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
buccai flap; fhese may refard
the early esfhefic resuif. To avoid
fhese incisions on fhe recipienf
site, fhe enveiope fechnique
was advocafed,^"'° The advan-
fage cf fhis procedure is fhe fasf
early heaiing fhaf resulfs from
fhe absence of fhese exfernal
incisions,
Mosf of fhese surgical pro-
cedures have been advocaf-
ed and clinical results have
been reporfed in the literafure
for the treatmenf of isolafed
gingivai recessions. For fhe
treotmenf of muifipie adjacenf
gingival recessicns, however,
very seidom have procedures
been presenfed and their clini-
cal oufcomes reported. There-
fore, the purpose of fhis clinical
reporf was fc show the prelimi-
nary resulfs obtained w\fU a
The Internotionai Journai of Periodontics & Restorative Dentistry
modificafion of fhe CTG and
envelope techniques for fhe
freafmenf of muifipie adjacenf
gingivai recessions in fhe anfe-
rior areas of the moufh.
Procedure
This surgicai procedure involves
a CTG piaced in a mulfienve-
lope recipienf bed (funnei). This
tunnel is made of a suprape-
riosfeoi bed under a pedicle
flap wifhouf any exfernal inci-
sions, A CTG is fhen piaced and
secured fhrough fhis funnel,
covering fhe adjacenf exposed
roofs. The surgical procedure is
shown in Fig 1, A sfep-by-sfep
descripfion of fhe proposed sur-
gical procedure is exemplified
by fhe case reporfs presenfed.
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.
Pafienf 1 is shown in Fig 2 and
patient 2 is shown in Fig 3,
The mosf common indica-
tions for CTGs are esfhefic
demands from fhe pafienfs,
Miiler Ciass I and li recession,
denfai hypersensifivify because
of exposed cemenfoenamel
juncfion (CEJ), and fhe neces-
sity fo augmenf a narrow band
of keratinized gingival fissue. The
relaflve confraindicafions fhaf
may iimif fhe resulfs of fhe con-
necfive fissue aufograft are
heavy smoking, impaired heai-
ing response from the pafienf,
Miiler Ciass III or IV recession, or
the exisfence cf an exfremely
thin periodonfium fhaf wouid
Iimif the amounf of donor fissue.
The specific indicafions for surgi-
cai infervenfion wifh fhe funnel
CTG include muifipie adjocent

Fig 2a Severe gingival reaes^on on
maxiiiary left lateral inaisar, canine, and
premaiar in patient 1.
Fig 2d Danar tissue is placed aver the
treatment area to ensure that there is
enough tissue (also see Figs ¡b and Ic).
Fig 2g Tweive-manth healing af fhe
treated recessions.
L,
Fig 2b Preserved papiiiae are raised
ivjfh a partial-thickness inci^on (also see
Fig la)
Fig 2e Graft held by both sutures is
ready to slide through the tunnel by
means of a pull an bath sutures
(mesially and distdliy) and the help af a
dull instrument (olsa see Fig Id).
Fig2h Right side af the maxiila in
patient i shows wiae recession invoiving
central and laterai incisors and cdnine.
201
Fig 2c Tunnei is created beyond the
MGJ underneath the papillae of the
treated teeth (alsa see Fig io).
Fig2f Affer sliding It through fhe tun-
nel, graft is sutured w:th 2 square knots.
Fig 2i Tweive-month healing of the
treated recessions on the right side Of
the maxiiia in pdtient 1.
Volume 19. Number 2,1999
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


recessions (Figs 2a, 2h, and 3a),
situations in which very early
healing is needed tor esthetic
demands, or a need to reduoe
ttie number of surgical interven-
tions.
Preparation of the recipient bed
A tunnel under the b u c c a l
aspect of the gingival tissue is
first c r e a t e d . Similar to any
other graft, a sulcular partial-
thickness incision is made
through each recession area,
undermining the tissue far be-
yond the mucogingival junc-
tion (MGJ) so that there is
enough relaxation ot this pedi-
cle flap to allow the entrance
of the CTG underneath. The
partial dissection is then ex-
tended laterally through the
papillae between the treated
teeth without severing them
(Fig la). This incision must also
be extended 3 to 5 mm mesial
and distal from the lateral
teeth to allow spoce for the
seating of the mesial and distal
aspects of the CTG. Great care
should be taken when going
through ttie MGJ to avoid per-
foration of the flap; the large
convexities in this area of the
maxilla make perforation o
danger, since most surgical
instrumenis are straight in
shape. The other difficulty is
establishing the same plane
of dissection under the whole
flap to create a regulariy
shaped tunnel.
Preparation of the donor site
The second step is to harvest a
CTG from the paiatal mucosa
that is long enough to cover the
whole tunnei area. This graft is
procured in the conventional
way," The donor tissue area
usually extends from fhe distal
aspect of the canine to the
most distal aspect of the tub-
erosity, sometimes even involv-
ing the buccol ospect of the
tuberosity,'^ Since the amount
of donor tissue needed tor this
procedure may become quite
large, familiarity with the an-
atomic limitations of the palate
and the location ot the greoter
palatine neurovascular bundie
is recommended.'-'
Suturing
The most difficuit part of this
procedure is sliding the graft
through the tunnel,To overcome
this difficulty 2 sutures are first
placed, 1 at the most mesial
and ttie other at the most distal
aspect of the tunnel (Figs 1b
and l c ) . The needles poss
underneath fhe tunnel and exit
through the largest or most cen-
tral gingival recession, the one
through which the grafting tis-
sue wiil be introduced
With these 2 sutijres already
inside the tunnel, the graft is bit-
ten on both ends with vertical
mattress sutures. The entrance
ot fhese vertical mattress
sutures should always be on the
203
buccal aspect ot the graft. Both
suture needles are then taken
bockward through the tunnel to
a position close to the initial
puncture sites, so that the distal
needle returns to the distal end
of the tunnei and the mesial
needle returns to the mesial
ospect of the tunnel through 2
new bite points (Fig 1 d). When
the graft is held by the suture
material, it can be pushed
inside the tunnei through the
most central recession, insertion
is facilitated by pushing with a
dull instrument (4ÍÍ-4L curette or
dissector) ond pulling at the
same time, wifh the help ot an
ossistant, on both sutures at
each end. In this way the graft
gently slides under the tunnel. It
the tlap has been adequately
elevated, it can be positioned
corona! to the CEJ (Fig 2e). A
simple square knot will secure
the groft in its desired position
(Fig 2f), Mild compression with a
sterile gouze wifh saline is rec-
ommended for 5 minutes be-
fore completing the surgical
procedure.
Postoperative instructions and
heaiing
The patient is instructed not to
implement any oral hygiene
procedures that may disturb the
surgical areo during the first
postoperotive week. A 0.12%
chlorhexidine rinse is prescribed
tor this early heaiing phase.
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.

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

The International Journai ot Periodontics & Restorative Dentistry


of 91.6%, These differences ore
highly sfafisfically significanf (P =
0,0001) (Tabie 1), Affer 12 monfhs
only 1 of fhe recessions (A.8%)
manfained a residuai recession
of 2 mm, whiie fhe recessions of
fhe remaining 20 freafed feefh
were < 1 mm (95,2%), There was
a reducfion of 1 fo 2 mm in 9
teeth (42,9%) and of 3 mm or
more in 12 feefh (57,1%). For 1
footh 50% coverage was
achieved, ó teeth (28,6%) had
between 75% and 90% cover-
age, and 14 teeth (60.7%) had
100% root coverage af ttie end
of freafmenf.
Discussion
Mosf of fhe soff fissue graffing
surgical fechniques previously
described in fhe iiterafure have
freated 1 or 2 gingival reces-
sions in the same procedure,This
tunnel subepitheiial aufogratf
has fhe capabilify of freafing
severai adjacenf gingival reces-
sions in the same surgicci ap-
poinfmenf.
The advanfages of fhis fech-
nique are fhose demonstrated
by CTGs and those offered by
the envelope technique, wifh
fhe specific advanfage of early
inifial healing since no exfernal
incisions are made on fhe surgi-
cal site. Because of fhis fasf
healing, the procedure is highly
recommended in patients who
need fo be back fo public life
as soon as possible. Two weeks
after the surgicai treatmenf fhe
color mafching is very homoge-
neous and no surgical incisions
or suture mari<s are visible.
The only disadvantage fo
fhis fechnique when compared
fo other aufograft procedures is
the long recipient bed prepara-
tion time. Technical difficulties
include avoiding flap perfora-
fion once fhe dissecfion goes
beyond fhe MGJ, establishing
fhe same piane of dissecfion
under a iarge pedicie fiap, ond
avoiding severance of fhe bose
of fhe papilla of fhe same fime.
This requires o large amounf of
skill and pafience. As surgicai
insfrumenfs become smailer, fhis
preporafion fime wili gef shorfer.
Therefore, microsurgicai in-
sfrumenfs are highly recom-
mended.
The sufuring fechnique pro-
posed mighf be confusing af
firsf because of fhe presence ot
foo many iarge sufure fails in fhe
surgical area. To avoid fhis prob-
lem, fhe use of 2 differenf sufure
colors is suggesfed. Bofh sufures
musf be monofilamenf fo avoid
fearing the pedicle flap when
fhe sufures are pulied fo siide
the graff fissues under it
The clinical resulfs obfained
are comparabie fo resuifs from
pubiished reporfs using similar
surgicai procedures. In fhe firsf
pafient oniy 1 of fhe 6 freafed
feefh had a residuai 1 mm re-
cession affer 12 monfhs. Be-
cause fhe pafienf was a heavy
smoker (20 cigareffes a day),
fhe resuifs were very safisfacfory
In pafienf 2 over 95% roof
205
coverage was cbfained even
fhough foofh malposifion and
CEJ discrepancies were pre-
sent. According fo Miiler's crife-
ria, since Class III recessions are
a resuif of fhese discrepancies
fhey are less prone fo full roof
coverage, Neverfheless, a high
percenfage of roof coverage
and a large bond of kerafinized
fissue was achieved in fhis
pafienf. The only recession fhaf
achieved only 50% coverage
was a mandibuiar premolar in
pafienf 2, This may be becouse
of fhe necessffy of exfra sufures
on the graff material to hold it
up during heoling and to com-
pensafe for gravify if fhe funnel
is foo deep compared fo fhe
widfh of fhe gratfing fissue.
The nafure and qualify of
fhe affachmenf of fhe frans-
pianfed fissue on fhe roof sur-
face is nof weii known. One
concern abouf fhe use of CTGs
over large gingival recessions
such as fhose freafed in fhis
reporf is fhe possible creafion of
a resorpfion process on fhe
freafed roof surface. This con-
cern arises from regenerafion
sfudies fhaf describe roof re-
sorpfion affer infimafe confacf
befween living connecfive fis-
sue and a denuded root sur-
face in fhe absence of ofher
cellular comporfmenfs. We
have nof seen any such occur-
rence in our pafienf populafion.
On fhe ofher hand, Pasquinelli'''
described fhe hisfoiogic
achievemenf of new aftach-
ment on a gingival recession
Volume 19, Number 2.1999
206
that wqs treated with a CTG
after extraction for orthodontic
reasons. He showed the forma-
tion of new cementum and
fibrous attachment apparatus
under the grafted tissue. There is
not currently enough informa-
tion about which conditions
modulate the heaiing pattern;
therefore, more research is
needed in this area.
This study suggests that the
use of the proposed surgicai
technique oiiows the treatment
of muitiple adjocent recessions
in a single surgical procedure
with adequate early healing
and highiy predictabie root
coverage results.
Tiie International Journai of Periodontics & Restorative Denfisfry
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