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Intraoral dermis grafting: has it any advantages?
Intraoral dermis grafting: Has it any advantages? AL A. Pogrel, M.B., Ch.B., B.D.S., F.D.S.R.C.S.,*
San Francisco, Calif.
SCHOOL
FRANCISCO
OF DENTISTRY,
UNIVERSITY
OF CALIFORNIA
SAN
Results are reported from a series of twenty-four patients who received intraoral dermis grafts for a variety of conditions and have been followed for between 6 months and 4 years. Advantages and disadvantages of dermal grafting, including contracture, the final histologic and clinical appearance of the graft, and problems with the donor area, are discussed. (ORAL &JIG. ORAL M& ORAL PATHOL. 60~598-603, 1985)
W
heneverintraoral mucosais removed,eitherto eliminatediseasedtissuesor aspart of a preprosthetic procedure,a decisionmust be made concerning closureof the residualdefect.If the defectis small, then diit approximationof the woundedgesmay result in satisfactory healing with only minimal contracture.If the woundis overbone,asonthe hard palate,thenit may bepossibleto let it granulateand heal by secondaryepithelixationwith only minimal scarringandcontracture,but if this is attemptedon an area of nonattachedmucosa, then significant wound contracturewill result. It is now generally accepted.thatif onewishesto preventcontractureof an intraoral epithelial defect,then a graft of some type must be provided. Split-skin grafts, or Thierschgrafts,consistof the epidermisandpart of the dermisandarewidelyused for replacing skin defects. They rapidly gained acceptancefor intraoral grafting after they were popularizedby Obwegeser’for vestibuloplastyproceduresin his modificationof Trauner’soriginal technique.*It has beenshownthat the thinner the split skin graft, the better it will take at the graft site but the greaterwill be the contracture.3Conversely,the thicker a split-skin graft is, the lessit will contract, but its take is lesspredictable.Sincethis graft is, by definition,only a split thicknessof the skin (normally between%O,OOO and %S,OCXI of an inch) it will not normally include hair follicles or sweat glands, thoughin otherrespectsit doesretain the properties of skin and remainsorthokeratinizedwhen placed intraorally.Prosthodontistsmay considerthis advan*Assistant Professor, Division of Oral and Maxillofacial gery. 598
Sur-
tageousfor resistingthe possibletrauma from denture flanges.However,the graft is nonwettable. l$ll-thickness skin grafts, or Wolfe grafts, are usedin plastic surgerywheregoodcolor match and minimal contracturearerequired,They do, however, sufferfrom the disadvantages of occasionalproblems in closureof the donorsite and alsothe lesspredictabletakeof thegraft becauseof its greaterthickness, sinceit takeslongerfor new bloodvesselsto permeateit.3 Sincethis graft takesthe full thicknessof the skin, it will include hair follicles and sebaceous glands,which may continueto function after grafting. Becauseof theseproblems,there is very-little indication for intraoral full-thicknessskin grafting. Mucotomesareavailablefor takingsplit-thickness mucosalgrafts, usuallyfrom the buccalmucosa,for intraoral grafting techniques; these are well describedby Steinhauser.4 The disadvantages of this technique(besidesthe high cost of the mucotome) are the possibleproblemsin healing of the donor area,which cannotbedressedsatisfactorily,andalso the fact that it is difficult to obtainsufficientmucosa for the averagevestibuloplasty.Split-mucosalgrafts take well intraorally, althoughthey do exhibit quite marked contracture.The final appearanceof the graft resembiesthe surroundingmucosavery satisfactorily. Full-thicknessmucosalgrafts havealsobeenused both for vestibuloplastytechniquesand in periodontal surgery.The donorareais normally the palateor tuberosity region, where primary closure of the defect in the donor area is impossibleaSince it is attached mucosa, however, contraction does not occur and secondaryepithelizationtakesplace normally under a dressing or dressingplate. Fullthicknessmucosagrafts can alsobe taken from the
Intraoral
Volume60 Number 6
dermis grafting
599
1. Histologic appearance of dermal graft showing densecollagenous tissue and epithelial remnants in hair follicle. (Hematoxylin and eosin stain. Magnification, x80.)
Fig.
Fig.
2. Split-skin graft still attached and dermatome adjusfed to take dermal graft.
buccal mucosa.6 The advantages of a full-thickness mucosal graft are its lack of contracture and the fact that, since it is full thickness, mucus glandsin the graft may survive and continue to function, which may give a more physiologic denture-bearing surface. The disadvantages of full-thickness mucosal grafts are the more unpredictable nature of their take and the fact that it is often very difficult to obtain sufficient mucosa for the average vestibuloplasty. Recently xenografts, such as porcine dermis and epidermis and bovine dermis and epidermis, have become available as allografting materials. It has been shown, however, that these materials act as a
biologic dressing over a de-epithelized area and allow relatively painless secondary epithelization to occur beneath them, but the final contracture and scarring appear to be the same as with any other secondary epithelization technique.‘- 8 The use of dermis as a grafting material was first described in 1913.9 Dermis is the deep layer of the epithelium and mucosa and consists of the dense collagenous corium with hair follicles and sweat glands embedded in it. It aids the mitotic activity of the basal layer and plays a role in epidermal differentiation and appendages.*O It is often used as a covering layer, as when it is placed over the carotid vessels in a radical neck dissection, after which the
600
Pogrel
Oral Surg. December, 1985
Fig.
Fig.
3. Appearance of dermal graft.
4. Dermal graft in situ in vestibuloplasty and tattooed with India ink to measure contracture.
skin llaps are placed over the graft.” In this case it is the collagenous corium which takes, to provide a cover of fibrous tissue over the carotid vessels, while the epithelial elements in the corium degenerate and form epithelial rests. However, when dermis is placed on a skin or mucosal wound with the epithelial remnants outward, it will re-epithelize from the epitheliil elements left around the hair follicles and sweat glands (Fig. 1). The use of intraoral dermal grafting was first described by Smiler and associatesLz in 1977, and animal studies were reported by Rosner and colleegues13 in 1982 and Ueda and m-worked4 in 1984. These studies seem to con&m that intraoral dermal grafting was a simple tech-
nique with less morbidity to the donor areas than other grafting techniques, with less contracture at the graft site, and with a more physiologic epithelium developing. TECHNlQlJE
The technique that we have employed is basically ,I* with certain as described by Smiler and modifications. An automatic dermatome is necessary, and it is preferable to have one that can vary the width of the graft. First, a very thin (%o.m inch) split-skin graft is taken from the appropriate donor area; the graft is not detached at its far end but is removed from the dermatome intact (Fig. 2). This
Intraoral
Volume 60 Number 6
Fig.
dermis grafting
601
5. Appearance of healing dermal graft donor area.
Fig. 6. Clinical appearance of dermal graft used to cover an area resected for removal of carcinoma.
leaves the split-thickness graft pedicled from one end of the donor site. The blade of the dermatome is then narrowed so that the dermal graft can be taken from within the area covered by the split-skin graft. A dermal graft approximately %Z,OOO to %S.CKN inch in thickness is then taken and preserved in salinesoaked gauze (Fig. 3). Hemostasis is obtained, and the split-skin graft can be replaced over the donor site so that there is no raw donor site. This lack of a raw donor area is claimed as one of the great advantages of this technique. The dermis is then placed over the intraoral defect with the epithelial remnants on the outer surface, and it can be sutured in position and stabilized with a stent, if appropriate. In this study the grafts were
tattooed with India ink as described by Hillerupls (Fig. 4). RESULTS
Intraoral dermal grafting was carried out on twenty-four patients for a variety of reasons, including sulcus deepening and epithelial replacement following tumor surgery. In fourteen of the cases, there were problems in the donor area site, mainly because of hematoma formation under the returned split-skin graft which prevented a good take of the graft. In one case this resulted in almost complete failure of the graft and the necessity to regraft the area at a later date. In very thin persons, particularly females, the total
602
Pogrel
Oral Surg. December, I985
7. Histologic appearance of dermal graft showing parakeratinization and dense, well-vascularized connective tissue subepithelially. (Hematoxylin and eosin stain. Magnification, X40.)
Fig.
thickness of the epithelium may be only Ks.oooinch or slightly more,16 which means that if the total thickness of a split-skin graft and the dermal graft exceeds this, one will go right through the epithelium into the subcutaneous fat. This has been a complication on a number of occasions when attempts have been made to take dermis from the inner aspect of the arm; that is why we now take very thin split-skin grafts and dermal grafts. Also, hemostasis of a donor area has often proved difficult to obtain, despite the use of electrocautery and epinephrine-soaked gauze. This is because one is nearly at the full depth of the epithelium and there is a rich blood supply in this area. If hemostasis is not complete, the take of the split-skin graft that is reapplied will be less than optimal; this will leave some very deep denuded areas, which take considerable time to re-epithelize, since they are virtually full-thickness defects. This is another reason for taking the thinnest possible splitskin graft, since thii has the best opportunity to take over the area from which the dermis has been
removed. We have found that the healing of the donor area after a dermis graft has been taken is often quite prolonged and uncomfortable for the patient, often more so than after the taking of a thin split-skin graft in the conventional manner, particularly if a very thin split-skin graft is taken with a safety razor as recommended by Marx and associates.” In those cases in which the graft did take satisfactorily at the donor area, the patient still experienced discomfort in the donor area, presumably because of the depth of epithelium which had been removed, and it was believed that in many cases this discomfort was at least comparable to or, worse than, that associated with the taking of thin split-skin grafts. It is obvious that meticulous hemostasis of the donor site is essential, and in some cases this may be best obtained by placing moist dressings on the donor site for 24 hours before the split-skin graft is replaced over the area. This can be done without further general anesthesia, but it does prolong the whole operation. Clinically, after healing was complete, the dermis graft donor area, in general, showed a better color match than the split-skin graft donor area, although when the split-skin graft had been thin (around %O.OOO inch) there was virtually no difference in appearance between the two donor areas (Fig. 5). However, since the dermis with the hair follicles and sweat glands has been removed from the dermis donor area, the healed donor area lacks hair or sweat glands, while many of the hair follicles and sweat glands survive in the split-skin graft donor area since they are mainly in the dermal layer. In cases in which problems were encountered in the healing of the dermis donor area, the final result was inferior to that of a split-skin graft donor area. In all cases, the dermis took very well at the intraoral site and was associated with a very low incidence of pain and morbidity. The grafts were tattooed with India inkI in order to measure contracture. Because re-epithelization is taking place from the edges of the defect and also from the epithelial remnants in the hair follicles and sweat glands, in many respects this represents a secondary epithelization technique, and one might then envision excessive contracture. However, the rest of the dermis graft is dense collagenous tissue, which has very little power of contracture; therefore, one might imagine that the situation is comparable to secondary epithelization of the hard palate, in which there is very little contracture since the tissues are held rigid. It is not clear what the end result of this should be on an intraoral dermal graft, but Smiler and co-workersI
Intraoral
Volume 60 Number 6
suggested that the contracture of a dermal graft is less than that of a split-skin graft. In our series, the contracture of dermal grafts of between YROCVJ and %S,OOO inch was compared with contracture of splitskin grafts of between YIZ.OOO and YIS.OOO inch. There was slightly more contracture of dermal grafts than of the split-skin grafts, although this was not statistically significant. Contracture was a variable, depending on the thickness of the graft, the site in which it was placed, and whether or not a stent was used in the vestibuloplasty techniques. When the grafts were placed on the cheek mucosa in cases of tumor excision, contracture was approximately 50% in the split-skin grafts and approximately 55% in the derma1 grafts; when the grafts were placed in the labial vestibule for vestibuloplasty techniques, contracture of approximately 30% was seen for both types of graft when a stent was used. This does not appear to confirm previous reports that dermis contracts less than skin. Clinically, 6 months postoperatively a dermal graft does more closely resemble mucous membrane than do split-skin grafts (Fig. 6). Histologically, there appeared to be little difference between the dermal graft and the split-skin graft at 6 months, since neither contains functioning hair follicles, sweat glands, or mucous glands, although there was more orthokeratinization on the split-skin grafts. However, this is dependent on the original thickness of the graft taken, and if a very thin split-skin graft is placed it will not be highly keratinized. The dermal grafts contained more parakeratinization, which may explain the greater clinical resemblance to mucosa (Fig. 7). Smiler and associates” suggested that this greater histologic resemblance to mucosa may be due to the fact that the epithelium of a dermal graft arises from more pleuripotential cells which have greater powers of differentiation. The submucosa beneath the dermis graft consists of dense, well-vascularized, fibrous tissue. There is some debate over whether skin or mucosal grafts form the better denture base. Skin is better keratinized to withstand trauma but is not wettable. Mucosa, on the other hand, has more parakeratinization but is wettable and may therefore aid denture retention better.‘* The greater resemblance of the dermis graft to mucosa may therefore be of significance. The dermis graft is also thicker than a split-skin graft and contains more collagenous tissue, which might be thought to form a more satisfactory denture base, as it may be more resistant to trauma.
dermis grafting
603
SUMMARY
Experience with the use of intraoral dermal grafting on twenty-four patients is reported. Its advantages and disadvantages as compared with split-skin grafts are noted but, in general, it is not thought to offer significant advantages over the more usual technique of split-skin grafting. REFERENCES
1. Obwegeser HL: Die totale mundbodenplaskik. Schweiz Monatsschr Zahnheilkd 73: 565, 1963. L. * Trauner P: Alveoplasty with ridge extensions on the lingual side of the lower jaw to solve the problem of a lower dental prosthesis. ORAL SURG ORAL MED ORAL PATHOL 5: 340-346, 1952.
3. McGregor IA: Fundamental techniques of plastic surgery. Edinburgh, 1975, Churchill Livingstone pp. 58, 64. 4. Steinhauser EW: Free transplantation of oral mucosa for improvement of denture retention. J Oral Surg 27: 955-961, 1969. 5. Amphlet J, Colwell WC: Edentulous vestibuloplasty using the palatal graft technique. J Prosthet Dent 48: 8-14, 1982. 6. Willerup S: Preprosthetic vestibuloplasty with buccal mucosal graft: a two year follow-up study. Int J Oral Surg 11: 81-87, 1982. I. Quayle AA: The atrophic mandible: aspects of technique in lower labial vestibuloplastv. _ _ Br J Oral Sure. 16: 169-178. 1978. 8. Gregory EW, Triplett RG, Connole PW: Comparison of fresh autogenous and freeze-dried allogenic skin for mandibular vestibuloplasty. J Oral Maxillofac Surg 41: 75-79, 1983. 9. Loewe 0: Uber Haut implantation an stelle der freien faszien plaatik. Munchen med Wochenschr 24: 1320, 1913. 10. Briggaman R: Epidermal-dermal interactions in adult human skin; role of dermis in epidermal maintenance. J Invest Dermatol 51: 454-465, 1968. 11. Corso PF, Gerold FP: Use of autogenous dermis for protection of the carotid artery and pharyngeal suture lines in radical head and neck surgery. Surg Gynecol Obstet 117: 37-40, 1963. 12. Smiler D, Radack K, Bilovsky P, Montemarano P: Dermal graft-a versatile technique for oral surgery. ORAL SURG ORAL MED ORAL PATHOL
43: 342-349.
1977.
13. Rosner TM, Stern K, Doku HC: Autogenous dermal grafting vestibuloplasty in dogs. J Oral Maxillofac Surg 40: 9-12, 1982. 14. Ueda M, Toshio K, Tohru 0, Shuhei T: Experimental study of dermal grafts for reconstruction of oral mucosa. J Oral Maxillofac Surg 42: 213-223, 1984. 15. Hillerup S: Tattoo marking for registration of relapse after oral vestibuloplastv. Int J Oral Sura 4: 65-68. 1975. 16. Southwood WFW! The thickness orthe skin. ‘Plast Reconstr Surg 15: 423-429, 1955. 17. Marx RE, Vopal JJ, Kline SN: Use of a safety razor as a dermatome. J Oral Surg 36: 814-815, 1978. 18. Tideman H: A technique of vestibuloplasty using a free mucosal graft from the cheek. Int J Oral Surg 1: 76-82, 1972. Reprint
requests
to:
Dr. M. A. Pogrel Division of Oral and Maxillofacial Surgery School of Dentistry University of California San Francisco 5 13 Parnassus Ave. San Francisco, CA 94143
San Francisco, Calif.
SCHOOL
FRANCISCO
OF DENTISTRY,
UNIVERSITY
OF CALIFORNIA
SAN
Results are reported from a series of twenty-four patients who received intraoral dermis grafts for a variety of conditions and have been followed for between 6 months and 4 years. Advantages and disadvantages of dermal grafting, including contracture, the final histologic and clinical appearance of the graft, and problems with the donor area, are discussed. (ORAL &JIG. ORAL M& ORAL PATHOL. 60~598-603, 1985)
W
heneverintraoral mucosais removed,eitherto eliminatediseasedtissuesor aspart of a preprosthetic procedure,a decisionmust be made concerning closureof the residualdefect.If the defectis small, then diit approximationof the woundedgesmay result in satisfactory healing with only minimal contracture.If the woundis overbone,asonthe hard palate,thenit may bepossibleto let it granulateand heal by secondaryepithelixationwith only minimal scarringandcontracture,but if this is attemptedon an area of nonattachedmucosa, then significant wound contracturewill result. It is now generally accepted.thatif onewishesto preventcontractureof an intraoral epithelial defect,then a graft of some type must be provided. Split-skin grafts, or Thierschgrafts,consistof the epidermisandpart of the dermisandarewidelyused for replacing skin defects. They rapidly gained acceptancefor intraoral grafting after they were popularizedby Obwegeser’for vestibuloplastyproceduresin his modificationof Trauner’soriginal technique.*It has beenshownthat the thinner the split skin graft, the better it will take at the graft site but the greaterwill be the contracture.3Conversely,the thicker a split-skin graft is, the lessit will contract, but its take is lesspredictable.Sincethis graft is, by definition,only a split thicknessof the skin (normally between%O,OOO and %S,OCXI of an inch) it will not normally include hair follicles or sweat glands, thoughin otherrespectsit doesretain the properties of skin and remainsorthokeratinizedwhen placed intraorally.Prosthodontistsmay considerthis advan*Assistant Professor, Division of Oral and Maxillofacial gery. 598
Sur-
tageousfor resistingthe possibletrauma from denture flanges.However,the graft is nonwettable. l$ll-thickness skin grafts, or Wolfe grafts, are usedin plastic surgerywheregoodcolor match and minimal contracturearerequired,They do, however, sufferfrom the disadvantages of occasionalproblems in closureof the donorsite and alsothe lesspredictabletakeof thegraft becauseof its greaterthickness, sinceit takeslongerfor new bloodvesselsto permeateit.3 Sincethis graft takesthe full thicknessof the skin, it will include hair follicles and sebaceous glands,which may continueto function after grafting. Becauseof theseproblems,there is very-little indication for intraoral full-thicknessskin grafting. Mucotomesareavailablefor takingsplit-thickness mucosalgrafts, usuallyfrom the buccalmucosa,for intraoral grafting techniques; these are well describedby Steinhauser.4 The disadvantages of this technique(besidesthe high cost of the mucotome) are the possibleproblemsin healing of the donor area,which cannotbedressedsatisfactorily,andalso the fact that it is difficult to obtainsufficientmucosa for the averagevestibuloplasty.Split-mucosalgrafts take well intraorally, althoughthey do exhibit quite marked contracture.The final appearanceof the graft resembiesthe surroundingmucosavery satisfactorily. Full-thicknessmucosalgrafts havealsobeenused both for vestibuloplastytechniquesand in periodontal surgery.The donorareais normally the palateor tuberosity region, where primary closure of the defect in the donor area is impossibleaSince it is attached mucosa, however, contraction does not occur and secondaryepithelizationtakesplace normally under a dressing or dressingplate. Fullthicknessmucosagrafts can alsobe taken from the
Intraoral
Volume60 Number 6
dermis grafting
599
1. Histologic appearance of dermal graft showing densecollagenous tissue and epithelial remnants in hair follicle. (Hematoxylin and eosin stain. Magnification, x80.)
Fig.
Fig.
2. Split-skin graft still attached and dermatome adjusfed to take dermal graft.
buccal mucosa.6 The advantages of a full-thickness mucosal graft are its lack of contracture and the fact that, since it is full thickness, mucus glandsin the graft may survive and continue to function, which may give a more physiologic denture-bearing surface. The disadvantages of full-thickness mucosal grafts are the more unpredictable nature of their take and the fact that it is often very difficult to obtain sufficient mucosa for the average vestibuloplasty. Recently xenografts, such as porcine dermis and epidermis and bovine dermis and epidermis, have become available as allografting materials. It has been shown, however, that these materials act as a
biologic dressing over a de-epithelized area and allow relatively painless secondary epithelization to occur beneath them, but the final contracture and scarring appear to be the same as with any other secondary epithelization technique.‘- 8 The use of dermis as a grafting material was first described in 1913.9 Dermis is the deep layer of the epithelium and mucosa and consists of the dense collagenous corium with hair follicles and sweat glands embedded in it. It aids the mitotic activity of the basal layer and plays a role in epidermal differentiation and appendages.*O It is often used as a covering layer, as when it is placed over the carotid vessels in a radical neck dissection, after which the
600
Pogrel
Oral Surg. December, 1985
Fig.
Fig.
3. Appearance of dermal graft.
4. Dermal graft in situ in vestibuloplasty and tattooed with India ink to measure contracture.
skin llaps are placed over the graft.” In this case it is the collagenous corium which takes, to provide a cover of fibrous tissue over the carotid vessels, while the epithelial elements in the corium degenerate and form epithelial rests. However, when dermis is placed on a skin or mucosal wound with the epithelial remnants outward, it will re-epithelize from the epitheliil elements left around the hair follicles and sweat glands (Fig. 1). The use of intraoral dermal grafting was first described by Smiler and associatesLz in 1977, and animal studies were reported by Rosner and colleegues13 in 1982 and Ueda and m-worked4 in 1984. These studies seem to con&m that intraoral dermal grafting was a simple tech-
nique with less morbidity to the donor areas than other grafting techniques, with less contracture at the graft site, and with a more physiologic epithelium developing. TECHNlQlJE
The technique that we have employed is basically ,I* with certain as described by Smiler and modifications. An automatic dermatome is necessary, and it is preferable to have one that can vary the width of the graft. First, a very thin (%o.m inch) split-skin graft is taken from the appropriate donor area; the graft is not detached at its far end but is removed from the dermatome intact (Fig. 2). This
Intraoral
Volume 60 Number 6
Fig.
dermis grafting
601
5. Appearance of healing dermal graft donor area.
Fig. 6. Clinical appearance of dermal graft used to cover an area resected for removal of carcinoma.
leaves the split-thickness graft pedicled from one end of the donor site. The blade of the dermatome is then narrowed so that the dermal graft can be taken from within the area covered by the split-skin graft. A dermal graft approximately %Z,OOO to %S.CKN inch in thickness is then taken and preserved in salinesoaked gauze (Fig. 3). Hemostasis is obtained, and the split-skin graft can be replaced over the donor site so that there is no raw donor site. This lack of a raw donor area is claimed as one of the great advantages of this technique. The dermis is then placed over the intraoral defect with the epithelial remnants on the outer surface, and it can be sutured in position and stabilized with a stent, if appropriate. In this study the grafts were
tattooed with India ink as described by Hillerupls (Fig. 4). RESULTS
Intraoral dermal grafting was carried out on twenty-four patients for a variety of reasons, including sulcus deepening and epithelial replacement following tumor surgery. In fourteen of the cases, there were problems in the donor area site, mainly because of hematoma formation under the returned split-skin graft which prevented a good take of the graft. In one case this resulted in almost complete failure of the graft and the necessity to regraft the area at a later date. In very thin persons, particularly females, the total
602
Pogrel
Oral Surg. December, I985
7. Histologic appearance of dermal graft showing parakeratinization and dense, well-vascularized connective tissue subepithelially. (Hematoxylin and eosin stain. Magnification, X40.)
Fig.
thickness of the epithelium may be only Ks.oooinch or slightly more,16 which means that if the total thickness of a split-skin graft and the dermal graft exceeds this, one will go right through the epithelium into the subcutaneous fat. This has been a complication on a number of occasions when attempts have been made to take dermis from the inner aspect of the arm; that is why we now take very thin split-skin grafts and dermal grafts. Also, hemostasis of a donor area has often proved difficult to obtain, despite the use of electrocautery and epinephrine-soaked gauze. This is because one is nearly at the full depth of the epithelium and there is a rich blood supply in this area. If hemostasis is not complete, the take of the split-skin graft that is reapplied will be less than optimal; this will leave some very deep denuded areas, which take considerable time to re-epithelize, since they are virtually full-thickness defects. This is another reason for taking the thinnest possible splitskin graft, since thii has the best opportunity to take over the area from which the dermis has been
removed. We have found that the healing of the donor area after a dermis graft has been taken is often quite prolonged and uncomfortable for the patient, often more so than after the taking of a thin split-skin graft in the conventional manner, particularly if a very thin split-skin graft is taken with a safety razor as recommended by Marx and associates.” In those cases in which the graft did take satisfactorily at the donor area, the patient still experienced discomfort in the donor area, presumably because of the depth of epithelium which had been removed, and it was believed that in many cases this discomfort was at least comparable to or, worse than, that associated with the taking of thin split-skin grafts. It is obvious that meticulous hemostasis of the donor site is essential, and in some cases this may be best obtained by placing moist dressings on the donor site for 24 hours before the split-skin graft is replaced over the area. This can be done without further general anesthesia, but it does prolong the whole operation. Clinically, after healing was complete, the dermis graft donor area, in general, showed a better color match than the split-skin graft donor area, although when the split-skin graft had been thin (around %O.OOO inch) there was virtually no difference in appearance between the two donor areas (Fig. 5). However, since the dermis with the hair follicles and sweat glands has been removed from the dermis donor area, the healed donor area lacks hair or sweat glands, while many of the hair follicles and sweat glands survive in the split-skin graft donor area since they are mainly in the dermal layer. In cases in which problems were encountered in the healing of the dermis donor area, the final result was inferior to that of a split-skin graft donor area. In all cases, the dermis took very well at the intraoral site and was associated with a very low incidence of pain and morbidity. The grafts were tattooed with India inkI in order to measure contracture. Because re-epithelization is taking place from the edges of the defect and also from the epithelial remnants in the hair follicles and sweat glands, in many respects this represents a secondary epithelization technique, and one might then envision excessive contracture. However, the rest of the dermis graft is dense collagenous tissue, which has very little power of contracture; therefore, one might imagine that the situation is comparable to secondary epithelization of the hard palate, in which there is very little contracture since the tissues are held rigid. It is not clear what the end result of this should be on an intraoral dermal graft, but Smiler and co-workersI
Intraoral
Volume 60 Number 6
suggested that the contracture of a dermal graft is less than that of a split-skin graft. In our series, the contracture of dermal grafts of between YROCVJ and %S,OOO inch was compared with contracture of splitskin grafts of between YIZ.OOO and YIS.OOO inch. There was slightly more contracture of dermal grafts than of the split-skin grafts, although this was not statistically significant. Contracture was a variable, depending on the thickness of the graft, the site in which it was placed, and whether or not a stent was used in the vestibuloplasty techniques. When the grafts were placed on the cheek mucosa in cases of tumor excision, contracture was approximately 50% in the split-skin grafts and approximately 55% in the derma1 grafts; when the grafts were placed in the labial vestibule for vestibuloplasty techniques, contracture of approximately 30% was seen for both types of graft when a stent was used. This does not appear to confirm previous reports that dermis contracts less than skin. Clinically, 6 months postoperatively a dermal graft does more closely resemble mucous membrane than do split-skin grafts (Fig. 6). Histologically, there appeared to be little difference between the dermal graft and the split-skin graft at 6 months, since neither contains functioning hair follicles, sweat glands, or mucous glands, although there was more orthokeratinization on the split-skin grafts. However, this is dependent on the original thickness of the graft taken, and if a very thin split-skin graft is placed it will not be highly keratinized. The dermal grafts contained more parakeratinization, which may explain the greater clinical resemblance to mucosa (Fig. 7). Smiler and associates” suggested that this greater histologic resemblance to mucosa may be due to the fact that the epithelium of a dermal graft arises from more pleuripotential cells which have greater powers of differentiation. The submucosa beneath the dermis graft consists of dense, well-vascularized, fibrous tissue. There is some debate over whether skin or mucosal grafts form the better denture base. Skin is better keratinized to withstand trauma but is not wettable. Mucosa, on the other hand, has more parakeratinization but is wettable and may therefore aid denture retention better.‘* The greater resemblance of the dermis graft to mucosa may therefore be of significance. The dermis graft is also thicker than a split-skin graft and contains more collagenous tissue, which might be thought to form a more satisfactory denture base, as it may be more resistant to trauma.
dermis grafting
603
SUMMARY
Experience with the use of intraoral dermal grafting on twenty-four patients is reported. Its advantages and disadvantages as compared with split-skin grafts are noted but, in general, it is not thought to offer significant advantages over the more usual technique of split-skin grafting. REFERENCES
1. Obwegeser HL: Die totale mundbodenplaskik. Schweiz Monatsschr Zahnheilkd 73: 565, 1963. L. * Trauner P: Alveoplasty with ridge extensions on the lingual side of the lower jaw to solve the problem of a lower dental prosthesis. ORAL SURG ORAL MED ORAL PATHOL 5: 340-346, 1952.
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Dr. M. A. Pogrel Division of Oral and Maxillofacial Surgery School of Dentistry University of California San Francisco 5 13 Parnassus Ave. San Francisco, CA 94143