Accepted Manuscript

What is the Safety Zone for palatal soft tissue graft harvesting based upon the
locations of the Greater Palatine Artery and Foramen? A systematic review

Lorenzo Tavelli, DDS, Shayan Barootchi, DMD, Andrea Ravidà, DDS, MS, Tae-Ju
Oh, DDS, MS, Hom-Lay Wang, DDS, MS, PhD

PII: S0278-2391(18)31114-5
DOI: 10.1016/j.joms.2018.10.002
Reference: YJOMS 58487

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 8 June 2018

Revised Date: 1 October 2018
Accepted Date: 1 October 2018

Please cite this article as: Tavelli L, Barootchi S, Ravidà A, Oh T-J, Wang H-L, What is the Safety
Zone for palatal soft tissue graft harvesting based upon the locations of the Greater Palatine Artery
and Foramen? A systematic review, Journal of Oral and Maxillofacial Surgery (2018), doi: https://
doi.org/10.1016/j.joms.2018.10.002.

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 ACCEPTED MANUSCRIPT
What is the Safety Zone for palatal soft tissue graft harvesting
based upon the locations of the Greater Palatine Artery and
Foramen? A systematic review
Lorenzo Tavelli, DDS *, Shayan Barootchi, DMD *, Andrea Ravidà, DDS, MS *, Tae-Ju Oh,
DDS, MS**, Hom-Lay Wang, DDS, MS, PhD ***

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* Resident, Department of Periodontics & Oral Medicine, University of Michigan School of

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Dentistry, Ann Arbor, MI, USA
** Professor, Department of Periodontics & Oral Medicine, University of Michigan School

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of Dentistry, Ann Arbor, MI, USA
*** Professor and Director of Graduate Periodontics, Department of Periodontics & Oral
Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA

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Corresponding author:
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Lorenzo Tavelli, DDS

Department of Periodontics and Oral Medicine
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University of Michigan School of Dentistry

1011 North University Avenue
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Ann Arbor, Michigan 48109-1078, USA.

TEL: +1 (734) 604-4364
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E-mail address: tavelli@umich.edu

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Word count:
Tables and figures: 2 tables, 4 figures
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Running title: Safety zone for palatal soft tissue graft harvesting
Key words: artery, palate, connective tissue, free gingival graft

Conflict of interest and source of funding: The authors do not have any financial interests,
either directly or indirectly, in the products or information listed in the paper. This paper was
partially supported by the University of Michigan Periodontal Graduate Student Research
Fund.
 ACCEPTED MANUSCRIPT
ABSTRACT

Objective: Palatal soft tissue graft harvesting is a common procedure in periodontal and implant

dentistry. However, most of the complications following this procedure are associated with the

underestimation of anatomical structures, such as the greater palatine artery (GPA). Therefore, the

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aim of the present study was to provide guidelines for a safety palatal harvesting.

Material and Methods: A systematic searching was conducted to identify cadaver and CBCT/CT

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studies assessing the location of the greater palatine foramen (GPF) and the path of the GPA in

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relation to the maxillary teeth. The effect of age, sex, cadaver or CBCT/CT studies on the location

of the GPF and on the course of GPA was also assessed.

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Results: Twenty-six studies, investigating 5768 hemipalates were included in the present
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systematic review. The most common location of the GPF was in the mid-palatal aspect of the third

molar (57.08%). As it traverses the palate anteriorly, the distance from the GPA to the maxillary
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teeth gradually decreases, except in the second premolar region where it has the tendency to

increase (13.8 ± 2.1 mm). The least distance from the GPA to the teeth was found in the canine area
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(9.9 ± 2.9 mm), while the greatest distance was in the second molar region (13.9 ± 1 mm). A safety
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zone for palatal harvesting was proposed based on the anatomical findings.
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Conclusions: The present study provides guidelines for identifying the position of the GPF and

defines a safety zone for harvesting an FGG/CTG, minimizing the risk of GPA injury.
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INTRODUCTION

Free gingival graft (FGG) harvesting from the palate was initially proposed by Nabers for

increasing the vestibular depth [1]. This technique was later modified by Sullivan & Atkins for

treating gingival recessions (GRs) [2]. The introduction of FGG has provided a reliable approach

for re-establishing or increasing the keratinized tissue width around teeth and implants, augmenting

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gingival thickness, treating single or multiple GRs, and deepening the vestibulum [3]. FGGs have

been extensively investigated, not only for their clinical outcomes, but also in regard to their

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healing. Clinical and histologic studies have been conducted to explain the mechanisms related to

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the revascularization and integration of the recipient bed, as well as factors that can influence its

success or shrinkage, such as thickness, the amount of connective tissue, and the nature of the

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recipient site (whether periosteum or denuded bone) [4-6].
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In the last decades, there has been an upward trend in replacing the FGG with the connective tissue

graft (CTG) for treating GRs, increasing soft tissue volume, masking discolored roots, crown
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margins or implants [3]. Indeed, better esthetic results, complete flap closure, healing of the donor

site by primary intention, are among the advantages that can been attributed to a CTG [3].
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Besides the advantages provided by soft tissue grafts, either FGG or CTG, palatal harvesting
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techniques present a crucial part of a procedure, as they are soundly correlated to patient morbidity,
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graft quality, and bleeding control. Thus, several harvesting approaches have been proposed,

including the trap-door, parallel incision, single-incision, epithelialized gingival graft techniques
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and many others. The superiority of any approach to the other remains controversial, as it has been
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demonstrated that the post-operative morbidity accompanied with secondary intention healing

(typical of the epithelialized gingival graft harvesting approach) can be efficiently minimized [7].

However, regardless of the palatal harvesting approach, prolonged intra- and post-operative

bleeding caused by injury to the palatal vessels, is one of the most common complications of this

procedure [8]. Hence, a thorough knowledge of the anatomy is necessary for reducing the risk of

complications. Indeed, it has been reported that the anatomy of the palatal vault strongly influences
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the risk of damaging the GPA, being on average 7, 12 and 17 mm from the CEJ of maxillary teeth

when the palatal vault is shallow, average and high, respectively [9]. Monnet-Corti et al. found that

the average distance from the GPA to canine and second molars were 12.07 ± 2.9 mm and 14.7 ±

2.9 mm, respectively. [10]. However, data gathered from fabricated casts, and assuming the course

of the GPA, are the major drawbacks of this study design. While the position of the greater palatal

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foramen (GPF), the course of the GPA and its distance from the CEJ of the teeth have been assessed

in several cadaver studies [11-13], there is still no agreement on the definition of a safety palatal

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harvesting zone based from anatomical landmarks that can guide clinicians during this procedure.

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Therefore, the purpose of this study was to define a safety zone for soft tissue graft harvesting by

comparing measurements from cadavers and CBCT/CT studies on the position of the GPF and the

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course of the GPA in relation to the teeth.
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MATERIAL AND METHODS
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Study design

To address the research purpose, the investigators designed and implemented a systematic review
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modeled after the Cochrane Collaboration’s recommendations for systematic reviews.

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The focused question was: “Is it possible to define a safety zone for palatal harvesting based upon
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the location of the greater palatine artery and foramen?”

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Sample identification and selection

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The study population was composed of all publications on GPF and/or GPA anatomy from 1980 to

January 2018. Electronic and manual literature searches, conducted by two independent reviewers

(L.T. and S.B.), covered studies across the National Library of Medicine (MEDLINE by PubMed),

EMBASE, and the Cochrane Oral Health Group Trials Register (Fig. 1). The MEDLINE/PubMed

search was performed on 1/13/2018 using the following strategy:

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• (greater[All Fields] AND palatine[All Fields] AND ("arteries"[MeSH Terms] OR

"arteries"[All Fields] OR "artery"[All Fields])) OR (greater[All Fields] AND palatine[All

Fields] AND foramen[All Fields]) AND English[lang]

The EMBASE search was completed on 1/13/2018 using the following strategy:

• (greater AND palatine AND ('artery'/exp OR artery) OR greater) AND palatine AND

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foramen

The search on the Cochrane Oral Health Group Trials Register was performed on 10/3/2017 using

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the following strategy:

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‘‘Greater palatine artery” [Search All Text] OR ‘‘Greater palatine foramen’’ [Search All

Text]. 


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Additionally, a manual search of related journals, including a complete search of Journal of
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Clinical Periodontology, Journal of Periodontology, International Journal of Periodontics and

Restorative Dentistry was also performed.

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Cadaver and cone beam computed tomography (CBCT)/ computed tomography(CT) studies were
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included if they analyzed at least one of the following outcomes: 1) distance between the CEJ of the
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maxillary teeth and GPA, 2) distance from the GPF to the mid sagittal suture, 3) distance between

the GPF and interincisive foramen, 4) distance between GPF and the posterior border of the hard
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palate, 5) position of the GPF in relation to the maxillary molars, 6) diameter of the GPF and GPA.

Contrarily, articles were to be excluded if: 1) cadaver or CBCT/CT studies not reporting
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measurements on GPA or GPF; 2) case report.

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Studies were initially screening by reading titles and abstracts. The definitive stage of screening

involved full-text examination using a predetermined data extraction form to confirm the eligibility

of each study. In all of the mentioned steps, data was independently extracted by two review

authors (L.T. and S.B.). When clinical data was lacking, authors were contacted. At each stage,

disagreement between reviewers was resolved through discussion and consensus. If a disagreement

persisted, the judgment of a third reviewer (A.R.) was decisive.

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Study Variables

The primary variables were the location of the GPF in relation to the teeth and the apico-coronal

distance from the path of the GPA to the CEJ of the teeth.

The secondary variables were: a) the distance between GPF and the interincisive foramen, posterior

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border of the mandible and the mid sagittal suture, and b) diameters of the GPF and GPA.

The third variables were the age, sex and study design (skulls vs CBCT/CT) and their effect on the

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outcomes.

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Data collection, management, and analyses

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Studies were excluded by screening titles and abstracts and full-text reading by two investigators
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(L.T., S.B.) using a predetermined data extraction form to confirm the eligibility of each study

based on the aforementioned criteria. The same two authors independently extracted data from the
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included articles. At each stage, disagreement between reviewers was resolved through discussion

and consensus. If a disagreement persisted, the judgment of a third reviewer (A.R.) was decisive.
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Weighted means and standard deviation were calculated based on the sample size of each included
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study (the number of hemipalates). Differences between the computed values for males and
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females, measurements from CBCTs or direct cadaveric measurements were also compared with t-

tests, at a significance level of 0.05. All statistical analyses were performed using the Rstudio
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software (Rstudio Version 1.1.383, Rstudio, Inc., Massachusettes, USA).

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RESULTS

Study selection and characteristics

Search results based on the PRISMA guidelines are depicted in figure 1. Twenty-six studies,

investigating 5768 hemipalates were included in the present systematic review [11-36]. Twenty-two

studies were direct measurements on cadavers/skulls [11-14, 16-20, 22-30, 32-34, 36], 3 were based
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on CBCT/CT studies [15, 21, 35], and in 1 study data from cadaver measurement and CTs were

combined [31]. Among the investigated palates, majority belonged to Caucasians (35.4%), followed

by Indians (28.6%), and Asian (11.1%) (Table 1).

Nine-teen studies described the distance between the GPF and the mid sagittal suture [14-19, 21,

23-34], 4 studies reported the distance between the GPA and the CEJ of maxillary teeth [11-13, 36],

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and 8 studies assessed the distance between the GPF and the interincisive foramen [16, 17, 19, 23,

28, 29, 31, 32]. The distance between GPF and posterior border of the hard palate was evaluated by

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14 studies [14, 16, 17, 19, 23, 25-29, 31-34], the position of the GPF itself was investigated by 19

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articles [12, 14-18, 20, 22-30, 33-35], while the diameter of the GPF and the GPA was described in

7 studies [13, 16, 21, 22, 26, 27, 29].

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Location of the Greater Palatine Foramen (GPF)

The location of the GPF was estimated to be in the mid-palatal side of the third molar in the 57.1%
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of the cases, between the second and third molar in 21.3%, and distal to the third molar in 13.5% of

the cases. Table 2 depicts the frequency of the position of the GPF in relation to the maxillary teeth.
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On average, the distance between the GPF and the interincisive foramen was 35.8 ± 3.4 mm, while
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the GPF was 3.8 ± 1.2 and 15.2 ± 1.3 mm from the posterior border of the hard palate and the MSS,
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respectively (Fig. 2). No significant differences were found between males and females for the

distance between the GPF and the mid sagittal suture (16.1 vs. 15.5 mm) and the study design
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(skulls vs. CBCT/CT) (14.6 vs. 15.4 mm) (p>0.05).

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Course of the Greater Palatine Artery (GPA)

The distance from the GPA to the CEJ of the maxillary teeth was calculated to be the following:

13.9 ± 1 mm to the second molars (M2), 13.0 ± 2.4 mm to the first molars (M1), 13.8 ± 2.1 mm,

and 11.8 ± 2.2 mm to the second (P2), and first premolars (P1), respectively, and 9.9 ± 2.9 mm to

the canine (C) (Fig. 3).

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Diameter of the Greater Palatine Foramen (GPF) and Artery (GPA)

The mean antero-posterior opening of the GPF was 4.1 ± 1.2 mm, while its mediolateral diameter

was estimated at 2.8 ± 0.8 mm. The diameter of the GPA in the second and first molars was

approximately 1.2 ± 0.3 mm, and 1.3 ± 0.4 mm, respectively. While 1.2 ± 0.4 mm, 0.8 ± 1.1 mm,

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and 0.8 ± 0.4 mm in relation to the P2, P1 and C teeth.

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Definition of a safety zone

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If a distance of 2 mm from the CEJ (that corresponds to the gingival margin in healthy

periodontium) is considered to be the physiologic biologic width [37], a safety zone for harvesting a

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FGG/CTG is determined by subtracting the standard deviation (SD) of the mean from the mean
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value itself (average distance from the CEJ to the GPA for each tooth) (Fig. 4).

The reason for subtraction of the standard deviation as well, was to reduce the possibility of injury
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to the vessel as much as possible, hence the term safety zone (SZ):

 () = 
ℎ    
  from the GPA − SD − 2
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DISCUSSION

Bleeding and paresthesia are the most common complications described after palatal soft tissue
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graft harvesting [38, 39]. The best precaution for minimizing the risk of complications is to be
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aware of anatomic structures [9]. Guidelines of palatal harvesting for avoiding the neurovascular

structures have previously been proposed; however, due to the limited sample size [22], the

assumption of the course of the palatal artery [10], and the nature of the article itself (expert

opinion) [9], a strong evidence-based definition of a safety zone for palatal harvesting is lacking.

Therefore, the purpose of the present article was to provide a definition of safety soft tissue graft

harvesting area based upon the position of the GPF and GPA.
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Our results showed that the GPA traverses the palate anteriorly, while approximating the maxillary

teeth, except in the first molar region where its distance (13 ± 2.4 mm) is smaller than the distance

to the second molar and to the second premolar (13.9 ± 1 and 13.8 ± 2.1 mm, respectively).

Interestingly, a similar pattern has been described in the literature for palatal mucosal thickness [40,

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41].

Age, gender, and population characteristics have been reported as factors that can affect the

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thickness of the palatal mucosa [40]. However, in the present study, we found a lack of a

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statistically significant correlation between these parameters and the distance of the GPF from the

landmark structures (mid sagittal suture, interincisive foramen and the posterior border of the hard

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palate). Nevertheless, these results should be interpreted with caution since the samples included in
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the present review were not homogeneous among the populations and only few studies reported

results specific for males and females [15, 19, 21, 24, 25, 31]. In addition, in agreement with a
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previous study, no differences were found when direct measurements in cadavers and CBCT/CT

results were compared [31].

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As reported by Tomaszewska et al., anatomical landmarks are essential tools for identifying the
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position of the GPF [31]. In this view, the present study contributes to the literature by providing
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the approximate location of the GPF based on its distance from the mid sagittal suture, interincisive

foramen and the posterior border of the hard palate. Although anatomical variability among subjects
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must be considered, the results of this study are supported by a total sample size of 5768
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hemipalates. In agreement with a previous systematic review [31], our results confirmed that the

most common location of the GPF is in the mid-palatal aspect of the third molar (57.1%), followed

by between the second and third molars (21.3%) and distal of the third molars (13.5%).

Nevertheless, palpation of the posterior palate should always be performed for identifying the

position of the GPF and the course of GPA. It has been reported that the artery is commonly at the

junction between the horizontal plate of the maxilla and the maxillary alveolar ridge [12]. In
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addition, in a cadaver study, Benninger et al. showed that the GPA runs in close proximity to the

greater palatine crest, which is prominent and can be palpated in most cases [11]. Fu et al. based on

fabricated study models, reported that the location of the GPF was underestimated up to 4 mm when

20 examiners were asked to estimate this anatomical landmark. This could reduce the chances of

injury to the vessel but also, limit the amount of CTG that can be harvested [12]. This highlights the

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flaw in the study design of Monnet-Corti et al. who estimated the mean distance of the GPA from

the CEJ of the second molar and the canines using only cast models [10].

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Recently, the use of ultrasound or magnetic resonance imaging for identifying the position of the

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GPF has been proposed [42, 43]. However, these methods do not seem practical in the daily

practice. By using the CEJ of the maxillary teeth as landmarks, the present study provides a safety

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zone that should minimize the risk of damaging the GPA during the harvesting procedures. Indeed,
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the safety zone takes into account not only the mean distance from the GPA to the CEJ of the teeth,

but also the calculated standard deviation. According to our results, the safety zone is greater at the
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M2 and P2 area, while it is significantly smaller at the P1 and C area. In agreement with our

findings, harvesting anterior to the distal of the canines is generally discouraged [10].
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Despite traditional beliefs of the palatal root of the first molar being the distal limit for harvesting a
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FGG/CTG [10, 40], the present study shows that extending the harvesting zone to the second molar
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can be safe if the graft height is within the proposed safety zone. However, it should be noted that

the diameter of the GPA was found to be widest at the molar areas, while gradually reducing in
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width when reaching anterior areas. This may explain the reason why several authors have
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suggested limiting the harvesting sites to the mesial aspect of the first molars [10, 22], where the

palatal mucosa is also thinner and less suited for the harvesting [41].

According to Monnet-Corti et al., a palatal harvesting of 8 mm in height, without damaging the

GPA was possible in almost all cases (93%) [10]; however, our study showed that this statement is

only valid for the posterior palate (from the second premolars to the second molars), and not in the
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anterior region of the palate where the graft height is reduced (7.6 and 5 mm for first premolar and

canine, respectively).

Regardless of the precautions for avoiding injury to the palatal vessels, hemorrhages do occur. A

possible explanation can be the different patterns of the GPA; types III and IV, as defined by Yu et

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al., run closer to the CEJ, and thus are associated with higher risk of GPA injury and bleeding than

the most common pattern (type I) where the lateral branch of the GPA runs anteriorly, giving off a

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medial and a canine branch in the proximity of the canine area [44]. According to Greenstein et al.

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deep sutures distal to the harvesting site before initiating the surgery should always be performed to

reduce the hemorrhage in the case of injury to the GPA[45]. If severe bleeding does occur,

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clinicians should apply pressure on the wound and use local anesthetic with vasoconstrictor. In case
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of persistent hemorrhage, deep sutures ligating the artery or electrocauterization should be

attempted [45].
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Among the limitations of the present study, 4 different patterns of the GPA described in the
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literature [44] could have influenced the measurements in the included studies. Also, despite the
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correlation of the height of the palatal vault to the GPA [9, 11], data on this aspect was not available
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in the examined articles. Moreover, a larger sample size of studies reporting on the measurements

of males and females may reveal a remarkable difference for each gender classification. Lastly, the
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proposed safety zone, (calculated from the CEJ of the maxillary teeth to the GPA) includes 2 mm of
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presumed distance from the gingival margin to the CEJ; this represents an ideal scenario where

patients are periodontally healthy without clinical attachment loss. However, in patients with

attachment loss on the palatal side or in edentulous patients, the proposed safety zone may not be

valid and other landmarks, such as crest prominence, mid sagittal suture, interincisive foramen and

the posterior border of the hard palate, should be used for identifying the position of the GPF and

course of the GPA.

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CONCLUSIONS

Within its limitations, the present study provides landmarks for identifying the position of the GPF

and defines a safety zone for harvesting an FGG/CTG, minimizing the risk of GPA injury.

Inter-individual variability, however, should also be considered when planning a palatal harvesting

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procedure; therefore, clinicians must be prepared in managing possible complications.

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ACKNOWLEDGMENT

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The authors do not have any financial interests, either directly or indirectly, in the products or

information listed in the paper. This paper was partially supported by the University of Michigan

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Periodontal Graduate Student Research Fund.
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All the authors contributed to the manuscript and agreed to the submission.
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FIGURES AND TABLES

Figure 1. PRISMA flowchart.

Figure 2. Schematic drawing representing the location of the GPF (red mark) and its distance from

the interincisive foramen (IF), mid sagittal suture (MSS) and posterior border of the hard palate

(PB).

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Figure 3. Schematic drawing representing the distance between the CEJ of the maxillary teeth (M2,

M1, P2, P1 and C) and the GPA.

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Figure 4. Schematic representation of the safety zone in healthy periodontium. The safety zone was

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determined with respect to the average distance between the CEJ of each tooth and the GPA, its

standard deviation and 2 mm for the gingival margin.

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Table 1. Characteristics of the included studies.
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Table 2. Location of the GPF in relation to the maxillary teeth.
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Table 1. Characteristics of the included studies

Sample
Article Study design Population
(hemipalates)
Ajmani 1993 [14] Cadaver African and Indian 198
Aoun et al. 2015 [15] CBCT Lebanese 116
Benninger et al. 2012 [11] Cadaver NA 34
Cagimni et al. 2017 [16] Cadaver Anatolian 240
Chrcanovic & Custodio 2010 [17] Cadaver South American 160
D’Souza et al. 2012 [18] Cadaver Indian 80

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Fu et al. 2011 [12] Cadaver NA 21
Gibelli et al. 2017 [19] Cadaver Caucasian 200
Hassanali & Mwaniki 1984 [20] Cadaver African 250

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Ikuta et al. 2013 [21] CBCT South American 100
Kim et al. 2014 [13] Cadaver Asian 43
Klosek et al. 2008 [22] Cadaver Asian 42

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Kumar et al. 2011 [23] Cadaver Indian 200
Langenegger et al. 1983 [24] Cadaver African 100
Methathrathip et al. 2005 [25] Cadaver Asian 320
Nimigean et al. 2013 [26] Cadaver Caucasian 200

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Piagkou et al. 2011 [27] Cadaver Caucasian 142
Saralaya & Nayak 2007 [28] Cadaver Indian 264
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Sharma & Garud 2013 [29] Cadaver Indian 139
Sujatha et al. 2005 [30] Cadaver Indian 138
Tomaszewska et al. 2014 [31] Cadaver and CT Caucasian 1500
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Vidulasri & Thenmozhi 2015 [32] Cadaver Indian 100

Wang et al. 1988 [33] Cadaver Asian 200
Westmoreland & Blanton 1982 [34] Cadaver Indian 600
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Yilmaz et al. 2015 [35] CBCT Turkish 345

Yu et al. 2014 [36] Cadaver Asian 36
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Legend. CBCT: Cone Beam Computed Tomography; CT: Computed Tomography; NA: Not
Available
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Table 2. Location of the Greater Palatine Foramen (GPF) in relation to the maxillary teeth

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Between 1M-2M Mid-palatal aspect of 2M Between 2M-3M Mid-palatal aspect of 3M Distal to 3M

Frequency 0.84 % 6.21 % 21.25% 57.08% 13.54%

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Legend. 1M: first maxillary molar; 2M: second maxillary molar; 3M: third maxillary molar

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