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Case report: tunnel technique to cover a gingival recession
Dr. Laura Flückiger, expert in periodontal surgery, treated a case of gingival recession (Miller class I, RT1) on tooth 43 and followed its evolution over a year after the operation. By applying the procedure of a modified coronally advanced tunnel* combined with a subepithelial connective tissue graft*, the gingival recession was fully covered.
Step 1: Preparation guidelines for the operation
In the initial phase of the process, Dr. Laura Flückiger made an intrasulcular incision. Being careful not to open or perforate the papillae helped to preserve it and give a more aesthetic result. After that, a gentle preparation and tunnelling is recommended for a better periodontal regeneration. This includes taking into account the position of the mental nerve.
Dr. Flückiger advises a full flap preparation in the region of the gingival margin as well as a split flap further apically before the graft removal.
Step 2: Graft removal process
Dr. Laura Flückiger proceeds to specific actions to remove the graft.
The first incision (in this case mesially 16 to distally 13) has to correspond to the length of connective tissue required for coverage, with 3mm distance to the gingival margin. The second incision has to be parallel to the first one with a depth of approximately 1 to 1.5 mm. Before proceeding with the next incisions, Dr. Flückiger reminds us of the importance of preparing the undermining split flap from distal to mesial, superficial and parallel in depth, as well as taking into account the major palatine artery.
In order to remove the graft properly, it is necessary to make a mesial and distal incision at the beginning and at the end. With a deep incision corresponding to the end of the required graft width, the graft will finally be removed.
Step 3: Fixation of the graft
If there is sufficient mobilisation of the flap, including the papillae, it is then possible to insert the connective tissue graft in one plane. It is essential to then clean the root surface, to be able to fixate the connective tissue graft, with 5/0 sutures, at both ends for insertion and positioning.To provide the best healing possible, it is recommended to do the fixation of the connective tissue graft with a 5/0 thread to the adjacent teeth 44/42.
Last step will be to close the seam without tension by using 5/0 and 6/0 sutures.
Evolution of the healing process
Thanks to the tunnel technique, results are already apparent after two months. During this healing process we can obviously notice the periodontal reconstruction.
Classifications of gingival recessions
Dr. Laura Flückiger refers to different different and complementary classification systems of gingival recession: the Miller classification and the Cairo classification. Recently, the European Federation of Periodontolgy proposes a new and even more comprehensive system.
Thin and sharp, yet robust and durable: our tunneling instruments gather these characteristics thanks to the unique know-how of our artisans, who hand-finish every tip. Dentists can perform delicate, minimally invasive periodontal microsurgery with extreme precision and comfort. Dr. Laura Flückiger’s favorites tunneling instruments are the TKR, the TKL and the TKI.
> Discover our entire range of tunneling instruments
Curious to see these instruments in action?
> Watch a video demonstrating a modified coronally advanced tunnel technique, by Dr. Michel Bravard (FR)
*References:
– Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent. 1994;14:216–27
– Bruno J. F. (1994). Connective tissue graft technique assuring wide root coverage. The International journal of periodontics & restorative dentistry, 14(2), 126–137.
– Aroca S, Molnar B, Windisch P, Gera I, Salvi GE, Nikolidakis S, Sculean A (2013) Treatment of multiple adjacent Millar class I and II gingival recessions with a modified coronally advanced tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol 40(7):713–720.
Photo credits: Dr. Laura Flückiger
