The Palatal Subepithelial Connective Tissue Flap

Method for Soft Tissue Management to

Cover Maxillary Defects: A Clinical Report
Fouad Khoury, Prof Dr med dent, PhD, DDS1/Arndt Happe, Dr med dent, DDS2

This article presents a technique for soft tissue reconstruction and covering defects associated
with maxillary implant-supported restorations. A pedicle subepithelial connective tissue flap is
prepared from the palatal mucosa near the area to be treated and is displaced into the receptor
site. The donor site remains primarily covered. An increase in soft tissue volume is achieved at
the receptor site, which is advantageous for various reasons. The pedicle graft has been used
for different indications: closure of the alveolus after immediate implant placement, papilla
reconstruction, defect and dehiscence repair, and multiple-layer closures after bone grafting
and treatment of peri-implantitis. Over a 32-month period, 103 patients were treated with this
method. Partial flap necrosis occurred in only 2 patients. All other patients showed significant
improvement over the preoperative condition. (INT J ORAL MAXILLOFAC IMPLANTS 2000;15:
415–418)

Key words: endosseous dental implantation, gingivoplasty, guided tissue regeneration,

pedicle graft, surgical flaps

I n some clinical situations it may be necessary to

have extra soft tissue available to reconstruct a
defect or to create an esthetic implant restoration.
membrane cannot always be placed as far away as
possible from the flap margin, as required by the
protocol. In these situations a multiple-layer closure
The literature describes different techniques for can be very advantageous.
repairing local defects of the alveolar process When immediate implant placement is involved,
through bone grafting and soft tissue grafting.1,2 different techniques have been used for obtaining
Other authors have reported on various procedures soft tissue coverage. Primary coverage of the alveolus
for obtaining soft tissue coverage of augmented can no doubt be achieved with a trapezoid full-thick-
areas after the placement of membranes or local ness flap utilizing the Rehrmann plastic procedure.4
bone transplantation.3 Primary coverage is espe- However, in the esthetic region, this procedure may
cially important if non-resorbable guided bone lead to extreme displacement of the mucogingival
regeneration membranes are used, since severe border. 5 Consequently, the attached gingiva is
dehiscence with infection can compromise the shorter, and disorders of the entire soft tissue archi-
entire augmented area. Furthermore, in practice the tecture may occur. Peri-implant attached and kera-
tinized mucosa is not only important from the point
of view of periodontal health 6; its absence often
results in color discrepancies of the peri-implant
mucosa and can be a great esthetic disadvantage for
1Professor, Department of Oral & Maxillofacial Surgery, University patients with a high smile line.7 For this reason,
of Münster, Münster, Germany; and Chairman, Privatklinik Landsberg,8 Langer,9 and Khoury and Happe10,11
Schloss Schellenstein, Olsberg, Germany. have reported on different procedures, with and
2Privatklinik Schloss Schellenstein, Olsberg, Germany.
without soft tissue transplantation, to achieve pri-
Reprint requests: Prof Dr Fouad Khoury, Department of Oral &
mary soft tissue closure without flap dislocation.
Maxillofacial Surgery, University of Münster, Waldeyer Strasse 30, Rosenquist5 described various techniques using free
D-48129 Münster, Germany. Fax: +49 251 8347182. gingival grafts for primary closure of the alveolus

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KHOURY/HAPPE

after immediate implant placement. Since he some- RESULTS

times observed necrosis with free grafts, Rosenquist
recommended the preparation of a mucosal pedicle The described technique has been used for the fol-
flap from the vestibule, folding it through a tunnel lowing indications: (1) alveolus closure after imme-
below the marginal gingiva and suturing it over the diate implant placement in 19 patients; (2) multi-
implant to the palatal mucosa. Although this method layer flap closure in 18 patients after lateral bone
has been described as being safe and predictable, its graft, 26 patients after onlay bone grafting, 15
application seems to be somewhat awkward. Fur- patients following augmentation in combination
thermore, surgery is performed vestibularly to the with e-PTFE membranes, and 8 patients after treat-
alveolar process, where scarring might compromise ment of peri-implantitis; and (3) reconstruction of
the esthetic outcome. large soft tissue defects and reconstruction of papil-
Besides the tuberosity region, free connective tis- lae in 17 patients.
sue transplants may also be obtained from the Bleeding related to flap preparation stopped in
palate.1 On the basis of these considerations, the most of the patients after the donor site was
authors herein present a method for defect repair sutured. However, in 6 patients the bleeding was so
and soft tissue reconstruction in which the palatal severe that electrocautery of the vessel became nec-
incision is extended up to the receptor site to pre- essary. Postoperative bleeding was not observed in
serve the pedicle shape of the connective tissue any of the patients. Visible partial flap necrosis
graft. This report presents initial results utilizing occurred in 2 patients (1 after immediate implant
this technique. placement and 1 after onlay grafting). In all other
patients the wound healed without complication.
The augmented connective tissue showed little
MATERIALS AND METHODS shrinkage and was covered by epithelium after
approximately 2 to 3 weeks. Postoperative morbid-
Between 1997 and 1999, 103 patients (69 females ity was similar to that after removing a free subep-
and 34 males) were treated with the described tech- ithelial connective tissue graft from the palate.
nique. The youngest patient was 19 years and the
oldest was 66 years, with an average of 39.5 years.
The technique was used for the following indica- DISCUSSION
tions: soft tissue closure after various augmentation
procedures with and without membranes (Figs 1a Soft tissue grafts have been successfully used in
and 1b), immediate implant placement, papillae periodontal treatment for many years to cover areas
reconstruction, correction of local defects, and of root recession and alveolar ridge reconstruc-
treatment of post-augmentation dehiscences or tion.1,3,12 The authors concur with others who have
peri-implantitis. suggested that the use of pedicle grafts presents a
After local anesthesia was administered, a palatal much more favorable prognosis than free grafts,5
paramarginal incision was made from the molar because an important part of the blood supply to
region to the defect to be covered. The length of the flap is maintained during and after the proce-
the incision depended on the size of the defect. Dis- dure. Important factors to be considered for the
section of the mucoperiosteal flap and the underly- long-term success of free mucosal and connective
ing preparation of a subepithelial connective tissue tissue transplants include primary fixation of the
flap to a depth of 5 to 8 mm were then performed. A graft, the possibility of revascularization, and revi-
sharp incision of the subepithelial tissue was then talization from the receptor site. Close contact to a
made parallel to the first incision in the same man- well-vascularized receptor site positively influences
ner to harvest a connective tissue graft, but leaving the prognosis of free grafts. A subepithelial connec-
it attached in the anterior region. The subepithelial tive tissue graft between the mucosa and the perios-
connective issue flap was then elevated (Fig 1c) and teum is more predictable and has a much better
rotated to cover the defect or reconstruct soft tissue chance of survival than free grafts over poor or non-
(Figs 1d and 1e). Because the donor site is situated vascularized areas such as a bone graft or a non-
in a well-vascularized area (palatal artery), heavy resorbable membrane.10 In these situations, pedicle
bleeding can occur and may require cauterization. grafts (flaps) are indicated.
Since only a subepithelial connective tissue flap was Although the technique presented here has also
removed, the palatal wound at the donor site could been applied in unfavorable and extreme situations,
be totally closed and sutured. Patients were advised the results obtained have been satisfactory. Partial
to rinse with 0.02% chlorhexidine for two weeks. flap necrosis occurred in 2 patients (1.9%); the 2

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416 Volume 15, Number 3, 2000 OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
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 KHOURY/HAPPE

Fig 1a (Above) Large bone defect in the region of the maxillary

left canine with the complete loss of labial and lingual plates.

Fig 1b (Right) Clinical situation after bone grafting with recon-

struction of the entire alveolar process.

Fig 1c Preparation of an 8-mm-wide subepithelial connective Fig 1d The palatal connective tissue flap is rotated to cover, in
tissue flap from the palatal mucosa. a first layer, the grafted bone.

Fig 1e The reflected buccal flap ensures 2-layer coverage of

the augmented area.

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OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF The International Journal of Oral & Maxillofacial Implants 417
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
KHOURY/HAPPE

patients were heavy smokers, and in one instance, REFERENCES

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418 Volume 15, Number 3, 2000 OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.