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\begin{document}

\title{Minimally invasive intrasulcular tunneling technique for treatment of
gingival recessions- Case Series}



\author[1]{Dler  Khursheed}%
\author[1]{Faraedon Zardawi}%
\affil[1]{University of Sulaimani}%


\vspace{-1em}



  
  \date{June 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Modification of coronally advanced flap (CAF) by tunneling procedure was
applied on four cases of gingival recession. Post-operative follow up,
at different time breaks recorded full coverage of almost all receded
root surfaces. The technique and the clinical outcome of this technique
will be demonstrated in this case series report.%
\end{abstract}%



\sloppy


\textbf{Minimally invasive intrasulcular tunneling technique for
treatment of gingival recessions- Case Series}\selectlanguage{english}
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\textbf{Abstract:}

Modification of coronally advanced flap (CAF) by tunneling procedure was
applied on four cases of gingival recession. Post-operative follow up,
at different time breaks recorded full coverage of almost all receded
root surfaces. The technique and the clinical outcome of this technique
will be demonstrated in this case series report.

\textbf{Keywords:} Advanced flap, tunneling procedure, connective tissue
graft, modification of tunneling.

\textbf{Background}

Localized or generalized location of gingival margin apical to
cementoenamel junction (CEJ) under different circumstances and etiologic
backgrounds called gingival recession.\textsuperscript{(1, 2)} These
causing decisive problems such as esthetic, phonetics, impeding plaque
control by pulling the gingival margin and
hypersensitivity.\textsuperscript{(3)} These problems often call for
either surgical or nonsurgical treatment. The ultimate goal of surgical
procedures is to achieve complete and predictable root
coverage.\textsuperscript{(2)} Several surgical approaches have been
accredited for root coverage, \textsuperscript{(4)} including free
gingival graft (FGG) and, connective tissue grafts (CTG) in combination
with different flap designs. \textsuperscript{(5-7)} Coronally advanced
flap (CAF) combined with CTG is considered the effective root coverage
procedure.\textsuperscript{(7)} Further, CAF could also be performed
without vertical incisions and gingival papillary involvement, which is
called tunneling procedure (TUN). \textsuperscript{(8, 9)} Surgical
tunneling procedure may be accomplished with combined partial and full
thickness flap; however, full thickness flap may be appropriate
especially for thin gingival biotypes. \textsuperscript{(6, 8)} Flap
tension should also be minimized to enhance both flap and stability over
the denuded roots. \textsuperscript{(10)} Flap undermining and muscle
dissection are essential for immobilization of the
graft.\textsuperscript{(11)} Therefore, this case series aimed to
present the predictability of covering recession with intrasulcular
tunneling preparation by extension of the flap further laterally and
apically using single tunneling instrument and modification of CTG
placement by laterally stretched suturing technique.

\textbf{Clinical presentation:}

In addition to demographic data, the following clinical measurements
were taken to determine recession types (RT).\textsuperscript{(12)}Width
and length of recessions, clinical attachment level (CAL), vestibular
depth from apical extent of the recessions, gingival biotype reference
and further, presence or absence of CEJ \(\pm\) cervical
lesions and tooth mobility were recorded for each individual recession
(Table 1).

All patients were systemically and periodontally fit for the surgery,
surgical procedures were performed by one, well skilled periodontist.
Details of the surgery and their possible complications were explained
to the patients, and signed informed consent was taken from them before
proceeding surgical procedures. Further, the study proposal was applied
to the scientific committee of the college of dentistry, University of
Sulaimani for registration and obtaining ethical approval for
undertaking this study.

\textbf{Case Management}

Root surface debridement was performed with a curette after giving local
anesthetics to the area by infiltration. Tunneling was performed using a
Hu-friedy tunneling knife (TKN1 \#1 HDL \#6) and a fine tissue separator
(Dentag Evo) \textbf{(Figure 1)} . The procedure was performed by
separating the gingival flap and vestibular mucosal tissues from
underling bone and muscular tissues, respectively. Separation and entire
tunneling preparation was carried out with single tunneling instrument
without using microblade for sulcular incision. Tunneling started from
margins of the recession, extended laterally to mid-facial line of the
adjacent teeth at level of facial CEJ, and extended further apically to
minimize tension from underline muscles \textbf{(Figure 2b)} .

The graft was passed under the tunnel and sutured from either side. The
original technique was modified in the current study by retaining the
graft with 2 circular stitches around adjacent teeth or with composite
filling. This will hold part of the graft fixed over the receded roots
and the other part over the underlying bone, without being sutured to
the flap, to retain the graft fixed in place and avoid dislodgment under
possible tension. In multiple recession cases, free gingival flap margin
was sutured independently and fixed by composite filling to the facial
surfaces of teeth \textbf{(Figures 2c)} . The palatal wound was dressed
using hemostatic sponge and fixed by sutures.

\textbf{Clinical outcomes:}

The study included 3 cases, two cases were single gingival recession
(RT2), Figures (3a-3j) and Figures (4a-4c), and the third case was two
multiple recessions on the upper, Figures (5a-5f) and lower teeth
Figures (6a-6c); all recessions recorded as RT1 except for \#21 and 31
were recorded as RT2 \textbf{Table 1} . The recessions were measured at
different follow up times postoperatively. Complete root coverage was
achieved on total 8 recessions involved in this study \textbf{Table 1} .

\textbf{Discussion:}

The incision free design and gingival papillary preservation are
considered as the main advantages of TUN.\textsuperscript{(8)} In the
current study sufficient tissue was undermined with minimum papillary
involvement around the recession area\textsuperscript{(9)} to release
active tension from surrounding tissues and approximate gingival
recession margins over the CTG. These would also lead to increase blood
supply to that part of the graft on the exposed root as it does not get
blood supply from underline exposed
root.\textsuperscript{(12)}Furthermore, the remaining part of the graft
under the tunnel gets dual blood supply from the underlying periosteum
and overlying subepithelial connective tissue respectively. This will
avoid necrosis of the free graft tissue over the denuded root surface by
providing dual nutrition for the graft.

The major design modification of the flap was further extension of the
flap on both side and the apical side to provide a relaxed bed for the
graft. Therefore, a modification in tissue preparation and CTG suturing
may add some advantages to the stability of the graft in term of
mechanical and biological aspects. In this procedure, the CTG is
completely secured by starching is laterally and sutured around the
teeth adjacent to the recession on both sides without being sutured to
the underlying periosteum and/or overlying flap tissue. In this
condition the graft is kept fixed with no shrinkage and better survival
rate. Stretching the graft avoid shrinkage and make the graft better
responsive to revascularization,\textsuperscript{(11, 13, 14)} . The
only limitation of applying this technique is when thin gingival biotype
is present that makes the tunneling preparation with partial thickness
flap is difficult (Table 2).

Higher predictability rate of the clinical outcome could be expected
with the current modification, while the tunnel flap and the graft are
relaxed and not under tension to avoid any mobility of the graft that
compromises the normal healing process.

\textbf{Acknowledgment:} The authors acknowledge the staff of department
of Periodontics for their kind help and support for fulfilling the
surgical procedures

\textbf{Conflict of interest:} No conflict of interest was declared by
the authors of this study

\textbf{Author contribution:} DK. Design and Case documentation, FZ.
Manuscript preparation, and final approval of the manuscript.

\textbf{Key Clinical message:} Coronally advanced flap (CAF) by
tunneling procedure is considered one of the effective root coverage
procedures particularly when it is combined with CTG. Modification of
the conventional technique. Post-operative follow up, at different time
breaks recorded full coverage of almost all receded root surfaces.

\textbf{References}

1. Periodontology AAo. Glossary of periodontal terms: American Academy
of Periodontology; 2001.

2. Slutzkey S, Levin L. Gingival recession in young adults: occurrence,
severity, and relationship to past orthodontic treatment and oral
piercing. American Journal of Orthodontics and Dentofacial Orthopedics.
2008;134(5):652-6.

3. Imano M, Spada PP, Macalossi JMS, Deliberador TM. Treatment of
Localized Gingival Recession by Means Tunnel Technique after the
Orthodontic Treatment. A Follow-Up of 1 Year. Case Reports in Dentistry.
2020;2020.

4. Zuhr O, Fickl S, Wachtel H, Bolz W, Hurzeler M. Covering of gingival
recessions with a modified microsurgical tunnel technique: case report.
International Journal of Periodontics and Restorative Dentistry.
2007;27(5):457.

5. Pradeep K, Rajababu P, Satyanarayana D, Sagar V. Gingival recession:
review and strategies in treatment of recession. Case reports in
dentistry. 2012;2012.

6. Sculean A, Allen EP. The Laterally Closed Tunnel for the Treatment of
Deep Isolated Mandibular Recessions: Surgical Technique and a Report of
24 Cases. International Journal of Periodontics \& Restorative
Dentistry. 2018;38(4).

7. Wessel JR, Tatakis DN. Patient outcomes following subepithelial
connective tissue graft and free gingival graft procedures. Journal of
periodontology. 2008;79(3):425-30.

8. Wang Y, Stathopoulou PG. Tunneling Techniques for Root Coverage.
Current Oral Health Reports. 2019;6(4):237-43.

9. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of
multiple adjacent gingival recessions with the tunnel subepithelial
connective tissue graft: a clinical report. International Journal of
Periodontics \& Restorative Dentistry. 1999;19(2).

10. Pini Prato G, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo F, et
al. Coronally advanced flap procedure for root coverage. Flap with
tension versus flap without tension: A randomized controlled clinical
study. Journal of Periodontology. 2000;71(2):188-201.

11. Shkreta M, Atanasovska-Stojanovska A, Dollaku B, Belazelkoska Z.
Exploring the gingival recession surgical treatment modalities: A
literature review. Open access Macedonian journal of medical sciences.
2018;6(4):698.

12. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The
interproximal clinical attachment level to classify gingival recessions
and predict root coverage outcomes: an explorative and reliability
study. Journal of clinical periodontology. 2011;38(7):661-6.

13. Miller Jr P. Regenerative and reconstructive periodontal plastic
surgery. Mucogingival surgery. Dental Clinics of North America.
1988;32(2):287-306.

14. Holbrook T, Ochsenbein C. Complete coverage of the denuded root
surface with a one-stage gingival graft. The International journal of
periodontics \& restorative dentistry. 1983;3(3):8-27.

\textbf{Figure Legends:}

\begin{enumerate}
\tightlist
\item
  Figure 1: Surgical instrument applied for tunneling procedure
\item
  Figure 2: Schematic illustration of modified tunneling procedure;
  preoperative state (a), dotted lines indicate extensions of the flap,
  placement of CTG (b), graft is sutured around adjacent teeth, the flap
  is further advanced coronally, sutured and fixed with composite
  filling (c), Root coverage postoperatively (d).
\item
  Figure 3, Pre-operative view RT2 (a), measurement of recession length
  and width (b\&c), extension of the tunnel laterally (d),
  de-epithelized free connective tissue graft (e), placement of the
  graft and sutured laterally (f), advancing the recession margins to
  cover the exposed graft (g), the donor graft area is sutured with
  hemostatic sponge (h), CRC two weeks and 13 months postoperatively (i
  \&j).
\item
  Figure 4: Pre-operative view RT1 (a), 3 mm gingival recession (b),
  complete root coverage after 2 months (c).
\item
  Figure 5: RT1 on teeth \# 42 and 43 (a), each had 3 mm recession (b
  and c), suturing the flap over the graft (d), complete root coverage
  after 2 weeks (f), healthy and stable gingiva after 3 months (g).
\item
  Figure 6: RT2 on teeth \#21,31 and RT1 on teeth \#22,32 (a), complete
  root coverage after 2 weeks (b), stable tissue after 2 months (c).
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