed to the hard palate
oral mucosa via the greater palatine and nasopalatine
nerves.14
EPG and SCTG harvest techniques13,15 involve surgical
trauma to the oral epithelium, the lamina propria, and the FIGURE 1 Case 1. Baseline appearance, mandibular anterior.
submucosa, and based on incision locations, both proce-
dures presumptively damage nerve fibers carrying sensory
information from the hard palate.14 The degree to which
direct injury to nerve tissue contributes to postoperative
pain at palatal donor sites has not been studied. However,
donor site paresthesia is a rare complication associated
with palatal tissue harvests.16
Relative to SCTG harvesting techniques, EPG harvests
may require slightly less time and surgical skill, and EPG
harvests may be possible when palatal tissue is too thin for
proper SCTG acquisition.17 Additionally, the composition
and clinical quality of palatal submucosa appear to vary
among patients. Some SCTG may consist of relatively
dense fibrous tissue, whereas other grafts may include FIGURE 2 Case 1. Recipient site prepared.
higher proportions of adipose and glandular tissue.14
Because EPG harvests include the palatal mucosa (epithe-
lium and lamina propria),14 graft integrity and suitability
for suturing appear consistently favorable.
Postoperative discomfort at EPG harvest sites has been
shown to correlate with graft width and thickness.6
Accordingly, residual thickness of palatal connective tissue
at EPG harvest sites appears negatively correlated with
postoperative discomfort.6 When necrosis of the overly-
ing palatal flap occurs at SCTG harvest sites, increased
postoperative pain is the typical result.4,6 Excessive pain
from areas of exposed palatal connective tissue has been
attributed to secondary intention healing.2,6 Specifically,
loss of the protective keratinized mucosa, direct exposure
FIGURE 3 Case 1. Clinical appearance at completion of EPG
of injured nerve fibers, and ensuing topical irritation may procedure.
amplify postoperative pain.2 In the present consecutive
case series, postoperative discomfort following EPG was
minimized using local measures and a combination of Case 1
systemic analgesics. In September 2017, a 53-year-old Army officer in
good general health presented complaining of GR that
had progressed over time. Generalized extrinsic staining
attributable to coffee, slight incisal wear, supereruption
Clinical Presentation, Case of mandibular incisors, recession type 2 (RT2) defects
Management, and Clinical Outcomes at teeth #23 through #26, minimal vestibular depth in
All patients in this report presented to the Department the mandibular anterior, and minimal attached gingiva at
of Periodontics, Army Postgraduate Dental School, Uni- tooth #23 were noted (Fig. 1).
formed Services University of the Health Sciences, Fort The periodontal findings, overall oral condition, and
Gordon, Georgia. Treatment options were discussed in prognosis were discussed with the patient in detail. Treat-
detail, and each patient completed a consent process ment options, including simply monitoring the reces-
involving verbal and written components. sion defects, were reviewed. The patient elected an EPG

2 Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 Focus on Epithelialized Palatal Grafts. Part 3
 C A S E R E P O R T

FIGURE 4 Case 1. Progress of palatal donor site healing. 4a Appearance at completion of surgery. 4b
Postoperative day seven. 4c Postoperative day 14. 4d Postoperative day 30.

FIGURE 5 Case 1. Postoperative day seven. FIGURE 7 Case 1. Postoperative day 30.

FIGURE 6 Case 1. Postoperative day 14. FIGURE 8 Case 1. Five months following EPG procedure.

Berridge, Johnson, Cheng, Swenson, Miller Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 3
C A S E R E P O R T

trimmed, tailored to the dimensions of the recipient site,

and secured with a combination
of 6/0 polypropylene# and 4/0
polytetrafluoroethylene sutures
(Fig. 3). Postoperatively, the
patient received ibuprofen
(800 mg) three times daily and
hydrocodone/acetaminophen (5/
325 mg) every four hours
as needed for analgesia. A rigid
FIGURE 9 Case 1. Recipient site. 9a Baseline appearance. 9b Five months following EPG procedure. palatal stent was used to provide
added protection of the collagen
membranes at the donor sites.
Toothbrushing at the recipient
site was withheld for three
weeks, and chlorhexidine rinses
were used twice daily to control
plaque accumulation until
normal oral hygiene measures
resumed. Frequent warm, gentle
saline rinses were encouraged.
At postoperative day seven,
the patient reported minimal
discomfort over the first week.
Recipient-site rather than
donor-site (Fig. 4) discomfort
was comparatively greater
based on the patient’s subjective
assessment. Opioid use was
limited to the first postoperative
day. Normal healing was noted
at the recipient site, and at
FIGURE 10 Case 2. Progress of palatal donor site healing. 10a Appearance at completion of surgery. 10b
Postoperative day seven. 10c Postoperative day 14. 10d Postoperative day 35. the palatal donor sites, the
collagen membrane appeared
partially degraded and partially
integrated with native tissue.
Healing proceeded uneventfully
resulting in a favorable clinical
outcome (Figs. 5 through 9).
The patient reported a positive
overall experience.

Cases 2 and 3
FIGURE 11 Case 2. Recipient site. 11a Baseline appearance. 11b Postoperative day 35. The proposed method for
protecting the donor site palatal
procedure at teeth #23 through #26 under moderate wound was used in two addi-
sedation. Intravenous (IV) midazolam and fentanyl were tional mandibular anterior EPG procedures. Two
titrated to achieve moderate sedation. Dexamethasone generally and periodontally healthy female patients
(8 mg) was also administered intravenously. Recipient presented with RT1 and RT2 defects and minimal
site preparation was similar to the technique described zones of attached gingiva. Patients 2 and 3 were aged
by Miller (Fig. 2).15 Bilateral EPG ≈2.5 mm thick were 54 and 29 years, respectively. Graft thicknesses were
harvested from oral mucosa of the hard palate. Collagen ≈2 to 2.5 mm. In both cases, collagen membranes∗∗
membranes were adapted to the donor sites and fixed were fitted to the palatal donor sites and sutured in place
with 4/0 polytetrafluoroethylene sutures.¶ The grafts were (Figs. 10 through 13), and both patients received the same

 HeliMendTM , Integra LifeSciences, Plainsboro, NJ. # Perma Sharp® polypropylene sutures, Hu-Friedy, Chicago, IL.
¶ CytoplastTM , Osteogenics Biomedical, Lubbock, TX. ∗∗ BioMend®, Zimmer Biomet, Warsaw, IN.

4 Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 Focus on Epithelialized Palatal Grafts. Part 3
 C A S E R E P O R T

Discussion
Clinicians have advocated
covering EPG harvest sites
during early healing to enhance
patient comfort or support
hemostasis (Table 1).1 – 4,6,17 – 19
Palatal stent placement is among
the simplest techniques used for
these purposes.1,2,4,20 An early
report advocated mattress
sutures or interproximal wire
ligation to stabilize surgical
dressings over EPG harvest
sites.2 More recently, a clinical
trial reported that topical
hyaluronic acid gels applied
at EPG harvest sites decreased
pain and accelerated epithe-
lialization.18 Platelet-rich fibrin
(PRF) sutured at EPG donor
FIGURE 12 Case 3. Progress of palatal donor site healing. 12a Appearance at completion of surgery. sites has shown promising
12b Postoperative day seven. 12c Postoperative day 14. 12d Postoperative day 30. results with respect to reduction
in postoperative pain and early
epithelialization of palatal
wounds.17,19 However, this
technique requires practitioners
to draw and process blood,17,19
which prolongs the surgical
visit and may be unappealing
to some patients. Collagen
membranes have been used
at small EPG harvest sites to
protect the exposed submucosa,
rendering pain from EPG and
SCTG harvest sites equivalent.6
The present case series suggests
collagen membranes may
effectively mitigate donor site
discomfort when considerably
larger and thicker grafts are
needed.
In addition to topical mea-
sures, a combined pharmacolog-
FIGURE 13 Case 3. Recipient site. 13a Baseline appearance. 13b Appearance at completion of surgery ical approach to analgesia may
13c Postoperative day 30 13d Three months following EPG procedure. optimize postoperative comfort.
A Cochrane review concluded
intraoperative and postoperative analgesics described in that a combination of acetaminophen and ibuprofen
case 1. Patient 2 reported minimal palatal pain during the provided more analgesia than either drug alone (at
first few postoperative days and no pain from the palate the same dose) with reduced risk of an adverse
at the follow-up appointment on day seven. Patient 3 event.21 In the present case series, the patients did
reported moderate donor site discomfort during the first receive acetaminophen and ibuprofen. However, the
postoperative week, which was adequately managed with acetaminophen was prescribed as a combination
the prescribed medications. By postoperative day 10, the drug containing hydrocodone. Using acetaminophen
patient reported minimal discomfort, and at the 14-day plus ibuprofen for analgesia and reserving the
follow-up appointment, the patient had no donor site narcotic as a rescue medication may be a preferable
discomfort. approach.

Berridge, Johnson, Cheng, Swenson, Miller Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 5
C A S E R E P O R T

TABLE 1 Reported methods to mitigate discomfort at epithelialized palatal graft donor sites

Author(s) Palatal wound treatment Comments

18
Yıldırım et al., 2018 Periodontal dressing with (test) or without Patients receiving HA gel at EPG palatal donor sites
(control) topically applied HA gel experienced less pain than control patients at
postoperative days three and seven. Test patients also
exhibited earlier CE of the palatal wounds.
Femminella et al., PRF (test) or gelatin sponge (control) Test patients showed significantly faster CE and reported
201617 significantly less discomfort compared with controls.
Aravindaksha et al., PRF (test) or a non-eugenol-based dressing PRF application at EPG palatal donor sites resulted in
201419 (control) earlier CE as well as diminished donor site discomfort
compared with a single control patient.
Zucchelli et al., 20106 Equine-derived collagen membrane No differences were demonstrated in the post-operative
pain at SCTG and contralateral EPG donor sites.
Wessel and Tatakis, Palatal stent Incidence of palatal pain at postoperative day three was
20081 significantly higher for EPG compared with SCTG
donor sites.
Griffin et al., 20063 Non-eugenol-based dressing Patients who received EPG were three times more likely
to develop moderate-to-severe postoperative pain or
bleeding compared with patients who received
SCTG-based procedures.
Rossman and Rees, Palatal stent plus gauze and pressure alone Pain assessment showed no differences across
199920 (control), oxidized regenerated cellulose, treatment groups.
or absorbable gelatin sponge
Jahnke et al., 19934 Acrylic palatal stent Palatal discomfort diminished 14 to 21 days following
EPG and seven to 18 days following SCTG harvests.
Farnoush, 19782 Acrylic oral appliance or retention of surgical This technique article did not compare treatment
dressing using wire ligation or mattress outcomes to controls.
sutures
HA = hyaluronic acid, CE = complete epithelialization, PRF = platelet-rich fibrin.

When autogenous palatal grafts are harvested under EPG donor sites, by their very nature, are uncomfort-
IV moderate sedation, a steroid can be added for anti- able. However, EPG may, in some cases, represent the
inflammatory and analgesic effects. Intraoperative dex- procedure best suited for achieving surgical goals. Prac-
amethasone appears to lower postoperative pain scores titioners can greatly reduce patient discomfort following
and reduce opioid use.22 Conversely, IV acetaminophen EPG procedures through a planned strategy for analgesia
has been shown to produce a modest but statistically sig- involving both topical and systemic methods.
nificant decrease in subjective post surgical pain without
decreasing narcotic use.23

6 Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 Focus on Epithelialized Palatal Grafts. Part 3
 C A S E R E P O R T

Summary

Why are these cases new  A prior study demonstrated that small EPG and SCTG palatal donor sites
information? were equally uncomfortable when EPG donor sites were protected with
collagen membranes.6 The present case series suggests collagen
membranes may effectively mitigate donor site discomfort when
substantially larger grafts are required.

What are the keys to successful  The collagen membrane should be fitted to the donor site, intimately
management of these cases? adapted to the exposed submucosa, and stabilized with sutures to allow
tissue integration.

What are the primary limitations  Relative efficacies of various reported techniques for managing EPG
to success in these cases? donor site discomfort are not known. Controlled clinical studies are
needed to determine whether the proposed technique is consistently
effective.
 Use of a collagen membrane to mitigate EPG donor site pain increases
the material cost of the procedure. The added cost may be justified to
improve patient-centered outcomes, particularly when large grafts are
necessary.
 Whether membrane characteristics such as collagen cross-linking
impact efficacy is unclear.

Acknowledgments 8. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage pro-
The views expressed in this manuscript are those of the cedures: a systematic review from the AAP regeneration workshop.
J Periodontol 2015;86:S8-S51.
authors and do not necessarily reflect the official policy
9. Chambrone L, Pannuti CM, Tu YK, Chambrone LA. Evidence-based
of the Department of Defense, Department of Army, US periodontal plastic surgery. II. An individual data meta-analysis for
Army Medical Department, or Uniformed Services Uni- evaluating factors in achieving complete root coverage. J Periodontol
versity of the Health Sciences. The authors report no 2012;83:477-490.

conflicts of interest related to this case series. 

10. Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts
for aesthetic purposes. Periodontol 2000 2001;27:72-96.

CORRESPONDENCE 11. Kim DM, Neiva R. Periodontal soft tissue non–root coverage pro-
Dr. Thomas M. Johnson, Department of Periodontics, Army Post- cedures: a systematic review from the AAP regeneration workshop.
graduate Dental School, Uniformed Services University of the Health J Periodontol 2015;86:S56-S72.
Sciences, 320 East Hospital Road, Fort Gordon, GA 30905. E-mail: 12. Cohen MS, Shorr N. Eyelid reconstruction with hard palate mucosa
thomas.m.johnson34.mil@mail.mil grafts. Ophthalmic Plast Reconstr Surg 1992;8:183-195.
13. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial con-
nective tissue graft palatal donor site: anatomic considerations for
References surgeons. Int J Periodontics Restorative Dent 1996;16:131-137.

1. Wessel JR, Tatakis DN. Patient outcomes following subepithelial con-
nective tissue graft and free gingival graft procedures. J Periodontol
14. Hansen JT. Head and neck. In: Netter’s Clinical Anatomy 3rd ed.
Philadelphia: Saunders; 2014:411-524.
2008;79:425-430. 15. Miller PD. Root coverage using a free soft tissue autograft following
2. Farnoush A. Techniques for the protection and coverage of the donor citric acid application. Part I. Technique. Int J Periodontics Restorative
sites in free soft tissue grafts. J Periodontol 1978;49:403-405. Dent 1982;2:65-70.
3. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative com- 16. Keceli HG, Aylikci BU, Koseoglu S, Dolgun A. Evaluation of palatal
plications following gingival augmentation procedures. J Periodontol donor site haemostasis and wound healing after free gingival graft
2006;77:2070-2079. surgery. J Clin Periodontol 2015;42:582-589.
4. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC. Thick free 17. Femminella B, Iaconi MC, Di Tullio M, et al. Clinical comparison of
gingival and connective tissue autografts for root coverage. J Periodon- platelet-rich fibrin and a gelatin sponge in the management of palatal
tol 1993;64:315-322. wounds after epithelialized free gingival graft harvest: A randomized
5. Del Pizzo M, Modica F, Bethaz N, Priotto P, Romagnoli R. The clinical trial. J Periodontol 2016;87:103-113.
connective tissue graft: a comparative clinical evaluation of wound 18. Yıldırım S, Özener HÖ, Doğan B, Kuru B. Effect of topically applied
healing at the palatal donor site. A preliminary study. J Clin Periodontol hyaluronic acid on pain and palatal epithelial wound healing: an
2002;29:848-854. examiner-masked, randomized, controlled clinical trial. J Periodontol

6. Zucchelli G, Mele M, Stefanini M, et al. Patient morbidity and root cov-
erage outcome after subepithelial connective tissue and de-epithelialized
2018;89:36-45.
19. Aravindaksha SP, Batra P, Sood V, Kumar A, Gupta G. Use of platelet-
grafts: a comparative randomized-controlled clinical trial. J Clin Peri- rich fibrin membrane as a palatal bandage. Clin Adv Periodontics
odontol 2010;37:728-738. 2014;4:246-250.
7. Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery 20. Rossmann JA, Rees TD. A comparative evaluation of hemostatic agents
procedures in the treatment of localized facial gingival recessions. A in the management of soft tissue graft donor site bleeding. J Periodontol
systematic review. J Clin Periodontol 2014;41:S44-S62. 1999;70:1369-1375.

Berridge, Johnson, Cheng, Swenson, Miller Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 7
C A S E R E P O R T

21. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus side-effects: systematic review and meta-analysis. Br J Anaesth
paracetamol (acetaminophen) for acute postoperative pain. Cochrane 2013;110:191-200.
Database Syst Rev 2013;6:CD010210. https://doi.org/10.1002/ 23. Strode MA, Sherman W, Mangieri CW, et al. Randomized trial
14651858.CD010210.pub2. of OFIRMEV versus placebo for pain management after laparo-
22. Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact scopic sleeve gastrectomy. Surg Obes Relat Dis 2016;12:772-
of perioperative dexamethasone on postoperative analgesia and 777.

 indicates key references.

8 Clinical Advances in Periodontics, Vol. 00, No. 0, April 2019 Focus on Epithelialized Palatal Grafts. Part 3