What Is the Safety Zone for Palatal Soft

Tissue Graft Harvesting Based on the

Locations of the Greater Palatine
Artery and Foramen? A Systematic
Review
Lorenzo Tavelli, DDS,* Shayan Barootchi, DMD,y Andrea Ravid
a, DDS, MS,z
Tae-Ju Oh, DDS, MS,x and Hom-Lay Wang, DDS, MS, PhDk
Purpose: Palatal soft tissue graft harvesting is a common procedure in periodontal and implant dentistry.
However, most of the complications after this procedure are associated with the underestimation of
anatomic structures, such as the greater palatine artery (GPA). Therefore, the aim of this study was to
provide guidelines for a safety zone for palatal harvesting.
Materials and Methods: A systematic search was conducted to identify cadaveric and computed
tomography (CT) or cone beam CT studies assessing the location of the greater palatine foramen
(GPF) and the path of the GPA in relation to the maxillary teeth. The effect of age, gender, and cadav-
eric and CT or cone beam CT studies on the location of the GPF and on the course of the GPA also was
assessed.
Results: This systematic review included 26 studies, investigating 5,768 hemipalates. The most common
location of the GPF was in the midpalatal aspect of the third molar (57.08%). As it traverses the palate ante-
riorly, the distance from the GPA to the maxillary 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 (9.9  2.9 mm), whereas the greatest distance was in the second molar region
(13.9  1 mm). A safety zone for palatal harvesting was proposed based on the anatomic findings.
Conclusions: This study provides guidelines for identifying the position of the GPF and defines a safety
zone for harvesting a free gingival graft or connective tissue graft, minimizing the risk of GPA injury.
Ó 2018 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 77:271.e1-271.e9, 2019

Free gingival graft (FGG) harvesting from the palate
was initially proposed by Nabers1 for increasing the
vestibular depth. This technique was later modified
by Sullivan and Atkins2 for treating gingival recessions
(GRs). The introduction of FGG has provided a reliable
approach for re-establishing or increasing the kerati-
nized tissue width around teeth and implants, aug-
menting gingival thickness, treating single or
multiple GRs, and deepening the vestibulum.3 FGGs
have been extensively investigated, not only for their

Received from Department of Periodontics and Oral Medicine,
University of Michigan School of Dentistry, Ann Arbor, MI.
*Resident.
yResident.
zResident.
xProfessor.
kProfessor and Director of Graduate Periodontics.
This article was partially supported by the University of Michigan
Periodontal Graduate Student Research Fund.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Tavelli:
Department of Periodontics and Oral Medicine, University of Michi-
gan School of Dentistry, 1011 N University Ave, Ann Arbor, MI
48109-1078; e-mail: tavelli@umich.edu
Received June 8 2018
Accepted October 1 2018
Ó 2018 American Association of Oral and Maxillofacial Surgeons
0278-2391/18/31114-5
https://doi.org/10.1016/j.joms.2018.10.002

271.e1
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271.e2
clinical outcomes but also regarding their healing.
Clinical and histologic studies have been conducted
to explain the mechanisms related to the revasculariza-
tion and integration of the recipient bed, as well as fac-
tors that can influence its success or shrinkage, such as
thickness, the amount of connective tissue, and the
nature of the recipient site (whether periosteum or
denuded bone).4-6
In the past few decades, there has been an upward
trend in replacing the FGG with the connective tissue
graft (CTG) for treating GRs; increasing soft tissue vol-
ume; and masking discolored roots, crown margins, or
implants.3 Indeed, better esthetic results, complete
flap closure, and healing of the donor site by primary
intention are among the advantages that can been
attributed to a CTG.3
Besides the advantages provided by soft tissue
grafts, either FGG or CTG, palatal harvesting tech-
niques present a crucial part of a procedure, as they
are soundly correlated to patient morbidity, graft qual-
ity, and bleeding control. Thus, several harvesting
approaches have been proposed: trap-door, parallel-
incision, single-incision, and epithelialized gingival
graft techniques and many others. The superiority of
any approach over the others remains controversial,
as it has been shown that the postoperative morbidity
accompanied by secondary intention healing (typical
of the epithelialized gingival graft harvesting
approach) can be efficiently minimized.7
However, regardless of the palatal harvesting
approach, prolonged intraoperative and postoperative
bleeding caused by injury to the palatal vessels is one
of the most common complications of this proced-
ure.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 the risk of damaging
the greater palatine artery (GPA), being on average 7,
12, and 17 mm from the cementoenamel junction
(CEJ) of the maxillary teeth when the palatal vault is
shallow, average, and high, respectively.9 Monnet-
Corti et al10 found that the average distance from the
GPA to the canines and second molars was
12.07  2.9 mm and 14.7  2.9 mm, respectively.
However, gathering data from fabricated casts and
assuming the course of the GPA are the major draw-
backs of this study design. Although the position of
the greater palatine foramen (GPF) and the course of
the GPA, as well as its distance from the CEJ of the
teeth, have been assessed in several cadaveric
studies,11-13 there is still no agreement on the
definition of a safety zone for palatal harvesting
based on anatomic landmarks that can guide
clinicians during this procedure. Therefore, the
purpose of this study was to define a safety zone for
soft tissue graft harvesting by comparing
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SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING
measurements from cadavers and cone beam
computed tomography (CBCT) or computed
tomography (CT) studies on the position of the GPF
and the course of the GPA in relation to the teeth.
Materials and Methods
STUDY DESIGN
To address the research purpose, we designed and
implemented a systematic review modeled after The
Cochrane Collaboration’s recommendations for sys-
tematic reviews. The focused question was as follows:
‘‘Is it possible to define a safety zone for palatal harvest-
ing based on the location of the greater palatine artery
and foramen?’’
SAMPLE IDENTIFICATION AND SELECTION
The study population was composed of all publica-
tions on GPF and/or GPA anatomy from 1980 to
January 2018. Electronic and manual literature
searches, conducted by 2 independent reviewers
(L.T. and S.B.), covered studies across the National Li-
brary of Medicine (MEDLINE by PubMed), Embase,
and the Cochrane Oral Health Group Trials Register
(Fig 1).
The MEDLINE (PubMed) search was performed on
January 13, 2018, using the following strategy:
(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 January 13,
2018, using the following strategy: (greater AND pala-
tine AND (‘artery’/exp OR artery) OR greater) AND
palatine AND foramen.
The search on the Cochrane Oral Health Group Tri-
als Register was performed on October 3, 2017, using
the following strategy: ‘‘Greater palatine artery’’
[Search All Text] OR ‘‘Greater palatine foramen’’
[Search All Text].
In addition, a manual search of related journals,
including a complete search of the Journal of Clinical
Periodontology, Journal of Periodontology, and Inter-
national Journal of Periodontics and Restorative
Dentistry, was performed.
Cadaveric and CBCT or CT studies were included if
they analyzed at least 1 of the following outcomes: 1)
distance between the CEJ of the maxillary teeth and
the GPA, 2) distance from the GPF to the midsagittal
suture, 3) distance between the GPF and the interinci-
sive foramen, 4) distance between the GPF and the
posterior border of the hard palate, 5) position of
the GPF in relation to the maxillary molars, and 6)
diameter of the GPF and GPA.
TAVELLI ET AL 271.e3

FIGURE 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. Abbreviations: CEJ, cementoenamel
junction; GPA, greater palatine artery; GPF, greater palatine foramen; IF, interincisive foramen; MSS, midsagittal suture; PB, posterior border
of hard palate.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2019.

Contrarily, articles were excluded if they were 1)
cadaveric or CBCT or CT studies not reporting mea-
surements on the GPA or GPF or 2) case reports.
Studies were initially screened 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 were independently
extracted by 2 review authors (L.T. and S.B.). When
clinical data were lacking, the study’s authors were
contacted. At each stage, disagreement between re-
viewers was resolved through discussion and
consensus. If a disagreement persisted, the judgment
of a third reviewer (A.R.) was decisive.
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 1) the distance be-
tween the GPF and the interincisive foramen, poste-
rior border of the mandible, and midsagittal suture
and 2) the diameters of the GPF and GPA.
The tertiary variables were age, gender, and study
design (skulls vs CBCT or CT) and their effect on
the outcomes.
DATA COLLECTION, MANAGEMENT, AND
ANALYSES
Studies were excluded by screening of titles and ab-
stracts and full-text reading by 2 investigators (L.T. and
S.B.) using a predetermined data extraction form to
confirm the eligibility of each study based on the afore-
mentioned criteria. The same 2 authors independently
extracted data from the 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.
Weighted means and standard deviations were
calculated based on the sample size (number of hemi-
palates) of each included study. Differences between
the computed values for male and female individuals,
measurements from CBCT scans, or direct cadaveric
measurements were compared by use of t tests, at a
significance level of .05. All statistical analyses were

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271.e4 SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING

performed using RStudio software (version 1.1.383;
RStudio, Boston, MA).
Results
STUDY SELECTION AND CHARACTERISTICS
The search results based on the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses) guidelines are depicted in Figure 1. This sys-
tematic review included 26 studies, investigating
5,768 hemipalates.11-36 In 22 studies, direct
measurements were performed on cadavers or
skulls11-14,16-20,22-30,32-34,36; 3 studies were based on
CBCT or CT scans15,21,35; and in 1 study, data from
cadaveric measurements and CT scans were
combined.31 Among the investigated palates, most be-
longed to white individuals (35.4%), followed by In-
dian (28.6%) and Asian (11.1%) individuals (Table 1).
Among the studies, 19 described the distance be-
tween the GPF and the midsagittal suture,14-19,21,23-34
4 reported the distance between the GPA and the
CEJ of the maxillary teeth,11-13,36 and 8 assessed the
distance between the GPF and the interincisive
foramen.16,17,19,23,28,29,31,32 The distance between
the GPF and the posterior border of the hard palate
was evaluated by 14 studies14,16,17,19,23,25-29,31-34 and
the position of the GPF itself was investigated by 19
articles,12,14-18,20,22-30,33-35 whereas the diameter of
the GPF and the GPA was described in 7
studies.13,16,21,22,26,27,29
LOCATION OF GPF
The location of the GPF was estimated to be on the
midpalatal side of the third molar in 57.1% of cases, be-
tween the second and third molars in 21.3%, and distal
to the third molar in 13.5%. Table 2 depicts the fre-
quency of the position of the GPF in relation to the
maxillary teeth.
On average, the distance between the GPF and the
interincisive foramen was 35.8  3.4 mm, whereas

Table 1. CHARACTERISTICS OF INCLUDED STUDIES

Article Study Design Population Sample (Hemipalates)

Ajmani,14 1993 Cadaveric African and Indian 198

Aoun et al,15 2015 CBCT Lebanese 116
Benninger et al,11 2012 Cadaveric NA 34
Cagimni et al,16 2017 Cadaveric Anatolian 240
Chrcanovic and Custodio,17 Cadaveric South American 160
2010
D’Souza et al,18 2012 Cadaveric Indian 80
Fu et al,12 2011 Cadaveric NA 21
Gibelli et al,19 2017 Cadaveric White 200
Hassanali and Mwaniki,20 1984 Cadaveric African 250
Ikuta et al,21 2013 CBCT South American 100
Kim et al,13 2014 Cadaveric Asian 43
Klosek and Rungruang,22 2009 Cadaveric Asian 42
Kumar et al,23 2011 Cadaveric Indian 200
Langenegger et al,24 1983 Cadaveric African 100
Methathrathip et al,25 2005 Cadaveric Asian 320
Nimigean et al,26 2013 Cadaveric White 200
Piagkou et al,27 2012 Cadaveric White 142
Saralaya and Nayak,28 2007 Cadaveric Indian 264
Sharma and Garud,29 2013 Cadaveric Indian 139
Sujatha et al,30 2005 Cadaveric Indian 138
Tomaszewska et al,31 2014 Cadaveric and CT White 1,500
Vidulasri and Thenmozhi,32 Cadaveric Indian 100
2015
Wang et al,33 1988 Cadaveric Asian 200
Westmoreland and Blanton,34 Cadaveric Indian 600
1982
Yilmaz et al,35 2015 CBCT Turkish 345
Yu et al,36 2014 Cadaveric Asian 36
Abbreviations: CBCT, cone beam computed tomography; CT, computed tomography; NA, not available.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2019.

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TAVELLI ET AL 271.e5

Table 2. LOCATION OF GPF IN RELATION TO MAXILLARY TEETH

Between Midpalatal Between Midpalatal

1M and 2M Aspect of 2M 2M and 3M Aspect of 3M Distal to 3M

Frequency 0.84% 6.21% 21.25% 57.08% 13.54%

Abbreviations: GPF, greater palatine foramen; 1M, first maxillary molar; 2M, second maxillary molar; 3M, third maxillary molar.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2019.

the GPF was 3.8  1.2 mm and 15.2  1.3 mm from the
posterior border of the hard palate and the midsagittal
suture, respectively (Fig 2). No significant differences
were found between male and female individuals for
the distance between the GPF and the midsagittal su-
ture (16.1 mm vs 15.5 mm) and the study design
(skulls vs CBCT or CT) (14.6 mm vs 15.4 mm) (P > .05).
COURSE OF GPA
The distance from the GPA to the CEJ of the maxil-
lary teeth was calculated as follows: 13.9  1 mm to
the second molar, 13.0  2.4 mm to the first molar,
13.8  2.1 mm to the second premolar,
11.8  2.2 mm to the first premolar, and
9.9  2.9 mm to the canine (Fig 3).
DIAMETER OF GPF AND GPA
The mean anteroposterior opening of the GPF was
4.1  1.2 mm, whereas its mediolateral diameter was
estimated at 2.8  0.8 mm. The diameter of the GPA
was approximately 1.2  0.3 mm and 1.3  0.4 mm
in the second and first molars, respectively, and
1.2  0.4 mm, 0.8  1.1 mm, and 0.8  0.4 mm in

FIGURE 2. Schematic drawing representing the location of the greater palatine foramen (GPF) (red dot) and its distance from the interincisive
foramen (IF), midsagittal suture (MSS), and posterior border of the hard palate (PB).
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2019.

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271.e6 SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING

FIGURE 3. Schematic drawing representing the distance between the cementoenamel junction of the maxillary teeth (second molar [M2], first
molar [M1], second premolar [P2], first premolar [P1], and canine [C]) and the greater palatine artery.
Tavelli et al. Safety Zone for Palatal Soft Tissue Graft Harvesting. J Oral Maxillofac Surg 2019.

relation to the second premolar, first premolar, and deviation as well was to reduce the possibility of injury
canine teeth, respectively. to the vessel as much as possible, hence the term
safety zone (SZ):
DEFINITION OF SAFETY ZONE
SZðmmÞ ¼ weighted mean distance from the GPA
If a distance of 2 mm from the CEJ (which corre-
sponds to the gingival margin in the healthy periodon-  SD  2
tium) is considered the physiological biological
width,37 a safety zone for harvesting an FGG or CTG
is determined by subtracting the standard deviation
Discussion
(SD) of the mean from the mean value itself (average
distance from the CEJ to the GPA for each tooth) Bleeding and paresthesia are the most common
(Fig 4). The reason for subtraction of the standard complications described after palatal soft tissue graft

FIGURE 4. Schematic representation of safety zone in healthy periodontium. The safety zone was determined with respect to the average dis-
tance between the cementoenamel junction of each tooth and the greater palatine artery, as well as its standard deviation and 2 mm for the
gingival margin.
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TAVELLI ET AL
harvesting.38,39 The best precaution for minimizing
the risk of complications is to be aware of anatomic
structures.9 Guidelines for palatal harvesting to avoid
the neurovascular structures have previously been
proposed; however, because of 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 a safe area for soft tissue graft harvesting
based on the position of the GPF and GPA.
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 mm and 13.8  2.1 mm, respectively). It is
interesting to note that a similar pattern has been
described in the literature for palatal mucosal
thickness.40,41
Age, gender, and population characteristics have
been reported as factors that can affect the thickness
of the palatal mucosa.40 However, in our study, we
found a lack of a statistically significant correlation be-
tween these parameters and the distance of the GPF
from the landmark structures (midsagittal suture, in-
terincisive foramen, and posterior border of the hard
palate). Nevertheless, these results should be inter-
preted with caution because the samples included in
this review were not homogeneous among the popula-
tions and only a few studies reported results specific
for male and female individuals.15,19,21,24,25,31 In
addition, in agreement with a previous study, no
differences were found when direct measurements
in cadavers and CBCT or CT results were compared.31
As reported by Tomaszewska et al,31 anatomic land-
marks are essential tools for identifying the position of
the GPF. In this view, our study contributes to the liter-
ature by providing the approximate location of the
GPF based on its distance from the midsagittal suture,
interincisive foramen, and posterior border of the hard
palate. Although anatomic variability among patients
must be considered, the results of this study are sup-
ported by a total sample size of 5,768 hemipalates.
In agreement with a previous systematic review,31
our results confirmed that the most common location
of the GPF is in the midpalatal aspect of the third molar
(57.1%), followed by locations between the second
and third molars (21.3%) and distal to the third molars
(13.5%).
Nevertheless, palpation of the posterior palate
should always be performed for identifying the posi-
tion of the GPF and the course of the GPA. It has
been reported that the artery is commonly at the junc-
tion between the horizontal plate of the maxilla and
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271.e7
the maxillary alveolar ridge.12 In addition, in a cadav-
eric study, Benninger et al11 showed that the GPA
runs in close proximity to the greater palatine crest,
which is prominent and can be palpated in most cases.
Fu et al,12 on the basis of fabricated study models,
reported that the location of the GPF was underesti-
mated by up to 4 mm when 20 examiners were asked
to estimate this anatomic landmark. This could reduce
the chances of injury to the vessel but also limit the
amount of CTG that can be harvested.12 This finding
highlights the flaw in the study design of Monnet-
Corti et al,10 who estimated the mean distance of the
GPA from the CEJ of the second molar and the canines
using only cast models.
Recently, the use of ultrasound or magnetic reso-
nance imaging for identifying the position of the GPF
has been proposed.42,43 However, these methods do
not seem practical in daily practice. By using the
CEJs of the maxillary teeth as landmarks, our study
provides a safety zone that should minimize the risk
of damaging the GPA during the harvesting
procedures. Indeed, 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 second molar and second premolar
area whereas it is considerably smaller at the first
premolar and canine area. In agreement with our
findings, harvesting anterior to the distal region of
the canines is generally discouraged.10
Despite traditional beliefs of the palatal root of the
first molar being the distal limit for harvesting an
FGG or CTG,10,40 our study shows that extending
the harvesting zone to the second molar 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 width when reaching the
anterior areas. This may explain why several authors
have 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,10 a palatal harvest-
ing of 8 mm in height, without damaging the GPA, was
possible in almost all cases (93%); however, our study
showed that this statement is valid only for the poste-
rior palate (from the second premolars to the
second molars), not in the 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 is the different patterns of the GPA; types
III and IV, as defined by Yu et al,36 run closer to the CEJ
and thus are associated with a higher risk of GPA injury
271.e8
and bleeding than the most common pattern (type I),
in which the lateral branch of the GPA runs anteriorly,
giving off a medial branch and a canine branch in the
proximity of the canine area. According to Greenstein
et al,44 deep sutures distal to the harvesting site before
initiation of the surgical procedure should always be
performed to reduce hemorrhaging in case of injury
to the GPA. If severe bleeding does occur, clinicians
should apply pressure on the wound and use a local
anesthetic with a vasoconstrictor. In case of persistent
hemorrhage, deep sutures ligating the artery or elec-
trocauterization should be attempted.44
Among the limitations of this study is that the 4
different patterns of the GPA described in the litera-
ture36 could have influenced the measurements in
the included studies. In addition, despite the correla-
tion of the height of the palatal vault to the GPA,9,11
data on this aspect were not available in the
examined articles. Moreover, a larger sample size of
studies reporting on the measurements of male and
female individuals may show a remarkable difference
for each gender classification. Finally, the proposed
safety zone (calculated from the CEJ of the maxillary
teeth to the GPA) includes 2 mm of presumed
distance from the gingival margin to the CEJ; this
represents an ideal scenario in which 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 the crest prominence, midsagittal
suture, interincisive foramen, and posterior border of
the hard palate, should be used for identifying the
position of the GPF and course of the GPA.
Within its limitations, this study provides landmarks
for identifying the position of the GPF and defines a
safety zone for harvesting an FGG or CTG, minimizing
the risk of GPA injury. Interindividual variability, how-
ever, also should be considered when planning a
palatal harvesting procedure; therefore, clinicians
must be prepared to manage possible complications.
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SAFETY ZONE FOR PALATAL SOFT TISSUE GRAFT HARVESTING
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