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Mandibular Anterior Lingual Grafting – a practical guide for predictable treatment outcomes

Posted: January 5, 2021

This Case Report showcases a special surgical technique designed for optimal treatment in the anatomically challenging mandibular anterior lingual region. It was written to serve as a condensed, easy-to-read guide that provides practical clinical tips; instrument and suture material specifications; and postoperative photos showing outcomes three years post treatment

More in-depth information than what can appear in this journal are covered in the seminar, Mandibular Anterior Lingual Grafting, presented at dental conferences, study clubs and in private consultations throughout the US and Canada.  The article serves as a workbook for seminar attendees as well.

Click here to request your complimentary copy of the article

Mandibular Anterior Lingual Recession: Keratinized Tissue Grafting and Minimally Invasive Harvesting
Merijohn GK, Chambrone L, Brodsky A, Xenoudi P.  Clin Adv Periodontics 2020;0:1–8.


Introduction: The mandibular anterior lingual (MAL) keratinized tissue (KT) band is often insufficient in dimension: <2 mm height of which <1 mm is attached gingiva (AG). Its gingival phenotype is commonly characterized as thin (<1 mm) gingival thickness (GT) and having inadequate (<1 mm) AG width. When surgical treatment is indicated, prevention of significant apical displacement of the gingival margin and improvement of long-term gingival stability are enhanced by KT increase and phenotype modification in order to establish thick GT and adequate AG.

The aim of this case report is to describe a bilaminar surgical approach, the modified coronally advanced flap (mCAF) and connective tissue graft with retained KT band (mCAF + CTGkt). It is an outcomes-driven surgical approach for KT increase and phenotype modification in order to predictably establish thick GT and adequate AG. The mCAF + CTGkt procedure is minimally invasive, predictable, well-tolerated and addresses both the unique features of MAL anatomy and normal oral functioning movement during the postoperative healing phase.

Case presentation: A 48-year old female presented with chief complaint of MAL progressive gingival recession (GR). Attachment loss of 3-4 mm and lack of both KT and AG were documented. Primary treatment outcomes objectives were GR cessation, establish KT, increase GT and AG. A secondary outcome was decreasing GR.

Conclusion: The mCAF + CTGkt procedure resulted in KT increase, phenotype modification to establish thick GT and adequate AG, and decreased GR. It addressed unique features of MAL anatomy. Postoperative healing outcomes were not negatively impacted by normal oral functioning.

George K. Merijohn, DDS

San Francisco periodontist George K. Merijohn practiced 28 years and is associate professor in postdoctoral periodontics at UC San Francisco and U Washington. He is appointed special expert to the California Dental Board; serves as a consultant to dental schools, clinicians, and the legal profession; and is on the editorial board of the Journal of Evidence-Based Dental Practice. Dr. Merijohn leads seminars and workshops at major dental conferences and is published in peer-reviewed journals with articles on mucogingival clinical decision-making, risk assessment, and the evidence-based approach. More about George >

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