Volume 79 • Number 5
Case Report
Histologic Observation of Soft Tissue Acquired From
Maxillary Tuberosity Area for Root Coverage
Ui-Won Jung,* Yoo-Jung Um,* and Seong-Ho Choi*
Background: The palatal area has been the major
donor site for obtaining connective tissue for root-cov-
erage procedures. This study evaluated the long-term
outcome of using a gingival cuff from the maxillary tu-
berosity area as a donor site for root coverage proce-
dures.
Methods: Case 1: A 26-year-old female patient com-
plaining of tooth hypersensitivity and gingival reces-
sion on the maxillary left canine was treated with
root coverage using a pouch technique. A connective
tissue graft was obtained from the gingival cuff of
the maxillary tuberosity area. An additional gingivec-
tomy was performed at 3 months after surgery to trim
the bulk of the grafted tissue. Regular recall check-
up visits, including oral hygiene maintenance, oc-
curred every 6 months. The patient was followed for
35 months after surgery. Case 2: A 24-year-old female
patient with a chief complaint of tooth hypersensitiv-
ity and multiple areas of gingival recession in the
maxilla was treated with a pouch and semilunar tech-
nique. The patient was treated with the same surgical
protocol as in case 1. The patient was followed for
31 months after surgery.
Results: Full coverage was achieved in both cases
with uneventful healing. The gingival biotype changed
from a thin scalloped biotype to a thick flat biotype,
and the overall color match was successful. The histo-
logic findings of case 1 revealed good adaptation of the
grafted tissue with continuous epithelial lining into the
recipient site. The grafted tissue remained consistently
stable with no change in the probing depths.
Conclusion: The long-term evaluation of root cover-
age with a gingival cuff of the maxillary tuberosity area
showed it to be an easier method than obtaining the
graft from palatal masticatory mucosa, with a highly
predictable prognosis. J Periodontol 2008;79:934-
940.
KEY WORDS
Case report; connective tissue; gingival recession.
* Department of Periodontology, Research Institute for Periodontal
Regeneration, College of Dentistry, Yonsei University, Seoul, Korea.
934
E
sthetics is becoming an important concern in
dentistry. Harmonious and symmetric align-
ment of the teeth with a consistent shape, size,
and color is essential, and the importance with har-
monious soft tissue morphology has been empha-
sized. Gingival recession is one of the soft tissue
problems faced by dentists and patients.1-3 It causes
tooth hypersensitivity that is due to root exposure
and produces an unesthetic appearance with uneven
gingival margin levels. Therefore, there is a need for
a predictable technique for root coverage.
There are several approaches for treating gingival
recession: flap surgical procedures, e.g., coronally po-
sitioned flap,4,5 laterally sliding flap,6 double papilla
flap,7 semilunar coronally repositioned flap,8 and en-
velope technique;9 and procedures using graft mate-
rials in combination with flap operations.10-18 Graft
materials used in association with flap procedures in-
clude subepithelial connective tissue graft,10-12,16,18
acellular dermal matrix,11,18 bioabsorbable or non-
resorbable membrane,17 or enamel matrix deriva-
tives.12-16 Although various materials have been
introduced, an autogenous connective tissue graft
has shown the most predictable results.10,19-22
The connective tissue is obtained primarily from
the palatal area of the maxilla and provides the great-
est amount of connective tissue;23 however, this is not
true in all patients requiring root coverage. The thick-
ness of the palatal masticatory mucosa varies accord-
ing to the position in the dental arch and ranges from
2 to 5 mm.24-28
Anatomic structures, such as the greater palatine
artery, limit the size and amount of connective tissue
obtainable in patients with gingival recession.23 Com-
plications, such as patient discomfort, post-surgical
pain, paresthesia, and bleeding from the donor area,
can occur if the artery is injured. In addition, obtaining
connective tissue from the palatal area is technique
sensitive for a general practitioner to perform. There-
fore, an easier technique with fewer complications
should be considered.
doi: 10.1902/jop.2008.070445
J Periodontol • May 2008 Jung, Um, Choi

A gingival cuff is observed commonly in the distal at the distal aspect of the maxillary second molar
aspect of the most posterior tooth of the maxilla. This and in the tuberosity area. The clinical findings are
sometimes forms a pseudopocket that necessitates a shown in Table 1. All of the measurements were per-
gingivectomy. The firm, thick, keratinized tissue can formed using a color-coded probe. There was no prox-
be used as a source for a soft tissue graft25 and is in imal papilla loss clinically and no proximal bone loss
a zone away from the main blood vessels, which min- observed on the radiographs. The recession was clas-
imizes problems with hemostasis. Hirsch et al.29 intro- sified as Miller Class I, and a treatment plan was made
duced root coverage with a subepithelial connective for root coverage.
tissue graft obtained from the tuberosity area. In that
study, connective tissue was obtained during a pocket Table 1.
reduction procedure, and the results were very pre-
Probing Depths, Keratinized Gingiva, and
dictable with an esthetically pleasing outcome. How-
ever, obtaining connective tissue from the tuberosity Gingival Recession (mm) in Case 1
area could also be done by simple gingivectomy with-
out elevation of a mucoperiosteal flap in the posterior 35-Month
region. Connective tissue obtained by gingivectomy Baseline Follow-Up
does not require suturing of the donor site, and the Probing depth
level of postoperative pain is reduced compared to Mesial 2 2
a soft tissue graft acquired from the palate. The graft Middle 2 1
obtained from this area can be adapted easily to the Distal 2 2
recipient site by just removing the epithelium.
Keratinized gingiva: middle 1 5
This study evaluated the long-term outcomes of us- Gingival recession: middle 3 0
ing a gingival cuff in the maxillary tuberosity area as a
donor site for root coverage procedures based on clin-
ical and histologic findings.

CASE 1
Patient and Site Description
A 26-year-old woman visited the Department of Peri-
odontology, Dental Hospital of Yonsei University, on
June 1, 2004 with a chief complaint of hypersensitiv-
ity and gingival recession on the left maxillary canine
(Fig. 1). She was concerned about the esthetics and
the further progression of the gingival recession.
The patient was in good general health and was a
non-smoker.
An intraoral examination revealed an acceptable
oral hygiene status. The maxillary left canine was
Figure 2.
slightly prominent, and a thin, scalloped gingiva bio- Preparation of the recipient site. An intracrevicular incision was
type was observed. A thick gingival cuff was present performed to create the pouch.

Figure 1. Figure 3.
Clinical photograph of the left maxillary canine prior to surgery. Soft tissue was obtained from the maxillary tuberosity area.

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Maxillary Tuberosity Area for Root Coverage Volume 79 • Number 5

Initial therapy, including scal-

ing and oral hygiene instruc-
tion with proper toothbrushing
methods, was performed. An
ultrasoft brush was recommen-
ded to avoid further recession
caused by traumatic brushing.
Informed consent was ob-
tained from the patient after
careful explanation of the surgi-
cal procedure, prognosis, and
possible complications.

Figure 4. Surgical Procedures

A) The soft tissue obtained from the maxillary tuberosity area by a gingivectomy. B) Deepithelialization
A pouch technique was used for
of the soft tissue. root coverage of the canine
tooth. A thick gingival cuff of
the maxillary left tuberosity area
was selected as the donor site. After local anesthesia
of the recipient and donor sites with 2% lidocaine HCl
with epinephrine 1:100,000,† an intracrevicular inci-
sion was performed, and a partial-thickness flap
was elevated to prepare the pouch (Fig. 2). The de-
nuded root surface was planed carefully using peri-
odontal curets. After preparing the recipient site, the
gingival cuff was excised by a gingivectomy from
the left tuberosity area (Fig. 3). The donor soft tissue
was deepithelialized and trimmed with an epithelial
tag remaining (Fig. 4). The prepared connective tis-
sue was placed in the proper position of the recipient
bed and immobilized by suturing with 5-0 bioabsorb-
able suture‡ (Figs. 5 and 6). The patient was admin-
istered amoxicillin plus clavulanic acid, 375 mg,§
three times a day for 5 days postoperatively. The su-
tures were removed 10 days after surgery, and the pa-
Figure 5. tient was recalled for a check-up at 1 and 3 months
The suture technique for placing the graft. after surgery for postoperative care. The need for oral
hygiene was reinforced at each appointment. At the
3-month check-up, a gingivoplasty was performed
to trim the grafted connective tissue because of bulky
volume and color mismatch (Figs. 7 and 8). A regular
recall check-up was scheduled every 6 months.
Biopsy and Histologic Preparation
At the 3-month check-up, a gingivectomy was per-
formed under local anesthesia. The biopsy was fixed
in 10% neutral buffered formalin solution for 10 days.
All samples were embedded in paraffin, and 3-mm-
thick sections were obtained from the central part of
the specimen. The sections were stained with hema-
toxylin and eosin, and the slides were examined under
a light microscopei at ·30 and ·100 magnification.

† Kwangmyung Pharmaceutical, Seoul, South Korea.

‡ Polyglactin 910 braided bioabsorbable suture, Ethicon, Johnson &
Figure 6. Johnson, Edinburgh, U.K.
Clinical photograph after graft placement and suturing. § Augmentin, IlSung Pharmaceutical, Seoul, South Korea.
i LEICA DM-LB, LEICA, Wetzlar, Germany.

936
J Periodontol • May 2008
Figure 7.
Clinical photograph after 3 months. The gingiva was too bulky, and the
color was not in harmony with the original gingiva.
Figure 8.
Clinical photograph after the gingivoplasty and biopsy.
Histologic Observations
Under low magnification, the epithelium at the border
between the grafted area and the recipient site was
invaginated into the deeper layer of the tissues and
was continuous, showing good adaptation (Figs. 9A
and 9B). The epithelium of the grafted area was
well keratinized with well-defined rete pegs, and the
connective tissue layer was dense with many blood
vessels (Fig. 9C). In contrast, the epithelium of the
recipient site was non-keratinized with fewer rete
pegs. The underlying connective tissue was arranged
loosely with few blood vessels (Fig. 9D).
Clinical Observation
Wound healing was generally uneventful. The defect
with the gingival recession, 3 mm in height and 3
mm wide, was 100% covered after 30 months. The
amount of keratinized tissue was <1 mm before sur-
gery but increased to 5 mm after surgery, and there
was no difference in the probing depths before and af-
ter surgery.
The biotype of the soft tissue changed from a thin
scalloped type to a thick biotype. The grafted tissue
was bulkier, thicker, and brighter than the adjacent
Jung, Um, Choi
tissue. A gingivectomy was performed because of
the color mismatch, and a correction of the thickness
and color was achieved.
After 35 months of follow-up, the dimension of the
grafted tissue remained stable with no change in the
probing depths (Fig. 10).
CASE 2
Patient Description
A 24-year-old woman visited the Department of Peri-
odontology, Dental Hospital of Yonsei University, on
June 10, 2004. She also had a complaint of hypersen-
sitivity and generalized gingival recession in the max-
illary anterior teeth. The patient was a non-smoker
and was in good general health.
The oral hygiene status was acceptable, and she
had a thin, scalloped gingival biotype. All reces-
sions were classified as Miller Class I, and a thick gin-
gival cuff was present at the distal end of the maxillary
second molar and the tuberosity area. The clinical
findings are recorded in Table 2. The patient was sched-
uled to undergo root coverage. An informed consent
was obtained from the patient, and a surgical procedure
was performed similar to that in case 1.
Surgical Procedures
Although the overall surgical procedure was the same
as in case 1, the area requiring root coverage in this
case was greater than in case 1. Root coverage on
the canine and the first premolar area was performed
with the connective tissue obtained from the tuberos-
ity area by a primary gingivectomy. The papilla area
was tunneled, and the connective tissue obtained was
inserted into the tunneled space (Figs. 11 and 12).
The lateral incisor was covered by a second gingivec-
tomy from the same donor site, and the central incisor
was covered by a coronally positioned flap after a
semilunar incision (Fig. 13).
Clinical Observation
The grafted area healed well in both sites treated by
the tunneling and semilunar technique. Full coverage
(100%) was achieved in all surgical sites, and there
was a 4-mm gain of keratinized tissue. There was
no change in the probing depths compared to before
surgery.
At the 31-month follow-up, a scar remained at the
central incisor where the semilunar incision was
placed. However, the general color match was suc-
cessful (Fig. 14).
DISCUSSION
The main aim of this study was to introduce an alter-
native procedure for root coverage that reduces chair
time, has fewer complications, and is less technique
sensitive. The simplicity of the procedure provides ad-
vantages to the patient and the surgeon.
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Maxillary Tuberosity Area for Root Coverage Volume 79 • Number 5

In this study, the recipient site

was prepared using the enve-
lope technique. This procedure
was introduced by Raetzke9 in
1985, and it does not require
vertical incisions. It allows better
blood supply, improved healing,
a more esthetically pleasing out-
come, and less surgical time,
which is beneficial for wound
healing and patient discomfort.
The connective tissue for root
coverage is usually obtained
from the maxillary palatal masti-
catory mucosa between the first
premolar and second molar.23 A
trap door is raised to expose pal-
atal mucosa, and connective tis-
sue with a uniform thickness and
adequate size is obtained. How-
ever, this procedure is technique
sensitive. Careful consideration
of the greater palatine artery and
nerve location is needed to avoid
surgical damage. Suturing the
Figure 9.
Histologic view of the resected tissue. A) Overall view under low magnification. B) High magnification palate is also a time-consuming
of the border between the grafted tissue and the recipient site. C) High magnification of the grafted task.
area. D) High magnification of the recipient site. (Hematoxylin and eosin; original magnification: A, The tuberosity area of the
·50; B through D, ·200.) maxilla can be an alternative
donor site for connective tis-
sue.25 Although all patients re-
quiring root coverage do not have large tuberosities,
obtaining connective tissue from this area has many
advantages over the palatal mucosa. There are fewer
complications with hemostasis and minimal tissue
contraction after grafting. Hemostasis in the tuberos-
ity area can be achieved by pressure dressing with
gauze and additional injections of 2% lidocaine HCl
with epinephrine 1:100,000. Periodontal dressing¶
can be applied to the wound site. Contraction of the
connective tissue occurs commonly after obtaining
it from the palatal mucosa, which can result in insuf-
ficient connective tissue for root coverage. However,
Figure 10. as shown in case 1, the contraction of the connective
Clinical photograph at 35 months. tissue obtained from the tuberosity area was minimal,
and an additional gingivoplasty was required later.
The conventional Langer and Langer10 method for Similar findings were presented in the study by
root coverage involves two vertical incisions for coro- Hirsch et al;29 however, a mucoperiosteal flap was
nal positioning of the flap. The vertical incisions form also elevated in the posterior region to obtain a con-
scars when healed, resulting in an esthetically dis- nective tissue graft from the tuberosity area. The main
pleasing appearance. The blood supply to the grafted objective of the present study was to simplify the sur-
area is also reduced by the vertical incisions that may gical procedure. The connective tissue graft could be
impair healing at the wound site. Furthermore, con- obtained easily by simple gingivectomy as shown in
siderable surgical time and effort are required for su- this study.
turing, and there is a higher level of postoperative pain
and discomfort for the patient. ¶ Coe-Pak, GC America, Alsip, IL.

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J Periodontol • May 2008 Jung, Um, Choi

Table 2.
Probing Depths, Keratinized Gingiva, and
Gingival Recession (mm) in Case 2

31-Month
Baseline Follow-Up

Probing depth
Mesial 3 3
Middle 2 1
Distal 3 2

Keratinized gingiva: middle 1 5

Figure 11. Gingival recession: middle 4 0
Preparation of the recipient site; pouch and tunneling.

Figure 12.
A) The soft tissue from the maxillary tuberosity area. B) Deepithelialized soft tissue.

Figure 13. Figure 14.

Clinical photograph after graft placement and suturing. Clinical photograph after 31 months.

The histologic findings revealed good integration in
the epithelial layer of the donor tissues with the recip-
ient site. Well-developed rete pegs were also observed
in the keratinized epithelial layer, which may provide
mechanical resistance to external irritation. Good re-
vascularization was achieved from the overlying flap
and periosteum, with many capillaries in the grafted
connective tissue. The well-adapted grafted connec-
tive tissue was denser than the original connective tis-
sue, showing a change in gingival biotype. This change
in biotype provides long-term stability to the grafted
tissue. The follow-up results also showed firm and se-
cure tissue in the grafted area.
The anatomy of the tuberosity area limits the use
of this procedure to patients with an adequate amount
of tuberosity connective tissue. However, the root

939
Maxillary Tuberosity Area for Root Coverage
coverage procedure using the soft tissue from the
maxillary tuberosity area might be a simpler method
that yields highly predictable results.
ACKNOWLEDGMENTS
This work was supported by a grant from the Korea Re-
search Foundation, Seoul, South Korea (KRF-2007-357-
E00019) fundedby the Korean Government. The authors
report no conflicts of interest related to this case report.
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Submitted August 9, 2007; accepted for publication
September 14, 2007.