The International Journal of Periodontics & Restorative ... · antibiotics to prevent complications...

The International Journal of Periodontics & Restorative Dentistry

The use of connective tissue grafts inperiodontal surgery has increasedtremendously over the years.Originally, connective tissue graftswere used as replacements for auto-genous masticatory mucosa grafts(free gingival grafts).1,2 The connec-tive tissue grafts offered severaladvantages over free gingival grafts,probably the most important ofwhich is fewer complications in thedonor area. Recently, the connec-tive tissue graft has found many usesbeyond its original function as a sub-stitute for the free gingival graft.

A connective tissue graft hasbeen shown to be effective in restor-ing deformed edentulous ridges.3,4

This can permit placement of moreideal prosthetic restorations. How-ever, probably the greatest use ofconnective tissue grafts is for root-coverage procedures. Many authorshave demonstrated, with multipletechniques, that esthetic root cov-erage can be predictably obtain-ed.5–10 These root-coverage proce-dures may be performed for a widevariety of reasons, including elimi-nation of sensitivity, elimination of aplaque trap, treatment or preven-

Complications with Surgical ProceduresUtilizing Connective Tissue Grafts: A Follow-up of 500 ConsecutivelyTreated Cases

Randall J. Harris, DDS* Richard Miller, DDS** Laura Harris Miller, DDS** Christopher Harris, DDS***

The goal of this study was to evaluate the incidence and severity of the complica-tions that occur after connective tissue grafts are used. Five hundred consecutive-ly treated patients, for whom connective tissue grafts were used for root cover-age or gingival augmentation, were included in this study. Complications didoccur, but the rates and intensities seemed clinically acceptable. There was nopain reported in 81.4% of the patients, no bleeding in 97.0% of the patients, noinfection in 99.2% of the patients, and no swelling in 94.6% of the patients. Noneof the factors evaluated in this study were associated with a statistically significantincrease in the rate or intensity of complications. These factors included: age, sexof patient, smoking status, purpose of the graft (ie, for root coverage or for gingi-val augmentation), size of the recipient area, and the location of the defect beingtreated. Based on the results of this study, the incidence and severity of complica-tions seemed to be clinically acceptable. (Int J Periodontics Restorative Dent2005;25:449–459.)

*Private Practice, Reno, Nevada. **Graduate Student, Department of Periodontology, University of

Nebraska School of Dentistry, Lincoln, Nebraska.***Resident, Department of Oral and Maxillofacial Surgery, Baylor

College of Dentistry, Dallas, Texas.

Correspondence to: Dr Randall J. Harris, 855 West Seventh Street,Suite 24, Reno, NV 89503; fax: (775) 333-9364.

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Volume 25, Number 5, 2005

tion of root caries, treatment of amucogingival defect, or treatmentfor purely esthetic reasons. Anotherpossible use of a connective tissuegraft is for regenerative procedures.In recent case reports, human histo-logic evaluation of the results re-vealed regeneration in a recessiondefect treated with a connective tis-sue graft.11,12 Certainly, the numberof uses for connective tissue graftswill increase in the future.

Various techniques have beenproposed to obtain connective tissuegrafts. All have been shown to beeffective.5–7,9,10,13 However, little hasbeen documented on the possiblecomplications when a connective tis-sue graft is used. Reiser et al14 dis-cussed the anatomic considerationsin obtaining a connective tissue graft.This is critical in preventing compli-cations. Harris15 compared palatalsloughing when two connective tis-sue graft harvesting techniques wereused. Jahnke et al16 discussed palatalsloughing and its relation to verticalincisions when harvesting a connec-tive tissue graft. Calura et al17 exam-ined connective tissue grafts versusfree gingival grafts. They described aless painful donor area and fasterhealing in the recipient area with con-nective tissue grafts. Harris18 re-ported on the histologic makeup ofconnective tissue grafts in humans.However, there have been no largestudies to examine the incidence andseverity of complications when usingconnective tissue grafts.

The incidence and severity ofcomplications following periodon-tal surgery was reported by Curtis etal.19 However, the mucogingival sur-

gical treatment did not include con-nective tissue grafts. The ability ofvarious medications to control painafter periodontal surgery,20–25 theincidence of infection and the use ofantibiotics to prevent complicationsafter periodontal surgery,26–29 andthe value of periodontal dress-ings30–32 have all been reported.However, these articles do notaddress the potential complicationswhen connective tissue grafts areused. The goal of this study was toexamine the incidence and severityof complications following root cov-erage and gingival augmentationprocedures that involve a connec-tive tissue graft.

Method and materials

Five hundred consecutively treatedpatients were included in this study.All were treated with a surgical pro-cedure that involved a connectivetissue graft. There were 479 patientswho were treated with connectivetissue grafts for root-coverage pro-cedures. In all of these cases the pro-cedure involved a subepithelial graft(a connective tissue combined witha pedicle graft). Twenty-one patientswere treated with a connective tissuegraft in an attempt to achieve gingi-val augmentation without root cov-erage. Patients who received a con-nective tissue graft for augmentationof an edentulous ridge were notincluded in this study. The reasonfor excluding these patients was thelarge amount of variability in thelocations at which these grafts wereobtained, size of the grafts, and how

the grafts were used. In patients inwhom there might be multiple goalsof the surgical procedure, the patientwas assigned to a group based onthe primary goal of the procedure.

The mean age of the 500patients was 40.8 years old (range 14to 80, standard deviation 14.1). Thisgroup included 303 female and 197male patients. All patients weretreated by one of the authors in pri-vate practice. No attempt was madeto control the makeup of the group.Patients were included in the studybased solely on when they pre-sented for treatment. Any patienttreated with a connective tissue graftfor root coverage or gingival aug-mentation was included in this study.Since this study was solely interestedin looking at the complications thatoccurred, no attempt was made tolimit the patients to cases with MillerClass I or Class II defects.33 SinceMiller Class III and Class IV33 caseswere not excluded, mean root cov-erage and changes in keratinized tis-sue levels were not reported. Theseclinical changes have been reportedin many studies.34 The overall levelof health of the patients varied butin all situations was judged to beadequate to permit periodontal sur-gical procedures.

All surgical procedures wereperformed as previously described.When the goal was root coverage,the connective tissue graft was cov-ered or at least partially covered withan overlaying pedicle, as describedby Langer and Langer6 or Harris.10

Gingival augmentation was accom-plished in a similar manner to a con-ventional free gingival graft. The only

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under investigation were associatedwith increased or decreased com-plications. Each factor was evaluatedindividually. A Chi-square test wasused. Since there are no data avail-able on what results should beexpected, it was impossible to deter-mine an a priori hypothesis for sta-tistical analysis. Therefore, the entiregroup of 500 patients was used todetermine what would be ex-pected.35 A separate Chi-square wasused for each factor under investi-gation. If a statistically significantChi-square was found, follow-uptesting was done to determinewhich grouping was statistically dif-ferent.35

and severe complications requiredoperator visualization.”19p598 Exam-ples of the complications are shownin Figs 1 to 3. Pain was the mostsubjectively evaluated item. Figure 1shows a patient in whom the healingappeared normal. However, thepatient reported severe pain. Finalhealing at 10 months revealed com-plete root coverage. The donor areaof a different case that developed aninfection is shown in Fig 2. By 10 dayspostoperative, there were no signs ofinfection (see Fig 2c). An example ofa case with moderate pain, bleeding,and swelling is shown in Fig 3.

The secondary goal of thisstudy was to determine whetherany factors were associated withincreased or decreased complica-tions. The factors under investiga-tion included: age (greater than orless than the mean age of 40.8years old), sex of patient, smokingstatus (patients who smoked, re-gardless of frequency, were desig-nated as smokers), whether thegraft was used for root coverage orgingival augmentation, size of therecipient area (one, two, or threeor more defects), and location ofthe defect(s) (maxillary anterior,maxillary posterior, mandibularanterior, or mandibular posterior). Incases where the connective tissuegraft was in more than one loca-tion, the location where the major-ity of the graft was placed was usedto classify the patient. The “other”category of complications wasgrouped based on what they wereand reported.

Statistical analysis was done todetermine whether any of the factors

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modification was that a connectivetissue graft was used and the epithe-lial border was allowed to remain onthe connective tissue graft.

The connective tissue graftswere removed with a scalpel withparallel blades (Harris Double BladeGraft Knife), as previously de-scribed.10,15 The donor areas werepalatal to the molars and premolars.In all cases, an acrylic surgical stentwas placed over the donor area.Routine postoperative care wasgiven as previously described.10

Unless there was a medical reasonnot to use a certain medication,patients were placed on a non-steroidal anti-inflammatory drug,chlorhexidine rinse, and a narcoticpreparation, if needed, for pain. Nosystemic antibiotics were used,unless indicated as a prophylaxis fora medical condition.

Complications were divided intofive categories: pain, bleeding, infec-tion, swelling, and other. Themethod used to describe the inten-sity was that of Curtis et al.19 At allpostoperative visits and all otherpatient-doctor interactions, thepatients were evaluated for compli-cations. As Curtis et al suggested,“The authors empirically correlatedthe subjective and objective data tocreate a nominal variable (0 = none,1 = minimal, 2 = moderate, and 3 =severe) used in statistical analysis.The criteria established to deter-mine whether postoperative com-plications were present includedboth patient-related and operator-visualized findings. Complicationswere graded as nonexistent, mini-mal, moderate, or severe. Moderate

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Fig 1 Patient who reported severe pain,despite what clinically appeared to be nor-mal healing.

Fig 1a (left) Preoperative appearance ofmaxillary right premolars.

Fig 1b (right) Reflection of partial-thickness pedicle.

Fig 1c (left) Connective tissue graftsutured over defects.

Fig 1d (right) Final pedicle sutured overconnective tissue graft.

Fig 1e (above left) Donor area sutured.

Fig 1f (above center) Recipient area at 2weeks postoperative.

Fig 1g (above right) Donor area at 2weeks postoperative. The area appearedto be healing well, but the patient report-ed severe pain.

Fig 1h (left) Recipient area at 10 monthspostoperative. Root coverage is complete.

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Fig 2 (above) Donor area in a patient who suffered aninfection.

Fig 2a (above left) Donor area sutured at time of surgery.

Fig 2b (above center) Donor area at 4 days postopera-tive. Note area of infection (arrows).

Fig 2c (above right) Donor area at 10 days postopera-tive. All signs of infection are gone.

Fig 3 (below) Clinical views of patient who experiencedmoderate pain, bleeding, and swelling after graftingaround the mandibular left canine.

Fig 3a (below left) Preoperative view.

Fig 3b (below center) Connective tissue graft suturedover defects.

Fig 3c (below right) Pedicle sutured over connective tis-sue graft.

Fig 3d (above) Recipient site at 2 weekspostoperative.

Fig 3e (right) Recipient site at 2 monthspostoperative.

Results

Four hundred seven patients (81.4%)reported no pain. Seventy-onepatients (14.2%) reported minimalpain, 15 patients (3.0%) reportedmoderate pain, and 7 patients (1.4%)reported severe pain (Table 1).

No postoperative bleedingoccurred in 485 patients (97.0%).Minimal bleeding occurred in 11patients (2.2%), moderate bleedingoccurred in 1 patient (0.2%), andsevere bleeding occurred in 3patients (0.6%) (see Table 1). In allthree of the severe bleeding cases,

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the bleeding occurred at least 4 daysafter the surgery, from the donorarea, and after regular office hours.In all cases, the bleeding stoppedafter the donor area wound wasdebrided, irrigated, and resutured.No additional bleeding occurred inany of these cases.

There was no infection in 496patients (99.2%). One patient expe-rienced a minimal infection. This waslocalized to the area around thesuture used to close the palatalwound (see Fig 2). Moderate infec-tion occurred in two patients. Both ofthese infections were in the recipientarea and were limited to the areaimmediately adjacent to the graftedarea. One patient had a severe infec-tion that extended beyond the localsurgical area (see Table 1).

No swelling was seen in 473(94.6%) of the patients. Minimalswelling (15 patients) was definedas swelling limited to the immedi-ate surgical area. In moderateswelling (10 patients), the swellingextended beyond the immediatesurgical area. Severe swelling (2patients) was defined as swellingthat noticeably resulted in distor-tion of facial features (see Table 1).

No statistically significant differ-ence could be detected based onany possible factor under evalua-tion. These factors included age(Table 2), sex (Table 3), smoking sta-tus (Table 4), purpose of the graft(Table 5), size of the recipient area(Table 6), and location of the defect(s)(Table 7). Other complications arereported in Table 8.

Table 2 Complication rate with respect to patient age*

Complication/Severity, no. of patients (%)

age None Minimal Moderate Severe Chi-square†

PainAge > mean 204 (83.3) 25 (10.2) 11 (4.5) 5 (2.0)

10.57Age < mean 203 (79.6) 46 (18.0 ) 4 (1.6) 2 (0.8)

BleedingAge > mean 236 (96.3) 6 (2.5) 1 (0.4) 2 (0.8)

1.57Age < mean 249 (97.7) 5 (2.0) 0 (0.0) 1 (0.4)

InfectionAge > mean 243 (99.2) 0 (0.0) 2 (0.8) 0 (0.0)

4.00Age < mean 253 (99.2) 1 (0.4) 0 (0.0) 1 (0.4)

SwellingAge > mean 229 (93.5) 9 (3.7) 7 (2.9) 0 (0.0)

4.48Age < mean 244 (95.7 ) 6 (2.4) 3 (1.2) 2 (0.8)

OtherAge > mean 213 (86.9) 24 (9.8) 4 (1.6) 4 (1.6)

6.25Age < mean 230 (90.2) 24 (9.4) 0 (0.0) 1 (0.4)

*No. of patients: Age > mean (40.8 y) = 245; Age < mean = 255.†Degrees of freedom = 3; alpha = .01; critical level = 11.34.

Table 1 Summary of results (N = 500)

Severity, no. of patients (%)

Complication None Minimal Moderate Severe

Pain 407 (81.4) 71 (14.2) 15 (3.0) 7 (1.4)Bleeding 485 (97.0) 11 (2.2) 1 (0.2) 3 (0.6)Infection 496 (99.2) 1 (0.2) 2 (0.4) 1 (0.2)Swelling 473 (94.6) 15 (3.0) 10 (2.0) 2 (0.4)Other 443 (88.6) 48 (9.6) 4 (0.8) 5 (1.0)

Discussion

The incidence of complications afterconnective tissue grafts is relativelylow. Certainly, with any surgical pro-cedure, complications are possible.However, this study demonstratesthat the occurrence of complicationswith connective tissue grafts wouldbe considered by most clinicians tobe in an acceptable range.

The results of this study com-pare well with the results of Curtis et al,19 who evaluated soft tissue surgery, osseous surgery, and muco-gingival surgery. They reportedmoderate or severe postoperativecomplications in 5.5% of the cases.Postoperative pain was severe in4.6% of patients, moderate in 44.1%,minimal in 20.4%, and nonexistent in 30.9% of patients. Bleeding wassevere in 0.0%, moderate in 1.0%,minimal in 22.4%, and nonexistent in76.6% of the cases. Infections weresevere in 0.3%, moderate in 1.0%,minimal in 2.3%, and nonexistent in96.4% of the cases. Swelling wassevere in 0.7%, moderate in 0.3%,minimal in 21.0%, and nonexistent in78.0% of the cases. Their resultsshow a higher rate of complicationsthan in the present study in all areasexcept one. In the present study,severe bleeding occurred in 0.6% of the cases; this did not happen atall in the cases reported by Curtis et al.19

One difference between thepresent study and that of Curtis etal19 is in the number of factorspotentially influencing postopera-tive complications. Curtis et alexamined the same factors as the

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Table 3 Complication rate with respect to sex*


sex None Minimal Moderate Severe Chi-square†

PainMale 159 (80.7) 34 (17.3) 4 (2.0) 0 (0.0)

7.73Female 248 (81.9) 37 (12.2) 11 (3.6) 7 (2.3)

BleedingMale 191 (97.0) 3 (1.5) 0 (0.0) 3 (1.5)

5.94Female 294 (97.0) 8 (2.6) 1 (0.3) 0 (0.0)

InfectionMale 196 (99.5) 0 (0.0) 1 (0.5) 0 (0.0)

1.40Female 300 (99.0) 1 (0.3) 1 (0.3) 1 (0.3)

SwellingMale 192 (97.5) 3 (1.5) 2 (1.0) 0 (0.0)

5.52Female 281 (92.7) 12 (4.0) 8 (2.6) 2 (0.7)

OtherMale 176 (89.3) 20 (10.2) 0 (0.0) 1 (0.5)

3.51Female 267 (88.1) 28 (9.2) 4 (1.3) 4 (1.3)

*No. of male patients = 197; female patients = 303.†Degrees of freedom = 3; alpha = .01; critical level = 11.34.

Table 4 Complication rate with respect to smoking status*


smoking status None Minimal Moderate Severe Chi-square†

PainSmokers 54 (79.4) 12 (17.7) 1 (1.5) 1 (1.5)

1.31Nonsmokers 353 (81.7) 59 (13.7) 14 (3.2) 6 (1.4)

BleedingSmokers 66 (97.1) 1 (1.5) 0 (0.0) 1 (1.5)

1.34Nonsmokers 419 (97.0) 10 (2.3) 1 (0.2) 2 (0.5)

InfectionSmokers 67 (98.5) 1 (1.5) 0 (0.0) 0 (0.0)

6.83Nonsmokers 429 (99.3) 0 (0.0) 2 (0.5) 1 (0.2)

SwellingSmokers 66 (97.1) 2 (2.9) 0 (0.0) 0 (0.0)

1.94Nonsmokers 407 (94.2) 13 (3.0) 10 (2.3) 2 (0.5)

OtherSmokers 57 (83.2) 9 (13.2) 0 (0.0) 2 (2.9)

4.88Nonsmokers 386 (89.4) 39 (9.0) 4 (0.9) 3 (0.7)

*No. of smokers = 68; nonsmokers = 432.†Degrees of freedom = 3; alpha = .01; critical level = 11.34.

present study, with the exception ofsmoking. Additionally, they consid-ered race, systemic disease, aller-gies, medications, duration of thesurgery, periodontal case classifica-tion, and whether or not peri-odontal dressings were used. Thisincreased number of potential fac-tors allowed for a meaningful use ofmultivariate analysis with regressionanalysis. Future studies looking atcomplications should consider anincreased number of potential fac-tors that may affect the outcome ofthe surgical procedure. The factorscould then be evaluated individu-ally, which was the intent of thisstudy, as well as collectively withregression analysis. This could pro-duce a risk factor analysis that maybe useful clinically. However, thiswas beyond the intent of this pres-ent study.

The major shortcoming of thisstudy—the impossibility of per-forming a blinded evaluation—is theresult of it being completed in pri-vate practice. Additionally, the eval-uation of pain, in a study where painmedications are used, is not asmeaningful when no pain medica-tions were used. However, this is nota reasonable approach in a fee-for-service private practice environ-ment.

The amount of root coverageand gingival augmentation ob-tained were not reported in thisstudy. Studies have reported thatconnective tissue grafts are effec-tive for root coverage5–10,15,16,34 andgingival augmentation.1,2,17 Thiswas not the intent of this study.Probably a smaller number of

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Table 5 Complication rate with respect to root coverage (RC)versus gingival augmentation (GA)*


purpose of graft None Minimal Moderate Severe Chi-square†

PainRC 390 (81.4) 68 (14.2) 14 (2.9) 7 (1.5)

0.53GA 17 (81.0) 3 (14.3) 1 (4.8) 0 (0.0)

BleedingRC 464 (96.9) 11 (2.3) 1 (0.2) 3 (0.6)

0.68GA 21 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)

InfectionRC 475 (99.2) 1 (0.2) 2 (0.4) 1 (0.2)

0.18GA 21 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)

SwellingRC 455 (95.0) 12 (2.5) 10 (2.1) 2 (0.4)

10.02GA 18 (85.7) 3 (14.3) 0 (0.0) 0 (0.0)

OtherRC 424 (88.5) 46 (9.6) 4 (0.8) 5 (1.1)

0.40GA 19 (90.5) 2 (9.5) 0 (0.0) 0 (0.0)

*No. of patients: RC = 479; GA = 21.†Degrees of freedom = 3; alpha = .01; critical level = 11.34.

Table 6 Complication rate with respect to size of recipient area (number of defects treated)*


no. of defects None Minimal Moderate Severe Chi-square†

Pain1 232 (79.7) 46 (15.1) 8 (2.8) 5 (1.7)2 146 (83.4) 21 (12.0) 6 (3.4) 2 (1.1) 2.913 or more 29 (85.3) 4 (11.8) 1 (2.9) 0 (0.0)

Bleeding1 282 (96.8) 7 (2.4) 1 (0.3) 1 (0.3)2 170 (97.1) 4 (2.3) 0 (0.0) 1 (0.6) 4.353 or more 33 (97.1) 0 (0.0) 0 (0.0) 1 (2.9)

Infection1 288 (99.0) 1 (0.3) 1 (0.3) 1 (0.3)2 174 (99.4) 0 (0.0) 1 (0.6) 0 (0.0) 1.733 or more 34 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)

Swelling1 272 (93.5) 11 (3.8) 6 (2.1) 2 (0.7)2 169 (96.6) 2 (1.1) 4 (2.3) 0 (0.0) 5.853 or more 32 (94.1) 2 (5.9) 0 (0.0) 0 (0.0)

Other1 261 (89.7) 25 (8.6) 1 (0.3) 4 (1.4)2 153 (87.4) 18 (10.3) 3 (1.7) 1 (0.6) 5.353 or more 29 (85.3) 5 (14.7) 0 (0.0) 0 (0.0)

*No. of patients: 1 defect = 291; 2 defects = 175; 3+ defects = 34.†Degrees of freedom = 6; alpha = .01; critical level = 16.81.

patients could have been used.However, the intent was to includeas many patients as possible so thatall of the divisions, based on thefactors, would include at least five(1%) of the cases. This did not occurbecause there were few complica-tions. However, a Chi-square wasstill used, because the resultsrevealed no statistically significantresults. If a statistically significantChi-square had been found in a sit-uation with fewer than five cases,then additional statistical testingwould have been needed.35

Other surgical techniques usingdifferent materials have been sug-gested as replacements for surgicaltechniques that employ connectivetissue grafts. A free gingival graftcan be used in place of a connec-tive tissue graft for gingival aug-mentation.34 Guided tissue regen-eration34 and acellular dermalmatrix36 have been suggested asreplacements for connective tissuegrafts for root coverage. Additionalstudy into the incidence and sever-ity of the complications of theseprocedures is needed; this willmake it possible for clinicians tochoose not only the most pre-dictable procedure, but also theprocedure with the fewest and leastsevere complications and will per-mit an evidence-based evaluationof the risks and rewards of proce-dures that can be used to treat sim-ilar situations.

Based on the results of thisstudy, the rate and severity of thecomplications associated with con-nective tissue grafts seem manage-able and clinically acceptable.

Certainly, connective tissue graftsare not a perfect procedure. As withany surgical procedure, some com-plications do occur. However, therate and severity of complicationswith connective tissue grafts are rel-atively low.

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Table 7 Complication rate with respect to location of defect(s)*


location None Minimal Moderate Severe Chi-square†

PainMax ant 95 (97.4) 16 (14.0) 1 (0.9) 2 (1.8)Max post 49 (76.6) 11 (17.2) 2 (3.1) 2 (3.1)

16.37Mand ant 162 (86.2) 23 (12.2) 3 (1.6) 0 (0.0)Mand post 101 (75.4) 21 (15.7) 9 (6.7) 3 (2.2)

BleedingMax ant 111 (97.4) 2 (1.8) 0 (0.0) 1 (0.9)Max post 61 (95.3) 2 (3.1) 0 (0.0) 1 (1.6)


InfectionMax ant 114 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)Max post 64 (100.0) 0 (0.0) 0 (0.0) 0 (0.0)


SwellingMax ant 105 (92.1) 8 (7.0) 0 (0.0) 1 (0.9)Max post 62 (96.9) 0 (0.0) 2 (3.1) 0 (0.0)


OtherMax ant 104 (91.2) 7 (6.1) 1 (0.9) 2 (1.8)Max post 58 (90.6) 3 (4.7) 2 (3.1) 1 (1.6)


*No. of patients: maxillary anterior (max ant) = 114; maxillary posterior (max post) = 64; mandibularanterior (mand ant) =188; mandibular posterior (mand post) = 134.†Degrees of freedom = 9; alpha = .01; critical level = 21.67.

Acknowledgments

We would like to thank Linda Harris for herhelp during the clinical phase of this study,the collection of the data, and the writing ofthis manuscript. The Harris Double BladeGraft Knife used in this study was designedby one of the authors. We would like to thankBill and Vince Holden (of H & H Company) formanufacturing this instrument, as well as sev-eral other instruments used in this study.

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Table 8 Frequency of complications designated as “other”

Type of complication n (%)

Minimal complications Periodontal dressing fell off 9 (1.8) Periodontal dressing removed by patient 9 (1.8) Trauma to recipient area 6 (1.2) Recipient area was sensitive 6 (1.2) Ecchymosis (limited) 5 (1.0) Nausea from medication 5 (1.0) Donor area sutures were loose or annoying 4 (0.8) Recipient area sutures were loose or annoying 4 (0.8) Patient concerned about dressing feeling loose 4 (0.8) Donor area suture fell out 3 (0.6) Palatal stent irritated palate 1 (0.2) Total 56*

Moderate complications Temporary paresthesia in donor area 2 (0.4) Ecchymosis (over large area) 1 (0.2) Nausea and vomiting from medication 1 (0.2) Total 4 (0.8)

Severe complications Allergic reaction requiring medical intervention 2 (0.4) Paresthesia in donor area that continued beyond final postoperative appointment (3 mo) 1 (0.2) Treated tooth cracked and had to be extracted 1 (0.2) Surgery was "very stressful" for patient 1 (0.2) Total 5 (1.0)

*Note:There were 56 minimal “other”complications in 48 patients.This was 9.6% of the 500 patients.Eight of the patients experienced 2 minimal ”other”complications.

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