Sullivan, H., Atkins, J., Free autogenous gingival grafts. III. Utilization of grafts in the treatment of gingival recession. Periodontics. 6:152, 1968

The purpose of this paper is to report some basic concepts developed in plastic surgery for grafting over avascular areas and to derive from these a technique for the treatment of gingival recession.

• Phenomenon of Bridging - in cases requiring coverage of exposed roots, a small part of the recipient bed will be the avascular root surface. To prevent necrosis over this avascular area, the graft must receive circulation from the adjacent vascular portions of the bed. This result in graft survival over the avascular area is known as the phenomenon of bridging.
• Classification of Gingival Recession - it can be classified according to depth and width into four general morphologic categories 1) deep wide recession, 2) shallow wide recession, 3) deep narrow recession, 4) shallow narrow recession. The most difficult to treat is the deep wide recession. There is two and three point collateral circulation , 3 point will maintain approximately 1-2 mm of new keratinized tissue over the apical portion of the deep wide recession.
• For the deep narrow recession extending into the alveolar mucosa, theoretically two-point collateral circulation should bridge the narrow avascular area. The shallow narrow recession is usually maintained by conservative therapy.
• Surgical Technique - Modification techniques- 1) surgical correction of existing soft tissue deformities by gingivoplasty-gingivectomy. Osteoplasty through incisions may be used to correct any minimal osseous defect. 2) the beds apical margin should be placed several millimeters apical to the apex of the recession. 3) the avascular root should be curetted as the final step.
• Donor Site - Bridging often requires a large amount of tissue, usually from the palate. The thinner graft will be able to survive longer periods without circulation. However greater graft resistance to future functional stress is related to the greater thickness of its lamina propria.
• The author uses intermediate split-thickness gingival graft in cases where, for esthetic consideration, it is desirable to attempt to cover large avascular areas or maximum bridging is desired.
• Placement of the graft - Where esthetics is a problem or optimal bridging is expected, the coronal margin of the graft should be placed at the level of the marginal tissue on the adjacent teeth. If not then 2-3 mm apical to the apex of the recession.
• Immobilization and postoperative care - need adequate stabilization and intimate contact of the graft and its bed should be obtained w/o placing sutures in the area directly adjacent to the bridged tissue.

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