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Mouth Retractors for Buccal Mucosa Graft Harvest

Adequate intraoral exposure is an important part of buccal mucosa graft (BMG) harvest. The aim is to see the donor surface clearly while protecting Stensen's duct (parotid orifice opposite the second maxillary molar) and the lip vermillion. The literature describes the general approach more than it compares specific devices head-to-head; most reconstructive urologists and oral or maxillofacial surgeons develop a preference based on mouth size, harvest side (unilateral versus bilateral), and available instrumentation.[1][2]

Retractor Options​

Dingman Mouth Gag​

The Dingman is a self-retaining frame used in palatal surgery and adaptable to BMG exposure.[3] Its frame and tongue blades maintain mouth opening while separate cheek retraction can expose the donor surface.[12] The Pilling 070450 set includes a frame and three blades.[12]

  • Good for: bilateral harvest or sustained exposure when the frame fits the mouth and planned field
  • Trade-off. Larger setup time and footprint than a simple bite-block plus cheek retractor

Kilner-Doughty Mouth Gag​

A self-retaining frame with dental or palatal supports and interchangeable tongue depressors. SURTEX describes a U-shaped frame with sliding tooth claws. Support and suspension depend on the actual system; use its compatible components rather than improvising a connection to a stand.[14]

  • Good for: bilateral harvest, prolonged cases, oral-surgery-team-shared trays
  • Trade-off: more components and setup than a handheld cheek retractor and bite block

Denhardt Mouth Gag​

A ratcheted mouth gag with opposing curved blades. The SURTEX Denhart pattern uses a lever-operated lock and serrated working surfaces; blade covers and tooth protection depend on the model.[13]

  • Good for: solo or lightly assisted harvest, longer harvests, bilateral harvest
  • Trade-off: wider profile; can obstruct posterior cheek mucosa access in a small mouth

Molt Mouth Gag​

A ratcheted spreader with curved blades and finger-ring handles.[15] Different sizes allow selection for the available oral opening.[15]

  • Good for: small mouths, posterior cheek exposure
  • Trade-off: check tooth contact, available working space and stability in the individual patient

Jennings Mouth Gag​

A wire-frame mouth gag with an adjustable opening. Assess where its frame and contact surfaces sit relative to the planned donor site.

  • Good for: an alternative when its configuration gives suitable access and the team is familiar with it

Minnesota Cheek Retractor​

A single-handed curved blade for lateral cheek retraction. It does not hold the mouth open on its own. Standard pairing with a bite-block or Dingman / Denhardt for intraoperative BMG access.

  • Good for: assistant-driven lateral retraction during graft harvest

Lone Star (Scott) Elastic Stay-Hook Adaptation​

Some surgeons adapt the Lone Star elastic stay-hook ring for cheek retraction during BMG harvest. The hooks evert and stabilize the buccal mucosa against the cheek, creating a taut donor surface without continuous handheld retraction.

  • Use considerations: model-specific labeling and instructions, familiarity with the ring system, and careful control of hook position and tension

Seldin / Lip Retractor​

A simple lip retractor that pulls the lower or upper lip outward and helps distribute traction at the vermilion and oral commissure. Used only as an adjunct.

Bite Block​

Not strictly a retractor, this is a soft plastic or rubber block placed between the contralateral molars that holds the mouth open passively under anesthesia.

  • Good for: small, quick harvests where a formal mouth gag is excessive
  • Trade-off: does not retract the cheek or tongue; confirm position and maintain accountability for the block

Specialized Oral Retractors​

Eppley et al. (1997) described a dedicated specialized oral retractor for BMG harvest in their early urethroplasty series, reporting adequate graft size and no donor-site complications in 12 patients.[4] Eppley's series describes the specialized retractor without comparing it with general-purpose mouth gags.

Workhorse Setup — Mouth Gag + Cheek Retractor + Lip Stay-Suture​

One practical combined technique, adapted to the planned harvest:[5]

  • Standard mouth gag (Dingman / Denhardt / Kilner-Doughty) holds the mouth open
  • Stay sutures placed through the lateral edge of the lip further retract and stabilize the cheek. This combination provides visualization of the inner cheek
  • Lip retractor to protect the ipsilateral corner of the mouth
  • Stay sutures at superior and inferior graft outline tied to the retractor frame to flatten the donor surface for sharp dissection

Practical Considerations for the Whole Harvest​

Retractor choice is one part of exposure. Check dentition, mouth opening and the airway with the anesthesia team before placing or tightening a gag. Protect teeth, lips and tongue, and reassess pressure during the harvest. Account for any removable covers, blocks and packing.

  • Plan the airway with anesthesia. Nasal intubation can clear the oral field when appropriate; an oral tube secured away from the harvest side may also be used. The airway choice depends on patient and procedural factors, and local-infiltration techniques have also been described.[6]
  • Stensen's duct (parotid orifice opposite the second maxillary molar) identified and marked before incision to avoid injury during harvest.[5]
  • Submucosal infiltration or hydrodissection can help define the plane and provide local hemostasis. Select the local anesthetic, vasoconstrictor and total dose with the anesthesia team, accounting for all other administered local anesthetic.[5][6]
  • Size the graft to the reconstructive defect and available donor tissue. Single-cheek harvest is described in the donor-site literature.[7]
  • Plan unilateral versus bilateral harvest according to the graft needed and each cheek's usable area.[8] The SGURS survey describes variation in practice.[8] In the retrospective 553-patient Barbagli cohort, bilateral cheek harvest was associated with greater odds of patient dissatisfaction (multivariable OR 2.72); consider single-cheek harvest when it provides enough tissue.[10]
  • Keep the dissection superficial to the buccinator muscle. Reassess the plane and improve exposure if visibility is poor.[9]

Donor-Site Morbidity — What the Data Show​

  • Barbagli 2014, n = 553 consecutive patients undergoing single- or bilateral-cheek oral mucosa graft harvest with donor-site closure for urethroplasty: 98.2% patient satisfaction; 95.5% reported no closure-related late difficulty opening the mouth and 95.8% no closure-related dry mouth.[10] This was a retrospective cohort using a nonvalidated questionnaire, with wound closure.[10]
  • Soave 2018 RCT, 135 patients, compared closure with nonclosure of the inner-cheek donor site. Nonclosure was noninferior for intensity and affective quality of oral pain at the assessed time points.[11]
  • Fabbroni 2005 oral-surgery-driven series: mild trismus was reported early in 4 of 23 patients, with one late complaint.[9]

Example Setup (At-a-Glance)​

A practical starting arrangement, modified for the patient and planned BMG harvest:

ElementChoicePurpose
Mouth-holdingDingman or Kilner-DoughtySustained self-retaining exposure
Cheek retractionMinnesota (or Lone Star hook adaptation)Lateral cheek eversion
Lip protectionSeldin / lip retractor + lateral-lip stay sutureVermillion protection + further cheek stability
Donor-surface flatteningStay sutures at graft cornersTaut surface for sharp dissection
AirwayNasal or suitably positioned oral ETT, selected with anesthesiaAirway security with access to the donor site
InfiltrationIndividualized local anesthetic/vasoconstrictor planPlane definition and hemostasis within the total dose limit
Anatomic landmarkStensen's duct markedAvoid parotid-orifice injury

Local preference and institutional tray composition drive most variation. The constants: mouth held open stably, cheek retracted laterally, lip protected, donor surface taut and dry, Stensen's duct identified and avoided, dissection stays superficial to the buccinator.

See also: Buccal Mucosa Graft, The Oral Cavity, Lone Star Retractor.

References​

1. Markiewicz MR, Lukose MA, Margarone JE 3rd, Barbagli G, Miller KS, Chuang SK. "The oral mucosa graft: a systematic review." J Urol. 2007;178(2):387–94. doi:10.1016/j.juro.2007.03.094

2. Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. "Current controversies in reconstructive surgery of the anterior urethra: a clinical overview." Int Braz J Urol. 2012;38(3):307–16. doi:10.1590/s1677-55382012000300003

3. Rao LP, Peter S. "Modification of the Dingman mouth gag for better visibility and access in the management of cleft palate." Cleft Palate Craniofac J. 2015;52(2):250–3. doi:10.1597/13-070

4. Eppley BL, Keating M, Rink R. "A buccal mucosal harvesting technique for urethral reconstruction." J Urol. 1997;157(4):1268–70. doi:10.1016/s0022-5347(01)64947-4

5. Gülpınar Ö, Zumrutbas AE, Sancı A, et al. "The outcomes of three buccal mucosal graft urethroplasty techniques in women with urethral stricture disease." Neurourol Urodyn. 2021;40(8):1921–1928. doi:10.1002/nau.24764

6. Goel A, Dalela D, Sinha RJ, Sankhwar SN. "Harvesting buccal mucosa graft under local infiltration analgesia — mitigating need for general anesthesia." Urology. 2008;72(3):675–6. doi:10.1016/j.urology.2008.04.047

7. Barbagli G, Vallasciani S, Romano G, et al. "Morbidity of oral mucosa graft harvesting from a single cheek." Eur Urol. 2010;58(1):33–41. doi:10.1016/j.eururo.2010.01.012

8. Berg C, Singh A, Hu P, et al. "Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons." Urology. 2024;191:139–143. doi:10.1016/j.urology.2024.06.019

9. Fabbroni G, Loukota RA, Eardley I. "Buccal mucosal grafts for urethroplasty: surgical technique and morbidity." Br J Oral Maxillofac Surg. 2005;43(4):320–3. doi:10.1016/j.bjoms.2004.11.025

10. Barbagli G, Fossati N, Sansalone S, et al. "Prediction of early and late complications after oral mucosal graft harvesting: multivariable analysis from a cohort of 553 consecutive patients." J Urol. 2014;191(3):688–93. doi:10.1016/j.juro.2013.09.006

11. Soave A, Dahlem R, Pinnschmidt HO, et al. "Substitution urethroplasty with closure versus nonclosure of the buccal mucosa graft harvest site: a randomized controlled trial with a detailed analysis of oral pain and morbidity." Eur Urol. 2018;73(6):910–922. doi:10.1016/j.eururo.2017.11.014

12. Teleflex/Pilling. Dingman mouth gag with blades, 070450. Manufacturer configuration.

13. SURTEX. Denhart Mouth Gag. Manufacturer design and mechanism.

14. SURTEX. Kilner-Doughty Mouth Gag. Manufacturer frame and blade configuration.

15. SURTEX. Molt Mouth Gag. Manufacturer design and available sizes. Manufacturer pages checked September 20, 2026.