CASE REPORT

Novel Surgical Approach for Root Coverage of Single Deep Recessions

on Mandibular Incisors: Gingival Pedicle With Split-Thickness Tunnel
Technique (GPST)
Michele Agusto,∗ Kerri Thomas Simpson,∗ Arif Salman∗ and Gian Pietro Schincaglia∗

Introduction: Gingival recession is a very common mucogingival defect in the adult population, with mandibular
central and lateral incisors being the most frequently affected teeth. Limited information is available about the management
of isolated deep recession lesions in the mandibular anterior area, where the predictability of the root coverage is reduced
by unfavorable anatomical conditions. The purpose of this case report is to present a novel surgical technique for deep
labial recessions on mandibular incisors, based on a gingival pedicle with split-thickness tunneling (GPST), in combination
with connective tissue graft (CTG).
Case Presentation: A 25-year-old female patient presented with a Class II Miller isolated buccal recession on
#24, 5 × 3 mm. The recipient site design consisted of a laterally positioned flap with a width of 4 mm, in combination
with a split-thickness tunnel preparation that reached the mesial line angle of #25 and extended beyond the mucogingival
junction. A CTG (13 × 7 mm) was harvested from the palate and properly adapted over the root surface. Graft and flap
were secured with internal mattress and single-interrupted sutures. Complete root coverage was obtained and maintained
at 6 months with excellent esthetic outcomes.
Conclusion: This novel surgical approach, based on the combination of laterally displaced pedicle flap and tunneling
in addition to CTG, seems to lead to promising results for the treatment of single deep mandibular anterior recessions. Clin
Adv Periodontics 2019;00:1–6.
Key Words: Connective tissue graft(s); cosmetic periodontal plastic surgery; gingival recession; mucogingival surgery.

Background
Gingival recession is defined as the apical shift of the gin-
gival margin with respect to the cemento-enamel junction
(CEJ),1 which leads to the exposure of the root surface.
This condition may promote the occurrence of dental
hypersensitivity and root alterations in the cervical area or
∗ Department of Periodontics, School of Dentistry, West Virginia
University, Morgantown, WV
Received November 16, 2018; accepted March 18, 2019
doi: 10.1002/cap.10063
may represent an esthetic issue for the patient.2 The over-
all prevalence of gingival recession in the adult population
has been reported to be >60%,3 with mandibular central
and lateral incisors being the most frequently affected
teeth (26% to 35%).4,5 The etiology of recession has
been principally associated to plaque accumulation and/or
mechanical trauma,6 but several other predisposing
factors have been suggested, such as high frenum attach-
ment, dental malposition, and thin periodontal biotype.7
Several surgical approaches have been proposed to
address buccal recessions including coronally advanced
flap (CAF), laterally positioned flap (LPF), double pedicle
flap (DPF), tunneling (TUN), and guided tissue regenera-
tion (GTR) among others.8 Although CAF in addition to

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C A S E R E P O R T
subepithelial connective tissue graft (CTG) has been indi-
cated as the gold-standard procedure for root coverage
(RC), the majority of the studies on RC mainly include
maxillary premolars, canines, and incisors.8 Recently, a
great deal of attention has been dedicated to gingival
recession on mandibular anterior teeth. Evidence has
emerged that orthodontic therapy may be a risk factor for
the integrity of the periodontal support and, in orthodon-
tically treated subjects, mandibular incisors seem to be
the most vulnerable to the development of labial gingival
recessions.9 This supports the need for finding clinical
strategies to predictably treat this type of lesion. In this
regard, a recent systematic review showed that tooth
location considerably affects the chance to achieve com-
plete RC following CAF procedure.10 In particular, it was
reported that the mean RC for the mandibular incisors
(95.7%) was less than that for the other tooth types
(97.1% to 100%).11 The surgical challenge for mucogin-
gival procedures in the mandibular anterior region is often
related to the presence of several unfavorable anatomi-
cal factors, such as limited vestibular depth, thin tissues
and papillae, prominent roots, deep bony dehiscence,
high frenum, and muscular attachments. Limited infor-
mation is available about the management of isolated
deep recession lesions in this district of the mouth: in
particular, in recent years few different approaches have
been described, such as CAF in addition to CTG and the
removal of the labial submucosal tissue (LST) 12 or the
laterally closed tunnel (LCT).13 This report introduces a
modified surgical technique for deep labial recessions on
mandibular incisors, based on the combination of LPF and
TUN, in addition to CTG (GPST, gingival pedicle with
split-thickness tunnel technique).
Clinical Presentation
A 25-year-old, healthy (ASA I, according to the American
Society of Anaesthesiologists’ classification of Physical
Health),14 female patient presented with a Class II Miller
isolated buccal recession on #24, with signs of marginal
soft tissue inflammation (Fig. 1). The patient was non-
FIGURE 1 Initial presentation.
2 Clinical Advances in Periodontics, Vol. 00, No. 0, xxx 2019
FIGURE 2 Recession depth at baseline.
smoker and had no history of periodontal disease, with
full mouth plaque and bleeding scores less than 10%.
No evidence of root caries or cervical alteration on tooth
#24 was observed. The patient had undergone a fixed
orthodontic treatment and, at the time of the first exam-
ination, a fixed lingual retainer was present from #22
to #27. The recession depth (RECdepth ), that is the dis-
tance between the cemento-enamel junction (CEJ) and
the free gingival margin, was 5 mm (Fig. 2), whereas
the recession width (RECwidth ), defined as the maxi-
mum mesio-distal measurement of the defect, amounted
to 3 mm. Clinical evaluation confirmed the absence of
interproximal attachment loss on mesial and distal of
#24. Also, no caries nor periapical radiolucency was
observed on radiographic examination. The treatment
plan included an adult prophylaxis, in addition to pro-
viding customized oral hygiene instructions, which was
performed 4 weeks before the surgery. Verbal and written
informed consent was obtained from the patient before
her enrollment in the study.
Case Management
After infiltration of local anesthesia (lidocaine 36 mg with
epinephrine 0.018 mg), the recipient bed was prepared
as follows (Fig. 3). Scaling and root planing was per-
formed with ultrasonic and hand instruments before flap
elevation. The inflamed tissue collar was removed and,
starting from the distal line angle of the CEJ, a horizontal
incision, whose length was greater than RECwidth , was
made distally, maintaining a distance of at least 1 mm
from the gingival margin of the adjacent tooth. The distal
point of the horizontal incision was connected to a ver-
tical incision which extended beyond the mucogingival
junction (MGJ) and ended with a cut-back preparation,
functional to prevent excessive tension of the flap after
its lateral displacement. A split-thickness pedicle was ele-
vated, and particular care was taken to avoid perforations
and to preserve a homogeneous thickness of the flap in its
entirety. Mesially to the recession, a split-thickness tunnel
Novel Surgical Approach for Root Coverage of Single Deep Recessions on Mandibular Incisors
 C A S E R E P O R T

FIGURE 5 CTG after harvesting.

FIGURE 3 GPST technique. Initial presentation (3a); Flap design (3b);

CTG dimensions (3c); Suturing (3d).

FIGURE 6 Adaptation of CTG over the recipient bed.

FIGURE 4 Recipient bed preparation.

was prepared: the partial dissection was extended to the

base of the interdental papilla and the soft tissues beyond
the MGJ and reached the facial aspect of #25 (Fig. 4).
A subepithelial CTG was harvested from the left side
of the palate, by using the single incision technique15 : a
horizontal split thickness incision was made from #11
to #14 ≈ 3 mm from the gingival margin and a 1.5-
mm thick graft was obtained (Fig. 5). After achieving
complete hemostasis, the donor site was dressed with
collagen† and stabilized with external crossed mattress
sutures (Monofilament Nylon 6-0‡ ) (Fig. 6). The dimen-
sion of the graft was based on at least 3 × RECwidth and
FIGURE 7 Donor site after suturing.
at least 1 × RECdepth. The graft was then adapted onto
the recipient bed (Fig. 7). First, the mesial third of the
graft was inserted under the tunnel and was secured with with two interrupted sutures. Finally, the pedicle was
an internal mattress suture. Then, the distal border of positioned mesially to passively cover the middle portion
the graft was sutured to the adjacent keratinized tissue of the graft and provide additional vascular supply in
proximity of the exposed root. Single interrupted sutures
† CollaTape Absorbable Collagen, Zimmer Biomet, Palm Beach were used to stabilize the flap and guarantee its precise
Gardens, FL. adaptation without tension (Fig. 8). Pressure with a moist
‡ Monosof clear 18’’ P-10 cutting, size 6-0, Covidien Sutures, Min- gauze was applied for 5 minutes to dissolve the blood clot
neapolis, MN. which may interfere with the plasmatic diffusion to the

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C A S E R E P O R T

FIGURE 8 Recipient site after suturing.

FIGURE 10 Healing at 1 week (donor site).

FIGURE 11 Healing at 2 weeks (recipient site).

FIGURE 9 Healing at 1 week (recipient site).

graft. The patient was instructed to avoid brushing the

area for 4 weeks and to rinse with chlorhexidine 0.12%
twice a day for 4 weeks. Sutures were removed after
2 weeks.

Clinical Outcomes
The postoperative recovery was uneventful. No pain nor
discomfort was reported after 2 weeks, and the use of
anti-inflammatory medications was limited to the first day
after surgery. Healing at 1 week, 2 weeks, 1 month, and
6 months is presented in Figs 9 through 13. Complete RC
was achieved after 4 weeks and maintained until the last
examination at 6 months (Fig. 13). Furthermore, apical
displacement of the frenum was obtained, in addition to 2
mm of keratinized tissue. Probing depth measured at the
mid-buccal site of #24 amounted to 1 mm. The patient
was highly satisfied by the esthetic appearance of the
surgical site after 4 weeks, which was regarded as perfectly
matching with the color and texture of the adjacent soft
tissues.
FIGURE 12 Healing at 1 month.
Discussion
Treatment of deep labial gingival recessions in the
mandibular anterior area represents a major clinical chal-
lenge owing to several anatomical conditions, such as high
insertion of labial frenum and muscular fibers, limited
vestibular depth, thin tissues, and lack of keratinized
mucosa.12 These factors compromise the predictability of
RC procedures, because of an increased risk for flap per-
foration and inadequate primary wound stability, as well

4 Clinical Advances in Periodontics, Vol. 00, No. 0, xxx 2019 Novel Surgical Approach for Root Coverage of Single Deep Recessions on Mandibular Incisors

FIGURE 13 Healing at 6 months.
as insufficient passivation of the flap, with high tendency
of early dehiscence. Only a limited number of surgical
approaches has been described as a practical option for
RC on mandibular anterior teeth. The use of CAF in
addition to CTG in the treatment of gingival recessions
in the mandibular incisors has shown only 48% of com-
plete RC.12 To improve this outcome, the removal of the
deep LST has been advocated by Zucchelli et al.,12 with
further concern of morbidity at the recipient site. More
recently, a modified tunnel technique, called “the laterally
closed tunnel” (LCT), was introduced by Sculean and
Allen.13 This approach is specifically designed for deep
isolated mandibular Miller Class I, II, and III recessions
and is based on the preparation of a large mucoperiosteal
pouch, whose margins are approximated to each other to
cover the CTG placed underneath. Although promising
results are shown in this case series, even when interden-
tal attachment loss is present, the authors underline the
importance of a tension-free displacement of the margins
of the tunnel. However, in some cases, the passive lateral
Agusto, Simpson, Salman, Schincaglia
C A S E R E P O R T
closure of the flap margins is limited and only a partial
coverage of the graft can be accomplished. In this clinical
scenario, the portion of the graft that is left exposed is
over the root surface of the tooth, so its vascular supply
may be compromised. To prevent necrosis, an increased
dimension of the graft to an 11:1 ratio of covered ver-
sus exposed graft is recommended.16 To deal with these
anatomical and surgical challenges, the GPST technique
presented in this report seems to be an encouraging alter-
native approach for the management of single deep labial
recessions in the mandibular anterior area, especially in
the presence of high frenum attachment and minimal
vestibular depth, where achieving a tension-free flap and
its proper adaptation may be more difficult. Indeed, the
lateral displacement of a pedicle flap provides less tension
when compared with CAF, hence reducing the chance
of flap dehiscence or mobilization and graft exposure in
close proximity of the recession defect. This risk appears
to be more significant in presence of shallow vestibule
or inserting frenula, where the coronal mobilization of
a tension-free flap is extremely difficult. Moreover, the
LPF approach results in an early more favorable esthetic
outcome, since no displacement of MGJ occurs. The com-
bination of the LPF with a tunnel preparation increases
the vascular bed available to support the CTG, and in
turn helps to stabilize the flap in its final position. With
GPST technique, the main advantage is represented by
the optimal vascularization of the CTG. Indeed, the blood
supply of the graft over the exposed root is provided
by the pedicle flap, whereas the two lateral sides derive
their nourishment from the tunnel pouch and the vascular
periosteal plexus, respectively.
Conclusions
Within the limitations of this case report, GPST technique
may provide predictable RC in isolated deep recession
treatment in the anterior mandible. Further clinical stud-
ies are necessary to confirm the efficacy of this surgical
approach.
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Summary
Why is this case new  Limited information is available about the management of isolated deep
information? labial recessions in the mandibular anterior teeth
 Novel surgical approach, called GPST technique, is described to
specifically address this type of defect

What are the keys to successful  Horizontal incision RECwidth

management of this case?  Cut-back preparation helps to mobilize the flap without tension
 CTG width 3 times RECwidth
 CTG height RECdepth
 Proper graft and flap stabilization need to be achieved

What are the primary limitations  Limited mesio-distal dimensions which do not allow to obtain a pedicle
to success in this case? with adequate horizontal width
 Very thin biotype may not be suitable because of the risk of inadequate
flap vascularization

Acknowledgments 
8. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage pro-
cedures: a systematic review from the AAP Regeneration Workshop. J
The authors report no conflicts of interest related to this Periodontol 2015;86(2 Suppl):S8-51.
case report. 
9. Renkema AM, Fudalej PS, Renkema AA, Abbas F, Bronkhorst E,
Katsaros C. Gingival labial recessions in orthodontically treated and
untreated individuals: a case - control study. J Clin Periodontol
CORRESPONDENCE 2013;40(6):631-637.
Dr. Gian Pietro Schincaglia, Department of Periodontics, P.O. Box 9490,
Morgantown, WV 265069490. Email: gian.schincaglia@hsc.wvu.edu 10. Zucchelli G, Tavelli L, Ravida A, Stefanini M, Suarez-Lopez Del Amo
F, Wang HL. Influence of tooth location on coronally advanced flap
procedures for root coverage. J Periodontol 2018;89(12):1428-1441.
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