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Treatment of Multiple Adjacent Gingival Recessions

with the Tunnel Subepithelial Connective Tissue
Graft: A Clinical Re....

Article in The International journal of periodontics & restorative dentistry · May 1999
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The internationai Journai of Periodontics & Restorative Dentistry
 199

Treatment of Multiple Adjacent

Gingival Recessions with the Tunnel
Subepitheliai Connective Tissue
Graft: A Clinical Report

Ion Zabalegui, MD, DOS' Different surgical cosmetic tech-

Alberta Sicilia. MD. DÛS, Dr Med" niques for the coverage ot
Jordi Cambra. MD, DDS'" exposed roots caused by gingi-
Jaime Gil, MD, DDS, Dr Med"" val recession hove been devel-
Mariano Sanz MD, DDS, Dr Med""' oped and improved since more
and more patients demand
This arficle describes a surgical periodontal plastic procedure for the cov- procedures fo improve their
erage of multiple adjacent gingivai recessions. This surgical technique is esthetic appearance, Ditferent
based on the cansfruction ot a funnel under the gingival tissue by means surgicai techniques hove pro-
of a sulcuiar incisian beyand the mucogingival line without raising the ven efficient in the treatment of
popilloe. A iarge connective tissue graft obtained from the paiatai mucosa this condition; good results in
is introduced through this funnel, covering the adjacent gingival recessions. root coverage and gain in clini-
A suturing technique to oliow this graft to Slip through the tunnel under the
cal attachment have been
gingival tissues and to secure and stabiiize the graft covering the reces-
reported with free gingival
sions is described, Tweive-month postoperative results are presented from
grafts^; sliding fiaps either later-
21 teeth that were freafed with this technique: 100% raot coverage was
oily,^ coronaiiy,'' or tTansposition-
ochieved in 66.7% af the recessions treated, with a mean root surfoce cov-
oliy^; connective tissue grafts^-*
erage of 91.6%. This study suggests that the use of this surgicai procedure
allows the treatment of multiple adjacent recessions in a single procedure
(CTG); and recently guided tis-
with adequate early healing and highly predictable root coverage results.
sue regeneration.^
Ont J Periodonîics Restorative Dûnt 1999; 19:199-206.) For these procedures, the
CTG has been very frequently
used because of its demon-
strated advantages, which
include improved coior blend-
'Private Practice. Biibdo, Spain. ing, reduced morbidity in the
"Professor of Periodontoiogy, University of Oviedo, Spain. donor site, and high degree of
'Prívate Practice, Barcelona, Spain. clinical success. However, most
•Professor of Prosthodontics, University Pdis Vasco, Bilbao, Spain. ot the time CTGs have been
•Professor of Peri odontology. University Complutense of Madrid,
used in combination with coro-
Spain.
naiiy positioned flaps, which
Reprint requests: Dr Ion Zabalegui, Edificio Albia 1 -12,48001 necessitate incisions on the
Bilbao, Spain.

Volume 19, Number 2,1999

200

Fig la Parfial-fhicknesssulcular inci-

sions preserve the popillae by under-
mining the tissue corono! to the CEJ
and beyond the MGJ.

Fig Ib Eirst suture is introduced

through the most distai recession. It
passes through fhe funnel and the nee-
dte exifs fhrough fhe most media/ or
targest recession.

Fig ic Second suture is placed on the

opposite side of the tunnet in the same
manner as the firsf. if exifs fhrough the
same recession as fhe first suture.

Fig Id Graft held by both sutures is

ready to slide through the tunnel by
means of a puil on both sutures
(mesiaiiy and distalty) and the help of a
duii insfrument.

buccai flap; fhese may refard modificafion of fhe CTG and Pafienf 1 is shown in Fig 2 and
the early esfhefic resuif. To avoid envelope techniques for fhe patient 2 is shown in Fig 3,
fhese incisions on fhe recipienf freafmenf of muifipie adjacenf The mosf common indica-
site, fhe enveiope fechnique gingivai recessions in fhe anfe- tions for CTGs are esfhefic
was advocafed,^"'° The advan- rior areas of the moufh. demands from fhe pafienfs,
fage cf fhis procedure is fhe fasf Miiler Ciass I and li recession,
early heaiing fhaf resulfs from denfai hypersensifivify because
fhe absence of fhese exfernal Procedure of exposed cemenfoenamel
incisions, juncfion (CEJ), and fhe neces-
Mosf of fhese surgical pro- This surgicai procedure involves sity fo augmenf a narrow band
cedures have been advocaf- a CTG piaced in a mulfienve- of keratinized gingival fissue. The
ed and clinical results have lope recipienf bed (funnei). This relaflve confraindicafions fhaf
been reporfed in the literafure tunnel is made of a suprape- may iimif fhe resulfs of fhe con-
for the treatmenf of isolafed riosfeoi bed under a pedicle necfive fissue aufograft are
gingivai recessions. For fhe flap wifhouf any exfernal inci- heavy smoking, impaired heai-
treotmenf of muifipie adjacenf sions, A CTG is fhen piaced and ing response from the pafienf,
gingival recessicns, however, secured fhrough fhis funnel, Miiler Ciass III or IV recession, or
very seidom have procedures covering fhe adjacenf exposed the exisfence cf an exfremely
been presenfed and their clini- roofs. The surgical procedure is thin periodonfium fhaf wouid
cal oufcomes reported. There- shown in Fig 1, A sfep-by-sfep Iimif the amounf of donor fissue.
fore, the purpose of fhis clinical descripfion of fhe proposed sur- The specific indicafions for surgi-
reporf was fc show the prelimi- gical procedure is exemplified cai infervenfion wifh fhe funnel
nary resulfs obtained w\fU a by fhe case reporfs presenfed. CTG include muifipie adjocent

The Internotionai Journai of Periodontics & Restorative Dentistry

 201

Fig 2a Severe gingival reaes^on on Fig 2b Preserved papiiiae are raised Fig 2c Tunnei is created beyond the
maxiiiary left lateral inaisar, canine, and ivjfh a partial-thickness inci^on (also see MGJ underneath the papillae of the
premaiar in patient 1. Fig la) treated teeth (alsa see Fig io).

Fig 2d Danar tissue is placed aver the Fig 2e Graft held by both sutures is Fig2f Affer sliding It through fhe tun-
treatment area to ensure that there is ready to slide through the tunnel by nel, graft is sutured w:th 2 square knots.
enough tissue (also see Figs ¡b and Ic). means of a pull an bath sutures
(mesially and distdliy) and the help af a
dull instrument (olsa see Fig Id).

Fig 2g Tweive-manth healing af fhe Fig2h Right side af the maxiila in Fig 2i Tweive-month healing of the
treated recessions. patient i shows wiae recession invoiving treated recessions on the right side Of
central and laterai incisors and cdnine. the maxiiia in pdtient 1.

Volume 19. Number 2,1999

L,
202

Fig 3a Preoperative view ot patient 2. Gingivai rei\=sslon in Fig 3b Twelve-month healing of the treofed recessions.
the maxilla affects both first premolors. both canines, both lot-
sral incisors, and ieft central incisor There is a very narrow
band of keratinized tissue on both conines and both lateral
incisors and a very thin periodontium.

Fig 3c Right lateral view of the treated recessions dfter ¡2 Fig 3d ieff laferal view of the treoted recessions dfter 12
monthsaf heaiing. Large amount of keratinized tissue ond very months of healing. Note that 4 teeth were treated during the
high percentage of root coverage ore evident even though same surgicol procedure.
fhe recessions were Miiler Class III.

the internotionoi Journal of Periodontics S Restorative Dentistry

 203

recessions (Figs 2a, 2h, and 3a), Preparation of the donor site buccal aspect ot the graft. Both
situations in which very early suture needles are then taken
healing is needed tor esthetic The second step is to harvest a bockward through the tunnel to
demands, or a need to reduoe CTG from the paiatal mucosa a position close to the initial
ttie number of surgical interven- that is long enough to cover the puncture sites, so that the distal
tions. whole tunnei area. This graft is needle returns to the distal end
procured in the conventional of the tunnei and the mesial
way," The donor tissue area needle returns to the mesial
Preparation of the recipient bed usually extends from fhe distal ospect of the tunnel through 2
aspect of the canine to the new bite points (Fig 1 d). When
A tunnel under the b u c c a l most distal aspect of the tub- the graft is held by the suture
aspect of the gingival tissue is erosity, sometimes even involv- material, it can be pushed
first c r e a t e d . Similar to any ing the buccol ospect of the inside the tunnei through the
tuberosity,'^ Since the amount most central recession, insertion
other graft, a sulcular partial-
of donor tissue needed tor this is facilitated by pushing with a
thickness incision is made
dull instrument (4ÍÍ-4L curette or
through each recession area, procedure may become quite
dissector) ond pulling at the
undermining the tissue far be- large, familiarity with the an-
same time, wifh the help ot an
yond the mucogingival junc- atomic limitations of the palate
ossistant, on both sutures at
tion (MGJ) so that there is and the location ot the greoter
each end. In this way the graft
enough relaxation ot this pedi- palatine neurovascular bundie gently slides under the tunnel. It
cle flap to allow the entrance is recommended.'-' the tlap has been adequately
of the CTG underneath. The elevated, it can be positioned
partial dissection is then ex- corona! to the CEJ (Fig 2e). A
tended laterally through the Suturing simple square knot will secure
papillae between the treated the groft in its desired position
teeth without severing them The most difficuit part of this (Fig 2f), Mild compression with a
(Fig la). This incision must also procedure is sliding the graft sterile gouze wifh saline is rec-
be extended 3 to 5 mm mesial through the tunnel,To overcome ommended for 5 minutes be-
and distal from the lateral this difficulty 2 sutures are first fore completing the surgical
teeth to allow spoce for the placed, 1 at the most mesial procedure.
seating of the mesial and distal and ttie other at the most distal
aspects of the CTG. Great care aspect of the tunnel (Figs 1b
should be taken when going and l c ) . The needles poss
through ttie MGJ to avoid per- underneath fhe tunnel and exit Postoperative instructions and
foration of the flap; the large through the largest or most cen- heaiing
convexities in this area of the tral gingival recession, the one
maxilla make perforation o through which the grafting tis- The patient is instructed not to
danger, since most surgical sue wiil be introduced implement any oral hygiene
instrumenis are straight in With these 2 sutijres already procedures that may disturb the
shape. The other difficulty is inside the tunnel, the graft is bit- surgical areo during the first
establishing the same plane ten on both ends with vertical postoperotive week. A 0.12%
of dissection under the whole mattress sutures. The entrance chlorhexidine rinse is prescribed
flap to create a regulariy ot fhese vertical mattress tor this early heaiing phase.
shaped tunnel. sutures should always be on the Sutures are removed at 7 to 8

Vpiume 19.Number2,1999
204

The foliowing outcome vari-

Evolution of the variables related to root coverage abies ore reported below: initial
with proposed surgical procedure (n = 21) vertical recession, final reces-
Baseline Final Reduction % coverage sion, reducfion of recession, and
Mean 3.38" 0.33' 3.05 91.59
root coverage expressed as the
Standard deviation 1.36 0.55 1.25 13.95 percent reduction of the reces-
Mode 2 (8 cases) 0(14 cases) 2 ¡8 cases) 100 ¡14 cases) sion. The descriptive statistics
Range 2-6 0-2 1.5-6 50-100 were based on colculotions for
'Kolmogorov-Smirnov t e i i = 1.0514, P = 2189; paired r test = -11.14, P = 0.0001. the mean, stondord deviation
(SD), mode, ronge, and fre-
quency distribution of fhe ob-
served values, Comparafive
analysis of the recessions before
and 1 year after treatment was
performed using the Student's f
test for paired data, after the
appliootion ossumptions had
been checked.

Results
doys. Since no externai incisions that were treoted with this pro-
are visibie on the surgicai area, cedure are exemplified by the 2 Tabie 1 shows the evolution of
heaiing of the buccal fiop is cose reports presented. In case the outcome variables mea-
achieved at a very early stoge 1 the recessions were caused by sured with the proposed surgi-
without any visibie surgical signs energetic tooth brushing (Fig 2). ooi technique. Before fherapy
by the end of fhe second post- Case 2 had a thin periodontium the mean vertical recession in
operative week. combined with tooth molposi- the 21 treated teeth was 3,4
tloning. This patient also hod an mm (SD 1,36): the most fre-
open bite, CEJ discrepancy, and quent recession was 2 mm (8
Case reports a narrow band of keratinized tis- teeth). Ten ot the treated teeth
sue (Fig 3a), had an initiai recession > 4 mm
Patients (47,6%) and eieven teeth had
recessions that ranged trom 2
Patients selected for this proce- Data analysis to 3 mm (52.4%). Of the 21
dure presented muitipie adjo- recessions, 19 couid be consid-
cent buccai recessions in the Ciinical measurements of the ered Miller Ciass 1 or II, and 2
anterior maxilia and demanded distance from the gingival mar- were Class III os a result of tooth
a grafting procedure for cos- gin to the CEJ were recorded to molposition.
metic reasons. The types of the nearest miiiimefer with a thin One year after the pro-
recessions treated ranged from manual periodontol probe (Hu- posed surgicai procedure, there
shallow (2 mm) to deep (6 mm), Friedy) immediateiy prior to the was o mean reduction of reces-
but in all cases they were wide surgicai procedure and 1 year sion of 3 mm (SD 1,5), which rep-
(Figs 2a, 2h, and 3a),Tt^e patients after the surgical procedure. resenfs a mean root coverage

The International Journai ot Periodontics & Restorative Dentistry

 205

of 91.6%, These differences ore color mafching is very homoge- coverage was cbfained even
highly sfafisfically significanf (P = neous and no surgical incisions fhough foofh malposifion and
0,0001) (Tabie 1), Affer 12 monfhs or suture mari<s are visible. CEJ discrepancies were pre-
only 1 of fhe recessions (A.8%) The only disadvantage fo sent. According fo Miiler's crife-
manfained a residuai recession fhis fechnique when compared ria, since Class III recessions are
of 2 mm, whiie fhe recessions of fo other aufograft procedures is a resuif of fhese discrepancies
fhe remaining 20 freafed feefh the long recipient bed prepara- fhey are less prone fo full roof
were < 1 mm (95,2%), There was tion time. Technical difficulties coverage, Neverfheless, a high
a reducfion of 1 fo 2 mm in 9 include avoiding flap perfora- percenfage of roof coverage
teeth (42,9%) and of 3 mm or fion once fhe dissecfion goes and a large bond of kerafinized
more in 12 feefh (57,1%). For 1 beyond fhe MGJ, establishing fissue was achieved in fhis
footh 50% coverage was fhe same piane of dissecfion pafienf. The only recession fhaf
achieved, ó teeth (28,6%) had under a iarge pedicie fiap, ond achieved only 50% coverage
between 75% and 90% cover- avoiding severance of fhe bose was a mandibuiar premolar in
age, and 14 teeth (60.7%) had pafienf 2, This may be becouse
of fhe papilla of fhe same fime.
100% root coverage af ttie end of fhe necessffy of exfra sufures
This requires o large amounf of
of freafmenf. on the graff material to hold it
skill and pafience. As surgicai
up during heoling and to com-
insfrumenfs become smailer, fhis
pensafe for gravify if fhe funnel
preporafion fime wili gef shorfer. is foo deep compared fo fhe
Discussion Therefore, microsurgicai in- widfh of fhe gratfing fissue.
sfrumenfs are highly recom-
Mosf of fhe soff fissue graffing mended. The nafure and qualify of
surgical fechniques previously The sufuring fechnique pro- fhe affachmenf of fhe frans-
described in fhe iiterafure have posed mighf be confusing af pianfed fissue on fhe roof sur-
freated 1 or 2 gingival reces- firsf because of fhe presence ot face is nof weii known. One
sions in the same procedure,This foo many iarge sufure fails in fhe concern abouf fhe use of CTGs
tunnel subepitheiial aufogratf surgical area. To avoid fhis prob- over large gingival recessions
has fhe capabilify of freafing lem, fhe use of 2 differenf sufure such as fhose freafed in fhis
severai adjacenf gingival reces- colors is suggesfed. Bofh sufures reporf is fhe possible creafion of
sions in the same surgicci ap- musf be monofilamenf fo avoid a resorpfion process on fhe
poinfmenf. fearing the pedicle flap when freafed roof surface. This con-
fhe sufures are pulied fo siide cern arises from regenerafion
The advanfages of fhis fech-
the graff fissues under it sfudies fhaf describe roof re-
nique are fhose demonstrated
sorpfion affer infimafe confacf
by CTGs and those offered by The clinical resulfs obfained
befween living connecfive fis-
the envelope technique, wifh are comparabie fo resuifs from
sue and a denuded root sur-
fhe specific advanfage of early pubiished reporfs using similar
face in fhe absence of ofher
inifial healing since no exfernal surgicai procedures. In fhe firsf
cellular comporfmenfs. We
incisions are made on fhe surgi- pafient oniy 1 of fhe 6 freafed have nof seen any such occur-
cal site. Because of fhis fasf feefh had a residuai 1 mm re- rence in our pafienf populafion.
healing, the procedure is highly cession affer 12 monfhs. Be- On fhe ofher hand, Pasquinelli'''
recommended in patients who cause fhe pafienf was a heavy described fhe hisfoiogic
need fo be back fo public life smoker (20 cigareffes a day), achievemenf of new aftach-
as soon as possible. Two weeks fhe resuifs were very safisfacfory ment on a gingival recession
after the surgicai treatmenf fhe In pafienf 2 over 95% roof

Volume 19, Number 2.1999

206

that wqs treated with a CTG References 8. Perez A. injerto submucoso iibre de
encía: Una nueva perspectiva. Boi
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1. Miiler PD. Root coverage using ttie
reasons. He showed the forma- free tissue o u t o g r o f t citric a c i d 9. Roetzke PB. Covering localised areos
tion of new cementum and application, lil. A suocessfui and pre- of (oot exposure employing the
fibrous attachment apparatus dicfable prooedure in deep-wide "enveiope" technique. J Periodontol
under the grafted tissue. There is recession. Int J Periodontics 1985:58:397-402,
Restorative Dent 1985:5(2):15-37.
not currently enough informa- !0. Alien A. Use of the suproperiosteal
2. Romanos GE, Bernimoulin JR envelope in soft tissue grafting for
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PedOdontol 1993,04:683-688.
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3 i-iarris RJ, Harris AW. The coronally posi- sue graft from ttie paiafe. inf J
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i 3. Reiser GM. Bruno Jf, Mohan PE, Larkin
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Cattabriga A, Cattabriga M. Sub- 14. Pasquinelii KL The histoiogy of new
pedicie connective tissue graft versus ataoi^ment utiiizing a fhick oufoge-
free gingival graft in the coverage of nous saft tissue graft in an area of
exposed roof surfaces. A 5-year clini- deep recession: A case repart. Int J
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Guided tissue regeneration versus
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199ó;67:l,216-1,223

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