|Year : 2014 | Volume
| Issue : 6 | Page : 816-820
|Treatment of multiple gingival recessions adopting modified tunnel subepithelial connective tissue graft technique
Jagmohan Singh1, Vipin Bharti2
1 Department of Dentistry, Employees' State Insurance Model Hospital, (Ministry of Labour and Employement, Government of India), Bari Brahmana, Jammu and Kashmir, India
2 Department of Periodontology, Government Dental College and Hospital, Patiala, Punjab, India
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|Date of Submission||29-Aug-2013|
|Date of Decision||04-Jul-2014|
|Date of Acceptance||05-Jan-2015|
|Date of Web Publication||02-Mar-2015|
| Abstract|| |
Gingival recession related to periodontal disease or developmental problems can result in root sensitivity, root caries, and esthetically unacceptable root exposures. In the past, multiple surgical procedures have been proposed to obtain root coverage on exposed buccal root surfaces. There has been great interest in the treatment of gingival recession defects, especially with subepithelial connective-tissue grafting (SCTG). Recent advances have focused on SCTG by the tunnel technique. This article highlights the esthetic results obtained by adopting a modification of the tunnel technique using a single vertical incision along with autologous SCTG in the management of multiple adjacent Miller Class-II gingival recessions. A single vertical incision was used along with tunnel preparation for the facile placement of SCTG into the prepared tunnel. After 6 months of follow-up, the clinical condition was stable with satisfactory root coverage outcome. An excellent esthetical outcome was achieved and the patient was satisfied with the result.
Keywords: Connective-tissue grafting, esthetics, gingival grafting, gingival recession, tunneling procedure
|How to cite this article:|
Singh J, Bharti V. Treatment of multiple gingival recessions adopting modified tunnel subepithelial connective tissue graft technique. Indian J Dent Res 2014;25:816-20
Periodontitis is a destructive inflammatory disease of the supporting tissues of the teeth and is caused either by specific microorganisms or by a group of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession, or both.  Gingival recession is defined as the displacement of the gingival margin apical to the cementoenamel junction (CEJ)  and may involve one or more tooth surfaces. This condition may be associated with periodontal disease or related to mechanical factors such as tooth brushing.  Indications for root coverage include esthetic demand, root hypersensitivity, prevention or management of root caries and cervical abrasion, enhancement of restorative outcomes, and prevention of disease progression in areas where hygiene cannot be maintained adequately. ,
|How to cite this URL:|
Singh J, Bharti V. Treatment of multiple gingival recessions adopting modified tunnel subepithelial connective tissue graft technique. Indian J Dent Res [serial online] 2014 [cited 2020 Jan 28];25:816-20. Available from: http://www.ijdr.in/text.asp?2014/25/6/816/152212
In the past, multiple surgical procedures such as sliding pedicle grafts, free gingival grafts, subepithelial connective-tissue grafts (SCTG), "envelope" or tunnel techniques, guided tissue regeneration using synthetic membranes, and the use of acellular dermal connective-tissue allografts have been reported to achieve improvements in recession depth (RD), clinical attachment level (CAL), and width of keratinized tissue. , The SCTG has become one of the most researched procedures used to achieve root coverage augmentation. Multiple indications such as root coverage, pontic site development, implant site regeneration, and increasing the width of attached gingiva have established the connective-tissue graft as the gold standard technique in mucogingival surgery. 
The transplantation of autologous connective-tissue, harvested primarily from the palate and positioned onto the deficient site along with various bilaminar procedures have been published since the early 1980s with repeated success and predictability. ,,, The dual blood supply from both periosteal or osseous base and the overlying flap is responsible for the increased predictability of bilaminar procedures, which helps in revascularization of the graft tissue.  The main shortcoming of these procedures was to necessitate incisions on the buccal flap that may retard the early esthetic results due to hampered lateral and papillary blood flow to the graft placed under the flap. To avoid these incisions at the recipient site, the envelope , and tunnel  procedures were advocated. These procedures seem to be more predictable and demonstrate more satisfactory results than previously described techniques, which may be explained by the fact that less trauma is caused during preparation of the recipient site if the intermediate papillae remain intact.
Since the tunnel connective-tissue graft technique described by Zabalegui et al.,  very few modifications in the tunnel preparation have been reported by using vertical incisions. , Vertical incisions along with tunnel preparation have been advocated in the literature for the purpose of facile graft placement and flap mobilization. This article puts emphasis on a case in which SCTG was used to augment recession coverage employing supraperiosteal tunnel procedure accompanied with a single vertical incision for the management of multiple adjacent Miller Class-II recession defects. The SCTG was introduced directly into the tunnel through the vertical incision.
| Case report|| |
A 32-year-old male patient came to our department with the chief complaint of receding gums and sensitivity with regard to 13 and 14. Patient also complained of difficulty in maintaining oral hygiene in the affected area. Patient was nonsmoker. On clinical examination, a Miller Class-II recession defect crossing mucogingival junction was present in 13 and 14 on the buccal aspect [Figure 1]. There was clinical attachment loss of 7 mm and 5 mm with regard to 13 and 14. The distance between the CEJ and gingival margin was 5 mm and 4 mm with regard to 13 and 14 [Figure 1] and the distance between the gingival margin and the base of the sulcus was 2 mm and 1 mm with regard to 13 and 14 [Table 1] and [Table 2]. The intraoral periapical radiographic examination revealed no evidence of crestal bone loss and the lamina dura was found intact around the roots of both 13 and 14.
As the width of attached gingiva was inadequate in the buccal aspect of 13, 14, it was decided to treat the gingival recession by using a supraperiosteal tunneling procedure combined with SCTG harvested from the palate. A single vertical incision was planned simultaneously along with the tunnel preparation on the recipient site to allow direct placement of the SCTG into the prepared tunnel. "Trap-door" flap design was planned to harvest SCTG from the donor site (palate).
A general assessment of the patient was made through history and routine laboratory investigations. The surgical procedure was explained to the patient, and the informed consent obtained. Preparation of the patient included scaling and root planning and oral hygiene instructions. Modified Stillman's brushing technique was prescribed to the patient. Immediately before surgery, patient was asked to rinse 15 mL of 0.075% solution of basic fuschin to stain the dental plaque after that it was removed from the affected teeth using rubber polishing cups and polishing paste.
Parameters were assessed with the University of North Carolina-15 periodontal probe. Following parameters were assessed at baseline (before surgery) and 6 months after the surgical procedure.
1. Clinical RD - distance between CEJ to the most apical point of the gingival margin.
2. Probing depth (PD) - distance between the gingival margin and the bottom of the gingival sulcus.
3. Clinical attachment level - measured from the CEJ to the bottom of the gingival sulcus.
| Surgical procedure|| |
0Incisions and recipient bed preparation
After anaesthetizing the area, intrasulcular partial-thickness incision around the involved teeth were performed by using an orbans interdental knife and 15c blade in order to create a deep partial-thickness envelope at each recession site extending beyond the mucogingival junction while leaving the tip of interproximal papillae intact. The partial-thickness incisions were given far beyond the mucogingival junction, for the purpose of possible coronal mobilization of the gingival flap. Using the same instruments, separate partial-thickness envelopes of each recession site were then subsequently interconnected, resulting in a tunnel preparation [Figure 2]. A split thickness pouch was created apical to papilla, which extended 10 mm apical to the recessed gingival margin and papilla and 5 mm mesial and distal to the denuded root surface. A single vertical incision extending beyond the mucogingival line was made from the mesial corner of the base of the papilla between the 12 and 13. The entire papilla was not included in order to minimize inadvertent gingival recession on an untreated tooth. A periosteal elevator was then subsequently inserted through the vertical incision for ensuring that tunnel was large enough and free of tissue tags to allow facile placement of the SCTG.
Preparation of donor site and graft placement
Subepithelial connective-tissue grafts was harvested from the palate, following a "trap-door" flap design.  A No. 15c blade was used to make a partial-thickness horizontal incision, with a bevel about 3 mm apical to the gingival margin of the first premolar, extending toward the first molar. Two vertical incisions were made mesiodistally. Tissue forceps was used to lift the prepared palatal flap edge. It was then reflected toward the center of the palate using a 4-0 black silk suture [Figure 3]a] and the underlying connective-tissue was exposed. An incision perpendicular to the bone was made around the edge of the connective-tissue, facilitating its reflection from the bone. A small periosteal elevator and Kirkland knife were used to reflect the connective-tissue and harvest it. The tissue was then placed on saline soaked gauze while the palatal wound was closed using 4-0 black silk sutures [Figure 3]b]. By delicately holding SCTG with tissue pliers, the uneven and adipose/glandular tissue was removed with 15c blade, after which SCTG was delicately seated in the prepared supraperiosteal tunnel through vertical incision using a universal (4R-4 L) curette [Figure 4]a] and secured to the mesial papillae of the 13 with Vicryl 5-0 suture material and the gingival margin of the flap was coronally placed and secured by horizontal mattress (5-0 Vicryl) sutures [Figure 4]b]. The vertical incision was then sutured with the help of independent interrupted suturing using Vicryl 5-0 sutures. Periodontal dressing (Coe pak, GC America, Alsip, IL) was used to cover the surgical site.
|Figure 3: (a) Palatal flap elevation by using suture. (b) Suturing of palatal flap after harvesting subepithelial connective-tissue grafting|
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|Figure 4: (a) Subepithelial connective-tissue grafting (SCTG) was introduced in the tunnel through vertical incision. (b) SCTG sutured in position|
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| Postoperative care|| |
Amoxicillin 500 mg and ibuprofen 400 mg thrice daily were prescribed for 5 days. Patient was instructed to follow all the normal oral postoperative hygiene instructions. Patient was instructed to rinse the oral cavity with 0.12% chlorhexidine Gluconate (Aster-X, Sandika Pharmaceuticals, Delhi, India) mouth rinse for 2 weeks. Patient was advised to avoid pulling his lip to observe the surgical site. The patient was recalled after 24 h, 3 days and then after 10 days. The periodontal dressing was changed after 10 days and was removed together with the sutures after 15 th postoperative day. Recall appointments were scheduled weekly during the 1 st month, then monthly up to 6 months postsurgery. Professional tooth cleaning was performed, and oral hygiene reinforced at each appointment. In this case, there was no postoperative complication and healing was satisfactory [Figure 5] and [Figure 6]. The patients did not have any postoperative complications.
| Results|| |
After 6 months of follow-up, the treated site showed 5 mm and 4 mm gain in CAL and reduction of 4 mm and 4 mm in RD with regard to 13 and 14. Furthermore, 13 showed 1 mm reduction in PD at 6 months [Table 1] and [Table 2]. Thus, clinical examination revealed a complete coverage and approximately 82% root coverage with regard to 14 and 13 after 6 months of the procedure with excellent tissue contour and color with no sign of inflammation. The final outcome was esthetical pleasant and patient was satisfied with the result [Figure 6].
| Discussion|| |
Many soft-tissue grafting procedures have been developed to cover root surfaces and increase the zone of attached gingiva. , The SCTGs have been proven to be effective to achieve improvements in RD, CAL, and width of keratinized tissue. ,
The use of connective-tissue grafts for root coverage was first reported by Langer and Langer.  A partial-thickness flap with two vertical incisions was elevated on the recipient site, followed by placement of the SCTG. After that, Nelson  proposed use of a full-thickness flap to cover the SCTG. The success rate of these grafting techniques was attributed to the double-blood supply at the recipient site from the subepithelial connective-tissue base and the overlying flap. However, these techniques were frequently used with a coronally positioned flap that may retard early esthetic results because of incisions on the buccal flap. To avoid these incisions at the recipient site, in 1985, Raetzke  and in 1994, Allen  reported the "supraperiosteal envelope" technique for the management of gingival recessions. The advantage of this technique is the fast early healing due to the absence of vertical release incisions. However, the envelope technique has been advocated in the literature for the management of isolated gingival recessions. In 1999, Zabalegui et al.  proposed the supraperiosteal envelope technique by performing a tunnel approach in the management of multiple adjacent gingival recessions. Utilization of a tunnel technique maintains the integrity of the gingival interdental papillae, facilitates healing, and provides highly aesthetic results. ,,, The advantages of such preparation are less tissue reflection, less scarring, increased vascularity, and better graft adaptation and security. 
In the traditional tunnel technique, the tunnel is created with only the access provided by the gingival sulcus.  This is technically difficult and time-consuming. Space provided by the gingival sulcus is small. Tearing of the buccal gingiva or the papillae is not uncommon when the access is small. The small access through the gingival sulcus also makes placement of the SCTG extremely difficult. Sutures have been frequently used to pull the graft into tunnel through gingival sulcus. Although vertical incision allow facile placement of the graft into the tunnel preparation. A suture is not required to pull the graft through the tunnel, and the position of the graft is easily verified with direct visual inspection. Finally, the vertical incision makes it easier to detect and correct any tissue tags that impinge on tissue mobility and the placement of the graft. 
The use of the SCTG offers a combination of both the pedicle flap and the free gingival graft. The pedicle flap allows for possible root coverage since it retains its apical blood supply and therefore survives over an avascular root surface. The free gingival graft supplies a resilient type of connective-tissue with a genetic predisposition, which ensures thickness and keratinization.  In addition, even when one-half to two-thirds of the graft is covered with the flap, remaining portion, which is not covered will survive over the denuded root. The double-blood supply, that is, that from the underlying periosteum and overlying flap, seems to be enough to nourish the entire graft.  Another advantage of SCTG is that the donor tissue obtained from the undersurface of the palatal flap, which is sutured back in primary closure; therefore, healing is by first attention. 
The SCTG along with tunnel technique is most desirable in achieving thickening of the gingival margin. The thicker gingival margin is most stable to allow for the possibility of "creeping attachment" of the margin.  Creeping attachment is known as the postoperative migration of the gingival marginal tissue in a coronal direction over portions of previously denuded root. This phenomenon can be detected 1-12 months after graft surgery with an average coverage of approximately 1 mm.  In the present case, it was interesting to evaluate that 1 mm clinical RD was further reduced with regard to 13 at 6 months as compared to RD at 1-month follow-up. The additive 1 mm reduction of RD with regard to 13 at 6 months follow-up was due to creeping attachment.
The current case report suggests that the use of the proposed surgical technique in conjugation with SCTG combines several techniques that maximize their benefits in the form of facile placement and positioning of the graft within the prepared tunnel. In addition, the tunnel autologous soft-tissue graft technique also seems to minimize trauma to vascular supplies available to the graft, preserves intact papillae and promotes esthetic blending of involved tissues.
| Conclusion|| |
Within limits of this case report, it can be concluded that the root coverage augmentation and esthetical outcomes can be more satisfactory upon surgical treatment adopting SCTG in conjugation with modified tunnel procedure. However, it is important to emphasize that this is a short-term report and longitudinal clinical studies with large sample size are needed to provide solid evidence of SCTG impact on soft-tissue reconstruction in periodontal therapy along with modification of tunnel technique by using single vertical incision.
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Department of Periodontology, Government Dental College and Hospital, Patiala, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]
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