1

Connective Tissue Grafting Employing

the Tunnel Technique: A Case Report of
Complete Root Coverage in the
Anterior Maxilla

Giorgio A. E. Santarelli, MD, DMD* Gingival recession can be defined

Riccardo Ciancaglini, MD, DMD** as root surface exposure to the oral
Francesca Campanari, DDS* cavity because of the destruction of
Cinzia Dinoi, DDS* the marginal gingival tissues and of
Silvia Ferraris, DDS* the epithelial connective attachment
of one or more teeth. However, peri-
Techniques for surgical root coverage have been continuously revised over the past
odontal recession is a more accu-
few decades. With increased knowledge on the etiopathogenesis of gingival reces-
rate term because alveolar bone and
sions and on the repair/regeneration mechanisms of deep and superficial periodon-
cementum are also lost. The litera-
tal tissues, procedure simplification has been possible, and more predictable and
stable results have been obtained. The maintenance of maximal blood supply has ture reports that the main factors1
brought major changes in flap design. The coverage of contiguous recessions on contributing to this phenomenon are
the maxillary central incisors using a conservative technique for the incision of the toothbrush trauma,2–4 tooth malpo-
recipient site is presented, along with the 11-month follow-up from surgery. A sition5 such as morsus tectus, vestib-
supraperiosteal tunnel was performed for the insertion and stabilization of a con- ularization, position in the points of
nective tissue autograft. (Int J Periodontics Restorative Dent 2001;21:77–83.) curvature of the dental arch (ie, ca-
nines or first premolars), periodontal
types 2 or 4 (thin bone covered,
respectively, by thick or thin soft tis-
sues), iatrogenic factors (uncon-
trolled orthodontic movement6–9 in
terms of force, direction, or dental
inclination), improper restora-
tions,10,11 oral habits, and viral infec-
tions of the gingiva.12
The etiopathogenesis of peri-
odontal recession is based on the in-
**Department of Oral Rehabilitation, San Raffaele Hospital IRCCS, flammation and subsequent des-
University of Milan, Italy. truction of the connective tissue of
**Chairman of Prosthetic Dentistry, University of Milan, Italy.
the free gingiva. The oral epithe-
**Reprint requests: Dr Giorgio A. E. Santarelli, Galleria Passarella 2, 20122 lium migrates to the borders of the
Milan, Italy. e-mail: giorsan@tin.it destroyed connective tissue. The

COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING Volume 21, Number 1, 2001
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
2

thickening of the gingival and sul- • Class 2 = marginal tissue reces- lesion and to increase the quantity of
cular epithelial basal laminae sion that extends to or beyond keratinized tissue on the denuded
reduces the quantity of connective the mucogingival junction. There root surface to protect it from tooth-
tissue between them. Thus, blood is no loss of periodontal tissue in brush abrasion and dental caries.28
supply is reduced, negatively influ- the interdental area, and 100% Complete root coverage has been
encing the repair of the initial root coverage can be antici- clinically defined on the basis of the
lesion.13,14 As the lesion progresses, pated. following criteria29: (1) the marginal
the connective tissue disappears • Class 3 = marginal tissue reces- tissue reaches the level of the ce-
and the oral epithelium fuses with sion that extends to or beyond mentoenamel junction (CEJ); (2) clin-
the junctional/sulcular epithelium. the mucogingival junction. There ical attachment is present; (3) sulcus
In recessions caused by plaque and is loss of periodontal tissue in the depth is 2 mm or less; and (4) bleed-
tartar, the initial ulcer appears in the interdental area or malposition- ing on probing is absent.
junctional epithelium of the sulcus, ing of the teeth. Partial root cov- Many patients seek treatment
and the destruction of the connec- erage can be anticipated. because of concerns with esthetic
tive tissue occurs from the inside • Class 4 = marginal tissue reces- appearance, root sensitivity, or fear
out. In toothbrush trauma lesions, sion that extends to or beyond of early loss of the affected tooth.
destruction occurs from the outside the mucogingival junction. There The clinician should, however, be
in.15 is severe loss of periodontal tis- aware of other complications that
Many procedures for surgical sue in the interdental area or can arise from the exposure of denti-
root coverage have been proposed severe malpositioning of the nal tissue to the oral cavity, such as
since Grupe and Warren 16 first teeth. Root coverage cannot be root caries and tooth discoloration.
described the laterally positioned anticipated. Furthermore, it must be remem-
flap in the mid-1950s. Different sur- bered that exposed roots are prone
gical approaches use either pedicle However, greater predictability to abrasion and erosion.
flaps or free grafts (further divided of results became achievable only This case report presents the
into epithelialized partial-thickness with the introduction of bilaminar esthetic results obtained through bil-
grafts and deep connective tissue connective tissue grafting tech- aminar grafting with deep connec-
grafts). This classification is only the niques. In the mid-1980s, a series of tive tissue in Miller Class 1 reces-
beginning of a branching out of in- articles demonstrated the efficacy of sions on the maxillary central
novations, modifications, and varia- bilaminar techniques for the pre- incisors. A conservative incision tech-
tions comprising at least 50 surgical dictable treatment of denuded nique for the preparation of the
solutions to the problem of peri- roots.18–23 The main advantage of recipient site was used.
odontal recessions. these techniques was that the vas-
Miller17 classified soft tissue cularization of the surrounding tis-
defects, also taking treatment prog- sues could be exploited. It is this fac- Method and materials
nosis into account: tor that increased the predictability
of results in terms of area covered A 33-year-old woman who exhibited
• Class 1 = marginal tissue reces- and tissue blending.24 The fact that multiple maxillary recessions was
sion that does not extend to the the graft was furnished with a dou- referred to the authors’ department.
mucogingival junction. There is ble blood supply played a major role The lesions were probably caused by
no loss of periodontal tissue in in its improved and more predictable anatomic traits associated with trau-
the interdental area, and 100% survival in the recipient site.25–27 The matic toothbrushing. General health
root coverage can be antici- final objective of these techniques conditions were good, and the
pated. was to stop the progression of the patient was a nonsmoker (Fig 1).

The International Journal of Periodontics & Restorative Dentistry COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
 3

After signing a consent form for sur- Results

gical therapy, the patient was in-
structed in correct oral hygiene tech- Healing was uneventful (Fig 7). The
niques and placed in a prophylaxis sutures placed in the palate were
program until inflammatory indices removed after 1 week. The sutures
reached zero. placed on the buccal aspect were
Before surgery, 150 mg of keto- removed after 15 days. At the 1-
profene retard was administered, month, 2-month, 3-month, 6-month,
and local anesthesia was performed and 1-year (Fig 8) postsurgical
with 2 cartridges (3.6 mL) of articain appointments, progressive adapta-
(1:100,000 epinephrine). A releas- tion of the edges of the graft to the
ing vertical incision extending surrounding tissues and increased
beyond the mucogingival line was morphologic and chromatic mimick-
made from the distal corner of the ing were observed. One year post-
base of the papilla between the operative, sulcular probing depth
maxillary left central and lateral was less than 2 mm, and no bleed-
incisors (Fig 2). A sulcular incision ing on probing was present. Root
was then made on the buccal as- coverage was complete, with gingi-
pects of the central incisors to re- val margins reaching the CEJ of both
move the junctional epithelium. A teeth. The position of the mucogin-
partial-thickness dissection from just gival junction remained the same,
above the CEJ of the incisors to the but the amount of keratinized gin-
mucogingival junction was made to giva on the left central incisor
undermine the interdental papilla, increased by 2 mm (3.5 mm preop-
thus connecting the two incisions in erative, 5.5 mm postoperative). The
a tunnel30,31 fashion (Fig 3). patient was placed in a maintenance
For deep connective tissue graft program consisting of prophylaxis
harvesting, a Harris scalpel with par- and motivation.
allel blades (H & H) was used32; the
scalpel was inserted paramarginally
to the left first and second premo-
lars, maintaining a 30-degree angle
to the palatal vault.33 The donor site
was covered with hemostatic colla-
gen sponge (Gingistat, Vebas S.
Giuliano) and sutured with 4-0 silk
suture (Vicryl, Ethicon/Johnson &
Johnson). The graft was seated in
the prepared pouch and secured to
the distal papillae of the central
incisors with Vicryl 6-0 suture mate-
rial (Figs 4 to 6).

COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING Volume 21, Number 1, 2001
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
4

Fig 1 Maxillary central incisors 15 days after professional oral Fig 2 Sulcular incisions on the central incisors, with maintenance
hygiene. of the interdental papilla and releasing incision on the papilla distal
to the left central incisor.

Fig 3 Undermining of the interdental papilla with an Orban 1/2 Fig 4 Graft is placed over the recipient site to evaluate the fit in
scalpel (Hu-Friedy) for creation of a supraperiosteal mucosal tunnel. shape and size.

Discussion sites by the omnipotent mesenchy- Root coverage can be classified

mal cells of the periodontal liga- as primary coverage, which is
The prerequisites for complete recu- ment.34,35 If these conditions are not achieved immediately after grafting,
peration of the periodontal tissues satisfied, tissue necrosis and scarred and secondary coverage, when
are the maintenance of adequate healing will occur, resulting in a creeping attachment occurs. 36
vascularization in the flaps and grafts reparative and not a regenerative Creeping attachment is the result of
and recolonization of the treated process. activation of the mesenchymal cells

The International Journal of Periodontics & Restorative Dentistry COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
 5

Fig 5 Graft adaptation to the recipient site is maintained by the Fig 6 Primary closure of the releasing incision is obtained with
pressure elastically exerted by the walls of the subpapillary muco- Vicryl 6-0 suture. Single stitches are also placed distal to the right
sal tunnel. central incisor to stabilize the connective tissue graft.

Fig 7 One-week follow-up. Fig 8 Eleven-month follow-up.

of the periodontal ligament. With Releasing incisions interrupt the graft and those originating from the
enough time and in the absence of superficial and intramural vascular- periosteum and the underlying bone
mechanical and infectious-inflam- ization. However, these are neces- occurs within the first 2 or 3 days.38
matory stimuli, this can turn into new sary for the placement and suturing Blood supply comes from the base
attachment formation.37 of the connective tissue graft and of the reflected flap because most of
Care must be taken with the for flap mobilization. Connection the centripetal blood vessels are
flap design of the recipient site. between the blood vessels of the intercepted by incisions and sutures.

COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING Volume 21, Number 1, 2001
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
6

Hypoxic conditions will occur in the References

areas furthest from the base of the
flap. These coronal areas are the 1. Calandriello M, Carnevale G, Ricci G.
Parodontologia. Torino: Cides Odonto,
anchorage sites of the transpapillary
1986:410–414.
sutures, which not only serve to posi-
2. Hirschfeld I. Toothbrush trauma reces-
tion the flap over the graft but coun- sion: A clinical study. J Dent Res
teract the elastic forces generated 1931;11:61–63.
both intrinsically and by postopera- 3. Agudio G, Pini Prato G, Cortellini P, Parma
tive swelling. Under these condi- Benfenati S. Gingival lesions caused by
improper oral hygiene measures. Int J
tions, if flap stabilization is not ach-
Periodontics Restorative Dent 1987;7(1):
ieved, contraction will occur and 52–65.
make vascular connection impossi- 4. Khocht A, Simon G, Person P, Denepitiya
ble and graft exposure inevitable. JL. Gingival recession in relation to history
Ideally, therefore, it is better to avoid of hard toothbrush use. J Periodontol
1993;64:900–905.
releasing incisions when possible,
opting for envelope flaps instead. If 5. Hirschfeld I. A study of skulls in the
American Museum of Natural History in
releasing incisions must be made, relation to periodontal disease. J Dent
their coronoapical extension must Res 1923;5:241–246.
be limited to the minimum neces- 6. Trossello VK, Gianelly AA. Orthodontic
sary. The envelope technique pro- treatment and periodontal status. J
posed by Raetzke20 and successively Periodontol 1979;50:665–671.

modified39,40 resolves these prob- 7. Steiner GG, Pearson JK, Ainamo J.

Changes of the marginal periodontium as
lems but does not permit the fixing
a result of labial tooth movement in mon-
of the graft to the periosteum; it is keys. J Periodontol 1981;52:314–320.
not the treatment of choice for mul- 8. Boyd RL. Mucogingival consideration and
tiple recessions in adjacent sites. their relationship to orthodontics. J
This case report shows the ad- Periodontol 1978;49:67–76.

vantages in terms of predictability of 9. Coatoam GW, Behrents RG, Bissada NF.

The width of keratinized gingiva during
coverage and esthetics when care is
orthodontic treatment: Its significance
taken to ensure proper access and impact on periodontal status. J
through minimal releasing incisions. Periodontol 1981;52:307–313.
The use of the tunnel technique not 10. Donaldson D. Gingival recession associ-
only preserves the papillary height ated with temporary crowns. J
Periodontol 1973;44:691–696.
between two mucogingival defects,
but also helps maintain adequate 11. Turner CH. A retrospective study of the fit
of jacket crowns placed around gold posts
blood supply to the underlying and cores, and the associated gingival
graft.30,31 We believe that this tech- health. J Oral Rehabil 1982;9:427–434.
nique is valuable for the treatment of 12. Contreras A, Slots J. Active cytomegalo-
Miller Class 1 or 2 recessions when virus infection in human periodontitis. Oral
esthetics are of paramount impor- Microbiol Immunol 1998;13:225–230.

tance. 13. Goldman H, et al. Periodontal Therapy,

ed 6. St Louis: Mosby, 1980.

The International Journal of Periodontics & Restorative Dentistry COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.
 7

14. Goldman H, Shuman A, Isenberg G. 26. Allen AL. Use of the supraperiosteal enve- 37. Pasquinelli KL. The histology of new
Atlante per il Trattamento Chirurgico lope in soft tissue grafting for root cover- attachment utilizing a thick autogenous
delle Affezioni Parodontali, ed 1. Milano: age. I. Rationale and technique. Int J soft tissue graft in an area of deep reces-
Scienza e Tecnica Dentistica Edizioni Periodontics Restorative Dent sion: A case report. Int J Periodontics
Internazionali SNC, 1983. 1994;14:217–227. Restorative Dent 1995;15:248–257.
15. De Sanctis M, Zucchelli G. Soft Tissue 27. Bouchard P, Etienne D. Subepithelial con- 38. Sullivan HC, Atkins JH. Free autogenous
Plastic Surgery, ed 2. Bologna: Edizioni nective tissue grafts in the treatment of gingival grafts. 3. Utilization of grafts in
Martina, 1997:42. gingival recessions. A comparative study the treatment of gingival recession.
16. Grupe H, Warren R. Repair of gingival of two procedures. J Periodontol 1994; Periodontics 1968;6(4):152–160.
defects by a sliding flap operation. J 65:929–936. 39. Santarelli GAE, De Mar P. Eine modi-
Periodontol 1956;27:92–95. 28. Bruno JF. Connective tissue graft tech- fizierte Technik zur Wurzeldeckung mitein
17. Miller PD Jr. A classification of marginal nique assuring wide root coverage. Int J em Epithel-Bindegewebe-Transplantat.
tissue recession. Int J Periodontics Periodontics Restorative Dent 1994;14: (Multiple root coverage by means of a
Restorative Dent 1985;5(2):8–13. 126–137. modified epithelial-connective grafting
technique.) Parodontologie 1993;2:
18. Langer B, Calagna LJ. The subepithelial 29. Miller PD Jr. Root coverage using the free
95–106.
connective tissue graft. A new approach soft tissue autograft following citric acid
to the enhancement of anterior cosmet- application. III. A successful and pre- 40. Santarelli GAE, De Mar P. La greffe
ics. Int J Periodontics Restorative Dent dictable procedure in areas of deep-wide épithélio-conjonctive a “enveloppe”
1982;2(2):23–33. recession. Int J Periodontics Restorative modifiée dans le traitement des réces-
Dent 1985;5(2):14–37. sions gingivales. J Parodontol Implantol
19. Nelson SW. The subpedicle connective Orale 1995;14:127–133.
tissue graft. A bilaminar reconstructive 30. Zabalegui I, Sicilia A, Cambra J, Gil J,
procedure for the coverage of denuded Sanz M. Treatment of multiple adjacent
root surfaces. J Periodontol 1987;58: gingival recessions with the tunnel subep-
95–102. ithelial connective tissue graft: A clinical
report. Int J Periodontics Restorative Dent
20. Raetzke PB. Covering localized areas of 1999;19:199–206.
root exposure employing the “envelope”
technique. J Periodontol 1985;56: 31. Blanes JR, Allen EP. The bilateral pedicle
397–402. flap–tunnel technique: A new approach
to cover connective tissue grafts. Int J
21. Langer B, Langer L. Subepithelial con- Periodontics Restorative Dent 1999;19:
nective tissue graft technique for root cov- 471–479.
erage. J Periodontol 1985;56:715–720.
32. Harris RJ. A comparison of two tech-
22. Ross SE, Crosetti HW, Gargiulo A, Cohen niques for obtaining a connective tissue
DW. The double papillae repositioned graft from the palate. Int J Periodontics
flap—An alternative. I. Fourteen years in Restorative Dent 1997;17:261–271.
retrospect. Int J Periodontics Restorative
Dent 1986;6(6):46–59. 33. Reiser GM, Bruno JF, Mahan PE, Larkin
LH. The subepithelial connective tissue
23. Nelson S. The subpedicle connective tis- graft palatal donor site: Anatomic con-
sue graft. A bilaminar reconstructive pro- siderations for surgeons. Int J Periodontics
cedure for the coverage of denuded root Restorative Dent 1996;16:131–137.
surfaces. J Periodontol 1987;58:95–102.
34. Nyman S, Gottlow J, Karring T, Lindhe J.
24. Allen AL. Use of the supraperiosteal enve- The regenerative potential of the peri-
lope in soft tissue grafting for root cover- odontal ligament. J Clin Periodontol
age. II. Clinical results. Int J Periodontics 1982;9:257–265.
Restorative Dent 1994;14:303–315.
35. Nyman S, Lindhe J, Karring T, Rylander H.
25. Allen EP. Pedicle flaps, gingival grafts, New attachment following surgical treat-
and connective tissue grafts in aesthetic ment of human periodontal disease. J
treatment of gingival recession. Pract Clin Periodontol 1982;9:290–296.
Periodontics Aesthet Dent 1993;5:29–38.
36. Matter J, Cimasoni G. Creeping attach-
ment after free gingival grafts. J
Periodontol 1976;47:574–579.

COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING Volume 21, Number 1, 2001
OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
OUT WRITTEN PERMISSION FROM THE PUBLISHER.