ACTA SCIENTIFIC DENTAL SCIENCES (ISSN: 2581-4893)

Volume 4 Issue 3 March 2020

Research Article

Tunnel and Pouch Technique for Management of Multiple Gingival

Defect with thin Gingival Biotype

Mandal S1*, Bose S1, Choudhuri P1, Chakrabarty H2, Ravi Prakash BS2 and
Chakraborty A3 Received: February 12, 2020
Published: February 20, 2020
1
Resident Periodontist, Department of Periodontics, Guru Nanak Institute of Dental
© All rights are reserved by Mandal S., et al.
Sciences and Research, India
2
Professor, Department of Periodontics, Guru Nanak Institute of Dental Sciences and
Research, India
3
Professor and Head, Department of Periodontics, Guru Nanak Institute of Dental
Sciences and Research, India
*Corresponding Author: Mandal S, Resident Periodontist, Department of Periodontics,
Guru Nanak Institute of Dental Sciences and Research, India.

Abstract
Traumatic tooth brushing habits and anatomic variations often leads to gingival recession. The exposed root surfaces not only
result in sensitivity but are unaesthetic too. Furthermore, the tissue resistances to such changes are very low in thin gingival biotype.
Periodontal plastic surgery plays a pivotal role in such cases. Many soft tissue graft material and technique have been studied by vari-
ous clinicians and researchers. From the point of view of evidenced based practice, autologous connective tissue grafts have the high-
est predictability and success rate. In this current case report, connective tissue graft is used along with tunnel and pouch technique
for recession coverage of multiple defects in thin gingival biotype.
Keywords: Periodontal Plastic Surgery; Root Coverage; Tunnel and Pouch; CTG

Abbreviations Connective tissue as a treatment option along with the above men-
CTG: Connective Tissue Graft; EVP: Evidence Based Practice tioned movement of the tissues.

Introduction Previously, the early indications of Connective tissue grafts were

The apical shift of the gingival margin with respect to the ce- only to increase tissue thickness. However, Langer and langer [3]
mento-enamel junction is defined as Gingival recession [1]. Vari- were the first one to use sub-epithelial connective tissue in both
ous predisposing factors have been suggested, like periodontal isolated and multiple recession coverage of adjacent teeth. Raetzke
biotype, impact of tooth brushing, cervical abrasion margin, orth- [4] enveloped the CTG while Allen [5] modified it by tunneling it
odontic treatments and other. supra-periosteally. To date, various modification and variations are
available in the literature.
Periodontal plastic procedures are the key to such clinical
challenges. Most of the procedure involves either the movement The current case report discusses the use of CTG in tunnel and
of tissues [2] (advancement, laterally) or creating pouch and / pouch technique for recession coverage of multiple adjacent teeth
or tunnel. Periodontal and aesthetic implant surgery widely uses in thin gingival biotype.

Citation: Mandal S., et al. “Tunnel and Pouch Technique for Management of Multiple Gingival Defect with thin Gingival Biotype”. Acta Scientific Dental
Sciences 4.3 (2020): 01-03.
Tunnel and Pouch Technique for Management of Multiple Gingival Defect with thin Gingival Biotype

02

Materials and Methods

A 23 years old young female patient reported with chief com-
plaint of hypersensitive teeth and receding gum in upper front
teeth. On further periodontal evaluation, following clinical findings
were elicited (Figure 1A):

• Miller class I gingival recession in 14

• Miller class II gingival recession in 12 and 13
• Inadequate attached gingiva: 1mm in 12, 13. 2 mm in 14.
• Thin biotype.
• Trauma from occlusion in 31.

After receiving appropriate consent from the patient for the

procedure, Local Anesthetic agents were administered. Scaling Figure 2
and root planning was done on the exposed root surface (Figure
1B). The trauma from occlusion with respect to right mandibular
central incisor was managed by selective grinding. Sulcular inci- Postoperative instructions were given to the patient. She was
sions were placed (Figure 1C). With the help of blunt instrument, a instructed to refrain from brushing at the level of surgical site for
tunnel was created (Figure 1D). minimum of two weeks. Appropriate analgesics for pain manage-
ment and 0.2% Chlorhexidine mouthrinses were advised.

Patient was recalled after 14 days for removal of sutures and

orthodontic buttons (Figure 3A). The patient was recalled after 1
month (Figure 3B) and 4 months (Figure 3C) post-operatively to
evaluate the healing.

Figure 1

The orthodontic buttons were bonded on facial aspects of 12,

13 and 14 (Figure 2A). The Connective tissue (Figure 2B) was pro-
cured by trap door technique from palate (Figure 2C). The plastic
palatal stent was given to the patient for uneventful healing of the
secondary trauma. The procured connective tissue graft was re-
ceived in the tunnel and pouch created. The sutures were placed by
coronally advancing the flap to bonded brackets (Figure 2D). Figure 3

Citation: Mandal S., et al. “Tunnel and Pouch Technique for Management of Multiple Gingival Defect with thin Gingival Biotype”. Acta Scientific Dental
Sciences 4.3 (2020): 01-03.
Tunnel and Pouch Technique for Management of Multiple Gingival Defect with thin Gingival Biotype

03

Results and Discussion Conclusion

During the entire post-operative observational period, signs of An evidence based practice always results in promising clini-
necrosis or hemorrhage were ruled out. Patient did not report of cal outcome. The CTG used in tunnel and pouch technique showed
pain from the palatal donor site post 15 days of healing. On the day satisfactory results. Larger sample size with long follow up would
of suture removal, the first sign of graft acceptance was noted. The prove the clinical efficacy of the procedure altogether.
tissue healing, pain and discomfort reduced eventually. The goal of
Acknowledgements
the treatment: root coverage and increase in tissue thickness and
Nil.
increase in apico-coronal and bucco-lingual dimensions of gingival
tissues were achieved. Significant improvement of aesthetic aspect Conflict of Interest
and the coverage of roots with tissue graft, absence of scars left None.
behind by suture were the notable finding (Figure 4A, 4B). Bibliography
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tology 1.1 (1996): 671-701.

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tissue graft technique for root coverage”. Journal of Periodon-
tology 56.12 (1985): 715-720.

4. Raetzke Peter B. “Covering localized areas of root exposure

employing the “envelope” technique”. Journal of Periodontol-
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5. Allen Andrew L. “Use of the supraperiosteal envelope in soft

tissue grafting for root coverage. Rationale and technique”.
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Figure 4 14.3 (1994).

6. Oates Thomas W., et al. “Surgical therapies for the treatment

of gingival recession. A systematic review”. Annals of Periodon-
Oates and co-worker6 in their systematic review have conclud- tology 8.1 (2003): 303-320.
ed that the predictability and success rate is high with use of con-
nective tissue graft. Among all the procedures reviewed, CTG was 7. Karring T., et al. “The role of gingival connective tissue in de-
concluded to be the biomaterial with maximum success rate. termining epithelial differentiation”. Journal of Periodontal Re-
search 10.1 (1975): 1-11.
The Connective tissue graft from palate transfers its genetic in-
8. Tatakis, Dimitris N., et al. “Periodontal soft tissue root cover-
formation in form of keratinization. This transfer from donor to re- age procedures: a consensus report from the AAP Regenera-
cipient site, where the recipient site has little contribution to qual- tion Workshop”. Journal of Periodontology 86 (2015): S52-S55.
ity and quantity on final outcome is termed as Fibro-genesis [7].
The quality of harvest plays a major role. The results obtained in
Assets from publication with us
the current case report suggest procurement of good quality CTG
• Prompt Acknowledgement after receiving the article
graft.
• Thorough Double blinded peer review
• Rapid Publication
However, insufficient CTG graft, patient’s refusal to have a sec-
• Issue of Publication Certificate
ond surgical site and morbidity are few of the disadvantages of the
• High visibility of your Published work
procedure [8]. But, when rationally weighed, the advantages are
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Citation: Mandal S., et al. “Tunnel and Pouch Technique for Management of Multiple Gingival Defect with thin Gingival Biotype”. Acta Scientific Dental
Sciences 4.3 (2020): 01-03.