containing dressings, noneugenol dressings, no dressings,
Clinical Evaluation of Free
Autogenous Gingival Grafts
Placed on Alveolar Bone
Part I. Clinical Predictability*
by
BRUCE DORDICK, D.D.s.†
J . GEORGE COSLET, B.S., D.D.S., M.S.D.‡
JAY S. SEIBERT, D.D.S., M.S.D.§
T H E T E C H N I Q U E of free autogenous gingival grafting has
undergone little modification since its introduction in
1, 2
Scandinavia in 1963 and in the United States in 1964.
The original description of the technique began with the
preparation of the recipient site utilizing sharp dissection
to remove surface epithelium, lamina propria, and sub­
mucosal layers, leaving a thin layer of connective tissue
and periosteum covering the osseous surfaces. It was
advocated that the remaining tissue should be smooth to
prevent dead spaces from occurring between the graft
9, 1 0
and its recipient bed. One of the few modifications in
the preparation of the recipient site is the use of a
fenestration at the base of the graft where the new
mucogingival junction is to be established.
The donor tissue is frequently taken from the palate,
although the use of edentulous ridge areas, tuberosities,
8-16
and attached gingiva has been described. The method
of excision of the graft from the donor site is a matter of
personal preference and various surgeons have used
scalpels, Xacto knives, blade breakers, Paquette knives,
gingivectomy knives, etc. The early literature frequently
mentions the use of surgical templates. 9-11,
Immobili­ 16,
zation techniques include suturing of the complete perim­
eter of the graft, 5, 8 - 1 0 , 1 8
coronal suturing only,
15
the use of tissue adhesives, and the adaptation of the
graft without the employment of sutures or adhesives.
The need for surgical dressings also has varied consider­
ably among practitioners. Clinicians have described the
use of topical antibiotics, rubber dam, telfa, eugenol-
T h i s work was done in cooperation with the Veteran's Administra­
tion Hospital, Philadelphia, Pennsylvania.
* Reprint requests should be sent to: D r . Bruce Dordick, 2805
M e d i c a l Towers, 255 South Seventeenth St., Philadelphia, P a . 19103.
t Department of Dentistry, T h o m a s Jefferson University.
X Director of Post-Doctoral Periodontics Program, Associate
Professor of Periodontics, University of Pennsylvania School of Dental
Medicine.
§ Associate Dean, Professor of Periodontics, University of Pennsyl­
vania School of Dental Medicine.
and combinations thereof.
Recently clinicians have tended to overemphasize free
grafting, seemingly forgetting the existence of other
procedures for increasing the zone of masticatory mu­
cosa. Included among these techniques are laterally
22-26
positioned pedicle g r a f t s , apically positioned
27 28
flaps, , and the double papillae positioned pedicle
29
procedure. Each has its indications and contraindica­
tions. Laterally positioned pedicle grafts are indicated
where sufficient attached tissue exists in an area adjacent
to a deficient zone of attached gingiva. The laterally
positioned pedicle graft is also preferred over the free
autogenous gingival graft in cases requiring root cover­
age, because its contiguous vascular supply gives it
greater predictability. The double papillae laterally posi­
tioned flap has limited use as it does not seem to be as
predictable as other modes of increasing the zone of
attached tissue. The partial thickness apically positioned
flap may be the most underused of the mucogingival
3
procedures for enlarging the zone of masticatory mucosa.
Where pocket depth exists it is the procedure of choice,
for it allows reduction of pockets as well as gaining
attached gingiva and deepening the vestibular fornix. The
4-10
free autogenous gingival graft should not be employed
when pocket depth is present, except as part of a two
stage procedure. The indications for free grafts include
insufficient attached gingiva and/or probeability to the
mucogingival junction. Although reports in the litera­
ture exist demonstrating the use of free autogenous grafts
6, 10, 16, 3 0 - 3 3
11-13
to cover denuded root surfaces, the predicta­
bility of this procedure is poor in comparison to the
laterally positioned flap. The free autogenous gingival
graft should not be used to cover a denuded root in a
gingival cleft when other more predictable plastic proce­
dures such as the laterally positioned flap can be utilized.
D E V E L O P M E N T OF P R E S E N T TECHNIQUE
17 During routine recall examinations of a large number
of periodontalLy treated patients, it was noted that many
12, 19, 2 0 gingival grafts which initially had exhibited no mobility,
now displayed postoperative clinical mobility. These
21 were not "floating" grafts in the sense that they just
moved freely with the alveolar mucosal tissues. They
were not observed to be raised in a horizontal plane
(perpendicular to the alveolar bone), but were simply
mobile when manipulated with an instrument such as the
periodontal probe in an antero-posterior and/or apico-
coronal direction. The significance of this finding may be
debated as to its clinical relevance, but it was evident that
in these patients the primary goal, attainment of a
functional band of firmly attached masticatory mucosa,
had not been achieved. It was suggested that improper
preparation of the recipient bed, leaving striated muscle
and too much areolar connective tissue, was at fault. This
559

560 Dordick, Coslet, Seibert
was ruled out by reviewing the surgical kodachromes of
these cases. A review of other potential causes of graft
mobility deemed it necessary to examine the unques­
tioned acceptance of the statement that free autogenous
gingival grafts should be placed on a recipient bed of
periosteum and connective tissue. The rationale was that
9, 1 0 , 1 9 , 3 4 ,
this aids in revascularizing the graft, mini­
36
mizing osseous resorption, and helping to obtain an
1 9 , 3 6 , 3 7
uneventful sequence of events in healing.
A careful review of the histology of periosteum brings
out several very relevant concepts. Periosteum, by defini­
tion, is that strata of cells, usually one to two cell layers
thick, which is intimately related to an osseous surface.
It is most noticeable as a distinct layer during active bone
formation and gradually loses its identity as a distinct
strata with age, becoming fibrotic. 38, 3 9
The periodontal complex of tissues seems to contain
two distinct types of periosteum. 40-42
The periosteal layer
subjacent to the attached gingiva seems to have its
connective tissue fiber orientation perpendicular to the
osseous surface. In the mucosal zone the periosteal
connective tissue fibers are oriented parallel to the bone.
The implications of these periosteal patterns are signifi­
cant. Clinically it is found that after dissecting away the
overlying tissue the periosteum in the gingival zone
usually appears fixed, while that in the mucosal area
(apical to the mucogingival junction) is often mobile.
These findings may be a function of their cellular and
fibrous orientations. To increase the zone of functional
attached masticatory mucosa in most cases it is necessary
to position the greater portion of the grafts apical to the
mucogingival junction. This relates the grafted donor
tissue to an area with a potentially mobile periosteal
base. This factor could easily account for some postoper­
ative graft mobility.
The periodontist has an obligation to the patient and
the restorative dentist to produce a gingival complex
which is both functional and stable. In the patient for
whom restorative dentistry is contemplated, these consid­
erations take on added significance. The zone of mastica­
tory mucosa must be able to resist the functional stresses
present in the oral cavity as well as the additional
irritation of the restoration. While the implications of a
mobile graft are uncertain, it seems likely that this type
of graft represents a tissue type intermediate to that of
attached gingiva and alveolar mucosa, and as such may
be more susceptible to future breakdown than a firmly
attached band of masticatory mucosa.
Another aspect which merits some consideration is
root coverage. In the attempt to achieve root coverage of
an area of gingival recession, one at best gains a long
epithelial and/or connective tissue attachment. These
both are tenuous and susceptible to breakdown, particu­
larly if they approximate restorative dentistry. The
question now arises, is it more appropriate clinically to
place the graft tissue on denuded bone in order to obtain
J. Periodontol.
October, 1976
a fixed attached base rather than a mobile periosteal
base.
METHODS AND MATERIALS
Sixty cases requiring free autogenous gingival grafts
3 5
were selected from among clinical patients requiring
periodontal therapy at the University of Pennsylvania
School of Dental Medicine. The indications for grafting
included inadequate zones of attached gingiva and/or
gingival crevices that could be probed to the mucogingi­
val junction (unattached, nonfunctional masticatory mu­
38
cosa). The sixty cases were randomized into two groups
utilizing a table of random numbers. Group A had
intermediate split thickness free autogenous grafts from
the palate placed on a recipient bed of denuded alveolar
bone, while Group B had similar donor tissue placed on a
clinically acceptable bed of "periosteum" and/or connec­
tive tissue. The surgical procedures were performed by all
of the authors to demonstrate that the procedure in
question would work in the hands of a cross section of
periodontists. One examiner (B.D.) was designated to
document all cases, examine the postoperative results,
and record measurements.
RECIPIENT SITE
Group A. After infiltration anesthesia with 2% xylo-
caine with 1:50,000 epinephrine, a horizontal incision to
bone was made slightly coronal to the mucogingival
junction. A t the mesial and distal terminae, vertical
oblique incisions were made to the osseous surface for
relaxation of the tissue and to achieve better blending
with the adjacent area (Diagram 2). Blunt dissection to
bone was then accomplished with a periosteal elevator
(Diagrams 3 and 4). The coronal aspect of the recipient
bed was beveled for better blending of graft contours.
Group B. Following the anesthetic technique described
in A , and incisions of similar design, sharp dissection was
performed to separate the epithelium, lamina propria,
muscle and elastic tissue from the underlying periosteum.
To assure a "clean" recipient site, tissue nippers were
used to smooth the area and remove any remaining
muscle and elastic tissue. Again the coronal aspect was
beveled for blending of tissue junctions.
DONOR SITE
The palate served as the donor tissue in all cases. The
gingival zone of the palate, that zone nearest the teeth,
was preferred because it has less fat and glandular tissue
(Diagram 5). Every attempt was made to minimize the
amount of donor tissue containing rugae. Grafts were
excised with a Bard-Parker N o . 15 (B.D., J . G . C . ) or a
Paquette knife (J.S.S.) and trimmed, if necessary, to size
and for removal of any fat or glandular tissue.
Volume 47
Number 10
IMMOBILIZATION
After adaptation with moist gauze, all grafts were
sutured in place with 5-0 plain gut suture on their coronal
aspect only (Diagrams 6 and 7). Lastly, a dressing of Coe
Pack* with Schlein's Powder† incorporated in it was
placed and dry foil positioned over the dressing. The
dressing was changed at l week and removed at 2 weeks
and healing patterns were observed (Diagram 8).
DOCUMENTATION
A standardized intraoral camera set-up with constant
magnification was employed to document the cases.
Kodachromes were taken immediately preoperatively,
after preparation of the recipient site, with the graft
sutured in place, and postoperatively at 7, 14, 21, 42, 60,
120 days and in some cases up to 1 year. Preoperative
and postoperative measurements were made with a
Michigan 0 probe to record sulcus depth and the zone of
masticatory mucosa. Observations were made as to pain,
postoperative graft mobility, tissue character, graft
demarcation, sequestrations, initial presence of dehis­
cences and fenestrations, and healing sequence.
RESULTS
A l l 60 grafts were clinically successful, including the 30
grafts placed on denuded bone. None was lost due to
necrosis, indicating the predictability of the experimental
procedures. Pain, a very subjective expression, was
measured utilizing an index of our own device based on
analgesic utilization:
5—Severe pain even with intake of codeine
4—Codeine required to obtain relief of pain
3—Codeine first evening only, some use of aspirin
2—Aspirin only needed
1—Some discomfort, but no aspirin needed
0—Comfortable
Half gradations were used within this scale. The analge­
sic prescribed was Tylenol‡ with one-half grain codeine.
There was statistically no difference between the pain
levels in Group A and B, although on the average, those
patients with the grafts placed on denuded bone were
slightly more comfortable. This however, is a subjective
finding.
N o evidence of sequestration or infection was noted in
the course of the study. A n interesting finding was that in
many cases a healing lag existed in the grafts placed on
denuded bone. In patients on whom bilateral grafts were
performed, Type A on one side and Type B on the other,
the side on which the graft was placed directly on the
osseous surface seemed to be several days behind the
* C o e P a c k — C o e Laboratories Inc., Chicago, Illinois
t Schlein's Powder—Schlein's Periodontal Supply Inc.,
N.J.
t Tylenol N o . 3 — M c N e i l Laboratories Inc., Fort Washington, P a .
Gingival Grafts 561
healing of the graft placed on the periosteal side during
the first 2 weeks of healing. A t about the second or third
postoperative weekly visit, the side with the delayed
healing (graft on denuded bone) had caught up to its
counterpart (graft on periosteum) in terms of healing.
Less postoperative swelling and better hemostasis
during surgery were observed by the patients and the
examiner in the cases in which the graft was placed
directly on the osseous surface. This may have been due
to the shorter time factor involved in the surgical
procedure, but more likely to the fact that a full thickness
mucoperiosteal flap is raised with few vessels severed
supraperiosteally or left in the recipient area, thus
resulting in less bleeding and edema.
Finally, examination of grafts for mobility showed that
in the cases placed on periosteum more than one-half (17
of 30) exhibited postoperative graft mobility in either an
antero-posterior, or apico-coronal direction, or both,
while none of the grafts placed on denuded bone demon­
strated this clinical finding. Initially very few of the grafts
were mobile in either direction. Mobility was not usually
observed in grafted tissue until 2, 4 or 6 months
postoperatively. Once mobility was demonstrated, it
remained during the duration of the study (Tables 1 and
2).
DISCUSSION
The applicability of this modification of a basic
therapeutic procedure as a clinical technique was the
main thrust of this paper. It is felt that this has been well
established. In our group of 60 cases, all of the test
procedures proved successful. Our criterion of success
was the clinical increase of the zone of masticatory
mucosa by the survival of our grafts. Postoperatively
graft survival could be detected in almost all instances by
the lighter color peculiar to the palatal tissue, differences
in the tissue character compared to adjacent areas, and
the presence of rugae where they existed in the initial
donor tissue.
In respect to pain response, according to our rather
subjective index, no significant difference was detected
between the two procedures. One of the initial concerns
about placing the grafts on denuded bone was that of an
increased pain response. Not only was this not the case,
but the clinical data intimates a lower pain response on
the "osseous procedure."
Improved hemostasis in the recipient site in the direct
osseous technique has significant clinical application. In
patients for whom vasoconstrictors are contraindicated
(i.e., hypertensives and coronary patients), the minimal
bleeding in the full mucoperiosteal flap used to expose
the recipient bone would facilitate the surgical procedure.
There is a better field of vision, less swelling due to
Dunellen,
edema and thus a smooth healing sequence.
The rationale behind the immobilization and blending
techniques warrant some discussion. Gut suture is util-
DIAGRAM 1. Preoperative area demonstrates the lower left premolars with gingival recession and a small band of nonfunctional
gingiva (nfg) on the facial surface. These areas are probeable to the mucogingival junction (mgj).
DIAGRAM 2. The initial incision is made with a bevel at the mucogingival junction. Mesial and distal vertical incisions (mvi and dvi)
are made after the beveled incision at the mucogingival junction is completed.

DIAGRAM 3. A full thickness mucoperiosteal flap (mf) is reflected with a periosteal elevator exposing a recipient bed of denuded
bone (db) and illustrating the bevel of the initial incision (b).
DIAGRAM 4. A bucco-lingual view demonstrating the bevel of the gingival tissue remaining on the buccal surface coronal to the
denuded recipient site (mg, marginal gingiva; bi, beveled incision; db, denuded bone; fmf,/w// thickness mucoperiosteal flap).

DIAGRAM 5. A bucco-palatal view demonstrating the donor tissue is obtained from the gingival palatal tissue rather than from the
lateral zone of the palate. Donor tissue from the gingival zone contains only dense collagenous connective tissue covered by
keratinized epithelium. If donor tissue is obtained from the lateral zone, it may contain part of the submucosa and thus fat or
glandular tissue which could result in graft failure, (g, gingival graft from gingival zone of the palate.)
DIAGRAM 6. The gingival graft (g) is sutured in place over the denuded bone with 5-0 plain gut sutures (s) to the remaining marginal
gingival tissue.

DIAGRAM 7. Bucco-lingual view of the graft (g) in place and sutured (s) to the marginal tissue in the area of the bevel produced by the
initial incision.
DIAGRAM 8. Postoperative result of increasing the zone of masticatory mucosa in the area of the lower left premolars.
562
Volume 47
Number 10 Gingival Grafts 563

PERIOSTEUM OSSEOUS

FIGURE la. Preoperative view of area showing nonfunctional FIGURE 2a. Preoperative view of opposite side of mouth of
gingiva (nfg), probeable to the mucogingival junction (mgj). same patient as in Figures I. Nonfunctional gingiva (nfg),
mucogingival junction (mgj).

FIGURE lb. Recipient bed preparation illustrating periosteum

(p) upon which graft is to be placed, bevel (b) to achieve FIGURE 2b. Recipient bed preparation illustrating denuded
blending with adjacent area, and mucosal flap (mf). bone (db) upon which graft is to be placed, bevel (b) to achieve
blending with adjacent area, and mucoperiostealflap(mf).

FIGURE lc. Graft (g) sutured (s) in position.

FIGURE 2c. Graft (g) sutured (s) in position.

FIGURE Id. One week healing. Note presence of superficial

necrotic tissue. FIGURE 2d. One week healing.

FIGURE le. Two weeks healing. FIGURE 2e. Two weaks healing.
 J. Periodontol.
564 Dordick, Coslet, Seibert October, 1976

PERIOSTEUM OSSEOUS

FIGURE If. Three weeks healing. FIGURE 2f. Three weeks healing.

FIGURE 1g. Six weeks healing. FIGURE 2g. Six weeks healing.

FIGURE 1h. Two months healing. FIGURE 2h. Two months healing.

FIGURE l i . Four months healing. This graft exhibits postoper­
ative mobility.
ized in our mucogingival procedures because during
healing of the grafted tissue it is desirable to minimize
manipulation. Through the use of absorbable sutures,
one avenue of disturbing the postoperative attachment
and maturation process is eliminated. The graft is
sutured in place so that the external bevel of the recipient
site corresponds with the internal bevel at the coronal
aspect of the graft. This type of "lap joint" seems to
virtually eliminate the thick bulgy appearance that often
occurs at the graft-bed junction if a "butt joint" is used.
The early survival of the graft placed directly on an
osseous surface is probably due to plasmatic circula-
FIGURE 2i. Four months healing.
9, 10, 14, 18, 34, 36, 4 0
tion although this has not been demon­
strated histologically. Prior to the reestablishment of
vascularization, the graft is totally dependent on a
diffusion of nutrients from the recipient bed, plasmatic
circulation. This phenomenon is hypothesized to be
essential in the healing of grafts placed on bone. Plas­
matic circulation probably occurs via the "weeping" of
the bone through its Haversian canals into the fibrin clot
interface and finally into the graft itself. A s healing
progresses there is probably capillary revascularization
by vessels penetrating the cortical plate of bone. It is not
known whether there is surface resorption and reforma-
Volume 47
Number 10 Gingival Grafts 565

OSSEOUS P R O C E D U R E

FIGURES 3a-3i. Illustrate preoperative, recipient bed prepara­

tion [denuded bone (db)], graft immobilization, and postopera­
tive visits at 7, 14, 21, 42 days and 2 and 6 months.
 J. Periodontol.
566 Dordick, Coslet, Seibert October, 1976

T A B L E 1. Grafts Placed on Bone* mobility was observed in the group placed directly on
N u m b e r of cases showing characteristic bone.
3. Osseous placed grafts demonstrated less swelling
Duration in days 7 14 21 42 60 120
0
and better hemostasis than did the periosteally placed
Presence of superficial ne­ 28 9 0 0 0
crotic tissue grafts.
Sequestrations 0 0 0 0 0 0 4. A healing lag was observed in the grafts placed on
Fenestrations and dehiscences 19 13 7 1 0 0 bone which lasted only for the first two postoperative
(soft tissue)
visits, approximately 2 weeks.
Presence of rugae 1 1 6 9 9 9
Graft mobility 0
5. N o infections or sequestrations were noted in any
0 0
Average pain response 2.98 0.13 0 0 0 0 case.
Graft demarcation 30 30 30 28 28 28
REFERENCES

* T h i r t y cases in each group.
T A B L E 2. Grafts Placed on Periosteum*
N u m b e r of cases showing characteristic
Duration in days 7 14
26 3 0
Presence of superficial ne­
crotic tissue
Sequestrations 0 0
Fenestrations and dehiscences 0 0
(soft tissue)
Presence of rugae 1 4
Graft mobility
Average pain response 3.13 0.2
Graft demarcation 28 28
* T h i r t y cases in each group.
tion of the cortical plate of alveolar bone in the recipient
site to facilitate this revascularization of the graft.
O f prime importance, however, and the reason this
work was undertaken, is the factor of graft mobility
postoperatively. To reiterate, the mobility factor con­
cerned with in this study is simply that which exists when
a "healed" graft is manipulated with an instrument. The
implications of this type of mobility are not clear, but it is
plausible to assume that in restorative cases future
problems could arise from having this mobile tissue
instead of a functional band of firmly attached mastica­
tory mucosa.
It is not our intention that this procedure take the
place of our currently utilized techniques of grafting, but
that it simply become one more tool in ourexpanding
therapeutic armamentarium and that the benefits in
terms of time required, simplicity, decreased bleeding
and swelling, and predictable result should be recognized.
SUMMARY
1. Thirty free autogenous gingival grafts were placed
on bone and 30 were placed on a periosteal bed. The
distribution into the groups was random. A l l 60 grafts
survived, showing that both procedures were predictable.
2. Over one-half (17 of 30) of those on periosteum
demonstrated mobility by 6 months postoperatively. N o
1. Bjorn, H.: Free transplantation of gingiva propria. Sven
Tandlak Tidskr 22: 684, 1963.
2. Bjorn, H.: Free transplantation of gingiva propria. Odon-
tol Revy 14: 323, 1963.
3. King, K. O., and Pennel, B. M . : Lecture: Philadelphia
Society of Periodontology, April, 1964.
21 42 60 120
4. Cowan, A.: Sulcus deepening incorporating mucosal
0 0 0
graft. J Periodontol 36: 188, 1965.
5. Nabers, J. M . : Extension of the vestibular fornix utilizing
a gingival graft—Case history. Periodontics 4: 77, 1966.
0 0 0 0
6. Nabers, J. M . : Free gingival grafts. Periodontics 4: 243,
0 0 0 0
1966.
7. Haggerty, P. C : The use of a free gingival graft to create
9 13 14 14
a healthy environment for full crown preparation, case history.
15 15 17
Periodontics 4: 329, 1966.
0 0 0 0
8. Becker, N . G.: A free gingival graft utilizing a presuturing
28 27 27 27
technique. Periodontics 5: 194, 1967.
9. Sullivan, H . C , and Atkins, J. H.: Free autogenous
gingival grafts. I. Principles of successful grafting. Periodontics
6: 121, 1968.
10. Sullivan, H . C , and Atkins, J. H.: The role of free
gingival grafts in periodontal therapy. Dent Clin North Am 13:
133, 1969.
11. Bressman, E., and Chasens, A. I.: Free gingival graft
with periosteal fenestration. J Periodontol 39: 298, 1968.
12. Sullivan, H . C , and Atkins, J. H . : Free autogenous
gingival grafts. III. Utilization of grafts in the treatment of
gingival recession. Periodontics 6: 152, 1968.
13. Snyder, A. J.: A technic for free autogenous gingival
grafts. J Periodontol 40: 702, 1969.
14. Gargiulo, A. W., and Arrocha, R.: Histo-clinical evalua­
tion of free gingival grafts. Periodontics 5: 285, 1967.
15. Frisch, J., and Bhaskar, S. N . : Free mucosal grafts with
tissue adhesives: Report of 17 cases. J Periodontol 39: 190,
1968.
16. Hawley, C. E., and Staffileno, H.: Clinical evaluation of
free gingival grafts in periodontal surgery. J Periodontol 41:
105, 1970.
17. Pennel, B. M . , Tabor, J. C , King, K. O., Towner, J. D.
Fritz, B. D., and Higgason, J. D.: Free masticatory mucosa
graft. J Periodontol 40: 162, 1969.
18. Oliver, R. C , Löe, H . , and Karring, T.: Microscopic
evaluation of the healing and revascularization of free gingival
grafts. J Periodont Res 3: 84, 1968.
19. Cohen, E. C , and Tusa, J. A.: Autogenous split
thickness gingival grafts. J Acad Gen Dent 18: 29, 1970.
20. Bernimoulin, J. P., and Lange, D. E.: Free gingival
grafts—Clinical aspects and cytology of their healing. Dtsch
Zahnaerztl Z 27: 357, 1972.
21. Ress, T. D., and Brasher, W. J.: A technique for
obtaining thin split-thickness grafts in periodontal surgery.
Oral Surg 29: 148, 1970.
22. Grupe, H . E., and Warren, R. F.: Repair of gingival
defects by a sliding flap operation. J Periodontol 27: 92, 1956.
Volume 47
Number 10
23. Corn, H.: Edentulous area pedicle grafts in mucogingi-
val surgery. Periodontics 2: 229, 1964.
24. Robinson, R. E.: Utilizing an edentulous area as a donor
site in the lateral repositioned flap. Periodontics 2: 79, 1964.
25. Pennel, B. M . , Higgason, J. D., Towner, J. D., King, K.
O., Fritz, B. D., and Sadler, J. F.: Oblique rotated flap. J
Periodontol 36: 305, 1965.
26. Grupe, H . E.: Modified techniques for the sliding flap
operation. J Periodontol 37: 491, 1966.
27. Nabers, C. L.: Repositioning the attached gingiva. J
Periodontol 25: 38, 1954.
28. Ariaudo, A. A., and Tyrrell, H . A.: Repositioning and
increasing the zone of attached gingiva. J Periodontol 28: 106,
1957.
29. Cohen, D. W., and Ross, S. E.: The double papillae
repositioned flap in periodontal therapy. J Periodontol 39: 65,
1968.
30. Vande Voorde, H . E.: Gingival grafting and gingival
repositioning. J Am Dent Assoc 79: 1415, 1969.
31. Ibbott, C. G.: The free gingival graft: Where and how to
use it. J Can Dent Assoc 36: 365, 1970.
32. Guldener, P. H.: Les greffes en chirurgie parodontale.
Rev Fr D'Odonto Stomatol 18: 457, 1971.
33. Mlinek, A., Smukler, H., and Buchner, A.: The use of
free gingival grafts for the coverage of denuded roots. J
Periodontol 44: 248, 1973.
PAPILLON-LEFEVRE SYNDROME
H i c k o r y , J . E . , Schell, J . , and Richard, G . E .
J Oral Surg 3 3 : 671, September, 1975.
Papillon and Lefevre described a case of severe periodontosis in
association with keratotic lesions of the palmar and plantar surfaces.
T h e syndrome involves severe destruction of alveolar bone on deciduous
and permanent teeth, with or without pockets, abscesses, and other
gingival signs. A case was reported of a 3-year-old boy who
referred to the oral surgery service for evaluation of asymptomatic
tooth mobility. M e d i c a l history revealed a chronic exfoliative dermati-
tis that had been treated as well as previous pneumonia. Otherwise the
child was a healthy patient with a complete blood count ( C B C ) within
normal limits. Generalized deep pockets and marked mobility were
found in his deciduous dentition. Radiographic examination disclosed
generalized severe alveolar bone destruction. In the differential diagno-
sis, cyclic neutropenia, vitamin C deficiency, and acrodynia were ruled
out. Tentative diagnosis of P a p i l l o n - L e f è v r e syndrome was made. Since
the patient was asymptomatic, no treatment was recommended and he
was referred to the prosthetic services in view of the poor dental
prognosis. A month later the patient developed acute distress with
fever, generalized gingival inflammation, and multiple
abscesses. U n d e r general anesthesia and prophylactic antibiotics, the
full mouth extraction procedure was performed, and the full denture
previously made was inserted. T w o days postoperatively, the patient
was discharged in good condition and functioning well with
dentures. T h e eventual outcome after the first visit could have been
predicted avoiding the sudden onset of the oro-dental problems.
Tachikawa USAF Hospital, APO San Francisco, California
Dr. G . Ramirez
Gingival Grafts 567
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Abstracts
THE PERIODONTAL ABSCESS
Miyasato, M . C .
Periodont Abstr 2 3 : 53, Summer, 1975
In this review of the literature of the periodontal abscess extending
back to the latter part of the 19th century, the author indicated that,
although recognized and treated for a long time, the periodontal abscess
still presents a problem to the clinician in terms of diagnosis and
treatment, more importantly in diagnosis. T h e periodontal abscess was
was described by definitions, formation and pathogenesis, microbiology,
diagnosis, therapy, and prognosis. In summary, the relative paucity of
information on the periodontal abscess is identified, since most articles
have been based on clinical observations. There is a lack of literature
regarding the microbiology and pathogenesis of the lesion, and more
study is needed to gain insight into modes of treatment for chronic
periodontal defects. Dr. W . Myones
PERIODONTAL DISEASE INFORMATION IN COLLEGE
HEALTH EDUCATION
Goldstein, M . S., and Freed, J . R .
J Prevent Dent 2 : 20, July-August, 1975.
T o determine what was actually being included in 20 college text-
gingival books printed between 1966 and 1973 regarding prevention of perio-
dontal disease, each book was reviewed for structural elements, perio-
dontal terminology, etiology of periodontal disease and prevention.
T h e results showed an inadequate coverage in the textbooks and that
the the authors of the textbooks are professional health educators who
are neither knowledgeable about periodontal disease, nor do they re-
gard it as important. University of California at Los Angeles, School
96233 of Public Health, Center for the Health Sciences, Los Angeles, Cali-
fornia 90024 D r . H . Israelson