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Current Oral Health Reports

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01-12-2019 | Incision | Clinical Periodontics (Y Stathopoulou, Section Editor)

Tunneling Techniques for Root Coverage

Authors: Yu Wang, Panagiota G. Stathopoulou

Published in: Current Oral Health Reports | Issue 4/2019

Abstract

Purpose of Review

Tunneling technique (TUN) has been introduced as a minimally invasive and highly esthetic treatment option for the treatment of gingival recession, one of the most frequent mucogingival deformities and conditions. The purpose of the present article is to review how specific technique modifications, different grafting materials, and different defect characteristics may affect the outcome of TUN for root coverage.

Recent Findings

TUN has been shown to be an efficacious root coverage technique that, in combination with various grafting materials, can achieve satisfactory root coverage outcomes in Miller class I and II recession defects that are more predictable in the maxilla and when multiple adjacent defects are treated. Recent evidence suggests that specific technique modifications may be promising for the treatment of challenging multiple Miller class III recession defects.

Summary

In order to achieve successful root coverage outcomes with TUN, the etiology of the defect should be identified and risk factors controlled, case selection is critical, specific technique modifications may be beneficial, and a variety of graft materials may be utilized.

Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol. 1999;70(1):30–43.PubMed

Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: short term results in the treatment of shallow marginal tissue recession. J Periodontol. 1989;60(6):316–9.PubMed

Harris RJ, Harris AW. The coronally positioned pedicle graft with inlaid margins: a predictable method of obtaining root coverage of shallow defects. Int J Periodontics Restorative Dent. 1994;14(3):228–41.PubMed

Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol. 2000;71(9):1506–14.PubMed

Zuhr O, Rebele SF, Cheung SL, Hurzeler MB, Research Group on Oral Soft Tissue B, Wound H. Surgery without papilla incision: tunneling flap procedures in plastic periodontal and implant surgery. Periodontol 2000. 2018;77(1):123–49.PubMed

Raetzke PB. Covering localized areas of root exposure employing the “envelope” technique. J Periodontol. 1985;56(7):397–402.PubMed

• Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent. 1994;14(3):216–27 This is the first article to apply tunneling concept on root coverage treatment of multiple adjacent recession defects. PubMed

Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: a clinical report. Int J Periodontics Restorative Dent. 1999;19(2):199–206.PubMed

Azzi R, Etienne D, Takei H, Fenech P. Surgical thickening of the existing gingiva and reconstruction of interdental papillae around implant-supported restorations. Int J Periodontics Restorative Dent. 2002;22(1):71–7.PubMed

10.

• Aroca S, Keglevich T, Nikolidakis D, Gera I, Nagy K, Azzi R, et al. Treatment of class III multiple gingival recessions: a randomized-clinical trial. J Clin Periodontol. 2010;37(1):88–97 The study shows that modified tunnel/CTG technique is predictable for the treatment of multiple class III recession-type defects. PubMed

11.

Aroca S, Molnar B, Windisch P, Gera I, Salvi GE, Nikolidakis D, et al. Treatment of multiple adjacent Miller class I and II gingival recessions with a Modified Coronally Advanced Tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol. 2013;40(7):713–20.PubMed

12.

Zuhr O, Fickl S, Wachtel H, Bolz W, Hurzeler MB. Covering of gingival recessions with a modified microsurgical tunnel technique: case report. Int J Periodontics Restorative Dent. 2007;27(5):457–63.PubMed

13.

Tal H, Moses O, Zohar R, Meir H, Nemcovsky C. Root coverage of advanced gingival recession: a comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. J Periodontol. 2002;73(12):1405–11.PubMed

14.

Ozenci I, Ipci SD, Cakar G, Yilmaz S. Tunnel technique versus coronally advanced flap with acellular dermal matrix graft in the treatment of multiple gingival recessions. J Clin Periodontol. 2015;42(12):1135–42.PubMed

15.

Baldi C, Pini-Prato G, Pagliaro U, Nieri M, Saletta D, Muzzi L, et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol. 1999;70(9):1077–84.PubMed

16.

Hwang D, Wang HL. Flap thickness as a predictor of root coverage: a systematic review. J Periodontol. 2006;77(10):1625–34.PubMed

17.

Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol. 1987;58(2):95–102.PubMed

18.

Wilcko MT, Wilcko WM, Murphy KG, Carroll WJ, Ferguson DJ, Miley DD, et al. Full-thickness flap/subepithelial connective tissue grafting with intramarrow penetrations: three case reports of lingual root coverage. Int J Periodontics Restorative Dent. 2005;25(6):561–9.PubMed

19.

Mazzocco F, Comuzzi L, Stefani R, Milan Y, Favero G, Stellini E. Coronally advanced flap combined with a subepithelial connective tissue graft using full- or partial-thickness flap reflection. J Periodontol. 2011;82(11):1524–9.PubMed

20.

Santarelli GA, Ciancaglini R, Campanari F, Dinoi C, Ferraris S. Connective tissue grafting employing the tunnel technique: a case report of complete root coverage in the anterior maxilla. Int J Periodontics Restorative Dent. 2001;21(1):77–83.PubMed

21.

Allen EP, Cummings LC. Minimally invasive soft tissue grafting. Minimally invasive periodontal therapy: clinical techniques and visualization technology. 2014;1:143.

22.

Blanes RJ, Allen EP. The bilateral pedicle flap-tunnel technique: a new approach to cover connective tissue grafts. Int J Periodontics Restorative Dent. 1999;19(5):471–9.PubMed

23.

Harris RJ, Miller LH, Harris CR, Miller RJ. A comparison of three techniques to obtain root coverage on mandibular incisors. J Periodontol. 2005;76(10):1758–67.PubMed

24.

Sculean A, Allen EP. The laterally closed tunnel for the treatment of deep isolated mandibular recessions: surgical technique and a report of 24 cases. Int J Periodontics Restorative Dent. 2018;38(4):479–87.PubMed

25.

Carranza N, Pontarolo C, Rojas MA. Laterally stretched flap with connective tissue graft to treat single narrow deep recession defects on lower incisors. Clin Adv Periodont. 2019 Mar;9(1):29–33.

26.

Abhyankar V, Wong D, Mascarenhas J. Treatment of a mandibular anterior lingual recession defect with minimally invasive laterally closed tunneling technique and sub-epithelial connective tissue graft. Int Arch Oral Maxillofac Surg. 2018;2:017.

27.

Chiantella GC. Tunneling coronally advanced flap for treatment of maxillary single gingival recessions: a microsurgical approach. Clin Adv Periodont. 2018 Sep 1;8(3):127–31.

28.

Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent. 2011;31(6):653–60.PubMed

29.

Chao JC. A novel approach to root coverage: the pinhole surgical technique. Int J Periodontics Restorative Dent. 2012;32(5):521–31.PubMed

30.

Zuhr O, Rebele SF, Thalmair T, Fickl S, Hurzeler MB. A modified suture technique for plastic periodontal and implant surgery--the double-crossed suture. Eur J Esthet Dent. 2009;4(4):338–47.PubMed

31.

Modaressi M, Wang HL. Tunneling procedure for root coverage using acellular dermal matrix: a case series. Int J Periodontics Restorative Dent. 2009;29(4):395–403.PubMed

32.

• Allen EP. Multiple tooth recession: papilla retention pouch procedure. Contemporary Oral Plastic Surgery Procedural Manual. Dallas, TX: Center for Advanced Dental Education. 2004:9–16. The “double back continuous sling suture," designed specifically for TUN with allograft, was first described by this article.

33.

Allen EP. Subpapillary continuous sling suturing method for soft tissue grafting with the tunneling technique. Int J Periodontics Restorative Dent. 2010;30(5):479–85.PubMed

34.

Santamaria MP, Neves F, Silveira CA, Mathias IF, Fernandes-Dias SB, Jardini MAN, et al. Connective tissue graft and tunnel or trapezoidal flap for the treatment of single maxillary gingival recessions: a randomized clinical trial. J Clin Periodontol. 2017;44(5):540–7.PubMed

35.

Bherwani C, Kulloli A, Kathariya R, Shetty S, Agrawal P, Gujar D, et al. Zucchelli's technique or tunnel technique with subepithelial connective tissue graft for treatment of multiple gingival recessions. J Int Acad Periodontol. 2014;16(2):34–42.PubMed

36.

Gobbato L, Nart J, Bressan E, Mazzocco F, Paniz G, Lops D. Patient morbidity and root coverage outcomes after the application of a subepithelial connective tissue graft in combination with a coronally advanced flap or via a tunneling technique: a randomized controlled clinical trial. Clin Oral Investig. 2016;20(8):2191–202.PubMed

37.

Azaripour A, Kissinger M, Farina VS, Van Noorden CJ, Gerhold-Ay A, Willershausen B, et al. Root coverage with connective tissue graft associated with coronally advanced flap or tunnel technique: a randomized, double-blind, mono-centre clinical trial. J Clin Periodontol. 2016;43(12):1142–50.PubMed

38.

Graziani F, Gennai S, Roldan S, Discepoli N, Buti J, Madianos P, et al. Efficacy of periodontal plastic procedures in the treatment of multiple gingival recessions. J Clin Periodontol. 2014;41(Suppl 15):S63–76.PubMed

39.

Papageorgakopoulos G, Greenwell H, Hill M, Vidal R, Scheetz JP. Root coverage using acellular dermal matrix and comparing a coronally positioned tunnel to a coronally positioned flap approach. J Periodontol. 2008;79(6):1022–30.PubMed

40.

•• Tavelli L, Barootchi S, Nguyen TVN, Tattan M, Ravida A, Wang HL. Efficacy of tunnel technique in the treatment of localized and multiple gingival recessions: a systematic review and meta-analysis. J Periodontol. 2018;89(9):1075–90 This article provides a meta-analysis of the efficacy of tunnel technique in the management of different ginigval recession defects. PubMed

41.

Tatakis DN, Chambrone L, Allen EP, Langer B, McGuire MK, Richardson CR, et al. Periodontal soft tissue root coverage procedures: a consensus report from the AAP Regeneration Workshop. J Periodontol. 2015;86(2 Suppl):S52–5.PubMed

42.

Wainwright DJ. Use of an acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns. 1995;21(4):243–8.PubMed

43.

Woodyard JG, Greenwell H, Hill M, Drisko C, Iasella JM, Scheetz J. The clinical effect of acellular dermal matrix on gingival thickness and root coverage compared to coronally positioned flap alone. J Periodontol. 2004;75(1):44–56.PubMed

44.

Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ, et al. Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol. 2001;72(5):571–82.PubMed

45.

Mahn DH. Use of the tunnel technique and an acellular dermal matrix in the treatment of multiple adjacent teeth with gingival recession in the esthetic zone. Int J Periodontics Restorative Dent. 2010;30(6):593–9.PubMed

46.

Wang HL, Suarez-Lopez Del Amo F, Layher M, Eber R. Comparison of freeze-dried and solvent-dehydrated acellular dermal matrix for root coverage: a randomized controlled trial. Int J Periodontics Restorative Dent. 2015;35(6):811–7.PubMed

47.

Chaparro A, De la Fuente M, Albers D, Hernandez D, Villalobos AM, Gaedechens D, et al. Root coverage of multiple Miller class I and II recession defects using acellular dermal matrix and tunneling technique in maxilla and mandible: a 1-year report. Int J Periodontics Restorative Dent. 2015;35(5):639–45.PubMed

48.

Cummings LC, Kaldahl WB, Allen EP. Histologic evaluation of autogenous connective tissue and acellular dermal matrix grafts in humans. J Periodontol. 2005;76(2):178–86.PubMed

49.

Harris RJ. A comparative study of root coverage obtained with an acellular dermal matrix versus a connective tissue graft: results of 107 recession defects in 50 consecutively treated patients. Int J Periodontics Restorative Dent. 2000;20(1):51–9.PubMed

50.

Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol. 2001;72(8):998–1005.PubMed

51.

Novaes AB Jr, Grisi DC, Molina GO, Souza SL, Taba M Jr, Grisi MF. Comparative 6-month clinical study of a subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recession. J Periodontol. 2001;72(11):1477–84.PubMed

52.

Paolantonio M, Dolci M, Esposito P, D'Archivio D, Lisanti L, Di Luccio A, et al. Subpedicle acellular dermal matrix graft and autogenous connective tissue graft in the treatment of gingival recessions: a comparative 1-year clinical study. J Periodontol. 2002;73(11):1299–307.PubMed

53.

Harris RJ. A short-term and long-term comparison of root coverage with an acellular dermal matrix and a subepithelial graft. J Periodontol. 2004;75(5):734–43.PubMed

54.

Gapski R, Parks CA, Wang HL. Acellular dermal matrix for mucogingival surgery: a meta-analysis. J Periodontol. 2005;76(11):1814–22.PubMed

55.

Girouard M-E. Root coverage comparing acellular dermal matrix to connective tissue graft using the coronally positioned tunnel technique. 2011.

56.

Fahmy RA, Taalab MR. Modified tunnel technique for management of gingival recession in esthetic zone using acellular dermal matrix versus connective tissue graft. Future Dental J. 2018.

57.

Cosgarea R, Juncar R, Arweiler N, Lascu L, Sculean A. Clinical evaluation of a porcine acellular dermal matrix for the treatment of multiple adjacent class I, II, and III gingival recessions using the modified coronally advanced tunnel technique. Quintessence Int. 2016;47(9):739–47.PubMed

58.

Vincent-Bugnas S, Borie G, Charbit Y. Treatment of multiple maxillary adjacent class I and II gingival recessions with modified coronally advanced tunnel and a new xenogeneic acellular dermal matrix. J Esthet Restor Dent. 2018;30(2):89–95.PubMed

59.

Cieslik-Wegemund M, Wierucka-Mlynarczyk B, Tanasiewicz M, Gilowski L. Tunnel technique with collagen matrix compared with connective tissue graft for treatment of periodontal recession: a randomized clinical trial. J Periodontol. 2016;87(12):1436–43.PubMed

60.

Pietruska M, Skurska A, Podlewski L, Milewski R, Pietruski J. Clinical evaluation of Miller class I and II recessions treatment with the use of modified coronally advanced tunnel technique with either collagen matrix or subepithelial connective tissue graft: a randomized clinical study. J Clin Periodontol. 2019;46(1):86–95.PubMed

61.

Kauvar AS, Thoma DS, Carnes DL, Cochran DL. In vivo angiogenic activity of enamel matrix derivative. J Periodontol. 2010;81(8):1196–201.PubMed

62.

Vincent-Bugnas S, Charbit Y, Lamure J, Mahler P, Dard MM. Modified tunnel technique combined with enamel matrix derivative: a minimally invasive treatment for single or multiple class I recession defects. J Esthet Restor Dent. 2015;27(3):145–54.PubMed

63.

Sculean A, Cosgarea R, Stahli A, Katsaros C, Arweiler NB, Brecx M, et al. The modified coronally advanced tunnel combined with an enamel matrix derivative and subepithelial connective tissue graft for the treatment of isolated mandibular Miller class I and II gingival recessions: a report of 16 cases. Quintessence Int. 2014;45(10):829–35.PubMed

64.

• Sculean A, Cosgarea R, Stahli A, Katsaros C, Arweiler NB, Miron RJ, et al. Treatment of multiple adjacent maxillary Miller class I, II, and III gingival recessions with the modified coronally advanced tunnel, enamel matrix derivative, and subepithelial connective tissue graft: a report of 12 cases. Quintessence Int. 2016;47(8):653–9 This study shows that modified tunneling in combination with EMD and SCTG can result in predictable root coverage outcomes in multiple maxillary Miller class I, II, and III recession defects. PubMed

65.

Shepherd N, Greenwell H, Hill M, Vidal R, Scheetz JP. Root coverage using acellular dermal matrix and comparing a coronally positioned tunnel with and without platelet-rich plasma: a pilot study in humans. J Periodontol. 2009;80(3):397–404.PubMed

66.

Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8–13.PubMed

67.

• Yaman D, Demirel K, Aksu S, Basegmez C. Treatment of multiple adjacent Miller class III gingival recessions with a modified tunnel technique: a case series. Int J Periodontics Restorative Dent. 2015;35(4):489–97 This study shows that modified tunneling may be a valuable and predictable technique for the treatment of multiple Miller class III recession defects. PubMed

Title: Tunneling Techniques for Root Coverage
Authors: Yu Wang
Panagiota G. Stathopoulou
Publication date: 01-12-2019
Publisher: Springer International Publishing
Keywords: Incision
Root Coverage
Published in: Current Oral Health Reports / Issue 4/2019
Electronic ISSN: 2196-3002
DOI: https://doi.org/10.1007/s40496-019-00231-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Tunneling Techniques for Root Coverage

Abstract

Purpose of Review

Recent Findings

Summary

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

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