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Received: 19 November 2020 Accepted: 2 January 2021
DOI: 10.1111/jerd.12712

CLINICAL ARTICLE

Soft tissue grafting with the tunnel technique

in the mandibular anterior: Myths and realities

Edward P. Allen DDS, PhD

Dallas, Texas, USA

Correspondence
Edward P. Allen DDS, PhD, Dallas, TX.
Email: epallen@epallendds.com
Abstract
Objective: To address the myths and realities of soft tissue grafting with the tunnel
technique in the mandibular anterior region.
Materials and Methods: Myths associated with use of the tunnel technique for soft
tissue grafting in the mandibular anterior region are identified and examined. Expla-
nations for the misunderstandings are presented and documented with case exam-
ples and evidence from scientific studies.
Results: Six myths are described and the realities are presented.
Conclusions: This report demonstrates that the tunnel technique can be successfully
used in the mandibular anterior region in the presence of anatomic features thought
to favor the use of more invasive surgical methods.
Clinical Significance: Soft tissue grafting in the mandibular anterior region has com-
plicating anatomical features including a strong frenal attachment, shallow vestibule
and thin tissue. These features may be successfully managed with a free gingival
graft, but that procedure results in an uncomfortable experience for the patient. The
tunnel technique, especially when combined with an acellular dermal matrix, dramati-
cally improves the patient experience and esthetic outcome without compromising
the clinical outcome.

KEYWORDS
periodontics, periodontics/orthodontics, periodontics/prosthodontics

1 | I N T RO DU CT I O N deepening of the vestibule in the mandibular anterior region, but it is

Soft tissue grafting has advanced over the past 75 years to become a
refined surgical procedure with predictable root coverage, enhanced
esthetics and a more pleasant experience for the patient. Develop-
ment of effective alternative graft materials has reduced the depen-
dence on the palate for donor tissue and site preparation has become
1-4
less invasive with the introduction of the tunnel technique (TUN).
Although the tunnel technique has been well received for soft tis-
sue grafting in most areas of the mouth, the free gingival graft (FGG)
is still favored for treatment of gingival recession (REC) and lack of
adequate attached gingiva in the mandibular anterior region. The FGG
has proven to be very effective in achieving a predictable gain of
attached gingiva, elimination of aberrant frenal attachments and
less predictable for covering exposed roots, has unfavorable esthetics
and results in significant discomfort associated with the palatal
donor site.
The connective tissue graft technique (CTG) provides all the ben-
efits of the FGG along with greater predictability of root coverage,
improved esthetics and a more comfortable palatal donor site. The
CTG has become the standard of care for treatment of REC in all
areas except the mandibular anterior where there are complications
associated with wound stability from the midline muscle pull and shal-
low vestibular form. Improvement in wound stability in the mandibular
anterior has been demonstrated by tunneling the midline papilla.3 In
spite of improvements in surgical recipient site design, the FGG has
remained a preference for many surgeons.

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ALLEN 153

Use of a coronally positioned tunnel has been described for treat-
ment of REC using both palatal connective tissue and alternatives to
5-8
autogenous tissue. Although TUN is commonly used to treat REC
in the maxillary arch; it is underutilized in the mandibular anterior area
due to concerns about keratinized tissue width (KTW), aberrant frenal
pull, vestibular form, deep recession, and thin mucosa. The purpose of
this report is to address the myths and realities of soft tissue grafting
with TUN in the mandibular anterior region.
2 | MYTHS
The myths associated with use of the TUN in the mandibular arch are:
1. There is minimal gain of KTW with the TUN.
2. The TUN will not eliminate an aberrant frenal attachment.
3. The TUN will result in reduced vestibular depth.
4. The TUN cannot be used in the presence of a shallow vestibule.
5. The TUN cannot be used to treat deep recession
6. The TUN cannot be used in the presence of thin tissue
3 | R E A LI T I E S
3.1 | keratinized tissue width
Gain of KTW is a long recognized important soft tissue grafting out-
come parameter for the accurate assessment of graft procedure suc-
cess. It is useful for all grafts placed in an exposed environment such
as FGG and pedicle grafts. It provides an easily determined outcome
parameter indicative of graft survival, although it may include tissue
generated from the periodontal ligament and marrow spaces and it
could represent scar formation. In the case of grafts partially or
completely covered by a coronally positioned flap or tunnel, KTW gain
represents the portion of the graft exposed at the time of surgery and
secondary graft exposure due to retraction of the overlying tissue.
However, KTW gain is not representative of the gain of stable, dense
connective tissue beneath the mucosal surface.
A 1-year randomized controlled trial of TUN with acellular dermal
allografts (ADM) found a gain of stable tissue extending 2.7 mm apical
to the mucogingival junction (MGJ).9 This finding demonstrated a sig-
nificant gain of functional tissue extending beyond the MGJ and indi-
cates the inaccuracy of KTW gain in assessing grafting procedures
where the graft is placed beneath a flap or within a tunnel. The extent
of stable connective tissue apical to the MGJ is the difference
between initial KTW and the vertical dimension of the graft and may
extend up to 8 mm (Figure 1). The submucosal zone of dense connec-
tive tissue was evaluated in a six-month randomized, controlled
human block-section study of both CTG and ADM covered by a
coronally positioned flap.10At 6 months post-surgery both graft types
were seen histologically as a dense collagenous connective tissue
layer in close contact with the alveolar bone. A loosely arranged
mucosal layer covered each graft. There were no differences in graft
thickness and neither graft type induced the epithelium to keratinize
(Figure 2).
Numerous studies have shown only a minimal KTW gain for
either CTG or allografts partially or completely covered by coronally
positioned tissue in root coverage procedures (Table 1).11-19 The suc-
cess of these procedures is achieved by the gain of dense connective
tissue firmly attached to the alveolar bone, which increases tissue
thickness and provides the same function of stable marginal tissue as
surface grafts. Thus, gain of KTW is not a useful outcome parameter
for assessing the success of grafting procedures where the graft is
partially or completely covered as in the TUN.

F I G U R E 1 (A) Gingival
recession and narrow zone of
keratinized tissue in the maxillary
right posterior region. (B) An
allograft on the surface prior to
inserting into the tunnel recipient
site. (C) A continuous sling suture
coronally positions and secures
the graft and tunnel. (D) Cheek
retraction at 6 months post-
surgery reveals the outline of the
dense graft with its apical border
approximately 8 mm apical to the
mucogingival junction
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154 ALLEN

3.2 | Frenum
An aberrant frenal attachment is a common finding associated with
REC in the mandibular anterior region and it is readily eliminated in
the recipient bed preparation for an FGG. This is accomplished by dis-
secting the frenal attachment free from the alveolar surface during
the creation of an immobile vascular bed for the FGG. Often a perios-
teal fenestration is made at the apical border of the bed to maintain
displacement of the frenum. The FGG attaches to the immobile bed
and maintains displacement of the frenum.
Recipient bed preparation is the key to frenal displacement in the
TUN as it is with the FGG. The TUN site preparation is made by sub-
periosteal dissection for a vertical distance of 7–8 mm apical to the
cementoenamel junction (CEJ). The tunnel is extended vertically
another 7–8 mm by sharp dissection immediately superior to the peri-
osteum to allow tension-free coronal positioning of the tissue margin
to the CEJ. The graft is placed in direct contact with the stable bony
bed. The dense connective tissue of the graft will attach to the rigid
bed and the overlying tissue will attach to the fixed graft, thus
dissipating the frenal pull on the margin (Figure 3).

3.3 | Vestibular form

There is a concern that coronal positioning of a tunnel will reduce ves-

F I G U R E 2 Six-month human histology demonstrating the dense
allograft (ADM) in direct contact with the alveolar bone (B) and
subjacent to the loosely arranged connective tissue of the mucosal
layer that is covered by a non-keratinized epithelium (EPI). Original
magnification ×40
tibular depth similar to that seen where a buccal flap is coronally posi-
tioned to cover a bone graft in alveolar ridge reconstruction.
However, soft tissue grafting with the TUN represents a different pro-
cess that results in a natural vestibular form or an extended vestibular
depth in the case of a shallow vestibule (Figure 4). Again, the surgical
outcome is a result of the manner of recipient bed preparation. The

Publications CTG partial cover CTG complete cover ADM complete cover T A B L E 1 KTW gain in mm following
partial or complete coverage of
Maurer, Hayes 2000 1.2
connective tissue grafts (CTG) and
Bouchard, Etienne 1994 1.0 complete coverage of allografts (ADM)
Müller, Eger 1998 1.1
Al-Zahrani, Bissada 2004 1.2
Han, John 2008 1.5 0.9
Paolantonio, Dolci 2002 1.5 0.8
Tal, Moses 2002 2.1 0.9
Aichelmann-Reidy 2001 1.6 1.2
Zuhr, Rebele 2014 0.6 0.3

F I G U R E 3 (A) Gingival recession, minimal to no attached gingiva and a broad aberrant frenal attachment involving the mandibular anterior
segment. (B) An allograft was placed in a tunnel recipient site facial to the six anterior teeth and secured at the level of the cementoenamel
junctions with a continuous sling suture. (C) At 4 years post-surgery, complete root coverage, thickened tissue and a normalized frenal
attachment has been achieved and maintained
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ALLEN 155

F I G U R E 4 (A) Severe Miller

Class lll gingival recession and
absence of attached gingiva
complicated by narrow papillae,
non-carious cervical lesions and a
shallow vestibule. (B) At 5 years
post-surgery, near-complete root
coverage with thickened tissue is
seen. Composite restorations
were placed in the cervical lesions
of the central incisors at six moths
post-surgery. (C) Shallow vestibule
and cervical lesions prior to
treatment. (D) Significant root
coverage, thickened tissue and
normalized vestibular form at
2 years and (E) 5 years post-
surgery

F I G U R E 5 (A) Deep gingival

recession with inflamed margins
at the right central incisor. (B) An
allograft is secured within the
tunnel with a continuous sling
suture. (C) The tissue is closed
over the graft by approximating
the lateral borders with
interrupted sutures. (D) Complete
root coverage and thickened
tissue at 6 months post-surgery

creation of a bony recipient bed for the dense connective tissue graft
attachment and release of the tension on the overlying tunnel tissue
by sharp dissection allow the graft to displace the vestibule apically.
3.4 | Deep recession
It can be difficult to coronally position a tunnel passively to the CEJ at
sites with deep recession, especially in the mandibular anterior region.
This problem can be overcome with a modified suturing method for
20
lateral closure of the overlying tissue. A standard tunnel site prepa-
ration is performed with horizontal extension to include teeth adja-
cent to the one with deep recession, thus allowing passive lateral
tissue movement. The graft is aligned within the tunnel to the level of
the CEJ. At the deep recession site, the coronal margin of the graft is
secured at the CEJ with a sling suture and the tissue borders lateral to
the exposed root are approximated and secured with interrupted
sutures. If adjacent teeth are included, the tunnel and graft are
secured with sling sutures at these teeth. No surface incisions are
needed to accomplish this lateral closure (Figure 5).
3.5 | Thin tissue
It is more difficult to perform the TUN in sites with thin tissue due to
potential inadvertent injury to delicate tissue during dissection of the
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156 ALLEN

F I G U R E 6 (A) Shallow
recession facial to the central
incisors and the left first premolar
and thin tissue with minimal to no
attached gingiva facial to all
anterior teeth and the left first
premolar. (B) Incision of the papilla
between the lateral incisor and
canine combined with
intrasulcular incisions creates a
W-shaped mini-flap facial to the
canine and lateral incisor
providing access for (C) tunneling
under the three midline papillae
and (D) facilitating allograft
insertion. (E) The site is secured
with a continuous sling suture.
Note the lack of visible trauma to
the tissue at the end of surgery.
(F) Complete root coverage and
thickened tissue is seen at
6 months post-op

tunnel. This problem is complicated in the mandibular anterior region
where narrow rooted teeth present a smaller sulcular perimeter for
the intrasulcular dissection. This small access is further reduced where
there is minimal recession. In addition, root prominences with inter-
radicular depressions introduce additional difficulties for safe and effi-
cient tunnel dissection. These complicating features can be mitigated
by use of access incisions. One access method employs papillary inci-
sions at the papilla between the canine and lateral incisor on both the
right and left sides (Figure 6).21 Next, bilateral W-shaped mini-flaps
are formed with intrasulcular incisions from the distal of the canine to
the mesial of the lateral incisor. Intrasulcular incisions are also made
facial to the central incisors. The two mini-flaps provide access for dis-
section of the tunnel apically and horizontally under the three midline
papillae. Problems associated with prominent roots and undercuts are
easily managed, and graft insertion is facilitated without risk of injur-
ing the tunnel tissue. Wound stability and retraction resistance is
provided by the three tunneled papillae.
4 | DISCUSSION
the palate. A recent study surveyed patients who had autogenous
grafts 10 years previously.22 They were asked if they would be willing
to undergo another needed grafting procedure. Patient willingness
was negatively impacted by grafting in the mandibular arch, treating
multiple teeth and perceived pain. The TUN significantly mitigates
these patient concerns.
The reluctance of surgeons to use the TUN in the mandibular
anterior region is based on the mistaken belief that anatomic features
found in this region impair the success of the TUN. The most signifi-
cant problematic feature is the midline frenum and the most common
treatment is frenectomy followed by an FGG. The TUN addresses the
frenum with an internal release and displacement, creation of a bony
recipient bed and placement of an allograft or autogenous graft on
the bony bed. The attachment of the dense graft to the bony bed
maintains displacement of the frenum.
A shallow vestibule is deepened in a similar fashion. The method
of subperiosteal recipient bed preparation within the tunnel displaces
minor muscle attachments and this displacement is maintained by the
attachment of the dense graft to the bony bed.

Soft tissue grafting with the TUN represents a significant advance in 5 | CONC LU SIONS
wound stability, esthetic outcome and patient experience. The
improvement for the patient is additionally improved by using an The TUN is an effective grafting procedure for both root coverage
effective allograft alternative to the connective tissue harvested from and soft tissue augmentation in the mandibular anterior region. It is a

ALLEN
minimally invasive procedure providing enhanced esthetics and a
greatly improved patient experience.
1. KTW gain has been an important gingival grafting outcome param-
eter and is useful for assessing procedures using exposed grafts.
However, it does not provide useful outcome information for
grafts that are covered by a flap or tunnel and should not be used
in studies comparing exposed grafts to covered grafts.
2. The rigid bony recipient bed in a properly prepared tunnel will
detach and displace an aberrant frenal attachment.
3. The TUN recipient site preparation will similarly detach and dis-
place minor muscle attachments to maintain normal vestibular
depth or gain normal vestibular depth in sites with a shallow
vestibule.
4. The TUN may be used in mandibular anterior sites with isolated
deep REC by employing a lateral closure technique at the
deep site.
5. The TUN may be successfully used in sites with thin mucosa and
shallow REC by using access incisions to facilitate both recipient
site preparation and graft insertion.
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How to cite this article: Allen EP. Soft tissue grafting with the
tunnel technique in the mandibular anterior: Myths and
realities. J Esthet Restor Dent. 2021;33:152–157. https://doi.
org/10.1111/jerd.12712