1.
Akemi Arzouman, David E. Deas, Michael P. Mills, Guy Huynh-Ba, Thomas J. Prihoda, Brian L. Mealey
Impact of Different SurgicalProtocols on Dimensional Changes of FreeSoft TissueAutografts. A
Randomized ControlledTrial
27 JULY 2020

2.
AIM
To determine if there is a difference in the amount of shrinkage during
healing of free soft tissue autografts (FSTA) using different surgical
techniques—suturing the vestibular flap margin apically to the base of
the recipient bed versus leaving the flap margin free and unsutured.

3.
INTRODUCTION
• Mucogingival surgery – Kim et al
• Novaes et al
• Controversy
• 2015 regeneration workshop by AAP
• FSTA
• Sullivan and Atkins – Shrinkage
• Robinson et al
• Gümüs and Bunduneli – Graft stability
• Recipient bed preparation

4.
The primary outcome was change in vertical graft
dimension (apico-coronal graft height) over time.
Secondary outcomes were change in horizontal (mesio
-distal) graft width and total graft area.

5.
MATERIALS AND METHOD

6.
• Informed consent
• Stone models
• Clear thermoplastic stent
On day of surgical appointment:-
• Digital photographic image
• Periodontal probes
• Who…. ?
• Randomization – Control & Test
• How…. ?

7.
Inclusion criteria
• Study participants included premolar or incisor tooth/
teeth in the maxilla or mandible with <2mm of keratinized
tissue requiring a free soft tissue autograft.
• Patients could be non-smokers, former smokers who
had quit for at least 12 months, or current smokers who
smoked ≤10 cigarettes per day.
• Patients had a periodontal diagnosis of gingival health
on an intact or reduced periodontium or gingivitis.

8.
Exclusion criteria
• Unable to commit to the study re-call schedule,
smokers who smoked >10 cigarettes per day, pregnant
women or those intending to become pregnant.
• Those with an uncontrolled systemic disease other
than periodontitis, or those with an autoimmune
disease.

9.
Post surgery:-
• Pictures
• Graft measurements – Baseline (T0)
Vertical measurements
Distance from the apical extent of the stent to the
coronal most position of the graft in each groove of
the stent and the distance from the apical extent of the
stent to the apical most position of the graft in each
groove of the stent.

10.
The graft’s mesio-distal midpoint was
determined from the most central study tooth and
the distance from the apical portion of the stent to the
graft’s vertical midpoint was determined.
At this vertical midpoint of the graft, the graft’s
Horizontal length was measured with a periodontal
probe laid on its side in a flat plane, if the graft was of
similar or smaller length of the probe.

11.
If the graft was longer than the probe or in a
Curved plane, a piece of floss was extended over
the graft and marked with surgical marker, at one
edge of the graft and clamped with cotton pliers, at the
other end. The floss was then measured with a
standardized ruler to determine the width of the graft.

12.
• At the 1-month (T1), 3-month (T2), and 6-month
(T3) recall appointments, a photograph was taken
with the pre-assigned periodontal probe with and
without the patient’s stent in place.
• The same vertical measurements were made with the
pre-assigned periodontal probe and stent by the same
examiner who made measurements at T0.
• Horizontal measurements were made using the
previously determined vertical graft midpoint at the
time of surgery.

13.
RESULTS

14.
DISCUSSION
• Hatipoğlu et al who found 10.2% horizontal, 24.8%
vertical, and 32.1% area shrinkage after 6 months of
healing.
• James and McFall noted 25% vertical graft shrinkage at 6
months.
• In 3 month study, Silva et al noted 22% horizontal, 31%
vertical, and 44% area graft shrinkage in their control non
-smoker group.
• Other studies showed 32.5% and 23.3% area shrinkage at 6
months.
• These studies note a range in graft shrinkage for horizontal
dimensions of 10.2 to 22%, vertical dimensions of 24.8 to 31%,
and area dimensions of 23.3 to 44%.

15.
• 7 patients root coverage attempted.
• Donor FSTA thickness
• Shape of donor FSTA
• Follow up time points

16.
CONCLUSION
• FSTA graft shrinkage is a common occurrence during post-
operative healing. Modifications to the surgical procedures of
FSTAs have been examined to try to limit the amount of graft
shrinkage.
• The current findings indicate that management of the mucosal
flap margin by suturing the flap apically compared to leaving the
flap margin free does not affect the vertical dimensional
shrinkage of the FSTA after 6 months of healing.
• There was significant shrinkage of the grafts at all time points
- 1, 3 and 6 months - compared to the time of graft surgery, but
no significant difference between suturing techniques.

17.
REFERENCES