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 Table of Contents  
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 118-122

Management of anterior multiple gingival recessions with modified coronally advanced tunnel technique

1 Postgraduate Course of Periodontology, School of Midwest Paulista, Piratininga, Brazil
2 Graduate Program in Dentistry, University of North Parana, Londrina, PR, Brazil
3 Postgraduate Course of Periodontology, School of Midwest Paulista, Piratininga; Graduate Progam in Oral Biology / Implantology, Sagrado Coração University - USC, Bauru, Brazil
4 Postgraduate Course of Periodontology, School of Midwest Paulista, Piratininga; Graduate Program in Dentistry, University of North Parana, Londrina, PR; Graduate Program in Dentistry, University of Western São Paulo, SP, Brazil

Date of Submission12-Nov-2019
Date of Acceptance08-Jan-2020
Date of Web Publication3-Feb-2020

Correspondence Address:
Dr. Luciana Prado Maia
University of North Parana (UNOPAR), Rua Marselha, 591, Jardim Piza, Londrina, PR
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmd.ijmd_55_19

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Gingival recessions (GRs) in anterior teeth are the most common complaint of patients for disharmony in the smile. The objective is to show a clinical case of GR treatment by the tunnel technique associated with subepithelial connective tissue graft (SCTG). We report a patient of 56-year-old, female, frequents specialization clinic of periodontics to treat Miller's Class I GR of 11 and 21 teeth. It was used tunnel technique because it does not result in scarring. This technique was associated with SCTG to guarantee increase the gingival thickness. After 14 days, the gingival margin was over the cemento-enamel junction with esthetic harmony. The position stability was maintained for 90 and 180 days. It is possible to conclude that a modified tunnel technique can be considered as a treatment of multiple GR on esthetic area.

Keywords: Gingival diseases; gingival recession; tissue transplantation

How to cite this article:
Calero JP, Gregorio D, Silveira EM, Maia LP. Management of anterior multiple gingival recessions with modified coronally advanced tunnel technique. Indian J Multidiscip Dent 2019;9:118-22

How to cite this URL:
Calero JP, Gregorio D, Silveira EM, Maia LP. Management of anterior multiple gingival recessions with modified coronally advanced tunnel technique. Indian J Multidiscip Dent [serial online] 2019 [cited 2022 Oct 5];9:118-22. Available from: https://www.ijmdent.com/text.asp?2019/9/2/118/277455

  Introduction Top

The smile disharmony caused by the gingival recession (GR) in anterior teeth is a common patients complaint. Complete root coverage through surgical techniques described by different authors has become the main objective to minimize both esthetic[1] and dental sensibility problems.[2] Many clinical studies have demonstrated high success for the use of subepitelial connective tissue, and that is why it is called the “gold standard” procedure for root coverage.[2],[3] In addition, cases with multiple GR should be treated simultaneously, avoiding multiples surgeries. The surgical technique should be correctly chosen considering the patient satisfaction regarding harmony, color, and thickness of the área.[4] A combination of techniques using a tunnel under the gingival tissue through an intrasulcular incision without lifting the papilla, followed by the placement of a subepithelial connective tissue graft (SCTG) was proposed.[5] The authors who described the technique published a single case report, and hence, it is important that more clinical reports are available on the literature to guarantee the predictability of the technique. The aim of this study is to report a clinical case using the modified coronally advanced tunnel technique for the treatment of multiple GR of anterior teeth.

  Case Report Top

A 50-year-old female patient attended in the periodontal clinic diagnosed with GR. The patient was neither a smoker nor had any systemic impairment. The main complaint of the patient was the lack of esthetics in the anterior teeth, treated with restoration in composite resin in the cervical region. The restoration exhibited diffuse margin invading gingival margin. In clinical examination, the patient had RG Miller's Class I[6] in the elements 11 and 21, which were probably present when the restoration was done [Figure 1].
Figure 1: Initial clinical aspect of the anterior area with the gingival recession in 11 and 21 teeth

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The treatment plan was to cover the GR using the modified tunneling technique, placing subepithelial connective graft from the palate using the technique describe by Edel (1974),[7] which consists of a partial-thickness trapezoidal palatal flap followed by subepithelial conective tissue graft harvesting.[7] The patient was informed about possible complications and predictability of the treatment and signed the informed consent. After this, basic periodontal therapy was performed, and oral hygiene instructions were given, recommending the Stillmans modified brush technique.

Initially, aseptic and antiseptic were performed for the surgical procedure. For extraoral and intraoral antisepsis, 2% and 0.12% chlorhexidine digluconate, respectively, were used. For anesthetic and hemostatic purposes, anterior area anesthesia was performed with articaine, by blocking the anterior superior alveolar nerve at the bottom of the vestibule of the surgical area and the palatine nerve of donor area. Then, with 15C scalpel blade, an intrasulcular incision was performed around the teeth 11 and 21, without compromising the papilla, and a partial-thickness flap extending apically to the mucogingival line was done to obtain greater mobility of the flap toward the coronal area [Figure 2]. With MOLT syndesomotome, partial thickness was separated in each recession area until the two sites were interconnected to complete the tunnel preparation [Figure 3]. With the periodontal probe, the tunnel was checked to ensure the easy sliding of the graft [Figure 4]. In the cervical lesions, marginal adjustment was done, eliminating the step formed by the misfit of the restoration. For the preparation of the graft donor area, to obtaining the extension needed to cover the recession, a map was made with the exact measurement of the defects, and it was transpolated to the donor site [Figure 5]. Then, with a 15°C scalpel blade, a horizontal incision of 2 mm was performed from the mesial gingival margin of tooth 26 to the distal of the 23, completed with two perpendicular relaxing incisions. The epithelial and connective tissues were separated by a partial flap until the flap reflex was achieved [Figure 6]. A 1.5 mm incision was deepened toward the bone around the quadrant prepared to obtain the subepithelial connective tissue [Figure 7]. The conjunctive graft obtained was placed submerged in physiological serum to preserve the normal conditions [Figure 8], whereas the synthesis of palatal tissues was performed using 5-0 Vicryl absorbable thread (Ethicon-Johnson & Johnson) with simple interromped suture in the mesial and distal areas and two X sutures all over its extension [Figure 9].
Figure 2: Intrasulcular incision of the papillae

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Figure 3: Preparation of a partial thickness flap extending apically to the mucogingival line

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Figure 4: Tunnel prepared

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Figure 5: Map of the donator area to obtain the graft tissue

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Figure 6: Separation of a partial flap

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Figure 7: Subepithelial connective tissue obtained

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Figure 8: Conjunctive tissue graft extension (almost 20 mm)

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Figure 9: Synthesis of the donator area

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For the adaptation of the connective graft in the tunnel, the graft has been delicately placed in the recipient site with the help of an Adson anatomical tweezer without teeth and the Molt surgical curette, until its complete adaptation [Figure 10]. To finish the procedure, the flap was moved coronally, and with 6-0 Vicryl absorbable thread (Ethicon-Johnson & Johnson), vertical mattress sutures were made in the papillae [Figure 11].
Figure 10: Adaptation of the connective graft in the tunnel

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Figure 11: Immediate postoperative aspect

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As postoperative care, 100 mg of nimesulide 12–12 h for 4 days and dipyrone sodium in case of pain were prescribed. The patient was also instructed regarding oral hygiene procedures with 0.12% clorexidine digluconate wash twice a day for a period of 14 days in addition to the application of cold compress thermal therapy in the first 24 h. The patient was advised to return in 14 days for the sutures removal [Figure 12]. Monthly controls were performed until 3 months, when complete radicular coverage, keratinized tissue gain, and patient satisfaction were observed [Figure 13]. The patient did not report any pain and compromise of signs or unpleasant symptoms.
Figure 12: Clinical aspect after 14 days

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Figure 13: Clinical aspect after 90 days

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  Discussion Top

The different surgical techniques applied as the treatment of GR have shown good predictability in results of root coverage and clinical attachment gain when combined with the use of free gingival grafts.[8] However, esthetic incompatibility in variables such as color and texture of gingival components from donator area stimulated the development of surgical techniques variation to meet the expectations of the patient and the operator. The use of SCTG offers a combination of both the pedicled flap and the free gingival graft. The pedicled flap allows, as far as possible, root coverage since it retains its own blood supply, and therefore, survives on an avascular radicular surface. The free gingival graft maintains a thin layer of the connective tissue with a genetic predisposition that ensures the thickness and keratinization.[5] The results obtained in the systematic review in which 23 clinical studies were included by Chambrone et al. to determine if the use of SCTG could be considered as the “Gold Standard” procedure in the treatment of GR defects, a significant statistical difference was found in the reduction of GR using SCTG,[2],[3] compared to some graft substitutes such as acellular dermal matrix and tissue-guided regeneration with reabsorbable membranes. The authors conclude that SCTG provides significant root coverage and gain in clinical attachment and keratinized tissue.

In the treatment of GR in anterior teeth, the use of tunneling technique could be the choice, since it avoids relaxing incisions and allows a continuous vascularization with blood supply for the graft, in addition to maintaining esthetics and faster healing.[8] In multiple GR with a depth ≤3 mm in which the esthetic demand is high, the tunneling technique could also be the ideal alternative because it keeps the papillae intact, and it is possible to connect several adjacent sites of recession in its extension and maintains the esthetics. Fast healing is achieved thanks to the blood supply of the flap, allowing to achieve the optimal and long-term functional result.[1],[6] When comparing the effectiveness of two techniques,[1],[4] the tunnelization technique with SCTG for the coating of multiple GR showed that both techniques used in the treatment of multiple GR defects demonstrated effectiveness in results of root coverage and increase in height of keratinized tissue.[1],[2]

In the present case, the presence of GR in teeth 11 and 21 with high esthetic demands was the reason why it was determined to perform root coverage using the modified tunneling technique plus SCTG placement.[5] Clinically, the results of root coverage are quantified by the measurement of the distance between the gingival margin and the cemento-enamel junction (CEJ).[9] Zabalegui (1999) showed 95% of root coverage in Miller Class I gingival recession, despite dental malpositioning,[4] while Miller (1985)[6] described 88 to 100% of root coverage in Class I and II recessions. In the present clinical case, 14 days after surgery, a margin disposed coronally to the CEJ was observed, with esthetic harmony (adaptation, color, texture, and thickness), a qualitative result compared with other studies.[5] After 90 days, these characteristics became more evident, and the patient reported satisfaction due to the esthetic results obtained, fulfilling her expectations.

A systematic review reported that all surgical procedures evaluated can provide a significant reduction in the depth of the GR and gain in the clinical attachment level in cases of Miller Class I and II GR defects.[3],[5] However, there are factors that determine the success of the use of the tunnel technique, one of them is the expertise or training of the professional since it is a delicate procedure in which the higher dexterity, the lower the probabilities of tissue fenestration.[5] In the present case, it was not possible to perform the technique with delicate microsurgical instruments; however, the clinical results were as expected, which could be due to a thick gingival biotype and the presence of a good band of keratinized tissue.

  Conclusion Top

The results observed lead to the conclusion that the modified tunneling technique can be considered an option in the treatment of Miller's Class I and II multiple GR, once the root coverage was reached, as well as the increase in the quantity and quality of gingival tissue, with a high level of esthetic satisfaction of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images, and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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;16:34-42.  Back to cited text no. 1
Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? J Dent 2008;36:659-71.  Back to cited text no. 2
Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol 2015;86:S8-51.  Back to cited text no. 3
Zucchelli G, Mele M, Stefanini M, Mazzotti C, Mounssif I, Marzadori M, et al. Predetermination of root coverage. J Periodontol 2010;81:1019-26.  Back to cited text no. 4
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;19:199-206.  Back to cited text no. 5
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.  Back to cited text no. 6
Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. J Clin Periodontol 1974;1:185-96.  Back to cited text no. 7
Xavier I, Alves R. Tunnel connective tissue graft - a clinical case. Rev Port Estomatol Med Dent Cir Maxilofac 2015;56:256-61.  Back to cited text no. 8
Jepsen K, Stefanini M, Sanz M, Zucchelli G, Jepsen S. Long-term stability of root coverage by coronally advanced flap procedures. J Periodontol 2017;88:626-33.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]


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