Q U I N T E S S E N C E I N T E R N AT I O N A L
PERIODONTOLOGY
Treatment of multiple adjacent maxillary Miller Class I,
II, and III gingival recessions with the modified
coronally advanced tunnel, enamel matrix derivative,
and subepithelial connective tissue graft:
A report of 12 cases
Anton Sculean, Prof, Dr Med Dent, MS, Dr hc 1/Raluca Cosgarea, Dr Med Dent2/Alexandra Stähli, Dr Med Dent 3/
Christos Katsaros, Prof, Dr Med Dent, PhD 4/Nicole Birgit Arweiler, Prof Dr Med Dent5/Richard John Miron, DMD,
Dr Med Dent, MS, PhD6/Herbert Deppe, Prof, Dr Med Dent7
Objective: To clinically evaluate the healing of multiple
adjacent maxillary Miller Class I, II, and III gingival recessions
(MAGR) treated with the modified coronally advanced tunnel
(MCAT) in conjunction with an enamel matrix derivative (EMD)
and subepithelial connective tissue graft (SCTG). Method and
Materials: Twelve systemically healthy patients (6 females)
with a total of 54 adjacent maxillary Miller Class I, II, or III
MAGR were consecutively treated with MCAT in conjunction
with EMD and SCTG. Out of the 54 recessions, 44 were clas-
sified as Miller Class I, five as Miller Class II, and five as Miller
Class III. Patients were included in the study if they present-
ed at least two adjacent recessions with a depth of ≥ 3 mm.
Measurements were made at baseline (immediately before
reconstructive surgery) and at 12 months postoperatively. The
primary outcome variable was complete root coverage (CRC)
Key words: enamel matrix derivative; modified coronally advanced tunnel; multiple adjacent maxillary Miller Class I,
II, and III recessions; root coverage; subepithelial connective tissue graft
1 Professor and Chairman, Department of Periodontology, School of Dental Med-
icine, University of Bern, Bern, Switzerland.
2 Assistant Professor, Department of Periodontology, Philipps University Marburg,
Germany; and Department of Prosthodontics, University Iuliu Hatieganu, Cluj
Napoca, Romania.
3 Postgraduate Student, Department of Periodontology, School of Dental Medi-
cine, University of Bern, Bern, Switzerland.
4 Professor and Chairman, Department of Orthodontics and Dentofacial Orthope-
dics, School of Dental Medicine, University of Bern, Bern, Switzerland.
VOLUME 47 • NUMBER 8 • SEPTEMBER 2016
Anton Sculean
(ie, 100% root coverage). Results: Healing was uneventful
in all cases without any complications such as postoperative
bleeding, allergic reactions, abscesses, or loss of SCTG. At 12
months, statistically highly significant (P < .0001) root cov-
erage was obtained in all patients and recessions. CRC was
obtained in 37 Miller Class I, three Miller Class II, and one
Miller Class III recessions, respectively. Mean root coverage
was 96%. Mean keratinized tissue width increased statistically
highly significantly (P < .004) from 2.04 ± 0.95 mm at baseline
to 2.37 ± 0.89 mm at 12 months. Conclusion: The present
findings indicate that the proposed treatment concept results
in predictable coverage of multiple adjacent maxillary Miller
Class I, II, and III MAGR. (Quintessence Int 2016;47:653–659;
doi: 10.3290/j.qi.a36562)
5 Professor and Chairman, Department of Periodontology, Department of Peri-
odontology, Philipps University Marburg, Marburg, Germany.
6
Assistant Professor, Department of Periodontology, College of Dental Medicine,
Nova Southeastern University, Fort Lauderdale, Florida, USA.
7 Professor, Department of Oral and Maxillofacial Surgery, Technische Universität,
Munich, Germany.
Correspondence: Professor Dr Anton Sculean, Department of Peri-
odontology, School of Dental Medicine, University of Bern, Freiburg-
strasse 7, 3010 Bern, Switzerland. Email: anton.sculean@zmk.unibe.ch
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Sculean et al
Predictable coverage of multiple adjacent gingival
recessions (MAGR) still represents one of the most chal-
lenging situations in plastic esthetic periodontal surgery.
This is mainly due to several factors such as anatomy
and position of the teeth and of the vestibule, depth and
width of the recessions, large avascular surface, limited
blood supply, and pull of frenula or muscles, which may
limit flap management thus impairing the outcomes.1,2
Systematic reviews evaluating the results obtained
with various surgical techniques in the treatment of
MAGR have shown that the modified coronally
advanced flap (MCAF) with and without soft tissue
grafting and the modified coronally advanced tunnel
(MCAT) using soft tissue grafting are predictable tech-
niques for the treatment of Miller Class I and II MAGR.1,2
The MCAT consists of preparation of a full thickness
flap without using vertical releasing incisions and inci-
sions in the area of the papillae to improve vasculariza-
tion and wound stability.3-7
Due to the coronal displacement of the tunneled
flap, the recessions and the soft tissue graft are com-
pletely covered, thus optimizing graft survival, reces-
sion coverage, and tissue blending. When used in com-
bination with subepithelial connective tissue grafts
(SCTG) or other types of soft tissue replacement grafts,
MCAT has been shown to result in predictable cover-
age of Miller Class I, II, and III MAGR.3-7
From a biologic point of view, plastic esthetic pro-
cedures should not only aim for complete restoration
of the lost soft tissue architecture but also to regener-
ate the tooth’s supporting tissues, including periodon-
tal ligament, root cementum, and alveolar bone.8
Scientific evidence from the last 20 years has
demonstrated that an enamel matrix derivative (EMD)
strongly influences the behavior of many cell types by
mediating cell attachment, spreading, proliferation,
differentiation, and survival, as well as expression of
transcription factors, growth factors, cytokines, extra-
cellular matrix constituents, and other molecules
involved in tissue regeneration.9
Histologic findings in animals and humans have pro-
vided evidence for periodontal regeneration (ie, formation
of cementum, periodontal ligament, and bone) following
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treatment of recession-type defects using a coronally
advanced flap (CAF) with EMD or EMD and SCTG.8
Since EMD has been shown to play a significant role
in wound healing favoring soft tissue regeneration and
angiogenic activity, it can be anticipated that combin-
ing EMD with SCTG may positively influence periodon-
tal wound healing/regeneration, which in turn would
additionally improve the clinical outcomes.10
Several controlled clinical studies have investigated
the use of EMD in treating buccal Miller class I and II
gingival recessions in conjunction with a coronally
advanced flap (CAF). In most studies, the additional
application of EMD in conjunction with CAF resulted in
increased keratinized tissue and more stable clinical
outcomes compared to CAF alone, thus pointing to the
clinical relevance of this approach.8,9
Moreover, clinical studies comparing treatment of
single and multiple gingival recessions with either CAF
combined with EMD and SCTG or CAF and SCTG have
shown a tendency for more favorable outcomes in
terms of complete root coverage (CRC) following the
additional use of EMD.11,12
These findings are in line with recent data from a
case series evaluating the outcomes following treat-
ment of isolated mandibular Miller Class I and II gingi-
val recessions using the MCAT combined with EMD and
SCTG which have demonstrated CRC in 75% of cases
and a mean root coverage (MRC) of 96.25%, thus pro-
viding additional support for this treatment concept.4
Despite the fact that the MCAT appears to be a very
promising modality for the treatment of MAGR, data
evaluating the outcomes following the use of this tech-
nique in conjunction with EMD and SCTG are still lim-
ited. Therefore, the aim of this consecutive case series
was to clinically evaluate the healing of Miller Class I, II,
and III MAGR following treatment with MCAT in con-
junction with EMD and SCTG.
METHOD AND MATERIALS
Subject selection
Twelve systemically healthy, nonsmoker patients (6
women, aged from 22 to 54 years, mean age 25 years)
VOLUME 47 • NUMBER 8 • SEPTEMBER 2016

Fig 1 Baseline view of Miller class I MAGR located in the second
quadrant. Please note the gingival inflammation due to difficulties
in performing optimal plaque control measures.
Fig 3 Baseline view of Miller class I MAGR located in the first
quadrant.
with a total of 54 adjacent maxillary Miller Class I, II, or
III MAGR were included in the present prospective
cases series study (Figs 1 to 3). Inclusion criteria were
the presence of at least two adjacent recessions of a
depth of ≥ 3 mm and an adequate level of oral hygiene
evidenced by a full-mouth plaque score (FMPS) < 25%13
and full-mouth bleeding score (FMBS) < 25%.14 Written
informed consent was obtained from all patients.
Measurements were made at baseline (immediately
before reconstructive surgery) and at 12 months post-
operatively. The primary outcome variable was CRC (eg,
100% root coverage).
After having completed preliminary professional
tooth cleaning and having received individual oral
hygiene instructions, patients were consecutively
treated with MCAT in conjunction with EMD and SCTG.
Out of the 54 recessions, 44 were classified as Miller
Class I, five as Miller Class II, and five as Miller Class III.
VOLUME 47 • NUMBER 8 • SEPTEMBER 2016
Q U I N T E S S E N C E I N T E R N AT I O N A L
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Fig 2 Baseline view of Miller class I MAGR located in the second
quadrant.
Fig 4 Prepared tunnel (case depicted in Fig 1).
Surgical approach
All surgeries were performed by the same periodontist
with extensive experience in reconstructive and plastic
esthetic periodontal surgery (AS) using the MCAT as
described previously.3,4
Briefly, following local anesthesia, gentle root plan-
ing of the exposed root surfaces was performed by
means of Gracey curettes (Stoma). Intrasulcular inci-
sions at the treated teeth were placed using microsur-
gical blades (Key Dent, Micro Blades) and extended one
tooth mesially or distally if needed. Using specially
designed tunneling knives (Stoma), a full-thickness flap
was raised and prepared beyond the level of the
mucogingival junction leaving the interdental papillae
intact (Fig 4). The mucoperiosteal pouch was then care-
fully extended mesially and distally under the neigh-
boring papillae until the adjacent recessions were con-
nected. Subsequently, attaching muscles and inserting
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Sculean et al
Fig 5 Harvested connective tissue for the case shown in Fig 1.
Fig 6 The tunneled flap was advanced coronally to completely
cover the SCTG and the recessions and secured with sling sutures
(case depicted in Fig 1).
collagen fibers were removed from the inner aspect of
the tunneled flap (ie, connected pouches) using 15c
surgical and microsurgical blades (Key Dent, Micro
Blades) and Gracey curettes (Stoma,) until tension-free
coronal mobilization was obtained. If needed, the inter-
dental parts of the papillae were also gently under-
mined using the specially designed tunneling knife
(Sculean-Aroca, Stoma). Special attention was paid not
to disrupt the interdental papillary tissues and to avoid
flap perforation.
After tunnel preparation, a palatal SCTG of a thick-
ness of 1 to 1.5 mm was harvested by using the single
incision technique (Fig 5). Immediately after harvesting,
the SCTG was soaked for 5 to 10 minutes into EMD
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(Emdogain, Straumann) while the donor site was closed
with a modified mattress suture (5-0 Seralon, Serag-Wi-
essner).
Subsequently, the exposed root surfaces were con-
ditioned for 2 minutes with 24% ethylenediaminetetra-
acetic acid (EDTA; PrefGel, Straumann) to remove the
smear layer. The EDTA residues were removed from the
root surfaces and from the tunnel by copious irrigation
with sterile saline. Immediately after rinsing, the
exposed root surfaces were dried using sterile gauze
and EMD was applied onto the exposed root surfaces
and under the tunnel flap by means of a sterile syringe.
Care was taken to avoid blood contamination of the
root surfaces at the time of EMD application to improve
adsorption.15
Immediately after EMD application, the SCTG was
pulled in the tunnel by means of single or mattress
sutures and fixed at the inner aspect of the tunnel flap.
Subsequently, the graft was immobilized at the
cementoenamel junction or slightly below by means of
a sling suture (6-0 Seralon, Serag-Wiessner) in order to
obtain complete stability. Finally, the tunnel flap was
advanced coronally to completely cover the graft and
the recession using sling sutures (Fig 6).
Postsurgically, patients were given analgesics (2 ×
500 mg/day mefenamic acid; Mephadolor, Mepha
Pharma) for 2 to 3 days and antibiotics (2 × 1,000 mg
amoxicillin and clavulanic acid; Augmentin, Glaxo
Smith Kline) for 7 days to prevent infection. Patients
were not allowed to brush the surgical sites for 14 days
postoperatively. Patients were advised to use a 0.1%
chlorhexidine-digluconate mouthrinse solution (Chlor-
hexamed, GlaxoSmithKline) twice a day for 1 minute
during the first 21 days postsurgery. Patients resumed
tooth brushing 14 days after surgery. The palatal
sutures were removed 7 days after surgery, while those
from the recession were removed 14 to 21 days postop-
eratively. At that time point, patients were instructed in
mechanical tooth cleaning of the surgical sites using an
ultrasoft manual toothbrush (TePe Special Care) using
the roll technique, gradually returning to the regular
oral hygiene habits at 1 month postsurgery. Recall
appointments including professional supragingival
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tooth cleaning and individually designed oral hygiene

instructions were scheduled at 1, 3, 6, and 12 months Table 1 Descriptive results and significance at 12
months compared to baseline (Wilcoxon
postoperatively. signed ranks test)

Parameters Mean ± SD (mm) Min (mm) Max (mm) P value

Clinical assessments
RH bas 3.23 ± 1.04 1.75 5.31
The following clinical parameters were assessed at
RH 12 mo 0.16 ± 0.36 0.00 1.29 .002*
baseline and at 12 months postoperatively: FMPS,
RC 3.07 ± 0.86 1.54 4.02 .005*
FMBS, probing depths (PD), clinical attachment level
RW bas 3.84 ± 0.69 3.00 5.31
(CAL), CRC, MRC, keratinized tissue width (KTW). RW 12 mo 0.60 ± 1.02 0.00 3.27 .002*
RW gain 3.24 ± 1.19 0.97 4.70 .015*
Statistical analysis AG bas 2.91 ± 1.12 0.91 5.31
Statistical analysis was performed using the commer- AG 12 mo 3.67 ± 1.12 1.35 4.99 .023*
cially available software Instats 2000 (version 3.05, Graph- AG gain 0.87 ± 0.82 0.00 2.32 .003*
Pad Software). The primary outcome variable was CRC KG bas 2.04 ± 0.95 0.32 3.68
(ie, 100% root coverage). The significance of the differ- KG 12 mo 2.37 ± 0.89 0.88 3.59 .136

ence before and after treatment was evaluated with the KG gain 0.34 ± 0.70 −0.73 1.52 .004*

Wilcoxon signed ranks test. Differences were considered *Statistically significant P < .05.
AG, attached gingiva; bas, baseline; KG, keratinized gingiva; mo, months; RC, root cov-
statistically significant when the P value was < .05. erage; RH, recession height; RW, recession width.

RESULTS On a patient level, seven out of the 12 patients

Healing was uneventful in all cases without any compli-
cations such as postoperative bleeding, allergic reac-
tions, abscesses, or loss of SCTG. At 12 months, statisti-
cally highly significant (P < .0001) root coverage was
obtained in all patients and recessions (Table 1). The
treated recessions were distributed as follows: 15 pre-
molars, 17 canines, 13 lateral incisors, and 9 central
incisors. CRC was obtained in 12 out of the 15 pre-
molars, while at the remaining three teeth, recession
coverage (RC) varied between 89% and 92%. At
canines, 13 out of the 17 defects demonstrated CRC
while at the remaining four defects RC amounted to
94.2%, 82%, 86%, and 70.29%, respectively. CRC was
obtained in 10 out of the 13 lateral incisors, while the
remaining three defects exhibited a RC of 94.89%,
85.37%, and 48.24%, respectively. In the central inci-
sors, six out of the 10 defects demonstrated CRC, while
the remaining three defects measured a RC of 82.22%,
74.87%, and 64.89%, respectively. CRC was obtained in
37 out of the 44 Miller Class I, in three out of the five
Miller Class II, and in one out of the five Miller Class III
defects (Figs 7 to 9).
(58.33%) exhibited CRC, while MRC measured 96%.
Mean KTW increased statistically highly significantly
(P < .004) from 2.04 ± 0.95 mm at baseline to
2.37 ± 0.89 mm at 12 months.
DISCUSSION
The results of the present case series have shown that
the use of MACT combined with EMD and SCTG results
in predictable root coverage of Miller Class I, II, and III
MAGR recessions. At 12 months following surgery, sta-
tistically and clinically significant root coverage was
obtained in all patients and defects. CRC was obtained
in 37 Miller Class I, three Miller Class II, and one Miller
Class III recessions, respectively. CRC was measured in
seven out of the 12 patients (58.33%) with a corre-
sponding MRC of 96%. These results compare well with
those from previous reports utilizing various modifica-
tions of the tunnel technique in combination with SCTG
for the treatment of Miller Class I and II MAGR.3,16,17
In those studies, MRC amounted to 85%,17 90%,3
and 95%.16 When compared to the present results, it

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Sculean et al
Fig 7 At 12 months following reconstructive surgery, complete
root coverage and optimal tissue blending was obtained at all
recessions (case depicted in Fig 1).
Fig 9 At 12 months, complete root coverage at all recessions is
evident (case depicted in Fig 3).
should be kept in mind that in the present study, Miller
Class III MAGR was also included, where CRC is more
difficult to obtain when compared to Miller Class I and
II MAGR. On the other hand, the finding that CRC
occurred in one out of the five Miller Class III defects is
in line with the results of a randomized controlled clin-
ical study evaluating the treatment of Miller Class III
MAGR by means of MCAT and SCTG with or without the
application of EMD.5 In that study, MRC measured 82%
in the test group (ie, MCAT + SCGT + EMD) and 83% in
the control group (ie, MCAT + SCGT) respectively, while
CRC amounted to 38% in both groups.5
One of the major advantages of MCAT is related to
the fact that this technique includes preparation of a
full-thickness pouch by avoiding vertical releasing inci-
sions. Furthermore, due to the removal of the attaching
muscles and inserting collagen fibers from the inner
658
Fig 8 At 12 months complete root coverage and an excellent
esthetic outcome are evident at all recessions (case depicted in
Fig 2).
part of the flap, a tension-free coronal mobilization can
be obtained, allowing complete coverage. It has been
previously shown that flap thickness and tension-free
flap management and adaptation are critical factors for
obtaining predictable root coverage.18,19
The statistically significant increase of mean KTW
(ie, from 2.04 ± 0.95 mm at baseline to 2.37 ± 0.89 mm
at 12 months [P < .004]) was most likely mainly due to
the use of SCTG but also, at least to a certain extent, to
the cells originating from the tooth’s periodontal liga-
ment space. This finding is in agreement with the con-
clusions of a recent review indicating that the granula-
tion tissue originating from the periodontal ligament
space or from a connective tissue originally covered by
keratinized epithelium has the potential to induce kera-
tinization.20
When interpreting the results, it should be noted
that all patients included in the present case series
demonstrated an excellent level of oral hygiene and
were nonsmokers. It has been extensively demon-
strated that smoking and/or the presence of plaque
biofilm, are factors that negatively affect the outcomes
of any type of periodontal surgery.21,22
Furthermore, the present results compare well to
those obtained with other surgical techniques such as
CAF or the envelope modification of CAF with or with-
out the use of SCTG, thus pointing to the clinical rele-
vance of MCAT for treating MAGR.1,2
The rationale of using SCTG in conjunction with
MCAT is based on the anticipated effect of the graft to
VOLUME 47 • NUMBER 8 • SEPTEMBER 2016

increase flap thickness and to serve as a scaffold that
stabilizes the blood clot, factors that substantially influ-
ence wound healing and, consequently, the clinical
outcomes.2,23,24
This view appears to be supported by previous find-
ings from a controlled clinical study which have shown
that on a long-term basis (ie, up to 5 years), the use of
SCTG in conjunction with the MCAF yielded statistically
significantly better long-term stability compared to
non-grafted ones.24
In conclusion, within their limits, the findings of the
present cases series suggest that the proposed treat-
ment concept results in predictable coverage of multi-
ple adjacent maxillary Miller Class I, II, and III MAGR.
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