Received: 12 December 2019 Revised: 8 April 2020 Accepted: 8 April 2020

DOI: 10.1002/cre2.298

ORIGINAL ARTICLE

Anatomic factors influencing dimensions of soft tissue graft

from the hard palate. A clinical study

Khalid N. Said1,2,3 | Areej S. Abu Khalid4 | Fathima F. Farook1,3

1
College of Dentistry, King Saud Bin Abdul
Aziz University for Health Sciences, Riyadh, Abstract
Saudi Arabia Objectives: The aim of the present study was to measure the thickness of the palatal
2
Department of Dental Services, Ministry of
mucosa in a Jordanian (Middle Eastern) population as well as identify possible factors
National Guard-Health Affairs, Riyadh, Saudi
Arabia that may influence the thickness of palatal mucosa.
3
King Abdullah International Medical Research Material and Methods: Sixty period on tally healthy subjects (29 males and 31
Center, Riyadh, Saudi Arabia
4
females) were selected. Fifteen measurement points were defined on the palate. The
Department of Dental and Oral Health, Prince
Sultan Military College of Health Sciences, mucosal thickness in the hard palate was determined by “bone sounding” with a Hu-
Dhahran, Saudi Arabia
Friedy® round periodontal probe.
Correspondence Results: The overall mean thickness of the palatal masticatory mucosa was 3.23 ± 0.47 mm.
Fathima F. Farook, College of Dentistry, King
The mean thickness increased from the gingival margin to a more apical position
Saud Bin Abdul Aziz University for Health
Sciences, PO Box 3660, Riyadh, Saudi Arabia. irrespective of the tooth measured or side of the mouth in the following sequence:
Email: [email protected]
canine, second molar, first premolar, second premolar and lastly, the first molar. No sig-
nificant difference between gender, smoking status, gingival phenotype andsides of the
mouth with the thickness of palatal masticatory mucosa was determined. A significant
difference between palatal shape and palatal gingival thickness was found.
Conclusions: The most appropriate site for graft harvesting is the canine-premolar
area 8-13 mm from the mid-palatal aspect of each respective tooth in a Jordanian
population. Except for the palatal shape, the side of the mouth, smoking, gender or
gingival phenotype does not affect the graft harvest.

Clinical Relevance:
Scientific Rationale for Study: Knowledge on the thickness of the masticatory
mucosa is crucialin making decisions for surgical treatment modality and may affect
surgical outcome. We measured the thickness of the palatal mucosa in a Jordanian
population and identified possible influencing factors.
Principal Findings: The thickness varied according to the teeth and the canine to pre-
molar region was found to be the appropriate donor site.
Practical Implications: This information on safe zone for graft harvest can guide the
periodontist to make appropriate incisions and choose the appropriate location to
obtain a graft of adequate thickness and dimensions.

KEYWORDS

masticatory mucosa, palatal thickness, transgingival probing

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd

462 wileyonlinelibrary.com/journal/cre2 Clin Exp Dent Res. 2020;6:462–469.

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SAID ET AL. 463

1 | I N T RO DU CT I O N Participants with a history of any disease or surgery in the palate

or tuberosity, presence of any dental appliances in the upper arch,
Periodontal plastic surgical techniques have evolved to meet the previous orthodontic treatment, extracted or congenitally missing pre-
esthetic and functional demands of contemporary patients (Koke, molars, using medication that would affect the periodontal soft tissue,
Sander, Heinecke, & Muller, 2003; Yilmaz, Boke, & Ayali, 2015). Sev- malposition, or malalignment of the maxillary posterior teeth and
eral surgical techniques have been proposed to enhance the gingival those who declined participation were excluded. Informed consent
soft tissue volume and appearance (Yilmaz et al., 2015). The most was obtained after explaining the study protocol. The researcher com-
common donor site for soft tissue grafts in the oral cavity is the hard pleted a questionnaire collecting information regarding smoking sta-
palate and tuberosity (Ioannou et al., 2015). Attached keratinized tus, palate anatomy, type of occlusion as well as dental and medical
mucosa, palatal to the maxillary premolars, is used to harvest full- history.
epithelialized free grafts or subepithelial connective tissue grafts for Five vertical lines perpendicular to the gingival margin between
plastic surgery for oral and periodontal soft tissue augmentation pro- the canine and second maxillary molar were defined to determine
cedures (Raetzke, 1985; Seibert, 1983; Sullivan, 1968; Zucchelli 15 standard measurement points for the hard palate (Figure 1). Three
et al., 2020). horizontal lines running parallel to the gingival margin were
The thickness of the soft tissue graft plays an important role in established starting at the mid-palatal aspect of the canine and ending
the survivability of the graft, the healing modality and the clinical out- over the palatal root of the second molar. The distance from the gingi-
come of the mucogingival surgery (Kim & Neiva, 2015). The thickness val margin to the horizontal lines were 3 mm (point a), 8 mm (point b),
of the tissue to be grafted from the donor site is an important factor and 13 mm (point c), respectively. Five points were defined on each
in determining the appropriate treatment method and to predict the of the horizontal lines intersecting with the vertical lines, constituting
prognosis (Cairo, 2017; Stipetic, Hrala, & Celebic, 2005). Knowing the five positions, each located at the level of a tooth position. The first
thickness of the palate would guide the periodontist to make appro- position was determined at the mid-palatal aspect of the canine, sec-
priate incisions and, choose the appropriate location to obtain a graft ond at the mid-palatal aspect of the first premolar, third at the mid-
of adequate thickness and dimensions. Several factors are believed to palatal aspect of the second premolar, fourth over the palatal root of
affect the thickness of the palatal gingiva including age, gender, race,
smoking status, dentition, orthodontic treatment, systemic diseases,
drugs, immunosuppression, and individual variations (Heil et al., 2018;
Khatri et al., 2017; Manjunath, Rana, & Sarkar, 2015; Stipetic
et al., 2005).
Conflicting findings regarding the palatal mucosal thickness has
been reported in literature (Barriviera, Duarte, Januário, Faber, &
Bezerra, 2009; Gupta, Jan, Behal, Mir, & Shafi, 2015; Heil et al., 2018;
Müller, Heinecke, Schaller, & Eger, 2000; Song et al., 2008; Wara-
aswapati, Pitiphat, Chandrapho, Rattanayatikul, & Karimbux, 2001).
To our knowledge, none of the previous studies evaluated
patients from Arab or Mediterranean ethnicities. The lack of informa-
tion on regional differences in the thickness of the palatal masticatory
mucosa prompted us to carry out this study. The objective of the
study was to measure the thickness of the palatal mucosa in a Jorda-
nian (Middle Eastern) population as well as identify possible factors
that may influence the thickness of palatal mucosa.

2 | MATERIALS AND METHODS

The study design was a prospective study. A consecutive sampling

method was used to recruit 60 systemically healthy Jordanian partici-
pants who attended the Periodontics and Oral and Maxillofacial Sur- F I G U R E 1 Measurement points: Five vertical lines perpendicular
gery clinic at the Dental Teaching Center, Jordan University of to the gingival margin between the canine and second maxillary molar
Science and Technology. Participants who had periodontally healthy were defined to determine 15 standard measurement points (marked
in red) in the hard palate. Three horizontal lines running parallel to the
full maxillary dentition (except for third molars) and scheduled for
gingival margin were established starting at the mid-palatal aspect of
anesthetized procedures of the hard palate, were included. The study
the canine and ending over the palatal root of the second molar. The
protocol was approved by the Institutional Review Board of the distances from the gingival margin to the horizontal lines were 3 mm
University. (Point a), 8 mm (Point b), and 13 mm (Point c), respectively
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464 SAID ET AL.

the first molar, fifth over the palatal root of the second molar. Mea- contact) the surface of the mucosa. The probe was then removed
surements were done bilaterally. from the mucosa and the reading recorded at the corresponding site
The hard palate was anesthetized with a spray, followed by an on the diagram.
Octacaine injection with an epinephrine vasoconstrictor (2%) of If any rugae were present in the probing area, the “valley” point
1:100,000. A block injection was administered in the region of the instead of the “hill” point was defined as the measurement site. At
greater palatine foramen with 0.1 ml of anesthetic and in the region such points, the stopper was moved away to enable recording of the
of the incisive foramen with 0.05 ml. The anesthetic was injected thickness. The readings on the probe were approximated to the low-
slowly over 30 s and measurements were taken 10 min later. The est reading when the tissue thickness did not match the probe marks.
mucosal thickness in the hard palate and tuberosity was determined When the measurement was not exactly on the millimeter line of the
by “bone sounding” with a Hu-Friedy® round periodontal probe probe, the value was rounded up to the next half millimeter.
(round with 1 mm increments). Each probe was equipped with a spe- Apart from the above outcome measurement, the records of the
cial stopper (Impla System drill stopper®) originally manufactured for following explanatory variables smoking status, gingival phenotype
an implant 2.0 mm twist drill stabilization (Figure 2a). The stopper was (thick and thin phenotypes), palatal shape (high and shallow palate),
modified to stabilize the periodontal probe and to ensure that the and gender were also recorded. For the gingival phenotype, the thick-
probe inserted vertically in the palatal mucosa. The stopper was filled ness of the tissue in the bucco-palatal dimension was taken by
with hard acrylic resin and two rubber stoppers were inserted at the inserting a probe into the mid-buccal sulcus of the respective tooth. If
top and the end of the cylinder. the probe was visible through the tissue it was classified as thin, oth-
In the transverse dimension, the periodontal probe was posi- erwise thick. The palatal shape was reproduced for recording from
tioned with the tine at a right angle to the corresponding gingival mar- alginate impression casted in dental stone. For this, an impression of
gin of each tooth to be measured at the center of the tooth. This each subject was made with irreversible hydrocolloid impression
assured the correct alignment to lines a–c. In the sagittal dimension, material to obtain study casts poured with dental plaster.
an imaginary line was drawn through the tips of the canine cusp and All measurements were performed twice by the same investigator
the lingual cusps of the first and second premolars to create a parallel (intra-rater reliability ICC ≥0.995; p-value <.001). The average of the
line with the measurement points at 3, 8, and 13 mm from the second two measurements was taken as the final measurement for the thick-
premolar. An imaginary line through the mesiolingual cusps of the first ness at each site.
and second molars defined the parallel line for the first and second Analysis was performed using statistical software (SPSS®, version
molars. This was done to establish reproducible palatal points in the 23.0). Mean, median, with SDs of masticatory mucosa thickness in dif-
transverse and sagittal dimensions. ferent measurement points were presented using descriptive statis-
After securing the stopper to the probe, the probe tip was tics. The relation between palatal gingival thickness with other
inserted into the mucosa and forced down to the bone at each mea- variables gender, side, gingival phenotype, smoking, and palatal shape
surement site (Figure 2b). The probe was held perpendicular to the were analyzed using independent t tests. Pearson correlation analysis
palate and the angulation was confirmed by keeping the stopper wing was performed to see the relation between mean palatal thickness at
parallel to and as close as possible to (most of the time in direct the left and right sides. Statistical hypotheses tests were two-tailed
comparisons and the criteria for statistical significance were accepted
at the probability level p < .05.

3 | RE SU LT

Gender was equally distributed in the sample (n = 60) with 90%

nonsmokers.

3.1 | Palatal gingival thickness per site and tooth

F I G U R E 2 (a) Probe with stopper: view of the Hu-Friedy® The mean thickness of the masticatory mucosa at each measurement
periodontal probe with the stopper in place. Note that the stopper point is presented in Table 1. The mean thickness increased from
does not slip even if held upside down. This assures that the point a through to Point c irrespective of the tooth measured or side
measurement taken stays accurate when removed from the patient's of the mouth. The thickest areas were 13 mm from the mid-palatal
mouth. (b) Sounding technique: the probe inserted into the palatal
aspect of the following teeth in a decreasing order: upper second
gingival mucosa 3 mm from the gingival margin with the stopper
molar, upper first premolar, upper second premolar, upper canine, and
adjusted into position. Note that the long axis of the probe is
perpendicular to the palate and the horizontal wing of the stopper is finally the upper first molar (Table 1). At 3 mm from the mid-palatal
in direct contact with the mucosa aspect of the corresponding teeth, gingival thickness was highest at
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SAID ET AL. 465

TABLE 1 Tooth-wise comparison of

Tooth a b c Range (min–max) Average
thickness of palatal mucosa at Points a, b,
and c Canine 2.51 ± 0.56 3.75 ± 0.65 4.07 ± 0.56 2.0–5.0 3.44 ± 0.52
First premolar 2.15 ± 0.47 3.43 ± 0.70 4.29 ± 0.76 2.0–5.3 3.29 ± 052
Second premolar 2.17 ± 0.49 3.36 ± 0.85 4.25 ± 0.73 2.0–5.2 3.26 ± 0.54
First molar 1.82 ± 0.61 2.38 ± 0.73 4.01 ± 1.24 1.3–5.5 2.74 ± 0.63
Second molar 2.22 ± 0.91 2.74 ± 1.03 5.29 ± 1.29 1.2–6.5 3.41 ± 0.82
Range (min–max) 1.1–4.4 1.6–5.3 2.0–7.1 – –
Average 2.18 ± 0.41 3.15 ± 0.59 4.38 ± 0.67 – 3.23 ± 0.47

Note: The measurement points reflect the distances from the gingival margin to the horizontal lines: Point a at 3 mm, Point b at 8 mm, and Point c at
13 mm from the gingival margin.

TABLE 2 Mean thickness of palatal mucosa with SDs with

respect to gender, smoking status, gingival phenotype, and palatal
shape

Variable Categories Mean ± SD (mm) p-Value

Gender Male 3.22 ± 0.43 .85
Female 3.24 ± 0.52
Smoking status Smoker 3.14 ± 0.47 .61
Nonsmoker 3.24 ± 0.48
Gingival phenotype Thick 3.30 ± 0.50 .07
Thin 3.06 ± 0.50
Palatal shape High-narrow 3.33 ± 0.46 .03
Wide-shallow 3.06 ± 0.46
F I G U R E 3 Relationship of the thickness of the mucosa (mm) at
the measurement Points a, b, and c of right and left sides of the
canine (C), first premolar (PM1), second premolar (PM2), first molar
(M1), and second molar (M2) difference was found between the right and left side readings except
between the right and left canines at Points a (p = −.01) and
b (p = .04).
the canine site and lowest at the first molar area (Table 1). A similar Evaluating the correlation of the palatal gingival thickness of the
trend was found at 8 mm from the gingival margin but with a much right and left sides per tooth using a t-test, a significant correlation
sharper reduction at the first molar area and an increase in the first was found for all teeth (p < .01) and no significant difference (p = .12)
molar area close to the level of the thickness in the second premolar was found except for the canine (p < .01) and the first premolar
area (Table 1). At 13 mm, the thickness increased from the canine pos- (p = .03). Overall, the mean thicknesses of palatal gingiva in the right
teriorly, almost plateaued at the premolar area, and reduced only side (3.22 ± 0.51 mm) and in the left side (3.29 ± 0.50 mm).
slightly at the first molar area. The highest reading was measured at
the second molar area, which was significantly different to all the
other readings (Table 1 and Figure 3). The mean thickness of the pala- 3.3 | Palatal gingival thickness and smoking/
tal mucosa descends in the following sequence: canine, second molar, gender
first premolar, second premolar and lastly, the first molar.
No significant association was found between gender, smoking status
with gingival thickness regardless of the teeth and the measurement
3.2 | Palatal gingival thickness on the right and left points (Table 2).
sides

The graph in Figure 3 reflects the close association between the data 3.4 | Palatal gingival thickness and gingival
curvatures from both sides of the palate, showing a pattern of symme- phenotype
try of bilateral readings at each point (a, b, and c). There was a signifi-
cant positive correlation for the mean palatal thickness between the With regard to gingival phenotype, 66.7% of the sample consisted of
right and left Point a, b, and c pairs except for the first premolars thick, less scalloped gingival phenotypes with 33.3% consisting of thin,
(p = .11) and the second premolars (p = .06) at Point a. No significant more scalloped gingival phenotypes.
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466 SAID ET AL.

No significant difference was found between gingival phenotype upper second molar. However, due to the close proximity of the
and palatal gingival thickness (p = .07). However, at each measure- greater palatine neurovascular bundle, this site is not a suitable donor
ment site, a significant difference was found between gingival pheno- site since most of the complications are associated with the underesti-
type and palatal thickness in the following points at 13 mm from the mation of anatomic structures, such as the greater palatine artery
gingival margin: upper right canine (p = .04), upper right first premolar (GPA; Tavelli, Barootchi, Ravidà, Oh, & Wang, 2019). The thinnest
(p < .01), upper right second premolar (p = .02), upper left canine mucosa in the hard palate is in the region of the upper first molar,
(p = .01), and the upper left first premolar (p = .002). which can be explained by the position and curvature of the palatal
root of the maxillary first molar excluding the site as a possible donor
site. It is not advisable to harvest soft tissue grafts beyond this struc-
3.5 | Palatal gingival thickness and palatal shape ture to avoid increasing the risk of accidental damage to the GPA or
its branches.
With regard to the maxillary palatal shape, 63.3% of the sample Our study revealed that the thickest mucosa is within 8–13 mm
exhibited a narrow, high palate, with 36.7% exhibiting a wide, shallow from the gingival margin in the region of the upper second molar
palate. A significant difference between palatal shape and palatal gin- followed by the canine and then the premolar. The findings of this
gival thickness was found (p = .03; Table 2). study is on par with previous literature, reporting that the palatal side
of the maxillary first molar has the thinnest overlying mucosa and rec-
ommending the canine-premolar area for graft harvesting because the
4 | DISCUSSION mucosa is the thickest in the hard palate region (Müller, Schaller,
Eger, & Heinecke, 2000; Stipetic et al., 2005; Studer, Allen, Rees, &
The majority of the sample (91.4%) was between 13 and 30 years old, Kouba, 1997; Wara-aswapati et al., 2001).
which is the most frequent age group for mucogingival surgeries Several harvesting approaches have been proposed for soft tissue
(Moura et al., 2017; Zucchelli & De Sanctis, 2000). Half of the sample grafts such as trap-door, epithelialized gingival graft, split thickness,
was female, all were systemically healthy and 90% were nonsmokers de-epithelialized techniques, single incision, parallel incision, and many
(Table 1). Our exclusion criteria ensured minimal effects of potentially others. And different thicknesses have been suggested for the various
confounding factors of the palatal thickness. Based on literature, the grafting procedures. A few of the optimal thickness of palatal mucosa
thickness of masticatory mucosa has been evaluated by invasive and required for various grafting procedures demonstrated by different
noninvasive methods, such as using injection needles or probes studies are: 0.9 mm (James & McFall Jr, 1978), 2.0 mm (Miller, 1982),
(Claffey & Shanley, 1986; Goaslind, Robertson, Mahan, Morrison, & 1.5–2.0 mm (Goldman, Isenberg, & Shuman, 1976; Goldman
Olson, 1977; Olssoin, Lindhe, & Marinello, 1993; Pendleton, 1934), et al., 1976; James & McFall Jr, 1978; Miller, 1982), 1.0–1.5 mm(May-
histologic sections (Anderegg, Metzler, & Nicoll, 1995), cephalometric nard, 1977), and 0.8–1.3 mm (Soehren, Allen, Cutright, &
radiographs (Östlund, 1958), and ultrasonic devices (Baldi et al., 1999; Seibert, 1973). A free palatal graft of 0.9 mm thickness proved to be
Daly, 1971; Jan, 1987; Lytle, 1957; Terakura, 1986; Uchida, functionally sufficient regardless of whether they healed on denuded
Kobayashi, & Nagao, 1989). The ultrasonographic method of assessing alveolar bone or a periosteal bed (James & McFall Jr, 1978). The ideal
gingival thickness has several disadvantages (Daly, 1971), including thickness of the graft should be 1–1.5 mm thick. However, regardless
the relative unavailability of the instrument, difficulty in maintaining of the palatal harvesting approach, it can be recommended that
the directionality of the transducer, and (Eger, Müller, & 8–13 mm from the gingival margin at the canine-premolar area is the
Heinecke, 1996) non-reliable results when the thickness of gingiva most suitable area for the graft harvest.
exceeds 2–2.5 mm (Vandana & Savitha, 2005). Our mean thickness was 3.23 ± 0.46 mm, which is higher than
To overcome these disadvantages, “bone sounding” was used in findings from previous studies (Müller, Heinecke, et al., 2000; Studer
the current study. However, measurements of palatal thickness using et al., 1997; Wara-aswapati et al., 2001). The difference could be
bone sounding could be inaccurate due to the added thickness caused attributed to differences in race, thickness of the sub mucosa or the
by the anesthetic solution. Necessary precautions were taken to mini- method of measurement. Palatal gingival thickness can be under-
mize this unintended volume increase by using a minimal amount of estimated due to unavoidable compression of the mucosa with the
anesthetic solution, slow injection, waiting for a minimum of 10 min  c, & d'Hoedt, 2002) and the den-
ultrasound probe tip (Schulze, Curi
after injections before probing and by giving block injections in the tures in edentulous patients (Uchida et al., 1989). Shculze et al. com-
incisive papilla and greater palatine foramina (Müller, Schaller, & pared the measurements obtained by an ultrasonic device with needle
Eger, 1999). We used a stopper that was designed to assure the cor- probing (Schulze et al., 2002). Our findings are similar to those
rect positioning of the probe perpendicular to the evaluation point at obtained by the latter method only in the molar region. The measure-
the palate and exact probe readings after removal from the tissue ments reported by Uchida et al. (1989) using an ultrasonic device are
since the stopper does not slide on the probe due to the cylinder fill similar to the current study at the 13 mm points in the molar and pre-
(acrylic fill and rubber stoppers). molar areas.
The assessment of potential donor sites in the palate revealed There was no significant relation between gender and palatal gin-
that the thickest mucosa was 13 mm from the gingival margin of the gival thickness in our study. However, females showed a slightly
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SAID ET AL. 467

higher mean thickness than the males. Our results are in agreement that type of soft tissue graft (either FGG or subepithelial connective
with two studies that used a bone sounding technique (Studer tissue graft) may have a different effect on the vascular injury of the
et al., 1997; Wara-aswapati et al., 2001). However, Wara-aswapati palate (Tavelli et al., 2020).
et al. reported a slightly lower mean thickness for the females com- According to Brasher et al. (1975), grafts that are too thin fail to
pared to the males, which was not significant. The authors used a produce an adequately increased zone of keratinized gingival and if
comparable sample size and the same number of measurement points too thick, it will result in an exaggerated tissue profile in the area. An
but at slightly different distances from the gingival margin. Our study average thickness of 1 mm was suggested as an acceptable thickness
is in contrast to several previous studies reporting a thinner mucosa (Brasher et al., 1975). For thin grafts when 1 mm is an adequate donor
for females compared to males. The difference with the Ostlund study tissue thickness, the entire area from the canine to the second premo-
might be explained by the differences in sites chosen for measure- lar is a potential donor site. However, when thicker connective tissue
ment, measurement techniques or measurement error as the study grafts are required, any region between the canine and second premo-
was conducted with edentulous patients who may have been wearing lar could be used as donor graft tissue, if it is more than 8 mm from
dentures, which could have an influence on gingival thickness the gingival margin. The measurements at the 3 mm site for the
(Östlund, 1958). Menopause and aging atrophy are important factors canine-premolar region consist of connective tissue and epithelium,
causing ridge reduction (Lammie, 1956). Overall, the differences although above 2 mm.
between this study and others could be attributed to the lack of unifi- Our finding suggests that the area of the canine and premolars
cation in the selection criteria, method of measurement, type of mea- 8–13 mm from the gingival margin is the best site for harvesting pala-
suring device, sample size, and selected measurement sites and tal soft tissue grafts with less risk of endangering the greater palatine
different significance levels (Müller et al., 1999; Müller, Heinecke, bundle but with an absolute risk of an aesthetic unacceptable out-
et al., 2000; Östlund, 1958; Seibert, 1983; Stipetic et al., 2005; come particularly in free gingival grafts due to presence of the rugae.
Vandana & Savitha, 2005). However, clinicians should be cautious when involving the canine
No significant difference (p = .61) was found between smoking since the branches of the GPA tend to become more coronal due to
status and gingival thickness. Smokers represented only 10.3% of our variations in the topography of the GPA (Yu et al., 2014). Although
subjects. Our findings are consistent with those of Müller, Schaller, the thickest area is adjacent to the upper second molar, the presence
et al. (2000) who reported the same results using clinical parameters. of glandular tissue at this site and the fact that 13 mm from this tooth
A higher epithelial thickness histologically was observed in smokers is close to the soft palate posteriorly as well as the greater palatine
independent of the gingival health (Villar & de Lima, 2003). This may foramen, which could endanger the vessels arising from there. This,
be due to an actual lack of a relationship or due to the small sample together with the position and curvature of the palatal root of the
size of smokers (10.3%) in our study. upper first molar, limits the possible graft donation to the area
Our study showed no significant difference (p = .12) between the beyond 9 mm.
right and left sides of the mouth which was also reported by Uchida However, due to the close proximity of the greater palatine neu-
et al. (1989). The symmetry facilitates surgical decision making, rovascular bundle, this site is not a suitable donor site. The thinnest
irrespective of the sides. mucosa in the hard palate is in the region of the upper first molar,
No significant difference was found between gingival phenotype which can be explained by the position and curvature of the palatal
and palatal gingival thickness (p = .07). This is not in accordance with root of the maxillary first molar excluding the site as a possible donor
the results found by Müller, Schaller, et al. (2000), but may be due to a site. It is not advisable to harvest soft tissue grafts beyond this struc-
different classification of gingival phenotype and different measure- ture to avoid increasing the risk of accidental damage to the GPA or
ment points as they included the mandible. A unified classification for its branches.
gingival phenotype is not yet available to enable comparable analysis.
A significant difference between palatal shape and palatal gingi-
val thickness was found (p = .03). Jaws with high-narrow palates 5 | CONC LU SION
showed a significantly higher (p = .03) mean palatal gingival thick-
ness (3.33 ± 0.46 mm) compared to jaws with wide, shallow palates Within the limitations of this study, it can be concluded that the possi-
(3.06 ± 0.46 mm). However, this method of visual assessment is ble most appropriate site for graft harvesting is the canine-premolar
subjective. area 8–13 mm from the mid-palatal aspect of each respective tooth in
Recommendations have been suggested for specific palatal loca- a Jordanian population. However, beyond 13 mm from the gingival
tions to harvest donor graft tissue from the site closest to the tooth margin at the distal aspect of the second premolar, there is an
to any area extending between the distal of the second molar and the increased risk due to the presence of greater palatine neurovascular
canine or even up to the lateral incisor. These recommendations were bundle. The side of the mouth, smoking, gender, or gingival phenotype
based on uniformity of the thickness, vessels emergence, width and does not affect the graft harvest. Further studies are required to
thickness of the gingiva, and the amount of sub mucosa (Brasher, explore the potential risks of harvesting soft tissue grafts from areas
Rees, & Boyce, 1975; Soehren et al., 1973). It should also be noted deeper in the palate.
 20574347, 2020, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cre2.298, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
468 SAID ET AL.

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