Complications Related to Palatal Graft Harvesting

Analysis of the Complications in Palatal Graft Harvesting With the UPV/EHU Technique vs. Single Incision Technique.

Soft tissue defects can be a problem, especially in patients with high smile lines; in these clinical scenarios, the treatment with periodontal plastic surgery in combination with the use of a connective tissue graft (CTG) is considered the gold-standard procedure.

Single incision technique (Huerzeler & Weng, 1999) is one of the suggested procedures to harvest the CTG from palate. The UPV/EHU technique (Aguirre-Zorzano et al, 2017) showed less inflammation and post-surgical complications than trap-door technique, but also other technique should to be analysed.

However, there is still no consensus about which is the best technique to obtain this kind of graft. Therefore, clinicians should justify their choice based on the tissue's quality obtained and the patient's well-being, producing the least number of complications, such as inflammation, post-surgical pain, or recession in the donor area.

HYPOTHESIS:

Does the technique of obtaining an CTG of the palate using the "UPV/EHU technique" (Aguirre-Zorzano et al., 2017) result in a lower number of complications versus the "single incision technique" (Huerzeler & Weng, 1999)?

OBJECTIVES The main objective is to assess whether the complications occurring with the harvesting of the CTG using the "UPV/EHU technique" (Aguirre-Zorzano et al., 2017) are lower than with the "single incision technique"(Huerzeler & Weng, 1999), knowing the patient's perception of pain.

The secondary objectives are: a) necrosis of the palate, b) possible resulting recession in the donor area, and c) characteristics of the graft obtained

Study Overview

• Status: Enrolling by invitation
• Conditions: Cicatrization
• Intervention / Treatment: Procedure: UPV/EHU technique (Aguirre-Zorzano et al 2017); Procedure: Single incision technique (Huerzeler & Weng 1999)

Detailed Description

Type of Study: randomized clinical trial

Two different treatments (UPV/EHU technique (test) (Aguirre-Zorzano et al. 2017) vs. Single Incision technique (control) (Huerzeler & Weng, 1999)) will be compared. These techniques are usually used to harvest a CTG from the palate.

Main outcome: complications in the donor area.

Follow-up: 6 months.

UNIT OF ANALYSIS: The patient of the Master's Degree in Periodontology and Osseointegration from the University of the Basque Country (UPV/EHU), requires treatment with a CTG harvested from the palate.

SAMPLE SIZE CALCULATION: Using the visual analog pain scale (VAS pain) as the primary response variable, it is estimated that, to find a difference of 1 between test and control, with an SD= 1.26 (Wessel & Tatakis 2008), an alpha risk of 5% and a power of 85%, we would need 29 patients for each treatment group (Domenech and Granero 2010). In addition, taking into account possible dropouts, we would increase the number of patients by 20%, finally recruiting 35 patients per group.

Statistical analysis:

A descriptive study of the sample will be performed, based on moments (mean, standard deviation) if the parameters of normality are met or on ordinations (median and interquartile range), in case the parameters of normality are not met.

Subsequently, analytical statistics will be performed, and in addition, the intensity and duration of post-surgical pain after each surgical technique adjusted for possible confounding factors (clinical level of central sensitization, presence of pre-surgical pain, presence of post-surgical complications, use of added analgesic treatment) will be assessed using logistic regression.

• Study Type: Interventional
• Enrollment (Estimated): 70
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Spain
  • Vizcaya
    • Leioa, Vizcaya, Spain, 48940
      • UPV/EHU

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Patients of the UPV/EHU university dental clinic who required a connective graft of the palate in their treatment.
• Patients ≥ 18 years-old
• Absence of active periodontal disease ( healthy periodontal patients or periodontal patients who had received active periodontal treatment, and now they are included in a tailored supportive periodontal program)
• Full-mouth plaque index (FMPI) (O'Leary y cols. 1972) and full-mouth bleeding index (FMBI) (Ainamo y Bay, 1975) ≤ 25%

Exclusion Criteria:

• Smokers of ≥ 10 cigarettes/day
• Systemic conditions that contraindicated surgery
• The use of analgesic and/or anti-inflammatory drugs in the last 72 h
• The use of opioid drugs, anticonvulsants and/or antidepressants, except selective serotonin inhibitors, i.e., those drugs that act by reducing the painful experience
• Pregnancy or nursing women

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: UPV/EHU technique (Aguirre-Zorzano et al 2017); Harvesting a connective tissue graft from palate by the UPV/EHU technique.	Procedure: UPV/EHU technique (Aguirre-Zorzano et al 2017); The "UPV/EHU technique" (Aguirre-Zorzano et al., 2017) begins with the elevation of the full thickness flap (FTF) in the palate and an intrasulcular incision performed with a number 12 blade, preserving the papillae in the interproximal spaces. Then, the FTF is dissected with a 15c blade, holding the flap with tissue forceps, leaving the epithelium and a thin layer of the connective tissue in the flap, so that the underlying connective tissue can be harvested. After that the flap is sutured.
Active Comparator: Single incision technique (Huerzeler & Weng 1999); Harvesting a connective tissue graft from palate by the single incision technique	Procedure: Single incision technique (Huerzeler & Weng 1999); The CTG is harvested with the single incsion technique described by Huerzeler & Weng in 1999.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Post-surgical pain perception	The subject will we instructed to collect their perception of post-surgical pain in the VAS based on the UPV/EHU Pain diary (Fernandez-Jimenez et al, 2021). Specifically the subject will record: Its intensity (0-100mm), its duration (minutes or hours) and if any analgesic treatment has been necessary (No o Yes: Which?).	After surgery up to 14 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Post-surgical complications	The presence or not, as the description, of the post-surgical complications (PSC) that may appear will be collected.	After surgery first seven days.
Central Sensitization Inventory severity-level score of the subject Central Sensitization inventory (CSI) (Mayer et al. 2012)	Central Sensitization inventory (CSI) (Mayer et al. 2012) will be done, in which each subject will be asked on the frequency in which he perceives 25 symptoms and will be given a score of 0-4 finally establishing a clinical level in a range of 0-100 points (Subclinical: 0-29; Medium: 30-39; Moderate: 40-49 ; Severe: 50-59; Extreme: 60-100).	Baseline
Necrosis of the palate	After using 2 CP-11 periodontal probes by placing them perpendicularly, thus obtaining a measured in the X-axis and another in the Y-axis and multiplying both results, the donor area in mm2 will be obtained. From that point on, it will be possible to determine what degree of necrosis has occurred in the donor area by taking the following values as a reference (Aguirre-Zorzano et al. 2017): Value 0: total absence of necrosis. Value 1 : ≦30% of the donor area. Value 2: ≧ 30% of the donor area.	up to 7 days post-srugery
Gingival recession (REC) in donor area	Distance in mm from the amelocementaria line the gingival margin, measured at the vestibular midpoint. It will be registered in all the teeth present in the donor area at the beginning, and, during the follow-up only in the recessions to be treated	Change from baseline at following surgery sixth month respectively.
Thickness of the donor area of the palate and of the connective tissue graft	measured using 2 CP-11 periodontal probes and placing them perpendicularly, thus creating a measurement in the X axis and another in the Y axis, in order to obtain the area in mm2 of the graft obtained by multiplying both measurements, and placing a file with a rubber stopper in the central area of the graft to measure its thickness.	Surgery
Length of the donor area of the palate and of the obtained CTG(mm)	by positioning a CP-11 periodontal probe parallel to the donor area on the palate, as well as on the connective tissue graft obtained	Surgery
Width of the donor area of the palate and of the obtained CTG (mm)	by positioning a CP-11 periodontal probe perpendicular to the donor area on the palate, as well as on the obtained connective tissue graft.	Surgery
Area (mm2) of the donor area of the palate and of the obtained CTG	: measurement obtained by multiplying the variables length and width of the donor area, as well as of the obtained CTG.	Surgery
Extension of the bed recipient.	The number of teeth or implants will be registered in the bed receipt.	Baseline
Probing depth (PD)	Distance in millimeters from the gingival margin to the bottom of the periodontal pocket. It will be recorded at the beginning in all teeth present (except wisdow teeth) in 6 points per tooth (mesio-bucal, mid-bucal, disto-bucal, mesio-lingual, mid-lingual and disto-lingual) and, during follow-up, only in the recessions to be treated at the vestibular mid-point.	Change from baseline at following surgery sixth month respectively.
Pre-surgical pain perception.	In the VAS based on the UPV/EHU Pain Diary (Fernandez-Jimenez et al 2021) the examiner will record if the subject has had regional head and neck pain in the last month and if there is any pain in the immediate preoperative, if it is affirmative the intensity will be noted	Baseline
Full mouth bleeding index (FMBI) (Aynamo & Bay, 1975)	After a periodontal probing of all teeth, the presence (yes or no) of bleeding is recorded dichotomously at 6 points per tooth (mesio-bucal, mid-bucal, disto-bucal, mesio-lingual, mid-lingual and disto-lingual) and the percentage of sites that bleed from the total of probed sites is calculated (Ainamo and Bay 1975)	Change from baseline at following surgery sixth month respectively.
Full mouth plaque index (FMPI).	A plaque developer is used and the presence (yes or no) of plaque is recorded dichotomously at 6 points per tooth (mesio-bucal, mid-bucal, disto-bucal, mesio-lingual, mid-lingual and disto-lingual) and the percentage of sites with plaque of the total probed sites is calculated (O'Leary et al 1972).	Change from baseline at following surgery sixth month respectively.

Collaborators and Investigators

• Sponsor: University of the Basque Country (UPV/EHU)
• Investigators: Study Director: ANA MARIA GARCIA DE LA FUENTE, PHD, UPV/EHU

Publications and helpful links

General Publications

• Zucchelli G, Mounssif I, Mazzotti C, Montebugnoli L, Sangiorgi M, Mele M, Stefanini M. Does the dimension of the graft influence patient morbidity and root coverage outcomes? A randomized controlled clinical trial. J Clin Periodontol. 2014 Jul;41(7):708-16. doi: 10.1111/jcpe.12256. Epub 2014 May 8.
• Zucchelli G, Mele M, Stefanini M, Mazzotti C, Marzadori M, Montebugnoli L, de Sanctis M. Patient morbidity and root coverage outcome after subepithelial connective tissue and de-epithelialized grafts: a comparative randomized-controlled clinical trial. J Clin Periodontol. 2010 Aug 1;37(8):728-38. doi: 10.1111/j.1600-051X.2010.01550.x. Epub 2010 Jun 24.
• Hurzeler MB, Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Periodontics Restorative Dent. 1999 Jun;19(3):279-87.
• Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures. J Periodontol. 2006 Dec;77(12):2070-9. doi: 10.1902/jop.2006.050296.
• Del Pizzo M, Modica F, Bethaz N, Priotto P, Romagnoli R. The connective tissue graft: a comparative clinical evaluation of wound healing at the palatal donor site. A preliminary study. J Clin Periodontol. 2002 Sep;29(9):848-54. doi: 10.1034/j.1600-051x.2002.290910.x.
• Harris RJ, Miller R, Miller LH, Harris C. Complications with surgical procedures utilizing connective tissue grafts: a follow-up of 500 consecutively treated cases. Int J Periodontics Restorative Dent. 2005 Oct;25(5):449-59.
• Aguirre-Zorzano LA, Garcia-De La Fuente AM, Estefania-Fresco R, Marichalar-Mendia X. Complications of harvesting a connective tissue graft from the palate. A retrospective study and description of a new technique. J Clin Exp Dent. 2017 Dec 1;9(12):e1439-e1445. doi: 10.4317/jced.54337. eCollection 2017 Dec.

Study record dates

Study Major Dates

• Study Start (Actual): December 30, 2023
• Primary Completion (Estimated): December 30, 2025
• Study Completion (Estimated): January 30, 2026

Study Registration Dates

• First Submitted: October 28, 2023
• First Submitted That Met QC Criteria: October 28, 2023
• First Posted (Actual): November 2, 2023

Study Record Updates

• Last Update Posted (Actual): August 7, 2024
• Last Update Submitted That Met QC Criteria: August 6, 2024
• Last Verified: August 1, 2024

More Information

Terms related to this study

• Keywords: pain; connective tissue; palate
• Additional Relevant MeSH Terms: Pathologic Processes; Fibrosis; Cicatrix
• Other Study ID Numbers: 2023_01

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No