Mucogingival problems form a definitive diagnosis that includes an array of clinical findings, namely gingival recession (GR), shallow vestibule, inadequate width of attached gingiva (AG) and aberrant frenum [1]. Surgical endeavor by Goldman [2] for the correction of three specific problems, namely periodontal pockets that extend beyond mucogingival junction reaching the alveolar mucosa, an abnormal traction of the frenum that can transmit tension for the gingival margins causing recession, and the functional condition of a shallow vestibule that promotes a decrease of the attached gingiva levels, initiated the era of mucogingival surgery that has motivated other clinicians to develop numerous refinements.

Multiple techniques have been developed to obtain predictable root coverage. "Margaff" in 1985 proposed bridge flap technique to cover gingival recession [3]. However, this technique requires adequate attached gingiva apical to recession. So to overcome this limitation, the present technique modified the original bridge flap technique to cover the denuded root in patients with inadequate attached gingiva apical to recession.

Three patients either with Millers class I and II recession, otherwise systemically healthy in an age group of 20–30 years were selected after phase I therapy. The study was conducted in accordance with local ethical committee and written informed consent was obtained from those who agree to participate. The following parameters were recorded using UNC-15 probe at the baseline and six months after procedure (Figure 1) and (Figure 3).

• Recession width (RW)
• Recession height (RH - distance between fixed reference point on acrylic stent to gingival margin)
• Width of keratinized gingiva (GW)

Surgical technique
This technique presents a combination of coronally repositioned flap and a modification of original bridge flap. After administering local anesthesia (2% lignocaine hydrochloride with 1:80000 epinephrine), the following incisions were made (Figure 2):

• First oblique incision made slightly coronal to the CEJ at distal and mesial papilla of recession.
• Secondly, two vertical incisions were made from the line angles of adjacent teeth to recession and extends beyond mucogingival junction till the labial mucosa.
• After giving sulcular incision partial thickness falp was elevated
• Then the horizontal incision given in the labial mucosa to connect two vertical incisions and the flap was mobilized coronally till it covers the denuded root. After de-epethelialising the papilla, the flap was secured using individual sling sutures. Periodontal dressing was given followed by postoperative instructions.

Patients were prescribed antibiotics (novamox 500 mg thrice daily for 5 days) and analgesic (dicloron-P twice daily for 3 days). Chlorhexidine mouthwash (0.2%) was prescribed for four weeks after surgery. Sutures were removed after 10 days. All procedures were performed by same clinician and both preoperative and postoperative measurements were recorded by same individual.

The present technique reported an excellent postoperative outcome showing average of 76% coverage of exposed root surface (Table 1).

A wide variety of periodontal plastic surgical procedures have been described to correct mucogingival problems and to cover the denuded root surface [4]. An evaluation of adequate width of attached gingiva in patients with multiple recessions is an important factor before deciding on any procedure for root coverage [4] an unresolved controversy still exists in literature regarding the adequate attached gingiva for periodontal Health maintenance [5] the contemporary opinion suggests that the regions with less than 2 mm attached gingiva and thin gingival tissue are at increased risk of gingival recession and facilitate subgingival plaque formation because of incomplete pocket closure [1]. Hence, mucogingival therapy should be advocated for gingival augmentation and to create adequate vestibular depth in areas with insufficient attached gingival [6][7].

Contrary to the reports of Margaff et al. 1985, Romanos et al. 1993 and vijayalakshmi et al. 2008, who all stressed very little on the gain of width of attached gingiva by bridge flap technique [3] [8][9] study we have modified original bridge flap technique by giving two vertical incision extending beyond mucogingival junction till labial mucosa. The purpose of this technique is to eliminate donor site surgery, to increase predictability, better patient compliance, to satisfy patient's esthetic demands and to match the tissue color of grafted area. This technique is indicated when a single surgical procedure is desired to predictably cover the denuded root surfaces, in cases where inadequate keratinized gingiva apical to recession is available, and also to increase the width of attached gingiva with vestibular deepening at one step. We kept our study cases limited to the mandibular arch to get unbiased results as well as to be able to treat multiple mucogingival problems at the same time. The present technique presents a cost-effective single-step entity to correct mucogingival problems at a time with less morbidity to donor tissue.

The present technique reported an excellent postoperative outcome showing great coverage of exposed root surface with vestibular deepening in single step and can be performed in areas with inadequate attached gingiva apical to recession defect. It also offers additional advantages like less surgical trauma, less postoperative complications and better patient's satisfaction.

1. Goldman HM. Periodontia. 3ed. St Louis: C.V. Mosby Co.; 1953. p. 552–61.    
2. Gupta V, Bains VK, Mohan R, Bains R. Bridge flap technique as a single-step solution to mucogingival problems: A case series. Contemp Clin Dent 2011 Apr;2(2):110–4.   [CrossRef]   [Pubmed]    
3. Marggraf E. A direct technique with a double lateral bridging flap for coverage of denuded root surface and gingiva extension. Clinical evaluation after 2 years. J Clin Periodontol 1985 Jan;12(1):69–76.   [CrossRef]   [Pubmed]    
4. Verma PK, Srivastava R, Chaturvedi TP, Gupta KK. Root coverage with bridge flap. J Indian Soc Periodontol 2013 Jan;17(1):120–3.   [CrossRef]   [Pubmed]    
5. Remya V, Kishore Kumar K, Sudharsan S, Arun KV. Free gingival graft in the treatment of class III gingival recession. Indian J Dent Res 2008 Jul-Sep;19(3):247–52.   [CrossRef]   [Pubmed]    
6. Popova C, Kotsilkov K, Doseva V. Mucogingival surgery with free gingival graft (strip technique) for augmentation of the attached gingival tissues: Report of three cases. J IMAB Annl Proc (Scientific papers) 2007;2:25–30.    
7. Takei HH, Azzi RR, Han T. Periodontal plastic and esthetic surgery. In: Newmann MG, Takei HH, Klokkevold PR, Carranza FA eds. Carranza's Clinical Periodontology. 10ed. St Louis, Missouri: Saunders, Elsevier; 2006. p. 1005–26.    
8. Romanos GE, Bernimoulin JP, Marggraf E. The double lateral bridging flap for coverage of denuded root surface: longitudinal study and clinical evaluation after 5 to 8 years. J Periodontol 1993 Aug;64(8):683–8.   [CrossRef]   [Pubmed]    
9. Vijayalakshmi R, Uma S, Saravanakumar R, Ramakrishnan T, Emmadi P, Anitha V. Double lateral sliding bridge flap for the coverage of denuded roots: Two case reports. PERIO-Periodont Pract Today 2008;5:29–3.