Received: 3 October 2017 | Revised: 9 May 2018 | Accepted: 10 June 2018

DOI: 10.1111/jcpe.12960

RANDOMIZED CLINICAL TRIAL

Influence of suturing technique on wound healing and patient

morbidity after connective tissue harvesting. A randomized
clinical trial

Giovanni N. E. Maino* | Cristina Valles* | Antonio Santos | Andres Pascual |

Cristina Esquinas | José Nart

Department of Periodontology, Universitat

Internacional de Catalunya, Barcelona, Spain
Correspondence
Jose Nart, Department of Periodontology,
Universitat Internacional de Catalunya, C/
Josep Trueta s/n, 08195, Sant Cugat del
Vallès. Barcelona. Spain.
Email: josenart@uic.es
Abstract
Objectives: The aims of this randomized clinical trial were to investigate the influ-
ence of the suturing technique and the thickness of the pre-­and postoperative pala-
tal and flap mucosa on the early healing of the palate after harvesting a connective
tissue graft. Furthermore, patient pain perception was evaluated.
Material and methods: A subepithelial connective tissue graft was obtained from the
palate with a single horizontal incision technique. Patients were randomly assigned to
continuous interlocking suture group or criss-­cross suture group. The thickness of
the palatal mucosa and residual palatal flap was measured; however, these variables
were not randomized. One week postoperatively, the donor site wound healing was
recorded by the modified rate of early healing index (EHI). Patient’s pain perception
was assessed by a visual analogue scale.
Results: Thirty-­six patients were evaluated. No statistically significant differences
were found between suturing technique and wound healing (p = 0.215). Statistically
significant differences were found between postoperative flap thickness and EHI at
1, 3 and 6 mm from the incision line (p < 0.001). Negative correlations reaching sta-
tistical significance were found between the number of days of discomfort and re-
sidual flap thickness measured at 1, 3 and 6 mm.
Conclusions: No association between the suture technique and the EHI was ob-
served. Moreover, postoperative palatal flap thickness was associated with early
wound healing of the donor site. Finally, the greater the postoperative palatal flap
thickness, the less intensity of the pain perceived by patients.

KEYWORDS
connective tissue, pain perception, palate, suture techniques, wound healing

1 | I NTRO D U C TI O N
According to the literature, the subepithelial connective tissue graft
(SCTG) has been considered to be the “gold standard” for the treatment
of deep gingival recessions, achieving a good aesthetic and functional
*These two authors contributed equally to this work.
result over time (Cairo, Nieri, & Pagliaro, 2014; Chambrone & Tatakis,
2015; Madeley & Duane, 2017; Roccuzzo, Bunino, Needleman, & Sanz,
2002; Santamaria et al., 2013). However, this procedure requires har-
vesting the graft from a donor site, usually the palate, which extends
the complexity of the procedure and increases patient discomfort
(Cairo et al., 2012, 2016; Cortellini et al., 2009).

J Clin Periodontol. 2018;45:977–985. wileyonlinelibrary.com/journal/jcpe © 2018 John Wiley & Sons A/S. | 977
Published by John Wiley & Sons Ltd
978 | MAINO et al.
With the objective of reducing patient morbidity, various surgical
techniques have been described to harvest SCTG from the palate.
Edel (1974) was the first who showed a technique (trap door) with
the aim of keeping the palatal epithelial layer intact to obtain primary
intention healing with reduced patient discomfort. A single horizon-
tal incision parallel to the gingival margin and two vertical releasing
incisions was used to achieve sufficient visual access. Langer and
Calagna (1980) and Langer and Langer (1985) introduced a similar
method, including a second parallel horizontal incision to obtain a
graft with an intact epithelial margin of the same thickness of the
graft. Moreover, Raetzke (1985) and Harris (1997) introduced differ-
ent modifications to this technique; however, a denuded wound area
at the palate donor site was left resulting in an increased postopera-
tive pain. In this sense, Hürzeler and Weng (1999) presented a single-­
incision technique designed to allow primary wound healing, thereby
decreasing patient discomfort. Recently, a modification of this sur-
gical technique was introduced by Thalmair, Fickl, Hinze, Bolz, and
Wachtel (2010), who concluded that retaining part of the connective
tissue at the donor site allows an improved wound healing.
Healing of the donor site from the palate has been addressed
in some studies regarding patient morbidity (Wessel & Tatakis,
2008; Zucchelli et al., 2010). Del Pizzo, Modica, Bethaz, Priotto,
and Romagnoli (2002) evaluated early healing results of the palatal
wound by comparing three different surgical techniques for har-
vesting a connective tissue graft: the single incision, the free gin-
gival graft (FGG) and the trap door techniques. The results showed
significantly lower patient morbidity after harvesting an SCTG
compared to a FGG. However, when comparing single-­incision and
trap door techniques for obtaining SCTG, no marked differences
were observed. Fickl et al. (2014) investigated the early wound
healing comparing single-­incision versus the trap door techniques,
reporting that the single-­incision technique was less invasive, had
increased primary wound closure, and it was related to less pain
perception. However, the influence of the suturing technique and
the residual tissue thickness on the donor site has not been ex-
amined. In this context, Burkhardt, Hämmerle, and Lang (2015),
in a clinical study, concluded that pain perception was strongly
correlated to the residual palatal thickness and not related to the
extension of the denuded surface area after harvesting a FGG.
Due to the scarce information in the literature assessing palatal
wound healing and patient-­
related information after harvesting a
SCTG, the objectives of this study were to evaluate the influence of
(a) two types of palatal suturing techniques and (b) the thickness of
the pre-­and postoperative palatal and flap mucosa on early healing
after harvesting a connective tissue graft with a single-­incision tech-
nique. Furthermore, the patients’ pain perception was also evaluated.
2 | M ATE R I A L A N D M E TH O DS
2.1 | Study design and patient selection
This single-­
blind randomized clinical trial was performed at the
Clínica Universitaria de Odontología, Universitat Internacional de
Clinical Relevance
Scientific rationale for the study: The attempt to reduce the
morbidity and enhance wound healing in periodontal pa-
tients is of major concern for the scientific community.
Most of periodontal plastic surgeries require a donor site,
normally the palate that is related to an increase in the pa-
tient’s discomfort.
Principal findings: The suturing technique had no influence
on early wound healing. Moreover, residual palatal flap
thickness after subepithelial connective tissue graft har-
vesting is related to early wound healing and pain
perception.
Practical implications: A residual palatal flap thickness
>1 mm had significantly better early healing values, al-
though the suturing technique had no influence on it. The
greater the thickness of the pre-­and postoperative palatal
and flap mucosa, the lower the intensity of the pain
perceived.
Catalunya (UIC), from November 2015 to February 2017. The Ethical
Committee of UIC approved the protocol (Ref. PER-­ECL-­2015-­03)
and the study was performed in accordance with the Helsinki
Declaration of 1975 (as revised, amended, and clarified in its ver-
sion of 2013). All patients read and signed an appropriate informed
consent document prior to participation in the study. Patients with
gingival recessions or soft tissue deficiencies around implants need-
ing treatment with an SCTG were included.
The following inclusion criteria were applied: (a) age ≥18 years
and (b) systemically healthy without any systemic condition that
might impact directly on the inflammatory status. Exclusion cri-
teria were as follows: (1) pregnancy or lactating females; (2) pa-
tients with coagulation disorders; (c) subjects wearing partial or
full denture which had any contact with the palate; (d) severe
cognitive or psychiatric disorders; (e) smokers of more than 10
cigarettes per day; and (f) no SCTG previously harvested from
the site. Subjects smoking <10 cigarettes per day were requested
to stop smoking 7 days before and 14 days after the surgical
procedure.
2.2 | Sample size calculation
Sample size calculation was based on the main study outcome: Early
healing index (EHI). A difference of 1 between groups was consid-
ered clinically relevant. Assuming an alpha risk of 5% and a beta risk
of 20% in a two-­sided test, a total of 36 patients (18 subjects in each
group) were necessary to recognize as statistically significant a dif-
ference equal or >1. Due to the absence of studies, a common stand-
ard deviation of 1 was considered. To allow for possible dropouts, 40
patients were finally recruited.
MAINO et al.
2.3 | Study groups and randomization
Consecutive patients fulfilling these criteria were entered in the
study. Recruitment was carried out by one of the researchers (G.M.).
Two groups of 20 patients each, selected randomly, underwent sur-
gery using the single-­incision technique (Hürzeler & Weng, 1999) to
harvest a connective tissue graft from the palate. The donor site was
sutured using two different techniques: continuous interlocking su-
ture or criss-­cross interrupted suture. The randomization sequence
was created using a computer-­generated list. Allocation conceal-
ment was kept by means of opaque-­sealed envelopes that were
opened at the moment of suturing the donor site by someone not
involved in the study.
2.4 | Initial therapy
Before the surgical procedure, all patients underwent periodontal
therapy and received extensive oral hygiene instructions to pro-
vide a better oral environment. Full mouth plaque scores (FMPS)
(O’Leary, Drake, & Naylor, 1972) and full mouth bleeding scores
(FMBS) (Ainamo & Bay, 1975) were recorded after the hygienic
phase of the periodontal therapy. No surgery was performed until
patients reached an FMPS <20% and an FMBS <20%.
2.5 | Surgical intervention
Two expert operators (J.N. and A.S.) performed all surgical inter-
ventions. In order to prevent swelling and bias in the measurements
of the donor palatal site, local anaesthesia (2% articaine with epi-
nephrine dose 0.1 mg) was applied at the level of the major palatal
foramen at a minimal depth. After anaesthetic administration, a sin-
gle incision was performed (Hürzeler & Weng, 1999) between the
distal line angle of the canine to the mesial aspect of the maxillary
first molar and at 2 mm apical from the gingival margin using a n.15
blade (Swann-­Morton, Sheffield, UK). A calibrated examiner (G.M.)
recorded three measurements of the palatal thickness using an en-
dodontic file perpendicular to the bone. The file was fixed at the
F I G U R E 1 (a) Measurement of the
residual flap thickness at the midpoint
of the incision line at 3 mm. (b) The
endodontic file was fixed with a flowable
(a)
light-­curing composite
| 979
midpoint of the incision line at 1, 3 and 6 mm towards the mid pal-
ate with a flowable light-­curing composite. Subsequently, through
the first incision, a split-­thickness dissection was made parallel to
the long axis of the teeth and a 1.5-­mm thick graft was obtained
by a deeper sharp dissection parallel to the second incision. Much
care was taken not to perforate the superficial tissue. All SCTG were
standardized to length, width and thickness (12, 8 and 1.5 mm, re-
spectively) using a periodontal probe (PCP-­
UNC 15; Hu-­
Friedy,
Chicago, IL, USA).
Immediately after harvesting the graft, the same calibrated ex-
aminer (G.M.) recorded the thickness of the residual palatal flap at
the same levels described above and, to avoid tissue collapse and
measurements variability, the flat surface of a periosteal elevator
(PPR3S6, Hu-­Friedy) was used (Figure 1).
The treatment group assignment (suturing technique for the
palate) was performed at this time-­p oint. A sealed envelope was
given to the operator indicating the suture group: continuous in-
terlocking or interrupted criss-­cross suture. For both techniques,
primary wound closure was achieved using silk 4-­0 (Aragó S.L,
Barcelona, Spain), before grafting the recipient site. The SCTG har-
vesting and suturing the palate did never last more than 10 min in
all cases. Sutures were removed from the donor site after 1 week.
No periodontal dressing or vacuum device was applied postoper-
atively. All patients received azithromycin 500 mg once a day for
3 days. In cases of allergy to macrolides, doxycycline 100 mg once
a day for 5 days was prescribed. Furthermore, ibuprofen 600 mg
every 8 hr for 4 days was also prescribed. All patients were in-
structed to rinse with chlorhexidine digluconate 0.12% twice daily
for 4 weeks (Perio-­A id; Dentaid, Barcelona, Spain). The use of anti-­
inflammatory drugs was recorded daily to control patient’s drug
intake during the follow-­up time. Non-­compliant patients were
considered dropouts.
In order to evaluate the patient’s pain perception, they were
instructed by the same examiner (G.M.) to answer a questionnaire
based on a visual analogue scale (VAS) at 1, 2, 3, 7, 14, 21 and 28 days
postoperatively, preferably at the same time each day, following the
protocol reported by Burkhardt et al. (2015). A second questionnaire
(b)
980 | MAINO et al.
was given to smokers to record the number of cigarettes consumed
th
daily until the 14 day after surgery.
2.6 | Postsurgical procedures
Patients were monitored at 2 and 4 days after surgery. All patients
were recalled and examined every 7 days for evaluation over a fol-
low-­up period of 8 weeks. One week after surgery and after suture
removal, the EHI (Fickl et al., 2014) was assessed by a blinded exam-
iner (C.V.) in five different degrees:
1. Complete flap closure without fibrin line at the palate.
2. Complete flap closure with fibrin line at the palate.
3. Complete flap closure with small fibrin clot(s) at the palate.
4. Incomplete flap closure with partial necrosis of the palatal tissue.
5. Incomplete flap closure with complete necrosis of the palatal tis-
sue (more than 50% of the former flap is involved).
In case of EHI 2–5, subsequent healing and re-­epithelialization of
the palatal tissue was monitored weekly during 8 weeks until colour
and structure of the tissue was similar to the surrounding area. The
wound area was classified as either partially or fully keratinized. In case
of partial keratinization, the wound area was again classified as par-
tially or fully keratinized 1 week later.
2.7 | Statistical analysis
Descriptive statistical analysis included mean values and standard
deviations (SD) of quantitative variables, while qualitative variables
were expressed with frequencies and valid percentages. EHI was
considered the main outcome variable and, in order to improve the
clinical interpretation of secondary wound healing, it was trans-
formed into a binary variable EHI 1 + 2 vs. EHI 3 + 4 + 5. Residual
palatal flap thickness was also transformed into a categorical vari-
able (1 mm vs. >1 mm).
Comparisons of patient characteristics and EHI according
to suture technique were carried out using Mann–Whitney U test
(quantitative variable) or chi-­square test (Fisher test when expected
frequencies <5) in case of qualitative variables.
Relationships between pre-­and postoperative palatal flap thick-
ness and EHI and other relevant variables were also analysed using
Mann–Whitney test and chi-­square (Fisher test when expected fre-
quencies <5). To disclose associations between some of the outcomes,
TA B L E 1 Comparison of EHI between criss-­cross and continuous suture groups
EHIa,b EHI 1 EHI 2
n = 36 n = 6 (16.7%) n = 12 (33.3%)
Criss-­cross suture 2.72 (1.36) 4 (66.7) 4 (33.3)
Continuous suture 2.67 (1.14) 2 (33.3) 8 (66.7)
Notes. EHI, early healing index.
a
Mean (standard deviation). bMann–Whitney U test p = 0.212. cChi-­square test.
the Spearman correlation coefficient was utilized. The significance of
differences over time for pain was sought using the Friedman test.
Finally, a multivariate logistic regression model for degree of
EHI ≥ 3 was carried out. Postoperative palatal flap thickness at 1, 3
and 6 mm were included as categorical independent variables (1 mm
vs. >1 mm) (adjusted for palatal suturing techniques, age, gender and
tobacco). All analyses were performed with R Studio for windows
(3.2.5 version, Boston, MA, USA). Statistical significance was set at
the alpha level of 0.05.
3 | R E S U LT S
A total of 40 patients were recruited; however, four patients were
dropouts: two did not complete the follow-­up period, one patient
did not follow the medical prescription, and one patient had gen-
eral health complications during the study. Therefore, a total of 36
patients (18 patients in each group) were included in the analysis.
The sample consisted of 22 females (61.1%) and 14 males (38.9%)
with a mean age of 41.60 (7.1) years (range 32–60 years). There were
no statistical significant differences between groups at baseline in
any of these variables (p > 0.05). Regarding tobacco use, four sub-
jects (11.1%) were current smokers of <10 cigarettes/day and no
significant differences between treatment groups were observed
(p = 0.999). Furthermore, a total of nine (25%) patients presented
necrosis (EHI 4 and 5).
3.1 | Association between suture technique and EHI
The mean EHI was 2.72 (1.36) for the criss-­cross group and 2.67
(1.14) for the continuous suture group. Ten (55.6%) and 8 (44.4%)
patients exhibited high values of EHI (3–5) in the criss-­cross and
continuous suture groups, respectively. There were no statistically
significant differences between the two groups (p = 0.215) (Table 1).
3.2 | Association between preoperative palatal
thickness and early healing
The mean values of preoperative palatal thickness were 3.5 (0.8)
mm, 4.2 (0.9) mm and 5.1 (0.9) mm at 1, 3 and 6 mm from the incision
line. At 3 mm of distance, statistical significant differences between
EHI 1–2 and EHI 3–5 were observed (p = 0.024), indicating less de-
gree of EHI with a thicker preoperative palatal mucosa (Table 2).
EHI 3 EHI 4 EHI 5
n = 9 (25%) n = 5 (13.9%) n = 4 (11.1%) p-­valuec
6 (66.7) 1 (20) 3 (75) 0.215
3 (33.3) 4 (80) 1 (25)
MAINO et al. | 981

When analysing the correlations between variables, negative
correlations reaching statistical significance were found between
EHI and preoperative mucosal thickness at 3 mm (ρ: −0.38; p = 0.021)
and 6 mm (ρ: −0.57; p < 0.001). Thus, when preoperative mucosal
thickness decreases, the degree of EHI increases (Supporting infor-
mation Table S1).
3.3 | Association between postoperative palatal flap
thickness and early healing
Regarding the residual flap thickness, in cases of EHI 1 and 2, the
values at 1, 3 and 6 mm from the incision line were 1.7 (0.5) mm, 1.9
(0.4) mm and 2.5 (0.7) mm. The corresponding values for EHI 3–5
were: 1.1 (0.4) mm, 1.2 (0.4) mm and 1.8 (0.6) mm. Statistical signifi-
cant differences between EHI 1–2 and EHI 3–5 were observed at the
three levels of measurements (Table 2).
At 1 week postoperatively, 17 (77.3%) patients with a resid-
ual flap thickness of 1 mm, measured at 1 mm from the incision
line, exhibited high values of EHI 3–5. On the contrary, 13 (92.9%)
subjects with a residual flap thickness >1 mm presented EHI of
1 and 2 (p < 0.001). The same trend of healing was seen at 3 mm
from the incision line. While 15 (88.2%) subjects showed EHI val-
ues ranging from 3 to 5 when the postoperative palatal flap thick-
ness was 1 mm, 16 (84.2%) patients with a residual flap thickness
>1 mm presented low values of EHI (1–2) (p < 0.001). Finally, at a
distance of 6 mm, all subjects (n = 6) with a postoperative palatal
flap thickness of 1 mm presented EHI values ranged between 3
and 5 (p = 0.003) (Figure 2).
Again, negative correlations reaching statistical significance
were observed between EHI and postoperative palatal flap thick-
ness at the three levels of measurements (1 mm: ρ: −0.62; p < 0.001;
3 mm: ρ: −0.63; p < 0.001; 6 mm: ρ: −0.50; p = 0.002). In this sense,
when postoperative flap mucosa decreases, the degree of EHI in-
creases (Supporting information Table S1).
The regression model is represented in Table 3. At 3 mm from
the incision line, a residual flap thickness of 1 mm showed greater
probability of secondary wound healing (OR = 7.671, 95% CI:
2.928–36.450).

TA B L E 2 Distribution of the different

Total EHI 1 + 2 EHI 3 + 4 + 5
preoperative and residual palatal flap
N = 36 N = 18 N = 18 p-­value
thickness and early healing values
Preoperative mucosal 3.5 (0.8) 3.7 (0.8) 3.3 (0.8) 0.124
thickness at 1 mm
Preoperative mucosal 4.2 (0.9) 4.4 (0.8) 3.9 (1.0) 0.024
thickness at 3 mm
Preoperative mucosal 5.1 (0.9) 5.5 (0.9) 4.7 (0.8) 0.059
thickness at 6 mm
Postoperative palatal flap 1.4 (0.5) 1.7 (0.5) 1.1(0.4) <0.001
thickness at 1 mm
Postoperative palatal flap 1.6 (0.6) 1.9 (0.4) 1.2 (0.4) <0.001
thickness at 3 mm
Postoperative palatal flap 2.1 (0.8) 2.5 (0.7) 1.8 (0.6) <0.001
thickness at 6 mm
Total days of pain 6.5 (3.2) 4.6 (1.2) 8.4 (3.6) <0.001

Notes. EHI, early healing index.

The comparison was made between EHI 1 + 2 versus EHI 3 + 4 + 5.
Bold numbers are statistically significant p-­value <0.05.

FIGURE 2 Early healing according to postoperative palatal flap thickness

982 | MAINO et al.

TA B L E 3 Multivariate logistic regression model for early healing and flap mucosa on the early healing after harvesting a connective
index tissue graft with the single-­incision technique. In general, no associa-

OR Adj 95% CI p-­value tion between suturing techniques and early healing was found.
After obtaining a standardized 1.5 mm thick graft, the palatal
Postoperative palatal flap 1.978 0.52–23.31 0.137
wound healing was assessed at 1 week postoperatively according to
thickness at 1 mm
the Early Wound Healing Index described by Fickl et al. (2014). In the
Postoperative palatal flap 7.671 2.93–36.45 0.046
thickness at 3 mm present study, the mean residual flap thickness at the centre of the

Postoperative palatal flap 0.482 0.03–7.89 0.609
thickness at 6 mm
Notes. OR Adj, adjusted odds ratio; CI, confidence interval.
Model adjusted for palatal suturing techniques, age, gender and tobacco.
OR Adj for the association between postoperative palatal flap thickness
and EHI 3–5.
3.4 | Patient’s pain perception
Pain level of patients was determined with VAS pain values. The
highest amount of pain was perceived on the first postoperative day
and gradually decreased in the subsequent days. After 8 days, the
majority of the patients referred almost absence of pain. No patient
referred pain after 16 days (Figure 3).
Negative correlations reaching statistical significance were
found between the number of days of discomfort and residual flap
thickness measured at 1 mm (ρ: −0.407; p = 0.014), 3 mm (ρ: −0.408;
p = 0.014), and 6 mm (ρ: −0.337; p = 0.045). Thus, when the thick-
ness of the postoperative palatal flap increases, the number of days
of discomfort decreases.
Furthermore, a positive correlation was found between the de-
gree of EHI and prolonged morbidity (ρ: 0.764; p < 0.001). In this
sense, when the degree of EHI increases, the number of days of dis-
comfort also increases (Figure 4).
4 | D I S CU S S I O N
The aim of this study was to investigate the influence of the suturing
technique and the thickness of the pre-­and postoperative palatal
harvested area was 1.40, 1.60 and 2.10 mm at 1, 3 and 6 mm from
the incision line, respectively. Moreover, the mean EHI was 2.72 for
criss-­cross group and 2.67 for continuous suture group. These val-
ues are comparable with those reported by Fickl et al. (2014), who
referred a mean EHI value of 2.5 in the single-­incision groups after
harvesting a SCTG.
The results of the present study showed no statistical signif-
icant differences between the two groups when comparing the
effect of suturing techniques on early healing. Although there
are no data available concerning this issue, Burkhardt and Lang
(2005) reported better revascularization after 3–7 days using mi-
crosurgical instruments and polypropylene 7-­0 sutures compared
to conventional surgical techniques as used in this research (i.e.
silk 4- ­0 ).
In the present investigation, a significant association between
postoperative palatal flap thickness and EHI was observed. These
results indicate that a thickness of 1 mm in the first 3 mm of the flap
may not be enough to provide the sufficient blood supply for wound
healing without clinical signs of necrosis. In fact, a residual flap thick-
ness of 1 mm showed greater probability of secondary wound heal-
ing (OR = 7.67). On the contrary, better results on early healing were
shown when the residual flap thickness was >1 mm.
Thus, the more vascularization in the first millimetres of the
flap from the incision line, the less necrosis of the residual flap.
These results could be explained by the histomorphometric char-
acteristics of the palatal mucosa. It has been suggested that within
the first millimetre, 0.25 mm was occupied by keratinized epithe-
lial cells, while the remaining thickness of 0.75 mm accommodates
the epithelial lamina propria with the residual connective tissue
crossed by the course of blood vessels (Prestin, Rothschild, Betz,
& Kraft, 2012). Moreover, the vessels contained in the first milli-
metre of thickness showed a thinner epithelial wall compared to

F I G U R E 3 Postoperative pain
perception per day expressed in visual
analogue scale (VAS) values
MAINO et al.
FIGURE 4 Number of days of pain according to the early healing
index (EHI)
the vessels located at 2 mm of depth; thus, the greatest vascular
contribution was found in the deeper palate area (Zuhr, Bäumer, &
Hürzeler, 2014).
These observations lead to infer that the thickness of the resid-
ual flap plays a critical role on the vascular supply to prevent necrosis
and how it should gradually increase when moving from the incision
line to the deeper portion of the palate. In fact, at a distance of 6 mm,
all subjects with a postoperative palatal flap thickness of 1 mm pre-
sented EHI values ranged between 3 and 5. Other authors had also
underlined the role of blood supply on the healing of the residual
palatal flap. Broome and Taggart (1976) observed better healing
when the incision of the trap door technique was located mesially
in comparison with a distal incision. Therefore, a more compromised
healing was assessed when the incision was located distally, jeop-
ardizing vascularization. These findings are also in agreement with
those reported by Del Pizzo et al. (2002), who evaluated the clinical
wound healing at the palatal donor site by comparing different sur-
gical procedures to obtain SCTG. The results showed less secondary
healing when the single-­incision technique was used compared to
the trap door approach.
Our research found an association between the preoperative
thickness of the palatal mucosa measured at 3 mm from the inci-
sion line and the healing index. Therefore, the thicker the palatal
mucosa, the lower values of EHI. In this context, after obtaining a
1.5-­mm-­thick SCTG using the single-­incision technique, the residual
flap thickness will be greater with a 0.5–1 mm of periosteum cover-
ing the underlying bone.
Perceived pain following palatal graft harvesting was evaluated
using the psychometric tool of VAS. The present study showed
that perceived pain was the highest at the first postsurgical day
and decreased to presurgical levels after 2 weeks. Burkhardt et al.
(2015) described the first 3 days as the “acute phase” where pain
perception seemed to be at its highest level, and it was contin-
uously decreasing reaching very low levels after 2 weeks. The
pronounced pain reduction within the first week after graft har-
vesting might be explained by the stability of the blood clot pro-
vided by the residual flap, which protected the highly innervated
palatal periosteum (Weisel, 2007). Our investigation showed a
| 983
correlation between postoperative palatal flap thickness at 1, 3
and 6 mm and number of days of discomfort. A greater residual
palatal flap thickness resulted in a less prolonged pain. These re-
sults were in agreement with those reported by Zucchelli et al.
(2014) and Burkhardt et al. (2015), who evaluated 60 and 90
patients, respectively, and agreed that the residual thickness of
palatal mucosa was directly correlated to the intensity of pain per-
ceived. In this context, Mercadante (1997) and Burkhardt et al.
(2015) concluded that pain in the hard palate is caused by me-
chanical stimulus of the periosteum. According to these studies,
an anatomical barrier was provided by the residual palatal flap,
which stabilized the blood clot protecting the underlying sensi-
tive periosteum. This could explain the reduced pain perceived by
patients with increased thickness of the pre-­and postoperative
palatal measurements in the donor area.
It should be mentioned that Cortellini et al. (2009) reported that
a longer chair time (i.e. 17 min) to perform CAF + CTG compared to
CAF alone could have influenced some clinical parameters such as
inflammation and swelling at the recipient site; however, no data
were reported regarding the donor site. Cairo et al. (2012, 2016) also
confirmed higher postoperative morbidity and anti-­
inflammatory
medication consumption when performing CAF + CTG compared to
CAF alone, although in these studies, no data were reported regard-
ing the donor site either.
Moreover, a positive correlation was found between the degree
of EHI and prolonged morbidity. In fact, secondary wound healing
was associated to a higher amount of sloughing which has been ad-
vocated as the main cause of marked postoperative discomfort by
several authors (Edel, 1974; Harris, 1997; Jahnke, Sandifer, Gher,
Gray, & Richardson,1993).
The current investigation yields some limitations. The postoper-
ative flap mucosa was not a random variable and the methodology
used to perform the thickness measurements was probably less pre-
cise compared to an ultrasonic device. Furthermore, the SCTG was
harvested with a single blade and single-­incision technique; hence,
the standardization of the thickness of the graft could have been
imprecise. On the other hand, the surgical time for the harvesting
procedure was not calculated for every patient. Finally, for the mul-
tivariate analysis, due to the low number of patients who presented
necrosis, it was established a threshold for an impaired wound heal-
ing (i.e. EHI of 3).
5 | CO N C LU S I O N S
Within the limitations of our study, it can be concluded that: (a) there
is no association between the suture technique and the early wound
healing index; (b) postoperative palatal flap thickness seems to af-
fect the early wound healing of the donor site; (c) the greater the
postoperative palatal flap thickness, the less intensity of the pain
perceived by patients; and (d) an increased secondary wound healing
resulted in a more prolonged discomfort.
984 | MAINO et al.
C O N FL I C T O F I N T E R E S T
The authors have stated explicitly that there is no conflict of interest
in connection with this article. The study was self-­funded.
ORCID
Giovanni N. E. Maino http://orcid.org/0000-0002-2574-8109
Cristina Valles https://orcid.org/0000-0002-2690-1208
José Nart http://orcid.org/0000-0002-2363-4992
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How to cite this article: Maino GNE, Valles C, Santos A,
Pascual A, Esquinas C, Nart J. Influence of suturing technique
on wound healing and patient morbidity after connective
tissue harvesting. A randomized clinical trial. J Clin Periodontol.
2018;45:977–985. https://doi.org/10.1111/jcpe.12960

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