A Simplified Protocol for Protecting Palatal Soft Tissue Donor Sites Using an Oral Mucoadhesive Bandage

Summary

This protocol details a comprehensive method for protecting palatal donor sites by applying a collagen sponge and a mucoadhesive bandage, which is then stabilized with suspension sutures for enhanced, long-term wound healing.

Abstract

Harvesting autologous soft tissue from the hard palate is a standard procedure, but managing the donor site wound is critical for patient comfort and reducing complications. Traditional methods like palatal stents are often costly and uncomfortable. While commercially available mucoadhesive bandages offer a barrier, their adhesion alone is temporary and unreliable, often failing prematurely due to oral movements. A novel "palatal shield" technique using composite resin stabilized on adjacent teeth's palatal surface has been proposed to address postoperative discomfort, yet it still has limitations in adaptability. This article and accompanying video demonstrate a comprehensive protocol that overcomes this limitation by combining a collagen sponge scaffold with a mucoadhesive bandage, which is then firmly secured using stabilizing suspension sutures. The key protocol steps include: (1) placing a collagen sponge into the donor site after initial hemostasis; (2) applying the trimmed mucoadhesive bandage to cover the sponge and overlap onto the peripheral dry mucosa; and (3) firmly securing the entire dressing using crossed horizontal mattress suspension sutures. This multi-layer system creates a stable, long-lasting physical barrier that protects the underlying wound from mechanical irritation and bacterial contamination, addressing the issue of donor site morbidities such as postoperative bleeding and pain that plague both clinicians and patients. This method provides immediate hemostasis, significantly reduces postoperative pain, and promotes predictable, advanced healing. Compared to novel palatal stents made of light-curing hybrid composite resin, where some patients report speaking inconvenience, this protocol avoids such functional disruptions. Additionally, it eliminates the need for extra fabrication steps required by transparent palatal plates used in combination with artificial dermis. This protocol provides a reliable, cost-effective, and reproducible technique that enhances patient comfort and optimizes palatal donor site healing.

Introduction

The harvesting of autologous soft tissue grafts from the hard palate is widely used in periodontics and implant dentistry to treat gingival recession, augment soft tissue around implants, and improve esthetic outcomes^1,2,3. Autologous connective tissue grafts (CTGs) remain the gold standard for soft tissue grafting, with the hard palate being the most common donor site due to its abundant tissue supply⁴. However, the donor site on the hard palate is prone to postoperative complications such as bleeding, pain, and delayed healing-largely due to its exposure to mechanical stress during chewing and speaking, as well as the complex anatomical structure and rich blood supply of the palate^5,6.

Traditional methods for donor site management, including the use of customized palatal stents or sutures, have limitations^7,8. Palatal stents require laboratory fabrication, adding to treatment time and cost, and may cause discomfort if they fit poorly. Suturing alone can be technically difficult in areas like the posterior palate and may disrupt the blood clot if placed improperly. Consequently, a simpler, more cost-effective method is needed to protect the palatal donor site and reduce postoperative morbidity.

The oral mucoadhesive bandage, a commercially available mucosal wound care product, offers a promising solution⁹. Its primary advantage is the creation of a physical barrier, which effectively isolates the blood clot within the donor site from saliva and food debris. While its mucoadhesive properties allow it to adhere to moist surfaces, this adhesion is often temporary, rarely lasting more than 48 hours¹⁰. Furthermore, the complex oral environment and movements from speech or mastication can easily lead to premature dislodgment.

To overcome this limitation and ensure the bandage provides long-term wound protection, we developed a combined protocol. This technique utilizes stabilizing suspension sutures to firmly secure the mucoadhesive bandage, thereby greatly extending its functional time and maximizing its protective advantages. Suitability, clarifying that this protocol is most appropriate for harvesting small-to-medium size free gingival grafts. This protocol provides a step-by-step application of this combined technique, incorporating a collagen sponge scaffold, the mucoadhesive bandage barrier, and suture fixation. It is suitable for various palatal graft surgeries (including free gingival grafts and connective tissue grafts) and is accessible to both experienced clinicians and novices. The following sections describe the complete materials and methods to ensure the reproducibility and dissemination of this technique.

Protocol

Ethics Statement: This protocol follows the ethical guidelines of the Human Research Ethics Committee at Ethics Committee of Wuhan University Stomatological Hospital (Approval No: WDKQ2025B21). All participants provided written informed consent. This protocol will focus on the technical details of donor site management using this novel method. The general steps of this method are illustrated in Figure 1.

1. Pre-procedural Material Preparation

1. Assemble all necessary sterile materials (Figure 2): oral mucoadhesive bandage (see Table of Materials), sterile gauze pads, sterile surgical scissors, a sterile disposable ruler, sterile forceps, sterile tissue forceps, periodontal probe, sterile needle holder, 4-0 monofilament suture, collagen sponge, aspirator (suction device), disposable saliva ejector, local anesthetic injection syringe, disposable injection needles, local anesthetic solution (e.g., Articaine), No. 15 scalpel blade, sterile mouth mirror, povidone-iodine cotton balls, micro forceps, sterile drapes, sterile gloves, and a sterile surgical gown.
2. Open the bandage packaging using an aseptic technique.
3. Verify the expiration date on the bandage packaging. Do not use expired products, as this may reduce adhesive efficacy.

2. Harvest the ideal size of autologous soft tissue graft

1. Plan the required gingival graft size in advance based on the soft tissue augmentation surgery.
2. Adjust the dental chair position so that the maxillary occlusal plane is at a 45° angle to the floor when the patient's mouth is open.
3. Use a sterile mouth mirror to retract the corner of the mouth. Use sterile forceps to hold povidone-iodine cotton balls to disinfect the intraoral surgical site and the perioral area.
4. Put on a surgical mask and cap. Perform a surgical hand scrub, then put on a sterile surgical gown and sterile surgical gloves. Place a sterile surgical drape over the patient.
5. Administer local anesthetic infiltration at the maxillary palatal donor site. For cases at risk of major vessel injury (e.g., near the greater palatine artery), consider adding a vasoconstrictor to the anesthetic to reduce bleeding.
6. Use a periodontal probe to mark the position of the superior border of the intended gingival graft-avoiding areas with thin mucosa (e.g., 1.8-2.7 mm thick near maxillary molars) to prevent excessive tissue damage.
7. Use a No. 15 scalpel blade to make an initial horizontal incision along the probe mark, approximately 1.5-2.0 mm deep. Extend the incision length approximately 1 mm beyond the desired gingival graft length.
8. Use a No. 15 scalpel blade to make vertical incisions at the start and end points of the first horizontal incision, to a depth of approximately 1.5-2.0 mm. Extend the incision length approximately 0.5 mm beyond the desired gingival graft width.
9. At one end of the first horizontal incision, rotate the No. 15 scalpel blade to an angle parallel to the bone surface. Gradually dissect the connective tissue beneath the graft along the first horizontal incision. Advance the blade to a depth approximately 1 mm beyond the desired gingival graft width.
10. Finally, make an inferior horizontal incision at the palatal donor site, parallel to the first horizontal incision, at a depth of approximately 1.5-2.0 mm, to connect the two vertical incisions. This will completely free the gingival graft.
11. Use micro forceps to transfer the gingival graft into a container with sterile saline solution for preservation and later processing.

3. Initial Hemostasis of the Donor Site

1. Immediately following autologous soft tissue harvesting, place a sterile gauze pad directly over the palatal donor site.
2. Apply firm, direct digital pressure for 2-3 minutes to achieve initial hemostasis-a critical step to stabilize blood clots and prevent postoperative bleeding.
3. Remove the gauze and inspect the wound bed. Ensure the wound is free of excessive or large, unstable blood clots.
4. Gently remove only loose, non-adherent clots with a new sterile gauze pad.
   NOTE: Do not aggressively wipe the wound bed; a stable, thin blood clot is desirable for optimal healing.

4. Preparation of the Wound Bed and Adjacent Mucosa

1. Take a new, dry sterile gauze pad.
2. Gently pat the donor site wound bed to remove excess saliva and blood.
3. Crucially, use the dry gauze to pat dry the adjacent intact mucosa, extending 1-2 cm around the entire periphery of the wound.
   NOTE: The mucoadhesive bandage requires a moist, but not saturated, surface for optimal adhesion. Avoid excessive drying or desiccation of the tissues.

5. Placement of Appropriately Sized Collagen Material

1. Use a periodontal probe to measure the dimensions of the donor site.
2. Aseptically remove a collagen sponge. Use sterile scissors to trim the sponge to the same shape and size as the donor site.
3. Use sterile forceps to place the trimmed collagen sponge into the maxillary palatal donor site. Ensure it is in close contact with the underlying connective tissue.

6. Trimming and Shaping of the Bandage

1. Use a sterile disposable ruler to measure the length and width of the donor site wound (now covered by the collagen sponge).
2. Place the bandage on a sterile surface.
3. Use sterile surgical scissors to cut the bandage to the required size.
   NOTE: The bandage must be larger than the donor site to effectively cover the wound and protect the underlying materials.
4. Ensure the final trimmed bandage is 1-2 mm larger than the wound dimensions in all directions. This allows for a 1-2 mm overlap onto the intact, dried mucosa.
5. Bevel or round all corners and edges of the bandage. This minimizes sharp edges that can cause patient discomfort or snag, leading to premature dislodgment.

7. Bandage Application and Adhesion

1. Grasp the trimmed bandage with sterile forceps, avoiding contamination of the side that will contact the wound.
   NOTE: Before application, ensure to dry the surface of the collagen sponge and the gingival surface around the wound with sterile gauze. This facilitates the adhesion of the bandage.
2. Position the bandage on the surface of the collagen sponge and center it over the donor site. Ensure the 1-2 mm overlap onto the adjacent mucosa is uniform around the periphery.
3. Once positioned, use a dry, gloved finger pad to apply stable, gentle, and continuous pressure over the entire surface of the bandage.
4. Maintain this pressure continuously for 30-60 seconds to activate the mucoadhesive properties.
   NOTE: Apply pressure evenly, paying special attention to the edges. Do not use a "tapping" motion. Prematurely lifting the finger will result in incomplete adhesion.

8. Fixation of the bandage

1. Use a 4-0 monofilament suture to perform two horizontal mattress suspension sutures around the same tooth (or adjacent teeth), using the same needle entry and exit points. One is a parallel horizontal mattress suspension suture, and the other is a cross horizontal mattress suspension suture.
   NOTE: Monofilament sutures are selected to minimize bacterial wicking and plaque retention, thereby prolonging the adhesion time of the bandage.
2. Determine the scope of the suturing based on the position and size of the bandage. Generally, apply one such suture combination for every 10 mm of bandage length.
3. Ensure all needle entry and exit points are located above the inferior edge of the bandage but below the inferior edge of the donor site wound. This ensures the sutures firmly secure the bandage.
   Special Note: Ensure to apply "passive" or "gentle" tension when tying the sutures to ensure stability without lacerating the mucoadhesive bandage.

9. Verification of Adhesion and Stability

1. After the 30-60 s pressure hold, gently retract the patient's cheek or lip to visualize the bandage.
2. Gently run a sterile instrument or gloved finger over the edges of the bandage to confirm they are sealed against the mucosa.
3. Observe the bandage while gently moving the adjacent mucosal tissues to ensure it remains stable and does not dislodge.
4. If any edge appears to be lifting, use a gloved finger to apply additional localized pressure to that specific area for another 30 seconds.
5. If there are any problems that happen during the healing time, the following troubleshooting table can provide specific clinical solutions (Table 1).

Problems	Clinical Solutions
Premature dressing dislodgment occurs.	Replace with a new bandage and re-suture to secure the wound.
Suture loosening.	Remove the loose sutures and re-suture with enough pressure.
Unstoppable bleeding.	Add more sutures to compress bleeding sites
The bandage being too long or poorly positioned can make the patient feel nauseous.	Trim the bandage to the appropriate size and sew it in place, avoiding contact with the soft palate area.

10. Post-operative Patient Instructions

1. Instruct the patient to avoid touching the bandage with their tongue or fingers.
2. Advise the patient to consume a soft diet and avoid hot liquids and hard or crunchy foods for the first 24-48 hours.
3. Inform the patient that the bandage is designed to remain in place for several hours or days and will gradually dissolve or dislodge on its own. Instruct them not to pull it off.
4. Provide standard post-surgical instructions regarding pain management and oral hygiene (e.g., gentle rinsing with an antimicrobial mouthwash, avoiding brushing the surgical site).

11. Suture Removal and Evaluation

1. Schedule a follow-up appointment for the patient after two weeks.
2. Remove the palatal sutures and any remnants of the bandage.
3. Examine the healing of the palatal donor site. The length and width of the unhealed palatal wound are measured using a periodontal probe (UNC15) at 2 weeks, with measurements recorded as L_t and W_t. The wound healing rate (%) was then calculated using the following formula: [(L₀×W₀)−(L_t×W_t)]/(L₀×W₀)× 100, where L₀ and W₀ represent the initial wound dimensions.
4. Assess the patient's total pain score (summing spontaneous, eating, and pronunciation pain scores) and wound healing rate of life during the healing process according to the assessment form.
   NOTE: The continuous variables (pain scores, wound area, OHIP-14) are presented as Mean ± Standard Deviation (SD). No comparative hypothesis testing is performed as this is a technical protocol demonstration study.

Results

The efficacy of this comprehensive protocol was evaluated in a prospective cohort of 28 patients undergoing palatal soft tissue harvesting. The average size of harvested graft was 10mm long, 6mm wide, and 2mm thick. The application of the collagen sponge, mucoadhesive bandage, and stabilizing sutures (Protocol steps 5-8) provided consistent and quantifiable improvements in pain management, hemostasis, and wound healing.

Figure 3 illustrates the typical clinical pr...

Discussion

The protocol detailed here presents a comprehensive and systematic approach to palatal donor site management, designed to minimize postoperative morbidity. The success of this technique hinges on several critical steps. First is achieving thorough initial hemostasis (Protocol Step 3), which is fundamental for any wound dressing. Second is the sequential application of a collagen sponge (Protocol Step 5) to act as a wound scaffold, followed by the mucoadhesive bandage (Protocol Step 7) as a protective barrier. Finally, th...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
4-0 monofilament suture	WEGO/ Weigao Group	NW870	4-0 PROLENE Polypropylene Suture
Aspirator (suction device)	Yuwell / Jiangsu Yuwell Medical Equipment & Supply Co., Ltd.	N/A	N/A
Collagen sponge	BeiLing / Beijing Yierkang Bio-engineering Co., Ltd.	N/A	N/A
Disposable injection needles	C-K JECT/ C-K Dental Ind. Co., Ltd	27G	TERUMO DENTAL NEEDLE
Disposable saliva ejector	Changyang / Yangzhou Changyang Medical Industrial Co., Ltd.	N/A	N/A
Local anesthetic injection syringe	MORITA / Morita Medical Instrument (Shanghai) Co., Ltd.	N/A	N/A
Local anesthetic solution	Septodont	N/A	Septanest 40mg/ml adrenaline 1:100 000
No. 15 scalpel blade	Jinhuan / Shanghai Pudong Jinhuan Medical Products Co., Ltd.	0305	Sterile Carbon Steel Surgical Blades
Oral mucoadhesive bandage	Ora-Aid/ TBM Corporation	AG-202A	N/A
Periodontal probe	Hu-Friedy/ Hu-Friedy Mfg. Co., LLC	PCPUNC12	Single-ended, color-coded probe
Povidone-iodine cotton balls	PiaoAn/ Henan Piaoan Group Co., Ltd.	N/A	N/A
Scalpel Handel	Hu-Friedy/ Hu-Friedy Mfg. Co., LLC	10-130-05E	5 European Style Round Scalpel Handle
Sterile gloves	Gaobang / Guilin Zizhu Latex Products Co., Ltd.	MH6	No. 6 Front Surface Mouth Mirror
Needle holder	Hu-Friedy/ Hu-Friedy Mfg. Co., LLC	NH5052	Perma Sharp Needle Holder
Scissors	Hu-Friedy/ Hu-Friedy Mfg. Co., LLC	S5083	Iris Scissors, Curved, Perma Sharp