PerIodoNtics

78 INSIDE DENTISTRY—OCTOBER 2008

“The generally accepted properties of an

inside
PerIodoNtics
esthetic smile include harmony,
balance, and continuity of form.”

The Tunnel Technique in the Periodontal

Plastic Treatment of Multiple Adjacent
Gingival Recession Defects: A Review
Henry Salama, DMD; Maurice Salama, DMD; and David Garber, DMD

The generally accepted properties for the application of similar techniques necessary. If these restorations are ex- incising into or reflecting many of the
of an esthetic smile include harmony, in reconstructing gingival defects. This tremely shallow, their influence can be papillae within the surgical site, thereby
balance, and continuity of form. Gingival article reviews the surgical protocol required eliminated by root planing in the process minimizing the risk of losing papilla height
recession within the esthetic zone is a to use the tunnel technique in the treatment of flattening the root convexity, which in critical areas.
primary disruptor of these properties of multiple adjacent recession defects. actually aids the process of root cover- The type of graft to be used when the
and often must be corrected if an esthetic age. If the restorations to be replaced roots will be covered using a tunnel flap
smile is to be achieved. Periodontal plastic CASE REPORT are deeper, the authors prefer to replace design depends on the decision of whether
therapeutic surgical techniques are the A 55-year-old man presented with sig- them with the newest class of glass- the surgeon decides to position the flap
clinician’s tools for correcting such defects. nificant gingival recession in all three of ionomer restorative material, which ex- coronally. When deep recession defects
Many surgical protocols have been de- the maxillary sextants (Figure 1A and Fig- hibits the properties of being densified, exist and a coronally positioned flap is
scribed to achieve root coverage success- ure 1B). Previously placed and failing condensable, and viscous (GC Fuji IX contraindicated because of the desire to
fully. This article reviews and describes Class 5 restorations were present on sev- GP, GC America Inc, Alsip, IL). maximize the zone of keratinized attached
the tunnel technique with subepithelial eral of the exposed root surfaces. Minor gingiva, the authors prefer the use of
connective tissue grafts for the coverage toothbrush abrasion was present on the Treatment Design— subepithelial CTGs as described by Langer
of multiple adjacent gingival recessions. left maxillary canine, with the patient ex- Part 2: Flap Design and and Langer in 19851. This type of graft is
The axiomatic goal of reconstructive hibiting minor tooth sensitivity. No mobil- Choice of Graft Material chosen because of its increased ability to
therapy is the restoration of health, func- ity or fremitus was evident in any of the Given the patient’s midline diastema and survive when a portion of the graft is left
tion, and esthetics, which often requires maxillary sextants in question. The patient’s multiple adjacent recession defect, the exposed. This survivability often negates
correcting gingival recession defects with- desire was to improve the esthetics of his authors decided on an envelope tunnel6,8 the need to reposition the flap coronally
in the esthetic zone. To that end, periodon- smile as well as control what had been an type of flap design that would preserve and altering the position of the mucogin-
tal plastic procedures generally are used. increasing degree of recession. the level of the midline papilla best. This gival margin.
Several surgical techniques have been design also would maintain the best avail- However, if the recession is shallow
described in the literature to correct gin- Treatment Design— able vascularity for the tissue grafts that and/or a wide zone of keratinized, attached
gival recession defects successfully.1-10 Part 1: Preparation will be used to cover the defects. This sur- gingiva exists beyond the recession defects,
Langer and Langer1 used a subepithelial In preparation for treatment of a patient gical approach has the advantage of not then a coronally positioned flap may be
connective tissue graft (CTG) covered by with generalized patterns of gingival re-
a coronally positioned flap to achieve root cession, clinicians must first rule out or
coverage. Raetzke2 described the enve- identify and control any occlusal etiology
lope technique to place the CTG without that may be a contributing factor to the
the vertical incisions required in a coro- progression of the recession patterns. In
nally positioned graft. Zabalegui et al6 addition, instruction in proper tooth-
were the first to combine these techniques brushing and hygiene must be undertaken
in the treatment of multiple adjacent gin- before, during, and after therapy to ensure
gival recession defects through the use of that any periodontal plastic procedures
a mucosal partial-thickness “tunnel,” span- that are undertaken will not be traumatized
ning multiple teeth, to introduce the CTG. by the patient’s oral hygiene regimen. Figure 1A and Figure 1B Preoperative presentation of a patient exhibiting multiple adjacent gingival
Zuhr et al10 recently suggested the incor- Before commencing with any surgi- recession defects ranging from teeth Nos. 8 through 14. Notice that with a diastema present, elevating
poration of specialized microsurgical peri- cal intervention, any questionable restora- the midline papilla would have created additional risk of further loss in a critical area.
odontal plastic protocols and instruments tions must be removed and replaced if

Henry Salama, DMD Maurice Salama, DMD Maurice Salama, DMD

Private Practice, Clinical Assistant Professor Clinical Assistant Professor Periodontics
Atlanta, Georgia Periodontics Medical College of Georgia
Medical College of Georgia Augusta, Georgia
Augusta, Georgia
Private Practice
Private Practice Atlanta, Georgia
Atlanta, Georgia
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80 INSIDE DENTISTRY—OCTOBER 2008

Figure 2A through Figure 2D With the requirement of partial-thickness dissection around curved line angles to undermine and mobilize the papillae, while maintaining an intact blood supply to the tip, spe-
cial microsurgical instrumentation is required, such as the Tunneling Kit.

contemplated to cover an acellular collagen or intrasulcularly, especially because of the labial flap. To enhance the efficacious tical mattress monofilament sutures of
matrix (AlloDerm®, LifeCell Corp, Branch- the use of an epinephrine-infused anes- performance of periodontal plastic pro- 5-0 and 6-0 were used for this purpose
burg, NJ) completely. The use of an acel- thetic, so as not to compromise vascularity cedures in these difficult areas, specialized (Monocryl™, Ethicon, Inc, Somerville,
lular collagen matrix as a graft material to those areas during or after the surgery. curved microsurgical instruments and NJ) (Figure 4A and Figure 4B). This peri-
eliminates the requirement for an addi- The root surfaces were planed and knives were used (Tunneling Kit, Stoma odontal plastic microsurgical approach to
tional donor site, which is necessary when treated for 4 to 5 minutes with a tetracycline USA Inc, Melville, NY) (Figure 2C and flap dissection and suturing is much less
harvesting autologous soft-tissue grafts, HCL paste, which was made by mixing Figure 2D). These instruments not only traumatic to the surrounding tissue and
and thereby reduces the trauma to the the antibiotic with saline. The literature have the curvature required to hug the is, therefore, more likely to better main-
patient. However, the authors have found suggests that treating the root surface root surfaces during dissection, but also tain the vascularity of the surgical site
that predictable success with this type of before connective tissue grafts with any are small enough to cut safely in the restrict- during the critical early healing period. No
graft material requires complete flap cov- of several substances, such as tetracycline ed areas of the papillae. periodontal dressings are used if adequate
erage to maximize the potential for re- HCL, citric acid, or enamel matrix deriv- Subepithelial CTGs were harvested stability of the graft and flap is achieved.
vascularization of the graft and is, there- ative, can impart a positive effect on suc- from both sides of the palate and meas- The patient was instructed not to brush
fore, not always the best option when cessful outcomes.11-13 ured for dimensional appropriateness in the surgical sites for the first 2 weeks.
coronal repositioning of the labial flap is Sulcular incisions on the labial and the areas of the defects (Figure 3A). The Instead, during that time, he was instructed
not possible or desired. buccal only were performed with a Bard- CTGs were trimmed to size using sharp to rinse with 0.2% chlorhexidine diglu-
While subepithelial CTG usually heal Parker™ No. 15 blade (Becton, Dickinson, surgical blades. After the size of the re- conate for 2 to 3 times per day. Anti-inflam-
with a greatly reduced postoperative sequela and Co, Franklin Lakes, NJ) to begin the quired graft was established, the access matory and pain control medications were
when compared to free gingival grafts, it partial-thickness dissection. The split- for the graft to the subgingival space was prescribed for use as needed. At the 2-week
is still prudent to prepare a retainer with a thickness dissection then was extended ascertained (Figure 3B). If the graft is postoperative visit, any remaining sutures
palatal stent to protect the potential donor until continuity was established between significantly large, alternating papillae were removed and oral hygiene and plaque
site(s) during the first week of healing. all the recession sites without raising the may require release to facilitate the place- control was reviewed and reinforced.
papillae (Figure 2A and Figure 2B). ment of the graft. Of course, critical papil-
Treatment Design— When using standard straight-cutting lae, such as at the midline, should never DISCUSSION
Part 3: Surgical Procedure instruments, it is often difficult, if not be compromised (Figure 3C). The generally accepted properties of an
After the preparation phase, the surgical impossible, to extend the dissection effec- After the grafts were in place, micro- esthetic smile include harmony, balance,
visit began with local infiltration of anes- tively and to navigate the rounded tran- surgical instruments were used to suture and continuity of form. Gingival recession
thesia in the vestibule and in the palate. sitional line angles of the teeth, as well as and stabilize the grafts with the overlying within the esthetic zone is a primary dis-
Care was taken not to inject intrapapillary release the papillae, without perforating gingival flap. In the papillae regions, ver- ruptor of these properties and often must

Figure 3A through Figure 3C A subepithelial CTG is harvested, measured, and placed into position within the tunnel partial-thickness preparation.

Figure 4A and Figure 4B Vertical mattress 5-0 monofilament and vicryl sutures secured the two Figure 5A and Figure 5B Six months postoperative presentation showing complete coverage of
CTGs and the flaps. previously exposed root surfaces.
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INSIDE DENTISTRY—OCTOBER 2008 81

be corrected if an esthetic smile is to be 6. Zabelgui I, Sicilia A, Cambra J, et al. Treatment supported restorations. Int J Periodontics with tetracycline root conditioning and coro-
achieved. Periodontal plastic therapeutic of multiple adjacent gingival recessions with Restorative Dent. 2002;22(1):71-77. nally positioned flap procedure in the treat-
surgical techniques are the clinician’s tools the tunnel subepithelial connective tissue 9. Burkhardt R, Lang NP. Coverage of localized ment of human gingival recession defects.
for correcting such defects. The number graft: a clinical report. Int J Periodontics Re- gingival recessions: comparison of micro- and J Clin Periodontol. 1996;23(9):861-867.
one advantage of a surgical solution to storative Dent. 1999;19(2):199-206. macrosurgical techniques. J Clin Periodontol. 12. Bouchard P, Nilveus R, Etienne D. Clinical eval-
denuded roots, if it is achievable, is the 7. Guiha R, el Khodeiry S, Mota L, et al. Histo- 2005;32(3):287-293. uation of tetracycline HCl conditioning in the
ability to minimize restorative intervention logical evaluation of healing and revasculariza- 10. Zuhr O, Fickl S, Wachtel H, et al. Covering of gin- treatment of gingival recessions. A compara-
in many instances. In addition to regain- tion of the subepithelial connective tissue gival recessions with a modified microsurgical tive study. J Periodontol. 1997;68(3):262-269.
ing an esthetic gingival profile through graft. J Periodontol. 2001;72(4):470-478. tunnel technique: case report. Int J Periodontics 13. Castellanos A, de la Rosa M, de la Garza M,
root coverage, the increased zone of ker- 8. Azzi R, Etienne D, Takei H, et al. Surgical thick- Restorative Dent. 2007;27(5):457-463. Caffesse RG. Enamel matrix derivative and
atinized, attached gingiva creates a more ening of the existing gingiva and reconstruc- 11. Trombelli L, Scabbia A, Wikesjö UM, Calura coronal flaps to cover marginal tissue re-
maintainable periodontal environment, tion of interdental papillae around implant- G. Fibrin glue application in conjunction cessions. J Periodontol. 2006;77(1):7-14.
usually with significantly less sensitivity.
The tunnel technique is an approach
that optimizes esthetics and predictability
because of its ability to avoid releasing
critical papillae and maintaining a high
level of vascularity at the surgical site to
support the grafts.

CONCLUSION
The extent and predictability of root cov-
erage procedures for the treatment of
recession defects are dependent on the
quality of the vascularity that is main-
tained at the surgical site. The tunnel, or
envelope, technique optimizes vascularity
by eliminating the need for vertical releas-
ing incisions. Furthermore, when adja-
cent recession defects are present and are
connected by an esthetically critical papil-
la, the tunnel technique is an excellent
approach to protect the positional height
of the papilla.10 This flap design, in com-
bination with partial-thickness dissection,
creates the most optimal and vascular sub-
gingival environment for the placement
of subepithelial or acellular collagen matrix
type of grafts.
However, this surgical protocol is
more technique-sensitive than stan-
dard full-thickness flap approaches be-
cause the clinician must work in a more
confined environment. Microsurgical
instruments, therefore, are required to
navigate and adequately release the flap
and papillae around small curved sur-
faces. Using proper protocols, this ap-
proach is a very successful and predictable
method of treating multiple adjacent
root recession defects without compro-
mising the height of critical papillae (Fig-
ure 5A and Figure 5B).

REFERENCES
1. Langer B, Langer L. Subepithelial connec-
tive tissue graft technique for root coverage.
J Periodontol. 1985;56(12):715-720.
2. Raetzke PB. Covering localized areas of root
exposure employing the “envelope” technique.
J Periodontol. 1985;56(7):397-402.
3. Tarnow DP. Semilunar coronally repositioned
flap. J Clin Periodontol. 1986;13(3):182-185.
4. Harris RJ. The connective tissue and partial
thickness double pedicle graft: a predictable
method of obtaining root coverage. J Perio-
dontol. 1992;63(5):477-486.
5. Allen AL. Use of a supraperiosteal envelope
in soft tissue grafting for root coverage. I. Ra-
tionale and technique. Int J Periodontics
Restorative Dent. 1994;14(3):216-227.