Free Gingival Graft Shrinkage on Periosteal Bed and Denuded Alveolar Bone Recipient Site: A Randomized Clinical Trial

Free Gingival Graft Shrinkage on Periosteal Bed and Denuded Alveolar Bone Recipient Site: A Randomized Clinical Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Free Gingival Graft Shrinkage on Periosteal Bed and Denuded Alveolar Bone Recipient Site: A Randomized Clinical Trial Shabnam Ganjehzadeh, Farid Shiezadeh, Amir Moeintaghavi, Zahra Shooshtari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4493177/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective There are several techniques to increase keratinized tissue, and free gingival grafting (FGG) is one of the most predictable methods. One of the main disadvantages of this method is the significant tissue shrinkage of the graft, so it is desirable to find a method that is associated with less shrinkage. The purpose of the present study was to compare graft shrinkage rates and postoperative pain intensity following FGG augmentation on periosteal beds and denuded alveolar bone. Methods & Materials : 22 FGGs with a thickness of 1 to 1.5 mm were placed in the area between the mandibular premolars. The recipient site for FGG was a periosteal bed in the control group and denuded alveolar bone in the experimental group. Dimensions of the grafts were recorded clinically by periodontal probe as well as taking photographs, and the pain were assessed with VAS scale, 1, 2, 4 and 8 weeks after surgery. The percentage of tissue shrinkage was calculated, and two 2 groups were compared. Results 22 patients (7 males and 15 females) completed the study and of these, 10 patients were in the experimental group (denuded bone bed), and 12 patients were in the control group (periosteal bed). At all times, the percentage of shrinkage in length, width and area in the control group (periosteum) was higher than the test group (bone). The highest percentage of shrinkage in all 3 parameters occurred in the control group related to the time between baseline and 1st week. In the experimental group, the highest percentage of length changes occurred between baseline and the 1st week and the highest percentage of width and area changes occurred between weeks 1 and 2. Changes in length, width and area between baseline and the first week and between baseline and week 8 were significant between the two groups. The mean pain in the control group (periosteum) was higher than the experimental group and only in the first week this difference was statistically significant. Conclusion It can be concluded that epithelialized gingival graft placed on the denuded bone bed is associated with less tissue shrinkage as well as less pain and discomfort in the recipient area during 8 weeks of follow-up compared to FGG placement on the periosteal bed. Epithelialized gingival graft periosteum denuded bone tissue shrinkage pain Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The clinical significance of surrounding keratinized gingiva, still remains a subject of controversy. Some clinicians believe that an adequate width of keratinized gingiva is essential in order to assure the periodontal health of natural teeth and dental implants [ 1 ]. On the contrary, multiple studies claim that insufficient keratinized gingiva will not be problematic in patients who are able to maintain good oral hygiene and avoid traumatic tooth brushing. Nevertheless, gingival reconstruction and mucogingival surgery are mandatory in some clinical conditions. Extensive (progressive) gingival recessions, high frenal attachments, pre-orthodontic thin alveolar mucosa (isolated gingival recessions in candidate patients for fixed orthodontic therapy), restorations with deep subgingival margins and inability to maintain an effective level of plaque control are all indications for surgical periodontal intervention [ 2 ]. Free gingival graft (FGG) augmentation is a traditional and widely used approach in periodontal therapy. This treatment approach entails enhancing tissue thickness, gaining keratinized gingiva width, correcting mucogingival deformities and improving aesthetics. Although this grafting technique yields promising results, it is associated with some disadvantages such as postoperative pain and patient discomfort, high risk for intraoperative bleeding in the donor site, requiring two separate surgical procedures and color mismatch at the recipient site (1). Development of epithelial inclusion cysts and oral (bony) exostosis have also been reported following FGG augmentation [ 3 , 4 ]. The necessity of recipient bed preparation has been speculated over time. Some studies state that preserving the periosteum is integral to soft tissue vascularization and stability. On the contrary the literature contains animal studies which have established that the presence or absence of the periosteum does not seem to significantly impact the survival, healing pattern and attachment of the FGG [ 5 ]. This was also confirmed by another animal study by Caffesse et.al. [ 6 ] which stated that the presence or absence of the periosteum in the recipient site does not seem to influence the long-term success and healing of the graft. When FGGs are placed over the denuded alveolar bone, no sign of wound healing is observed until seven days after grafting. However, this delay does not seem to jeopardize the survival of FGGs. Graft nutrition is sufficiently accomplished through the adjacent tissues and also the clot formed at the fibrinous interface [ 7 ]. Minimal graft mobility, less postoperative edema and improved hemostasis are among the advantages of covering denuded alveolar bone with FGG. Graft shrinkage after this method has also been reported to be 1.5 to 2 times less compared to free gingival grafting on the periosteum. However, despite these benefits, graft healing is delayed for approximately 14 days. Previous experimental studies have evaluated graft shrinkage 24 weeks after free gingival grafting. Grafts that were placed over periosteal beds exhibited a shrinkage rate of 50%, whereas FGGs placed on denuded bone only shrunk by 24%. Furthermore, Maximum surface shrinkage occurred within the first 6 weeks after free gingival grafting [ 8 ] . Postoperative graft shrinkage has been reported to be 1.5 to 2 times greater when grafting on the periosteum compared to when placed on denuded alveolar bone. However, postoperative pain did not seem to significantly differ. Bone sequestration was not observed regardless of the presence or absence of the periosteum. Therefore, in the presence of adequate alveolar bone volume, FGG augmentation on denuded bone is a viable treatment approach for increasing keratinized tissue dimensions [ 9 ]. As previously mentioned, postoperative graft shrinkage is one of the main concerns when covering the denuded alveolar bone. This requires (necessitates) harvesting a larger FGG from the donor site; consequently, leading to greater patient discomfort and postoperative pain. In this commentary adopting (establishing) a surgical technique that is associated with lower graft shrinkage rates would be of great clinical importance. The pertaining literature is relatively scarce, lacks sufficient clinical evidence, and mostly includes animal or case-series studies which fail to compare the efficacy of the two treatment methods. Hence, the purpose of the present study was to compare graft shrinkage rates and postoperative pain intensity following FGG augmentation on periosteal beds and denuded alveolar bone. Methods and Materials Study design and participants In order to address the research objective, the authors designed and implemented a randomized clinical trial. The protocol of this study was approved by the Research and Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.DENTISTRY.REC.1399.022) and was registered in the Iranian Registry of clinical Trials under the code: IRCT20200807048327N1. The study was conducted in accordance with all relevant principle of the Declaration of Helsinki and CONSORT statement. Subjects were only enrolled after obtaining informed written consent. Subjects were recruited from patients who admitted to the Periodontics Department of Mashhad Dental School, Mashhad, Iran from January 2022 to January 2023. Inclusion criteria were as follows: a) systematically healthy American anesthesiology association (ASA) status I or II b) participants exhibited at least one mucosal (gingival) recession defect between teeth number 20–29 that indicated soft tissue augmentation through FGG c) no evidence of alveolar bone resorption on periapical radiograph d) probing depth < 3mm e) plaque score < 20% f) ability to maintain appropriate oral hygiene. Exclusion criteria consisted of: a) any general contraindications for dental and oral surgery b) taking any medications that would interfere with the healing process c) lactating or pregnant women d) history of periodontitis e) uncontrolled diabetes f) smoking g) alcohol consumption h) severe dental crowding. Patients who finally met the above-listed inclusion and exclusion criteria were enrolled and randomly allocated to experimental and control groups. In the experimental group, FGG was placed over denuded alveolar bone whereas in the control group FGG augmentation was performed on a periosteal bed (The recipient site for FGG was a periosteal bed in the control group and denuded alveolar bone in the experimental group). Randomization was achieved using block randomization technique and the table of random numbers. Allocation concealment was accomplished through sequentially numbered opaque sealed envelopes. The patients and study evaluator were blind to group allotment (double-blind randomized clinical trial). Surgical procedure Prior to the periodontal surgery, the subjects were instructed on how to floss and brush their teeth using Modified Stillman and Bass techniques. Full mouth supragingival and subgingival debridement (Scaling and root planning (SRP)) were performed for all subjects prior to undergoing surgery. Vestibular buccal injections of 2% lidocaine with 1/100,000 epinephrine lidocaine was administered in order to obtain local anesthesia and achieve hemostasis. The recipient bed was prepared as follows: a horizontal incision and two vertical releasing incisions at a 90-degree angle were made using a scalpel blade number 15 at the mucogingival line, extending up to 3 millimeters beyond the grafting area. In the test group, the incisions were extended to the bone, and a full-thickness flap was elevated using blunt dissection, exposing a denuded bed on the bone surface (Fig. 1 ). In the control group, a split-thickness flap was prepared using sharp dissection, and a periosteal bed was created (Fig. 2 ). In case of mobility of the apical bed area, it was stabilized using Vicryl 4 − 0 sutures. An FGG was harvested from the palate, adjacent to the maxillary premolars, with a distance of 2 millimeters from the gingival margin, according to the required dimensions and with a thickness of 1-1.5 millimeters. Before transferring it into the oral cavity, measurements of length (mesiodistal dimension) and width (apicocoronal dimension) were taken (Fig. 3 ). The surrounding area of the recipient bed was beveled in order to maximize aesthetic outcome, and the harvested graft was adapted to the recipient site and secured with interrupted sutures using nylon 5 − 0 (Fig. 4 ). In case of mobility, horizontal sling sutures were also utilized. A gauze soaked in normal saline was placed over the FGG with gentle pressure for 5 minutes to ensure better adaptation. Donor site bleeding was controlled by applying pressure with gauze and suturing using silk 3 − 0. All surgical procedures were performed by the same clinician with over 10 years of experience (F.S). Postoperative care After 14 days the sutures were removed from the grafted site. During this time, patients were instructed to avoid brushing and flossing in the recipient region and also adhere to a soft-diet. Patients were allowed to gently brush coronal to the grafted site using a soft toothbrush, 2–3 weeks post-periodontal surgery. Patients were advised to apply an ice compress to the surgical area during the first 24 hours after surgery. Chemical plaque control was maintained using antimicrobial mouthwash (0.12% digluconate chlorhexidine), twice a day for 14 days. In order to control postoperative pain, analgesics (Novafen t.i.d) were prescribed for three days. The sutures in the palate were removed after one week and the sutures in the graft site were removed two weeks after surgery. Examined parameters Patients were recalled 1,2,4 and 8 weeks after the grafting procedure and were evaluated in terms of graft shrinkage and postoperative pain intensity. Evaluations were performed by a trained and calibrated staff member (S.G) who was blind to the study allotment. Subjects’ perception of postoperative pain in the grafted site was subjectively assessed using visual analogue scale (VAS) [ 10 ]. An intraoral photograph (1:1) was taken from the grafted site at each follow-up visit and the graft dimensions were also clinically measured using a Michigan O probe. The photographs were imported in to a website ( www.elief.net ) and measurements were completed online. Measurements were done at baseline (T0), 1 (T1), 2 (T2), 4 (T3) and 8 (T4), weeks postoperatively. Figure 5 and 6 demonstrate the measurements carried out for determining graft dimensions. To measure the mesiodistal dimension of the graft, a specific tooth was selected as the reference point (e.g., the mandibular right central incisor), and 2mm below the cementoenamel junction (CEJ) was marked along its midbuccal surface (axis). The obtained point was used to measure the mesiodistal length of the graft. For apicocoronal measurements, another tooth was taken as the reference (e.g., the mandibular left central incisor) and the apicocoronal dimension of the graft was measured along the midbuccal surface (axis) of the reference tooth. In order to enhance measurement accuracy and standardize potential photo magnifications, a fixed landmark (e.g., the length of the right mandibular canine) was established and considered constant in all follow-up photographs. In all samples, clinically recorded measurements with a probe were compared to the calculated measurements from the photographs, and if there was a significant difference of more than 1 millimeter between the two measurements, that particular sample was excluded from the results. After recording and completing the initial measurements, dimensional changes in the grafted area including; shrinkage in mesiodistal and apicocoronal graft dimensions (absolute value and percentage) as well as the overall graft shrinkage rate (percentage), were calculated between each postoperative interval. The overall graft shrinkage rate was calculated using this formula: $$Graft shrinkage rate =\left(Baseline surface area -Postoperative surface area\right)÷Basline surface area\times 100$$ Pain intensity values were also recorded through VAS scores at each follow-up visit. Sample size calculation and statistical analysis A prior pilot study was conducted and according to the obtained results the mean surface area changes over an 8-week period were determined to be 9.6 ± 5.26 mm 2 and 8.3 ± 2.18 mm 2 for the control and experimental groups, respectively. Sample size estimation was performed using the formula for comparing two means, considering a statistical power of 80% and confidence interval of 95%. Initially, 9 participants were deemed adequate for each group. To compensate for potential dropouts, the sample size was increased to 11 participants per group. Data were subjected to statistical analysis using SPSS version 23 (SPSS, Inc, Chicago, Illinois). Shapiro-Wilk test was used to assess if the variables follow a normal distribution. Additionally, for comparing gender distribution among the groups, chi-square and Fisher's exact tests were applied. Significance level was set at p-value < 0.05. Results A total of 22 subjects, comprising 15 (68%) females and 7 (32%) accomplished the study. The control group consisted of 8 (66.7%) female and 4 (33.3%) male participants, while the experimental group included 7 (70%) females and 3 (30%) males. Subjects in the control and experimental groups had a mean age of 38.2 ± 10.2 years and 44.6 ± 7.5 years, respectively. According to Independent sample T-test, there was no statistically significant difference between the two study groups in terms of mean age (p=). Fischer’s exact test revealed that the experimental and control groups were not significantly different regarding gender distribution frequency (p = 0.115). Subjects underwent free gingival grafting in the anterior and premolar regions of the mandible. All grafts healed uneventfully, without exhibiting any signs of sloughing or total graft necrosis. Tables 1 displays graft dimensional changes from baseline until 8 weeks after the grafting procedure. Since data pertaining to changes in graft dimensions and surface area changes, were distributed normally; Independent samples T-test was utilized. FGG augmentation over a periosteal bed, (i.e., the control group) resulted in 5.92% mesiodistal reduction (14.93mm vs 14.05mm), 13.15% apicocoronal reduction (6.46mm vs 5.61mm) and an overall shrinkage rate of 18.30%; when evaluated 8 weeks postoperatively. In cases where the FGG was placed over a denuded alveolar bone (the experimental group), the vertical and horizontal dimensions of the grafted site had shrunk by 9.53% (16.3mm vs 14.61mm) and 22.40% (6.83mm vs 5.30mm), respectively. The overall graft shrinkage rate in the control group was 30.82%. Table 1 The mean percentage of graft dimensional changes between different time intervals in different study groups Postoperative time interval T0-T1 T1-T2 T2-T3 T3-T4 T0-T4 Mesiodistal changes (mean ± SD (%)) Denuded alveolar bone 2.06 ± 0.69 1.86 ± 0.56 1.39 ± 0.65 0.72 ± 0.55 5.92 ± 1.12 Periosteal bed 4.57 ± 2.35 2.02 ± 2.20 2.19 ± 1.01 1.06 ± 0.69 9.53 ± 3.03 p-value 0.004 0.822 0.047 0.226 0.002 Apicocoronal changes (mean ± SD (%)) Denuded alveolar bone 4.32 ± 2.86 4.62 ± 1.76 3.17 ± 1.23 1.75 ± 0.80 13.19 ± 3.53 Periosteal bed 12.60 ± 7.88 5.68 ± 3.18 4.98 ± 3.88 2.24 ± 1.84 23.49 ± 7.89 p-value 0.005 0.362 0.172 0.453 0.001 Surface area changes (mean ± SD (%)) Denuded alveolar bone 6.28 ± 3.36 6.39 ± 1.91 4.52 ± 1.63 2.46 ± 1.04 18.03 ± 4.04 Periosteal bed 16.57 ± 8.08 7.57 ± 4.05 7.08 ± 3.54 3.27 ± 2.09 30.82 ± 7.18 p-value 0.001 0.410 0.048 0.280 > 0.001 Throughout the follow-up periods, significant reductions were observed regarding the graft surface area as well as the mesiodistal and apicocoronal dimensions; in both groups. The shrinkage percentages continuously decreased throughout the follow up periods. At each postoperative time interval, the percentages in graft dimensional changes were always greater in the control group compared to the experimental group. Apicocoronal alterations, across all time points and in both groups, exhibited greater changes than mesiodistal alterations. The highest percentage changes for all three parameters in the control group occurred between baseline and week 1 (T0-T1). In the experimental group, the most significant mesiodistal changes were observed between T0-T1, while the most significant apicocoronal and area changes occurred during the T1-T2 postoperative time interval. Changes in mesiodistal and apicocoronal graft dimensions and graft surface area, that occurred during T0-T1 and T0-T8; were significantly different between the experimental and control group. Furthermore, alterations in horizontal graft dimensions and surface area between T2-T3 also exhibited statistically significant differences between the two groups (p = 0.047 and p = 0.048, respectively). Due to the non-normality of the pain parameter, Mann-Whitney U test was employed and used to compare the obtained postoperative VAS scores between the experimental and control groups. The results are depicted in Table 2 . Regardless of the recipient bed preparation method, the greatest amount of pain was reported during the first week postoperatively, and consistently decreased thereafter. Although the mean amount of postoperative pain intensity was greater in subjects who received free gingival grafting on denuded alveolar bone, this difference was only statistically significant during the first week after grafting surgery (p = 0.006). Discussion The results of this study indicated that soft tissue augmentation with an epithelialized FGG on a denuded alveolar bone bed exhibited less graft shrinkage compared to a periosteal bed over the course of 8 weeks. Specifically, the overall graft shrinkage after 8 weeks was 30.82% ± 7.18% on the periosteum and 18.30% ± 4.04% on denuded bone. The peak shrinkage in the control group occurred during the first week post-surgery, while in the experimental group, it manifested during the second week and subsequently showed a decline over time. Both the apicocoronal and mesiodistal dimensions of the graft in the control group demonstrated a more pronounced reduction, with the percentage decrease in the mesiodistal aspect being consistently greater than the decrease in the apicocoronal dimensions across both groups at all time points. Although postoperative pain and discomfort values in the recipient area were greater in the control group; however, this difference was only statistically significant during the first week. In 1978, James et al. [ 9 ] examined the placement of a FGG on denuded bone and periosteum in the mandibular incisor region using a split-mouth design for a duration of 24 weeks. Grafts placed on the periosteum underwent 1.5-2 times more shrinkage than those stabilized on denuded alveolar bone. This shrinkage discrepancy between the two groups aligns with findings from the current study. Furthermore, patient pain levels showed no statistically significant difference between the two groups in this research. In the first week, total shrinkage for grafts on bone and periosteum were 11.782% and 20.723%, respectively. By week 6, these percentages increased to 23.246% and 36.670%, and by week 24, they reached 24.850% and 48.310%. Overall, in the present study, graft shrinkage was less than that observed in James et al. study, which could be attributed to advancements in minimally invasive surgical techniques, microsurgery, and the use of 5 − 0 sutures. Additionally, unlike the mentioned study, we employed non-absorbable suture material, which maintains graft stability more effectively than Catgut sutures. An animal study by Caffesse et al. [ 6 , 7 ] compared the healing of FGGs with and without the presence of the periosteum in monkeys, using histological and radiographic evaluations. They reported that proliferation from surrounding tissues is sufficient for graft survival. While delayed remodeling on the bone recipient bed was expected, by day 28, the healing rate in both groups was equivalent. The presence of periosteum resulted in the retention of elastic fibers, which could be a contributing factor to the increased tissue shrinkage observed in grafts placed on a periosteal bed. In most studies, including the present one, the shrinkage of a gingival graft on a periosteal bed is greater than when placed on denuded alveolar bone. One potential explanation for this discrepancy could be the difference in graft mobility between the two groups. Healing of the gingival graft on the denuded bone occurs through the proliferation of granulation tissue from the surrounding gingival margins and the bone marrow, which becomes exposed with the dissolution of the cortical plate. In this context, Costich and Ramfjord [ 11 ] noted that grafts placed on a denuded bone exhibit minimal mobility. Brasher et al. [ 12 ] stated that graft mobility on the periosteal bed is associated with the inadequate removal of muscle fibers and the presence of loose areolar tissue in the submucosa of the recipient area. Moreover, the results of Dordick et al. [ 13 ] study demonstrated that over half of the grafts on the periosteal bed showed mobility, while none of the grafts placed on the denuded bone exhibited any signs of mobility. In 2015, Cifcibasi et al. [ 14 ] examined 30 FGGs on a periosteal bed for changes in length, width, and shrinkage over 1 and 3 months and reported the following results: The average vertical shrinkage of the graft was estimated at 10.63 ± 6.10% (from 0 to 30 days), 8.70 ± 5.16% (from 30 to 90 days), and 13.56 ± 10.87% (from 0 to 90 days). The average horizontal graft shrinkage was 6.96 ± 6.63% (from 0 to 30 days), 4.80 ± 3.40% (from 30 to 90 days), and 7.97 ± 9.81% (from 0 to 90 days). Both values are lower than those obtained in the current study. In their study, the graft thickness was 1.5 millimeters, and monofilament 5 − 0 sutures were used with a minimum number of stitches to secure the grafts, similar to what was performed in the current study. Contrary to the present study, they used a periodontal dressing on the grafts for 10 days. Measurements were solely taken using a periodontal probe with a measurement precision of 0.5 millimeters. This could explain the variance between the results of their study and ours. Given the study's case-series nature and the high standard deviation of reported data, extrapolating the obtained results is questionable. Several factors account for the variation in results across different studies, one of which is the variance in graft thickness. The clinical shrinkage of a graft depends on the amount of connective tissue it contains. If the graft is harvested between rete pegs and lacks any residual connective tissue in its depth, it will undergo shrinkage during the healing process. With the presence of 0.1 millimeters of connective tissue, the superficial epithelium remains, yet the graft undergoes considerable secondary shrinkage during healing. The more abundant this connective tissue, the less the shrinkage. Additionally, meticulous and gentle preparation of the recipient area, ensuring complete removal of elastic and muscle fibers, enables better graft healing and reduces its shrinkage. Areas of the periosteum that necrotize due to surgical trauma function similarly to periosteal fenestration and result in scar formation on the graft. The palatal mucosa adjacent to the maxillary teeth contains a slight amount of elastic fibers in its lamina propria, which mitigates primary tissue shrinkage and is considered favorable. Given the variable thickness of the epithelium in the oral region (0.6-1.0 millimeters), harvested grafts should not be less than 0.75–1.25 millimeters thick to contain an adequate amount of connective tissue [ 15 ]. Research concerning the comparison of pain in the recipient site when placing FGG on periosteal or denuded osseous beds is notably limited. Factors associated with reduced pain and discomfort post-operatively include graft dimensions (length > 14 millimeters, width ≤ 4 millimeters, and thickness > 2 millimeters) and a palatal mucosal thickness of less than 4 millimeters [ 15 ]. Wessel et al. [ 16 ] revealed that, on the third day after surgery, the average pain score using the VAS was 1.2 ± 4.8. Furthermore, 90% of patients reported pain in the donor site, 64% in the recipient site, and 9% in other areas. By the third week post-operatively, there was a significant reduction in pain, with an average VAS score reported as 0.2 ± 1.4. In this study, pain in the recipient area was assessed using VAS. Notably, the average pain intensity during the first week was significantly higher in the control group compared to the test group. One reason for the heightened pain in grafts placed on the periosteum could be the presence of nerve fibers within the periosteum. Additionally, due to greater rate of tissue shrinkage in the control group, pain receptors at the wound (scar) edges and in the underlying exposed periosteum are exposed and stimulated. If the bone is exposed to the oral environment, it may lead to severe necrosis and pain. However, in this study, the entire recipient bed was covered with a gingival graft, ensuring no bone exposure. Lastly, considering the subjective nature of pain and individual variations in pain thresholds, the obtained results might vary. They may not solely be associated with a more favorable tissue response in grafts placed on denuded alveolar bone. In this study, the percentage reduction in apicocoronal graft dimensions was consistently greater than the reduction in mesiodistal graft dimensions across all time points and in both groups. This discrepancy can be attributed to the persistence of muscular adhesions and the apical invasion of the graft into areas genetically predisposed to be alveolar mucosa. Thus, harvesting grafts with a smaller apicocoronal width may be preferable, both in terms of tissue shrinkage and in reducing post-operative pain, discomfort, and potential complications for the patient. One of the limitations of this study is the lack of standardization of the photography angle during follow-ups, which can lead to measurement errors. By considering consistent reference values on photographs and aligning the measurements with their clinical values, these errors can be largely controlled. Furthermore, the level of keratinized gingiva prior to surgery and the presence of bone dehiscence in the buccal area in the presence of gingival recession can influence the study outcomes. Additionally, the shallow vestibular depth and adhesion of muscular tissue, especially in the pre-molar regions, can compromise stability and subsequently impact the study results. Measuring patients' pain using the VAS scale is subjective, and the varying pain thresholds of patients can alter the results, rendering them not entirely reliable. For this reason, employing alternative methods or increasing the sample size could mitigate this error. In conclusion, further studies with larger sample sizes and extended follow-ups are necessary. It is also recommended to measure and compare the levels of keratinized gingiva present before surgery, the initial thickness of the graft, and its changes throughout the follow-ups. The method of securing the graft in the recipient area, for instance, using sutures or cyanoacrylate adhesive, and the application or non-application of a periodontal dressing over the graft, should also be evaluated and compared. Conclusion According to the obtained results, it can be concluded that soft tissue augmentation using FGG on denuded alveolar bone is associated with (induced) less graft shrinkage and postoperative pain compared to when placed on a periosteal bed, over the course of 8 weeks postoperatively. However, further well-designed clinical trials with longer follow-up periods are necessary in order to substantiate the findings of the present study. Declarations Acknowledgements The authors appreciate the continued support of the research counselor of Mashhad University of Medical Sciences. It is worth mentioning that the findings of this study were extracted from a postgraduate thesis project (no.721). Conflicts of Interest The authors have no conflict of interest to disclose. Funding Declaration The authors declare that there is no funding source for this article to disclose ETHICS APPROVAL AND CONSENT TO PARTICIPATE This study was approved by the Mashhad University of Medical Sciences Ethics Committee for research under the Code : IR.MUMS.DENTISTRY.REC.1399.022 HUMAN AND ANIMAL RIGHTS No animals were used for studies that are the base of this research. The reported experiments in accordance with the Ethical standards of the committee responsible for human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013. References Zucchelli G, Tavelli L, McGuire MK, Rasperini G, Feinberg SE, Wang HL, et al. Autogenous soft tissue grafting for periodontal and peri‐implant plastic surgical reconstruction. Journal of periodontology. 2020;91(1):9-16. Thoma DS, Lim HC, Paeng KW, Kim MJ, Jung RE, Hämmerle CH, et al. Augmentation of keratinized tissue at tooth and implant sites by using autogenous grafts and collagen‐based soft‐tissue substitutes. Journal of clinical periodontology. 2020;47(1):64-71. Vêncio EF, Mendonça EF. Epithelial inclusion cyst after free gingival graft: a case report. Restorative Dent. 2007;27:465-9. Echeverria JJ, Montero M, Abad D, Gay C. Exostosis following a free gingival graft. Journal of Clinical Periodontology: Case Report. 2002;29(5):474-7. Bissada NF, Sears SB. Quantitative assessment of free gingival grafts with and without periosteum and osseous perforation. Journal of periodontology. 1978;49(1):15-20. Caffesse RG, Nasjleti CE, Burgett FG, Kowalski CJ, Castelli WA. Healing of Free Gingival Grafts With and Without Periosteum: Part II. Radioautographic Evaluation. 1979. Caffesse RG, Burgett FG, Nasjleti CE, Castelli WA. Healing of Free Gingival Grafts With and Without Periosteum: Part I. Histologic Evaluation. 1979. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology: Elsevier health sciences; 2011. James WC, McFall Jr WT. Placement of free gingival grafts on denuded alveolar bone. Part I: clinical evaluations. Journal of periodontology. 1978;49(6):283-90. da Silva EJ, Godinho GV, Magalhães LRM, Volpato LER. Resection of large proportion ameloblastoma with immediate reconstruction: A case report. Int J Case Rep Images. 2021;12:101240Z01ES2021. Costich ER, Ramfjord SP. Healing after partial denudation of the alveolar process. 1968. Brasher WJ, Rees TD, Boyce WA. Complications of free grafts of masticatory mucosa. Journal of periodontology. 1975;46(3):133-8. Dordick B, Coslet JG, Seibert JS. Clinical evaluation of free autogenous gengival grafts placed on alveolar bone. Part I. Clinical predictability. Journal of periodontology. 1976;47(10):559-67. Cifcibasi E, Karabey V, Koyuncuoglu C, Duzagac E, Genceli E, Kasali K, et al. Clinical evaluation of free gingival graft shrinkage in horizontal and vertical dimensions. Journal of Istanbul University Faculty of Dentistry. 2015;49(3):11. Soehren SE, Allen AL, Cutright DE, Seibert JS. Clinical and histologic studies of donor tissues utilized for free grafts of masticatory mucosa. Journal of periodontology. 1973;44(12):727-41. Wessel JR, Tatakis DN. Patient outcomes following subepithelial connective tissue graft and free gingival graft procedures. Journal of periodontology. 2008;79(3):425-30. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4493177","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316563182,"identity":"b70b524a-9e7f-4554-bf5f-5d8ce5a8ced9","order_by":0,"name":"Shabnam Ganjehzadeh","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shabnam","middleName":"","lastName":"Ganjehzadeh","suffix":""},{"id":316563183,"identity":"6423f679-3016-4abc-91e8-8e5d16de95e2","order_by":1,"name":"Farid Shiezadeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBAC9gYeBomEHzb1/CBeQgERWngOALU87ElLkGwAaTEgUovkA7ZDCQYHQFyitPCfPXgjgedAnvH51YkfHhgwyPOLHSCgRSIv2SLB4k6x2Y23myWADjOcOTsBvxZ7CR4ziQSeZ4zbbpzdANKSYHCbgBYe/jNALWyHGTfPOLv5B3FaGHLAWhI38PduI9IWiRxji8SeNGOJG7zbLBIMJAj7Begww5s/ftjI8fef3XzzR4WNPL80AS0IIAFWKUGschDgP0CK6lEwCkbBKBhJAACIGkXiujNjgwAAAABJRU5ErkJggg==","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Farid","middleName":"","lastName":"Shiezadeh","suffix":""},{"id":316563184,"identity":"a27ba901-f364-41b1-b440-f02af73890b1","order_by":2,"name":"Amir Moeintaghavi","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"","lastName":"Moeintaghavi","suffix":""},{"id":316563186,"identity":"f6fcedb6-418a-401a-8182-317e70d7ee28","order_by":3,"name":"Zahra Shooshtari","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Shooshtari","suffix":""}],"badges":[],"createdAt":"2024-05-28 21:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4493177/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4493177/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59434424,"identity":"83a349d8-8839-4e07-9422-43871f545c71","added_by":"auto","created_at":"2024-07-01 19:00:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":967767,"visible":true,"origin":"","legend":"\u003cp\u003ePreparing recipient site with denuded alveolar bone (Control group)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/3c0d0db29ce2d91128ac9336.png"},{"id":59434423,"identity":"fdcec405-9e1c-4086-9700-49835791ba46","added_by":"auto","created_at":"2024-07-01 19:00:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":965996,"visible":true,"origin":"","legend":"\u003cp\u003epreparing the recipient site with a periosteal bed (Experimental group)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/510e20ee9149bd389bdc9e6d.png"},{"id":59434428,"identity":"dc4c6920-8026-4be3-8f3a-d57a7b9b5d51","added_by":"auto","created_at":"2024-07-01 19:00:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1437095,"visible":true,"origin":"","legend":"\u003cp\u003eMeasuring graft length and width using a periodontal probe\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/38cd1221d0eee7ddb7f6aaa4.png"},{"id":59435020,"identity":"4c44bc23-73d1-4c50-8d82-356939c8f6ec","added_by":"auto","created_at":"2024-07-01 19:08:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":926423,"visible":true,"origin":"","legend":"\u003cp\u003eAdapting and stabilizing the FGG on the recipient bed\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/b1ed3a6646036573761c97cd.png"},{"id":59434425,"identity":"39bb59fd-14c0-42a0-8a6e-569dcb66a996","added_by":"auto","created_at":"2024-07-01 19:00:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":688063,"visible":true,"origin":"","legend":"\u003cp\u003eMeasuring graft dimensions at baseline\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/b50e28dce18b0e200f0ab465.png"},{"id":59434429,"identity":"825654a5-0eba-4f5e-a2ef-a82feedb49e9","added_by":"auto","created_at":"2024-07-01 19:00:15","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":392906,"visible":true,"origin":"","legend":"\u003cp\u003eMeasuring graft dimensions 8 weeks postoperatively\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/884130ff1eb02442c0e9a8e0.png"},{"id":61894681,"identity":"53927e7c-70ed-495a-b3aa-ac2b5514890a","added_by":"auto","created_at":"2024-08-06 19:39:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9776097,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4493177/v1/b936fd9e-0da6-4af5-8fe7-b2754055473d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Free Gingival Graft Shrinkage on Periosteal Bed and Denuded Alveolar Bone Recipient Site: A Randomized Clinical Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe clinical significance of surrounding keratinized gingiva, still remains a subject of controversy. Some clinicians believe that an adequate width of keratinized gingiva is essential in order to assure the periodontal health of natural teeth and dental implants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. On the contrary, multiple studies claim that insufficient keratinized gingiva will not be problematic in patients who are able to maintain good oral hygiene and avoid traumatic tooth brushing.\u003c/p\u003e \u003cp\u003eNevertheless, gingival reconstruction and mucogingival surgery are mandatory in some clinical conditions. Extensive (progressive) gingival recessions, high frenal attachments, pre-orthodontic thin alveolar mucosa (isolated gingival recessions in candidate patients for fixed orthodontic therapy), restorations with deep subgingival margins and inability to maintain an effective level of plaque control are all indications for surgical periodontal intervention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFree gingival graft (FGG) augmentation is a traditional and widely used approach in periodontal therapy. This treatment approach entails enhancing tissue thickness, gaining keratinized gingiva width, correcting mucogingival deformities and improving aesthetics. Although this grafting technique yields promising results, it is associated with some disadvantages such as postoperative pain and patient discomfort, high risk for intraoperative bleeding in the donor site, requiring two separate surgical procedures and color mismatch at the recipient site (1). Development of epithelial inclusion cysts and oral (bony) exostosis have also been reported following FGG augmentation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe necessity of recipient bed preparation has been speculated over time. Some studies state that preserving the periosteum is integral to soft tissue vascularization and stability. On the contrary the literature contains animal studies which have established that the presence or absence of the periosteum does not seem to significantly impact the survival, healing pattern and attachment of the FGG [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This was also confirmed by another animal study by Caffesse et.al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] which stated that the presence or absence of the periosteum in the recipient site does not seem to influence the long-term success and healing of the graft.\u003c/p\u003e \u003cp\u003eWhen FGGs are placed over the denuded alveolar bone, no sign of wound healing is observed until seven days after grafting. However, this delay does not seem to jeopardize the survival of FGGs. Graft nutrition is sufficiently accomplished through the adjacent tissues and also the clot formed at the fibrinous interface [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Minimal graft mobility, less postoperative edema and improved hemostasis are among the advantages of covering denuded alveolar bone with FGG. Graft shrinkage after this method has also been reported to be 1.5 to 2 times less compared to free gingival grafting on the periosteum. However, despite these benefits, graft healing is delayed for approximately 14 days. Previous experimental studies have evaluated graft shrinkage 24 weeks after free gingival grafting. Grafts that were placed over periosteal beds exhibited a shrinkage rate of 50%, whereas FGGs placed on denuded bone only shrunk by 24%. Furthermore, Maximum surface shrinkage occurred within the first 6 weeks after free gingival grafting [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003ePostoperative graft shrinkage has been reported to be 1.5 to 2 times greater when grafting on the periosteum compared to when placed on denuded alveolar bone. However, postoperative pain did not seem to significantly differ. Bone sequestration was not observed regardless of the presence or absence of the periosteum. Therefore, in the presence of adequate alveolar bone volume, FGG augmentation on denuded bone is a viable treatment approach for increasing keratinized tissue dimensions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs previously mentioned, postoperative graft shrinkage is one of the main concerns when covering the denuded alveolar bone. This requires (necessitates) harvesting a larger FGG from the donor site; consequently, leading to greater patient discomfort and postoperative pain. In this commentary adopting (establishing) a surgical technique that is associated with lower graft shrinkage rates would be of great clinical importance. The pertaining literature is relatively scarce, lacks sufficient clinical evidence, and mostly includes animal or case-series studies which fail to compare the efficacy of the two treatment methods. Hence, the purpose of the present study was to compare graft shrinkage rates and postoperative pain intensity following FGG augmentation on periosteal beds and denuded alveolar bone.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eStudy design and participants\u003c/h2\u003e\n \u003cp\u003eIn order to address the research objective, the authors designed and implemented a randomized clinical trial. The protocol of this study was approved by the Research and Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.DENTISTRY.REC.1399.022) and was registered in the Iranian Registry of clinical Trials under the code: IRCT20200807048327N1. The study was conducted in accordance with all relevant principle of the Declaration of Helsinki and CONSORT statement. Subjects were only enrolled after obtaining informed written consent.\u003c/p\u003e\n \u003cp\u003eSubjects were recruited from patients who admitted to the Periodontics Department of Mashhad Dental School, Mashhad, Iran from January 2022 to January 2023. Inclusion criteria were as follows: a) systematically healthy American anesthesiology association (ASA) status I or II b) participants exhibited at least one mucosal (gingival) recession defect between teeth number 20\u0026ndash;29 that indicated soft tissue augmentation through FGG c) no evidence of alveolar bone resorption on periapical radiograph d) probing depth\u0026thinsp;\u0026lt;\u0026thinsp;3mm e) plaque score\u0026thinsp;\u0026lt;\u0026thinsp;20% f) ability to maintain appropriate oral hygiene.\u003c/p\u003e\n \u003cp\u003eExclusion criteria consisted of: a) any general contraindications for dental and oral surgery b) taking any medications that would interfere with the healing process c) lactating or pregnant women d) history of periodontitis e) uncontrolled diabetes f) smoking g) alcohol consumption h) severe dental crowding.\u003c/p\u003e\n \u003cp\u003ePatients who finally met the above-listed inclusion and exclusion criteria were enrolled and randomly allocated to experimental and control groups. In the experimental group, FGG was placed over denuded alveolar bone whereas in the control group FGG augmentation was performed on a periosteal bed (The recipient site for FGG was a periosteal bed in the control group and denuded alveolar bone in the experimental group). Randomization was achieved using block randomization technique and the table of random numbers. Allocation concealment was accomplished through sequentially numbered opaque sealed envelopes. The patients and study evaluator were blind to group allotment (double-blind randomized clinical trial).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003eSurgical procedure\u003c/h2\u003e\n \u003cp\u003ePrior to the periodontal surgery, the subjects were instructed on how to floss and brush their teeth using Modified Stillman and Bass techniques. Full mouth supragingival and subgingival debridement (Scaling and root planning (SRP)) were performed for all subjects prior to undergoing surgery. Vestibular buccal injections of 2% lidocaine with 1/100,000 epinephrine lidocaine was administered in order to obtain local anesthesia and achieve hemostasis. The recipient bed was prepared as follows: a horizontal incision and two vertical releasing incisions at a 90-degree angle were made using a scalpel blade number 15 at the mucogingival line, extending up to 3 millimeters beyond the grafting area. In the test group, the incisions were extended to the bone, and a full-thickness flap was elevated using blunt dissection, exposing a denuded bed on the bone surface (Fig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e). In the control group, a split-thickness flap was prepared using sharp dissection, and a periosteal bed was created (Fig.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). In case of mobility of the apical bed area, it was stabilized using Vicryl 4\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures. An FGG was harvested from the palate, adjacent to the maxillary premolars, with a distance of 2 millimeters from the gingival margin, according to the required dimensions and with a thickness of 1-1.5 millimeters. Before transferring it into the oral cavity, measurements of length (mesiodistal dimension) and width (apicocoronal dimension) were taken (Fig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e). The surrounding area of the recipient bed was beveled in order to maximize aesthetic outcome, and the harvested graft was adapted to the recipient site and secured with interrupted sutures using nylon 5\u0026thinsp;\u0026minus;\u0026thinsp;0 (Fig.\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e). In case of mobility, horizontal sling sutures were also utilized. A gauze soaked in normal saline was placed over the FGG with gentle pressure for 5 minutes to ensure better adaptation. Donor site bleeding was controlled by applying pressure with gauze and suturing using silk 3\u0026thinsp;\u0026minus;\u0026thinsp;0. All surgical procedures were performed by the same clinician with over 10 years of experience (F.S).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003ePostoperative care\u003c/h2\u003e\n \u003cp\u003eAfter 14 days the sutures were removed from the grafted site. During this time, patients were instructed to avoid brushing and flossing in the recipient region and also adhere to a soft-diet. Patients were allowed to gently brush coronal to the grafted site using a soft toothbrush, 2\u0026ndash;3 weeks post-periodontal surgery. Patients were advised to apply an ice compress to the surgical area during the first 24 hours after surgery. Chemical plaque control was maintained using antimicrobial mouthwash (0.12% digluconate chlorhexidine), twice a day for 14 days. In order to control postoperative pain, analgesics (Novafen t.i.d) were prescribed for three days. The sutures in the palate were removed after one week and the sutures in the graft site were removed two weeks after surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003eExamined parameters\u003c/h2\u003e\n \u003cp\u003ePatients were recalled 1,2,4 and 8 weeks after the grafting procedure and were evaluated in terms of graft shrinkage and postoperative pain intensity. Evaluations were performed by a trained and calibrated staff member (S.G) who was blind to the study allotment. Subjects\u0026rsquo; perception of postoperative pain in the grafted site was subjectively assessed using visual analogue scale (VAS) [\u003cspan\u003e10\u003c/span\u003e]. An intraoral photograph (1:1) was taken from the grafted site at each follow-up visit and the graft dimensions were also clinically measured using a Michigan O probe. The photographs were imported in to a website (\u003cspan\u003e\u003cspan\u003ewww.elief.net\u003c/span\u003e\u003c/span\u003e) and measurements were completed online. Measurements were done at baseline (T0), 1 (T1), 2 (T2), 4 (T3) and 8 (T4), weeks postoperatively.\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan\u003e5\u003c/span\u003e and \u003cspan\u003e6\u003c/span\u003e demonstrate the measurements carried out for determining graft dimensions. To measure the mesiodistal dimension of the graft, a specific tooth was selected as the reference point (e.g., the mandibular right central incisor), and 2mm below the cementoenamel junction (CEJ) was marked along its midbuccal surface (axis). The obtained point was used to measure the mesiodistal length of the graft. For apicocoronal measurements, another tooth was taken as the reference (e.g., the mandibular left central incisor) and the apicocoronal dimension of the graft was measured along the midbuccal surface (axis) of the reference tooth. In order to enhance measurement accuracy and standardize potential photo magnifications, a fixed landmark (e.g., the length of the right mandibular canine) was established and considered constant in all follow-up photographs. In all samples, clinically recorded measurements with a probe were compared to the calculated measurements from the photographs, and if there was a significant difference of more than 1 millimeter between the two measurements, that particular sample was excluded from the results.\u003c/p\u003e\n \u003cp\u003eAfter recording and completing the initial measurements, dimensional changes in the grafted area including; shrinkage in mesiodistal and apicocoronal graft dimensions (absolute value and percentage) as well as the overall graft shrinkage rate (percentage), were calculated between each postoperative interval. The overall graft shrinkage rate was calculated using this formula:\u003c/p\u003e\n \u003cdiv id=\"Equa\"\u003e\n \u003cdiv id=\"FileID_Equa\" name=\"EquationSource\"\u003e$$Graft shrinkage rate =\\left(Baseline surface area -Postoperative surface area\\right)\u0026divide;Basline surface area\\times 100$$\u003c/div\u003e\n \u003c/div\u003e\n \u003cp\u003ePain intensity values were also recorded through VAS scores at each follow-up visit.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eSample size calculation and statistical analysis\u003c/h2\u003e\n \u003cp\u003eA prior pilot study was conducted and according to the obtained results the mean surface area changes over an 8-week period were determined to be 9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.26 mm\u003csup\u003e2\u003c/sup\u003e and 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18 mm\u003csup\u003e2\u003c/sup\u003e for the control and experimental groups, respectively. Sample size estimation was performed using the formula for comparing two means, considering a statistical power of 80% and confidence interval of 95%. Initially, 9 participants were deemed adequate for each group. To compensate for potential dropouts, the sample size was increased to 11 participants per group.\u003c/p\u003e\n \u003cp\u003eData were subjected to statistical analysis using SPSS version 23 (SPSS, Inc, Chicago, Illinois). Shapiro-Wilk test was used to assess if the variables follow a normal distribution. Additionally, for comparing gender distribution among the groups, chi-square and Fisher\u0026apos;s exact tests were applied. Significance level was set at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 22 subjects, comprising 15 (68%) females and 7 (32%) accomplished the study. The control group consisted of 8 (66.7%) female and 4 (33.3%) male participants, while the experimental group included 7 (70%) females and 3 (30%) males. Subjects in the control and experimental groups had a mean age of 38.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 years and 44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 years, respectively. According to Independent sample T-test, there was no statistically significant difference between the two study groups in terms of mean age (p=). Fischer\u0026rsquo;s exact test revealed that the experimental and control groups were not significantly different regarding gender distribution frequency (p\u0026thinsp;=\u0026thinsp;0.115). Subjects underwent free gingival grafting in the anterior and premolar regions of the mandible. All grafts healed uneventfully, without exhibiting any signs of sloughing or total graft necrosis.\u003c/p\u003e\n\u003cp\u003eTables\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e displays graft dimensional changes from baseline until 8 weeks after the grafting procedure. Since data pertaining to changes in graft dimensions and surface area changes, were distributed normally; Independent samples T-test was utilized. FGG augmentation over a periosteal bed, (i.e., the control group) resulted in 5.92% mesiodistal reduction (14.93mm vs 14.05mm), 13.15% apicocoronal reduction (6.46mm vs 5.61mm) and an overall shrinkage rate of 18.30%; when evaluated 8 weeks postoperatively. In cases where the FGG was placed over a denuded alveolar bone (the experimental group), the vertical and horizontal dimensions of the grafted site had shrunk by 9.53% (16.3mm vs 14.61mm) and 22.40% (6.83mm vs 5.30mm), respectively. The overall graft shrinkage rate in the control group was 30.82%.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe mean percentage of graft dimensional changes between different time intervals in different study groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative time interval\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT0-T1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT1-T2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT2-T3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT3-T4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT0-T4\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eMesiodistal changes (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (%))\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDenuded alveolar bone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriosteal bed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.02\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eApicocoronal changes (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDenuded alveolar bone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriosteal bed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.60\u0026thinsp;\u0026plusmn;\u0026thinsp;7.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.98\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.49\u0026thinsp;\u0026plusmn;\u0026thinsp;7.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurface area changes (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDenuded alveolar bone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriosteal bed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.57\u0026thinsp;\u0026plusmn;\u0026thinsp;8.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.57\u0026thinsp;\u0026plusmn;\u0026thinsp;4.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.82\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThroughout the follow-up periods, significant reductions were observed regarding the graft surface area as well as the mesiodistal and apicocoronal dimensions; in both groups. The shrinkage percentages continuously decreased throughout the follow up periods. At each postoperative time interval, the percentages in graft dimensional changes were always greater in the control group compared to the experimental group. Apicocoronal alterations, across all time points and in both groups, exhibited greater changes than mesiodistal alterations. The highest percentage changes for all three parameters in the control group occurred between baseline and week 1 (T0-T1). In the experimental group, the most significant mesiodistal changes were observed between T0-T1, while the most significant apicocoronal and area changes occurred during the T1-T2 postoperative time interval.\u003c/p\u003e\n\u003cp\u003eChanges in mesiodistal and apicocoronal graft dimensions and graft surface area, that occurred during T0-T1 and T0-T8; were significantly different between the experimental and control group. Furthermore, alterations in horizontal graft dimensions and surface area between T2-T3 also exhibited statistically significant differences between the two groups (p\u0026thinsp;=\u0026thinsp;0.047 and p\u0026thinsp;=\u0026thinsp;0.048, respectively).\u003c/p\u003e\n\u003cp\u003eDue to the non-normality of the pain parameter, Mann-Whitney U test was employed and used to compare the obtained postoperative VAS scores between the experimental and control groups. The results are depicted in Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e. Regardless of the recipient bed preparation method, the greatest amount of pain was reported during the first week postoperatively, and consistently decreased thereafter. Although the mean amount of postoperative pain intensity was greater in subjects who received free gingival grafting on denuded alveolar bone, this difference was only statistically significant during the first week after grafting surgery (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"char\"\u003e\u003cbr\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1719314487.png\"\u003e\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study indicated that soft tissue augmentation with an epithelialized FGG on a denuded alveolar bone bed exhibited less graft shrinkage compared to a periosteal bed over the course of 8 weeks. Specifically, the overall graft shrinkage after 8 weeks was 30.82% \u0026plusmn; 7.18% on the periosteum and 18.30% \u0026plusmn; 4.04% on denuded bone. The peak shrinkage in the control group occurred during the first week post-surgery, while in the experimental group, it manifested during the second week and subsequently showed a decline over time. Both the apicocoronal and mesiodistal dimensions of the graft in the control group demonstrated a more pronounced reduction, with the percentage decrease in the mesiodistal aspect being consistently greater than the decrease in the apicocoronal dimensions across both groups at all time points. Although postoperative pain and discomfort values in the recipient area were greater in the control group; however, this difference was only statistically significant during the first week.\u003c/p\u003e \u003cp\u003eIn 1978, James et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] examined the placement of a FGG on denuded bone and periosteum in the mandibular incisor region using a split-mouth design for a duration of 24 weeks. Grafts placed on the periosteum underwent 1.5-2 times more shrinkage than those stabilized on denuded alveolar bone. This shrinkage discrepancy between the two groups aligns with findings from the current study. Furthermore, patient pain levels showed no statistically significant difference between the two groups in this research. In the first week, total shrinkage for grafts on bone and periosteum were 11.782% and 20.723%, respectively. By week 6, these percentages increased to 23.246% and 36.670%, and by week 24, they reached 24.850% and 48.310%. Overall, in the present study, graft shrinkage was less than that observed in James et al. study, which could be attributed to advancements in minimally invasive surgical techniques, microsurgery, and the use of 5\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures. Additionally, unlike the mentioned study, we employed non-absorbable suture material, which maintains graft stability more effectively than Catgut sutures.\u003c/p\u003e \u003cp\u003eAn animal study by Caffesse et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] compared the healing of FGGs with and without the presence of the periosteum in monkeys, using histological and radiographic evaluations. They reported that proliferation from surrounding tissues is sufficient for graft survival. While delayed remodeling on the bone recipient bed was expected, by day 28, the healing rate in both groups was equivalent. The presence of periosteum resulted in the retention of elastic fibers, which could be a contributing factor to the increased tissue shrinkage observed in grafts placed on a periosteal bed.\u003c/p\u003e \u003cp\u003eIn most studies, including the present one, the shrinkage of a gingival graft on a periosteal bed is greater than when placed on denuded alveolar bone. One potential explanation for this discrepancy could be the difference in graft mobility between the two groups. Healing of the gingival graft on the denuded bone occurs through the proliferation of granulation tissue from the surrounding gingival margins and the bone marrow, which becomes exposed with the dissolution of the cortical plate. In this context, Costich and Ramfjord [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] noted that grafts placed on a denuded bone exhibit minimal mobility.\u003c/p\u003e \u003cp\u003eBrasher et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] stated that graft mobility on the periosteal bed is associated with the inadequate removal of muscle fibers and the presence of loose areolar tissue in the submucosa of the recipient area. Moreover, the results of Dordick et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] study demonstrated that over half of the grafts on the periosteal bed showed mobility, while none of the grafts placed on the denuded bone exhibited any signs of mobility.\u003c/p\u003e \u003cp\u003eIn 2015, Cifcibasi et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] examined 30 FGGs on a periosteal bed for changes in length, width, and shrinkage over 1 and 3 months and reported the following results: The average vertical shrinkage of the graft was estimated at 10.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.10% (from 0 to 30 days), 8.70\u0026thinsp;\u0026plusmn;\u0026thinsp;5.16% (from 30 to 90 days), and 13.56\u0026thinsp;\u0026plusmn;\u0026thinsp;10.87% (from 0 to 90 days). The average horizontal graft shrinkage was 6.96\u0026thinsp;\u0026plusmn;\u0026thinsp;6.63% (from 0 to 30 days), 4.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.40% (from 30 to 90 days), and 7.97\u0026thinsp;\u0026plusmn;\u0026thinsp;9.81% (from 0 to 90 days). Both values are lower than those obtained in the current study. In their study, the graft thickness was 1.5 millimeters, and monofilament 5\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures were used with a minimum number of stitches to secure the grafts, similar to what was performed in the current study. Contrary to the present study, they used a periodontal dressing on the grafts for 10 days. Measurements were solely taken using a periodontal probe with a measurement precision of 0.5 millimeters. This could explain the variance between the results of their study and ours. Given the study's case-series nature and the high standard deviation of reported data, extrapolating the obtained results is questionable.\u003c/p\u003e \u003cp\u003eSeveral factors account for the variation in results across different studies, one of which is the variance in graft thickness. The clinical shrinkage of a graft depends on the amount of connective tissue it contains. If the graft is harvested between rete pegs and lacks any residual connective tissue in its depth, it will undergo shrinkage during the healing process. With the presence of 0.1 millimeters of connective tissue, the superficial epithelium remains, yet the graft undergoes considerable secondary shrinkage during healing. The more abundant this connective tissue, the less the shrinkage. Additionally, meticulous and gentle preparation of the recipient area, ensuring complete removal of elastic and muscle fibers, enables better graft healing and reduces its shrinkage. Areas of the periosteum that necrotize due to surgical trauma function similarly to periosteal fenestration and result in scar formation on the graft. The palatal mucosa adjacent to the maxillary teeth contains a slight amount of elastic fibers in its lamina propria, which mitigates primary tissue shrinkage and is considered favorable. Given the variable thickness of the epithelium in the oral region (0.6-1.0 millimeters), harvested grafts should not be less than 0.75\u0026ndash;1.25 millimeters thick to contain an adequate amount of connective tissue [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch concerning the comparison of pain in the recipient site when placing FGG on periosteal or denuded osseous beds is notably limited. Factors associated with reduced pain and discomfort post-operatively include graft dimensions (length\u0026thinsp;\u0026gt;\u0026thinsp;14 millimeters, width\u0026thinsp;\u0026le;\u0026thinsp;4 millimeters, and thickness\u0026thinsp;\u0026gt;\u0026thinsp;2 millimeters) and a palatal mucosal thickness of less than 4 millimeters [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWessel et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] revealed that, on the third day after surgery, the average pain score using the VAS was 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8. Furthermore, 90% of patients reported pain in the donor site, 64% in the recipient site, and 9% in other areas. By the third week post-operatively, there was a significant reduction in pain, with an average VAS score reported as 0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4.\u003c/p\u003e \u003cp\u003eIn this study, pain in the recipient area was assessed using VAS. Notably, the average pain intensity during the first week was significantly higher in the control group compared to the test group. One reason for the heightened pain in grafts placed on the periosteum could be the presence of nerve fibers within the periosteum. Additionally, due to greater rate of tissue shrinkage in the control group, pain receptors at the wound (scar) edges and in the underlying exposed periosteum are exposed and stimulated. If the bone is exposed to the oral environment, it may lead to severe necrosis and pain. However, in this study, the entire recipient bed was covered with a gingival graft, ensuring no bone exposure. Lastly, considering the subjective nature of pain and individual variations in pain thresholds, the obtained results might vary. They may not solely be associated with a more favorable tissue response in grafts placed on denuded alveolar bone.\u003c/p\u003e \u003cp\u003eIn this study, the percentage reduction in apicocoronal graft dimensions was consistently greater than the reduction in mesiodistal graft dimensions across all time points and in both groups. This discrepancy can be attributed to the persistence of muscular adhesions and the apical invasion of the graft into areas genetically predisposed to be alveolar mucosa. Thus, harvesting grafts with a smaller apicocoronal width may be preferable, both in terms of tissue shrinkage and in reducing post-operative pain, discomfort, and potential complications for the patient.\u003c/p\u003e \u003cp\u003eOne of the limitations of this study is the lack of standardization of the photography angle during follow-ups, which can lead to measurement errors. By considering consistent reference values on photographs and aligning the measurements with their clinical values, these errors can be largely controlled. Furthermore, the level of keratinized gingiva prior to surgery and the presence of bone dehiscence in the buccal area in the presence of gingival recession can influence the study outcomes. Additionally, the shallow vestibular depth and adhesion of muscular tissue, especially in the pre-molar regions, can compromise stability and subsequently impact the study results.\u003c/p\u003e \u003cp\u003eMeasuring patients' pain using the VAS scale is subjective, and the varying pain thresholds of patients can alter the results, rendering them not entirely reliable. For this reason, employing alternative methods or increasing the sample size could mitigate this error. In conclusion, further studies with larger sample sizes and extended follow-ups are necessary. It is also recommended to measure and compare the levels of keratinized gingiva present before surgery, the initial thickness of the graft, and its changes throughout the follow-ups. The method of securing the graft in the recipient area, for instance, using sutures or cyanoacrylate adhesive, and the application or non-application of a periodontal dressing over the graft, should also be evaluated and compared.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccording to the obtained results, it can be concluded that soft tissue augmentation using FGG on denuded alveolar bone is associated with (induced) less graft shrinkage and postoperative pain compared to when placed on a periosteal bed, over the course of 8 weeks postoperatively. However, further well-designed clinical trials with longer follow-up periods are necessary in order to substantiate the findings of the present study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors appreciate the continued support of the research counselor of Mashhad University of Medical Sciences. It is worth mentioning that the findings of this study were extracted from a postgraduate thesis project (no.721).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflict of interest to disclose.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no funding source for this article to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Mashhad University of Medical Sciences Ethics Committee for research under the Code\u003cstrong\u003e: \u0026nbsp;IR.MUMS.DENTISTRY.REC.1399.022\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHUMAN AND ANIMAL RIGHTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo animals were used for studies that are the base of this research. The reported experiments in accordance with the Ethical standards of the committee responsible for human experimentation\u003cstrong\u003e\u0026nbsp;(institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZucchelli G, Tavelli L, McGuire MK, Rasperini G, Feinberg SE, Wang HL, et al. Autogenous soft tissue grafting for periodontal and peri‐implant plastic surgical reconstruction. Journal of periodontology. 2020;91(1):9-16.\u003c/li\u003e\n\u003cli\u003eThoma DS, Lim HC, Paeng KW, Kim MJ, Jung RE, H\u0026auml;mmerle CH, et al. Augmentation of keratinized tissue at tooth and implant sites by using autogenous grafts and collagen‐based soft‐tissue substitutes. Journal of clinical periodontology. 2020;47(1):64-71.\u003c/li\u003e\n\u003cli\u003eV\u0026ecirc;ncio EF, Mendon\u0026ccedil;a EF. Epithelial inclusion cyst after free gingival graft: a case report. Restorative Dent. 2007;27:465-9.\u003c/li\u003e\n\u003cli\u003eEcheverria JJ, Montero M, Abad D, Gay C. Exostosis following a free gingival graft. Journal of Clinical Periodontology: Case Report. 2002;29(5):474-7.\u003c/li\u003e\n\u003cli\u003eBissada NF, Sears SB. Quantitative assessment of free gingival grafts with and without periosteum and osseous perforation. Journal of periodontology. 1978;49(1):15-20.\u003c/li\u003e\n\u003cli\u003eCaffesse RG, Nasjleti CE, Burgett FG, Kowalski CJ, Castelli WA. Healing of Free Gingival Grafts With and Without Periosteum: Part II. Radioautographic Evaluation. 1979.\u003c/li\u003e\n\u003cli\u003eCaffesse RG, Burgett FG, Nasjleti CE, Castelli WA. Healing of Free Gingival Grafts With and Without Periosteum: Part I. Histologic Evaluation. 1979.\u003c/li\u003e\n\u003cli\u003eNewman MG, Takei H, Klokkevold PR, Carranza FA. Carranza\u0026apos;s clinical periodontology: Elsevier health sciences; 2011.\u003c/li\u003e\n\u003cli\u003eJames WC, McFall Jr WT. Placement of free gingival grafts on denuded alveolar bone. Part I: clinical evaluations. Journal of periodontology. 1978;49(6):283-90.\u003c/li\u003e\n\u003cli\u003eda Silva EJ, Godinho GV, Magalh\u0026atilde;es LRM, Volpato LER. Resection of large proportion ameloblastoma with immediate reconstruction: A case report. Int J Case Rep Images. 2021;12:101240Z01ES2021.\u003c/li\u003e\n\u003cli\u003eCostich ER, Ramfjord SP. Healing after partial denudation of the alveolar process. 1968.\u003c/li\u003e\n\u003cli\u003eBrasher WJ, Rees TD, Boyce WA. Complications of free grafts of masticatory mucosa. Journal of periodontology. 1975;46(3):133-8.\u003c/li\u003e\n\u003cli\u003eDordick B, Coslet JG, Seibert JS. Clinical evaluation of free autogenous gengival grafts placed on alveolar bone. Part I. Clinical predictability. Journal of periodontology. 1976;47(10):559-67.\u003c/li\u003e\n\u003cli\u003eCifcibasi E, Karabey V, Koyuncuoglu C, Duzagac E, Genceli E, Kasali K, et al. Clinical evaluation of free gingival graft shrinkage in horizontal and vertical dimensions. Journal of Istanbul University Faculty of Dentistry. 2015;49(3):11.\u003c/li\u003e\n\u003cli\u003eSoehren SE, Allen AL, Cutright DE, Seibert JS. Clinical and histologic studies of donor tissues utilized for free grafts of masticatory mucosa. Journal of periodontology. 1973;44(12):727-41.\u003c/li\u003e\n\u003cli\u003eWessel JR, Tatakis DN. Patient outcomes following subepithelial connective tissue graft and free gingival graft procedures. Journal of periodontology. 2008;79(3):425-30.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Epithelialized gingival graft, periosteum, denuded bone, tissue shrinkage, pain","lastPublishedDoi":"10.21203/rs.3.rs-4493177/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4493177/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are several techniques to increase keratinized tissue, and free gingival grafting (FGG) is one of the most predictable methods. One of the main disadvantages of this method is the significant tissue shrinkage of the graft, so it is desirable to find a method that is associated with less shrinkage. The purpose of the present study was to compare graft shrinkage rates and postoperative pain intensity following FGG augmentation on periosteal beds and denuded alveolar bone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u0026amp; Materials\u003c/strong\u003e: 22 FGGs with a thickness of 1 to 1.5 mm were placed in the area between the mandibular premolars. The recipient site for FGG was a periosteal bed in the control group and denuded alveolar bone in the experimental group. Dimensions of the grafts were recorded clinically by periodontal probe as well as taking photographs, and the pain were assessed with VAS scale, 1, 2, 4 and 8 weeks after surgery. The percentage of tissue shrinkage was calculated, and two 2 groups were compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e22 patients (7 males and 15 females) completed the study and of these, 10 patients were in the experimental group (denuded bone bed), and 12 patients were in the control group (periosteal bed). At all times, the percentage of shrinkage in length, width and area in the control group (periosteum) was higher than the test group (bone). The highest percentage of shrinkage in all 3 parameters occurred in the control group related to the time between baseline and 1st week. In the experimental group, the highest percentage of length changes occurred between baseline and the 1st week and the highest percentage of width and area changes occurred between weeks 1 and 2. Changes in length, width and area between baseline and the first week and between baseline and week 8 were significant between the two groups. The mean pain in the control group (periosteum) was higher than the experimental group and only in the first week this difference was statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt can be concluded that epithelialized gingival graft placed on the denuded bone bed is associated with less tissue shrinkage as well as less pain and discomfort in the recipient area during 8 weeks of follow-up compared to FGG placement on the periosteal bed.\u003c/p\u003e","manuscriptTitle":"Free Gingival Graft Shrinkage on Periosteal Bed and Denuded Alveolar Bone Recipient Site: A Randomized Clinical Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 19:00:09","doi":"10.21203/rs.3.rs-4493177/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06a0d5f2-ad89-4b18-9ec2-11e11c6e1cb5","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-06T19:31:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-01 19:00:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4493177","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4493177","identity":"rs-4493177","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}