The modified tunnel technique – options and

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 1

Jamal M. STEIN1, 2 Christian HAMMÄCHER2

The modified tunnel technique – options and indications for mucogingival therapy

1- Department of Operative Dentistry, Periodontology and Preventive Dentistry, University Hospital Aachen, Aachen, Germany 2- Clinic for Implantology, Periodontology and Prosthodontics, Aachen, Germany Accepted for publication: 15 september 2011

The authors report no conflicts of interest relevant to this publication.

Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

RÉSUMÉ ABSTRACT Different methods for coverage of gingival recessions and soft tissue augmentations using pedicle flaps and/or connective tissue grafts (CTG) have been reported. One of the innovative techniques to increase the amount of keratinized tissue is the modified tunnel technique which is designed as split flap without vertical releasing incisions. In contrast to the original technique, the modification combines the insertion of a CTG with coronal advancement of the tunnel complex. The present article describes the main characteristics and highlights different indications and limitations for this technique. Depending on recession depth and the presence of keratinized tissue an indication guideline for decision making is introduced. KEY WORDS Mucogingival surgery, recessions, modified tunnel technique.

Différentes techniques ont été décrites pour recouvrir les récessions gingivales et augmenter les tissus mous : lambeaux pédiculés et/ou greffes de tissu conjonctif. Parmi les techniques novatrices visant à augmenter la quantité de tissu kératinisé, on trouve la celle de tunnélisation modifiée qui se définit comme étant un lambeau d’épaisseur partielle réalisé sans incisions de décharge. Contrairement à la technique d’origine, cette modification associe l’insertion d’une greffe de tissu conjonctif avec un repositionnement plus coronaire de l’ensemble de la zone tunnélisée. Cet article décrit les principales caractéristiques et met l’accent sur les différentes indications et limites que présente cette technique. Un guide des indications en fonction de la profondeur de la récession et la présence ou non de tissu kératinisé est présenté pour aider le clinicien dans sa prise de décision. MOTS CLÉS Chirurgie muco-gingivale, récessions, technique de tunnélisation modifiée.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 2

The modified tunnel technique – options and indications for mucogingival therapy Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

Introduction Gingival recessions are defined as exposure of the root due to an apical movement of the margo gingivae. Their prevalence seems to increase from 8% in children to 100% in adults with an age of 50 years and more (Kassab and Cohen 2003; Woofter, 1969). Etiologic factors comprise primary morphogenetic and secondary factors. Primary morphogenetic factors are the absence or dehiscence of buccal bone wall (Lost, 1984) and/or a thin gingival biotype (Müller et al., 2000), while traumatic brushing (Serino et al., 1994), inflammatory periodontal disease (Wennström, 1996) or orthodontic movement of teeth (Coatoam et al., 1981) are secondary factors. Plastic periodontal surgery offers several options to tr eat and pr event periodontal recessions. According to the suggestions of Miller (Miller , 1985) and Harris (Harris, 1994), the aims of surgical coverage of periodontal recessions are the establishment of a complete r oot coverage with a minimum of keratinized (at least 2 mm width), healthy periodontal tissue (pr obing depth < 3 mm, no bleeding of probing) and an esthetical result and physiologic form of the gingiva. The meaning of tissue thickness for stabilization of treatment results, e.g. the goal to turn a thin into a thick biotype, has already been emphasised in earlier studies (Wennström, 1990). Many surgical techniques have been proposed to achieve root coverage. Systematic reviews with meta-analyses (Roccuzzo et al., 2002; Oates et al., 2003; Cairo et al., 2008) demonstrated that for coverage of localized Miller class I and II r eces-

sions cor onally advanced flaps (CAF), connective tissue grafts (CTG) and guided tissue regeneration (GTR) can be used, however the amount of root coverage with CTG was statistically superior to GTR (Roccuzzo et al., 2002; Oates et al., 2003). Further, the combination of CAF with CTG showed a sign ificantly better percentage of coverage than CAF alone (Cairo et al., 2008). Similar, the use of biologic factors such as enamel matrix derivatives (EMD) in addition to the CAF significantly enhanced the clinical outcomes compared to CAF alone. Although root coverage after CAF + CTG and CAF + EMD did not significantly differ from each other (Cair o et al., 2008), the amount of keratinized tissue was higher after the use of CAF + CTG compared to CAF + EMD (McGuire and Nunn, 2003). For treatment of multiple recessions and those with Miller class III only limited data are available. In the last decades, coronally advanced flaps (Zucchelli and DeSanctis, 2000), connective tissue grafts using the “envelope” technique with preparation of a supraperiosteal mucosa flap (Raetzke, 1985) and its extension over more than one recession in form of a tunnelling pr ocedure (Allen, 1994) were the base of modifications and new flap designs to treat multiple recessions. In order to use an incision-free technique to cover recessions with optimal aesthetic appearance, the tunnel technique has been further developed and modified (Azzi and Etienne, 1998; Zabalegui et al., 1999). In the present article, indications, options and limitations for this technique will be reported.

The modified tunnel technique According to the protocol of Allen (Allen, 1994), the design for the original tunnel technique comprises the preparation of a supraperiosteal mucosa flap with intrasulcular incisions. This allows the mobilisation of the cervical gingiva and, ther efore, the creation of a “pouch”. By undermining the inter dental papillae a mucogingival tunnel between all adjacent pouches can be developed. The subepithelial CTG is then inserted into the tunnel, partly exposed over the recessions and sutured in this position. Since the amount of root coverage is depending on the size of the graft which survives over the root surface, necrosis of the exposed parts of the CTG is one of the problems which limit the pr edictability of this original technique. T o overcome this problem, a better coverage of the CTG should be achieved. Therefore, it has been suggested to coronally advance the pouch and the tunnel. This modification has been described by Azzi and Etienne (Azzi and Etienne, 1998). It requires a mucoperiostal dissection beyond the mucogingival junction and under each papilla. Another modification is the application of a microsurgical approach using micr osurgical blades and sutures, which minimizes the surgival trauma (Zuhr et al., 2007; Cortellini andT onetti, 2001). New tunnel instruments (e.g. Tunneling Knife I/II, Hu-Friedy, Rotterdam) which ar e small, specially curved elevators have been developed in order to facilitate the supraperiosteal preparation of the tunnel and minimize the risk for iatrogenic perforations. The main dif ferences

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 3

J. M. STEIN, C. HAMMÄCHER

regarding indication and flap design between the envelope technique, the original tunnel technique and the modified tunnel technique are presented in table 1. Figure 1 shows an example of a modified tunnel technique in a patient with multiple Miller class III recessions.

Advantages and efficacy of the modified tunnel technique Although CAF in combination with CTG has been considered as standard for coverage of recessions for a long time, the tunnel technique has been further developed because it offers several advantages. Since vertical releasing incisions can be avoided, it is possible to pr eserve the continuity of gingival papillae and optimize the blood supply of the flap. Thereby, interproximal tissue support is pr ovided by the underlying CTG. Further, gain of keratinized tissue and thickening of the gingiva can be achieved with this technique.

Both factors ar e important for the establishment of stable periodontal and/or peri-implant tissue. To date, there are only three studies published reporting results after root coverage using the tunnel technique. Aroca et al. treated 20 patients with multiple Miller class III r ecessions in a randomized contr olled split mouth study (Ar oca et al., 2010). They used a modified tunnel approach to insert a CTG with and without enamel matrix derivates (EMD). The authors demonstrate that the modified tunnel technique with CTG is a pr edictable method for Miller class III recessions. The additional application of EMD, however, did not enhance the clinical outcomes. The percentage of r oot coverage was 82% (CTG + EMD) and 83% (CTG), respectively. In another study on five patients with multiple recessions of Miller class I and II (Modaressi and Wang, 2009), acellular dermal matrix has been used instead of CTG for the tunnelling approach. In average, 61% o r ot coverage and 0.15% increase of tissue thickness could be ach ieved. In a

recent study (Thalmair et al., 2011), the amount of r oot coverage after treatment of eight patients with multiple Miller class I recessions using the modified tunnel technique was examined. The authors r eport a mean coverage rate of 93.3% after six months. If the initial r ecession depth was < 4 mm, complete coverage was found in 84%, in cases with initial r ecession depths of ≥ 4 mm, only 44% could be completely covered. In summary, limited data point to a high efficacy of the modified tunnel technique using CTG, in particular for recessions with moderate depths (< 4 mm). Further studies with a higher statistical power should be performed to verify the efficacy of this technique.

Treatment options for the modified tunnel technique Unfortunately, an indication scheme for the modified tunnel technique has not been reported in the litera-

Original tunnel technique modifiée

Modified tunnel technique

Singular recessions

Multiple recessions

Single or multiple adjacent recessions

One tooth

Multiple adjacent teeth

Multiple adjacent teeth

Mobilization of the adjacent papillae

No

No

Yes

Coronal advancement of the mucosal flap

No

No

Yes

Envelope technique Indication Horizontal extension of the mucosal flap

The table shows the main differences between envelope technique (Raetzke et al., 1985), the original tunnel technique (Allen, 1994) and the modidied tunnel technique (Azzi and Étienne, 1998) regarding to indication and flap design.

Table 1. Differences between envelope, original tunnel and modified tunnel techniques. Tableau 1. Différences entre les techniques de l’enveloppe, de tunnélisation d’origine et de tunnélisation modifiée.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 4

The modified tunnel technique – options and indications for mucogingival therapy Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

1a

1b

1c

1d

1e

1f

Fig. 1. Modified tunnel technique for coverage of multiple Miller class III recessions. a. Pre-operative view. b. Intrasulcular incision and preparation of a supraperiosteal mucosa flap. c. Coronal advancement of the tunnel flap. d. Insertion of the CTG. e. Fixation of the CTG using external vertical mattress sutures. f. Healing result 3 months post-operative. Fig. 1. La technique de tunnélisation modifiée pour le recouvrement de récessions multiples de classe III de Miller. a. Vue préopératoire. b. Incision intrasulculaire et préparation d’un lambeau muqueux supra-périosté. c. Déplacement en direction coronaire du lambeau tunnélisé. d. Insertion de la greffe de tissu conjonctif. e. Fixation de la greffe de tissu conjonctif à l’aide de sutures au point de matelassier verticales externes. f. Résultat de la cicatrisation à 3 mois postopératoires.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 5

J. M. STEIN, C. HAMMÄCHER

coronally advanced flaps (with CTG or EMD) seem to be a better alternative (fig. 2). In patients with multiple Miller class II, the modified tunnel technique can be a very efficient Coverage method since tunnel preparation apiof multiple recessions cally to the recession doesn’t requiAccording to the original idea of the re mobilisation of attached gingiva (fig. 3). In these cases the tunnel tunnel technique, this method can covering tissue mainly consists of be recommended for coverage of multiple recessions with Miller class alveolar mucosa which makes moI, II or III if the recession depths are bilisation and coronal advancement moderate (< 4 mm). From a practi- of the tunnel easier (less tissue tencal point of view, it should be noted sion). Also for Miller class III recesthat the difficulty of supracrestal pre- sions the tunnel technique provides good results (Aroca et al., 2010). In paration beyond the mucogingival junction increases with the width of contrast to Miller class I, dissection attached gingiva apically to the re- of the interdental papillae for coronal advancement of the tunnel comcession. For multiple Miller class I recessions with wide attached gin- plex even seems to be facilitated in giva beyond the recession (≥ 3 mm), Miller class III (fig. 1). ture by now. However, there are different treatment options that can be recommended.

2a

2b

2c

2d

Coverage of singular recessions Raetzke described the envelope technique in order to cover singular recessions using a CTG which was sutured or sticked in a supraperiosteal “envelope”, prepared as recession s urrounding m ucosal flap without vertical r eleasing incisions (Raetzke, 1985). One of the disadvantages of this technique was the fact that a high amount of the CTG was uncovered and predictability of root coverage was limited due to the risk of (partial) necrosis of the (often) wide exposed CTG. By undermining the adjacent papillae, the modified tunnel technique enables cor onal advancement of the tunnel.

Fig. 2. Example for an indication of a coronally advanced flap. a. Multiple Miller class I recessions with ≥ 3 mm width of keratinized tissue apical to the recessions. b. Incision design (according to Zucchelli and De Sanctis, 2000). c. Post-operative view. d. Healing results 3 months post-operative. Fig. 2. Exemple d’une indication de lambeau déplacé coronairement. a. Récessions multiples de classe I de Miller avec ≥ 3 mm de largeur de tissu kératinisé situé apicalement aux récessions. b. Tracé d’incision (d’après Zucchelli et De Sanctis, 2000). c. Vue postopératoire. d. Résultats de la cicatrisation à 3 mois postopératoires.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:39 Page 6

The modified tunnel technique – options and indications for mucogingival therapy Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

Therefore, a higher amount of the CTG can be covered (fig. 4). Similar to the multiple r ecessions, the modified tunnel technique is not a suitable method if the amount of attached gingiva apically to the recession is ≥ 3 mm (alternative: CAF + EMD/CTG) or if the depth of the recession is ≥ 4 mm (alternative: lateral sliding flap +EMD/CTG (fig. 5) or free gingival graft). Figure 6 shows a decision guideline for the indication of the modified tunnel technique in or der to cover gingival recessions.

3a

Gingival thickening (“biotype switching”) Orthodontic movement of teeth might lead to iatrogenic exposure of roots, in particular in patients with thin gingival biotypes (W ennström, 1996). In those patients gingival augmentation (“biotype switching”) prior to the orthodontic treatment can prevent development of r ecessions (fig. 7). Also restoration of teeth with crowns with subgingival margin in esthetically relevant regions and thin gingival biotype might benefit from

a preceding thickening of the gingiva in order to avoid gingival tissue loss after crown insertion (Borghetti et al., 1990).

Peri-implant soft tissue augmentation Treatment on gingival r ecessions (dehiscence defects) on implants is still a challenge in mucogingival surgery. In order to remain or augment peri-implant tissue, we cr eated a treatment strategy for tissue conditioning prior, during or after implant

3b

Fig. 3. Coverage of two adjacent Miller class II recessions using the modified tunnel technique. a. Pre-operative view. b. Post-operative view. c. Healing result 4 months post-operative.

3c

Fig. 3. Recouvrement de 2 récessions adjacentes de classe II de Miller avec la technique de tunnélisation modifiée. a. Vue préopératoire. b. Vue postopératoire. c. Résultat de la cicatrisation à 4 mois postopératoires.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 7

J. M. STEIN, C. HAMMÄCHER

4a 4b

Fig. 4. Coverage of a singular Miller class II recession using the modified tunnel technique. a. Preoperative view. b. Post-operative view. c. Seven days post-operative (after suture removal). Fig. 4. Recouvrement d’une récession unitaire de classe II de Miller avec la technique de tunnélisation modifiée. a. Vue préopératoire. b. Vue postopératoire. c. Sept jours postopératoires (après la dépose des sutures).

4c

insertion using the modified tunnel technique. In patients wher e teeth with gingival recessions or thin gingival biotypes are planned to be replaced by immediate implants, we aim to cover the recessions and/or increase the gingiva thickness on the tooth three months prior to extraction and implant insertion. Since blood supply for the CTG on the tooth is provided by blood vessels from periodontal plexus, supraperiosteal plexus and the covering flap (Guiha et al., 2001), on implants nutrition for a CTG is given by a comparably compromised periostal nutrition and the

overlapping flap only. Therefore, root coverage with CTG will lead to a more stable gingival augmentation than on implants and should be considered whenever a tooth with a gingival deficit should be r eplaced by an (immediate) implant (fig. 8). Also during the insertion of an implant a CTG might help to impr ove the quantity and quality of peri-implant tissue. Alternatively or additionally, gingival augmentation can be performed after implant insertion, in particular during implant exposure. Thereby, the modified tunnel technique represents an elegant method to insert the CTG by careful lifting of

the papillae adjacent to the implant (fig. 9).

Limitations and conclusion The modified tunnel technique is an incision-free, minimally invasive method for gingival augmentation as blood supply can be maximally preserved and coverage of the graft is optimised compared to former techniques. However, there are limitations and contraindications which should be considered.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 8

The modified tunnel technique – options and indications for mucogingival therapy Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

5a

5b Fig. 5. Example for an indication of a lateral sliding flap. a. Pre-operative view. Recession depth ≥4 mm. Absence of keratinized tissue apical to the recession. b. Incision design. c. Healing result after 3 months. Fig. 5. Exemple d’indication de lambeau de translation latérale. a. Vue préopératoire ; profondeur de la récession ≥4 mm ; absence de tissu kératinisé dans la zone apicale à la récession. b. Tracé d’incision. c. Résultat de la cicatrisation à 3 mois. Fig. 6. Indication scheme for the treatment of recessions of Miller class I, II and III dependent on the presence of keratinized tissue apically and laterally to the recession defect, recession depth and gingival biotype. The modified tunnel technique can be recommended in cases with limited attached gingiva apically (< 3 mm) and recession depths of not more than 4 mm in Miller class I, II and III. Alternatively and in cases with recession depths of ≥4 mm, lateral sliding flaps can be considered if sufficient lateral keratinized tissue is present. In patients with lack of apical and lateral keratinized tissue, free gingival grafts may be applicable. KT: keratinized tissue; CAF: coronally advanced flap; EMD: enamel matrix derivates; CTG: connective tissue graft.

5c Recessions Miller’s class I, II, III Miller’s class I KT apical ≥ 3 mm THICK biotype

CAF + EMD

THIN biotype

CAF + CTG

Miller’s class I, II, III KT apical < 3 mm Recession depth < 4 mm

Recession depth ≥ 4 mm YES

KT lateral NO

6

Modified tunnel technique

Lateral sliding flap (+ EMD/CTG) Double papilla flap (+ EMD/CTG)

Free gingival graft

Fig. 6. Protocole d’indication pour le traitement de récessions de classes I, II et III de Miller selon la présence de tissu kératinisé dans la zone apicale et latérale de la récession, la profondeur de la récession et le biotype gingival. La technique de tunnélisation modifiée peut être recommandée pour les cas de gencive attachée limitée dans la zone apicale (< 3 mm) et des profondeurs de récession n’excédant pas 4 mm dans des classes I, II et III de Miller. En solution de remplacement, et pour les cas de récession dont la profondeur est ≥ 4 mm, les lambeaux de translation latérale peuvent être envisagés si l’on dispose d’une quantité de tissu kératinisé suffisante. Chez les patients présentant un manque de tissu kératinisé dans les zones apicales et latérales, on peut réaliser des greffes gingivales libres. TK : tissu kératinisé ; LDC : lambeau déplacé coronairement ; DMA : dérivés de la matrice amélaire ; GTC : greffe de tissu conjonctif.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 9

J. M. STEIN, C. HAMMÄCHER

7a

7b

7c

7d

Fig. 7. Gingival thickening prior to orthodontic treatment. a. Pre-operative view with thin gingival biotype and initial recession (Miller class II) on the right lower central incisor. b. Tunnelling preparation using two vertical « slot incisions » within the alveolar mucosa in order to insert the CTG. c. Postoperative view with sutures. d. Healing result 3 months post-operative. Fig. 7. Épaississement gingival préalable à un traitement orthodontique. a. Vue préopératoire en présence d’un biotype gingival fin et d’une récession initiale (classe II de Miller) sur l’incisive centrale mandibulaire droite. b. Préparation à l’aide de 2 incisions verticales « en fente » réalisées dans la muqueuse alvéolaire pour y glisser la greffe de tissu conjonctif. c. Vue postopératoire avec les sutures. d. Résultats de la cicatrisation à 3 mois postopératoires.

Besides general contraindications for oral sur gical treatments, smokers have a higher risk for impaired wound healing, graft necrosis and infection, which will worsen the results of root coverage with CTG (Martins et al., 2004; Chambrone et al., 2009). Further, initial thickness of the flap correlates with tr eatment success (Baldi et al., 1999; Hwang and Wang, 2009). Also, tr eatment fac-

tors such increased flap tension (PiniPrato et al., 2000) and surgical trauma (Burkhardt et al., 2005) will limit the gain of root coverage. Finally, it must be emphasized that especially the modified tunnel technique is a very technique sensitive method that requires experience and skills of the surgeon. Careful preparation of the flap, in particular in patients with thin biotype and small gingival

papillae, is essential for avoiding perforations. In a few cases, dissection of extremely thin papillae may be not possible due to the high risk of ruptures. As presented in figure 6, in patients with high recession depths (> 4 mm) and absence of keratinized tissue apically and laterally to the r ecession, a staged approach with a free gingival graft shoul d be pr eferred

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 10

The modified tunnel technique – options and indications for mucogingival therapy Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

8a

8b

8c

8d

8e

8f

Fig. 8. Modified tunnel technique prior to extraction and implant insertion. a. Upper central incisors with 2 mm recessions (covered by crowns). The right incisor is planned to be extracted. b. Replacement of both crowns by provisionals with shortened crown length. c. Coverage of both recessions using the modified tunnel technique with two « slot incisions ». d. Healing result 2 months later. e. Healing abutment 6 months after immediate implant insertion on the right central incisive. F. Definitive crowns on both central incisors. Fig. 8. Technique de tunnélisation modifiée avant extraction et implantation. a. Incisives centrales maxillaires présentant des récessions de 2 mm (couronnées). L’extraction de l’incisive droite est programmée. b. Remplacement des 2 couronnes par des provisoires plus courtes. c. Recouvrement des 2 récessions à l’aide de la technique de tunnélisation avec deux incisions « en fente ». d. Résultat de la cicatrisation 2 mois plus tard. e. Pilier de cicatrisation 6 mois après la pose d’un implant immédiat remplaçant l’incisive centrale droite. f. Couronnes finales sur les 2 incisives centrales.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 11

J. M. STEIN, C. HAMMÄCHER

against tunnelling techniques. This might, in particular, be the case if multiple recessions in the lower jaw are associated with a very flat vestibulum. In summary, (differential) indication for the tunnel technique should be done considering: – general health and smoking habits of the patient;

– experience of the surgeon; – size of the recession defects; – amount of surr ounding keratinized tissue. Regarding these parameters, the modified tunnel technique is an innovative method which extends the spectrum of plastic periodontal surgery. It allows gingival augmentation in different clinical situations, in

9a

9b

9c

9d

particular multiple recessions, with improved integration of the graft due to avoidance of vertical releasing incisions and maximal preservation of blood supply.

Fig. 9. Modified tunnel technique during implant exposure in order to remain and optimize peri-implant soft tissue. a. Upper left lateral incisor prior to extraction due to periodontal bone loss. b. Six months after implant insertion and gingival forming by an ovate pontic. c. Mobilisation of the adjacent papillae. d. Preparation and coronal advancement of the tunnel. Fig. 9. Technique de tunnélisation modifiée lors de l’exposition de l’implant afin de pérenniser et d’optimiser les tissus mous péri-implantaires. a. Incisive latérale maxillaire gauche avant extraction, à la suite d’une perte osseuse d’origine parodontale. b. Six mois après la pose de l’implant, remodelage gingival à l’aide d’un pontique ovoïde. c. Mobilisation des papilles adjacentes. d. Préparation et déplacement en direction coronaire du tunnel.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 12

The modified tunnel technique – options and indications for mucogingival therapy Technique de tunnélisation modifiée : options et indications en chirurgie muco-gingivale

9e

9f

Fig. 9. Modified tunnel technique during implant exposure in order to remain and optimize peri-implant soft tissue. e. Insertion of the CTG. f. Healing result and definitive crown. Fig. 9. Technique de tunnélisation modifiée lors de l’exposition de l’implant afin de pérenniser et d’optimiser les tissus mous péri-implantaires. e. Insertion de la greffe de tissu conjonctif. f. Résultat de la cicatrisation et couronne finale.

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1

> OS X Couleur

JPI0112_P000_000_ART_A 7/03/12 9:40 Page 13

J. M. STEIN, C. HAMMÄCHER

BIBLIOGRAPHY
Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics R estorative Dent 1994;14:216-227.
Aroca S, Keglevich T, Nikolidakis D, Gera I, Nagy K, Azzi R et al. Treatment of class III multiple gingival er cessions : a randomized-clinical trial. J Clin Periodontol 2010;37:88-97.
Azzi R, Étienne D. Recouvrement radiculaire et reconstruction papillaire par greffon conjonctif enfoui sous un lambeau vestibulair e tunnélisé et tracté coronairement. J Parodontol Implant Orale 1998;17:71-77.
Baldi C, Pini-Prato G, Pagliaro U, Nieri M, Saletta D, Muzzi L et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage ? A 19-case series. J Periodontol 1999;70:1077-1084.
Borghetti A, Laborde G, Borghetti G, Fourel J. Gingival thickening with a submerged connective tissue graft. J Parodontol 1990;9:311-317.
Burkhardt R, Lang NP. Coverage of localized gingival recessions : comparison of micr o- and macr osurgical techniques. J Clin Periodon tol 2005;32:287-293.
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures : a systematic review. J Clin Periodontol 2008;35:136-162.
Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. The influence of tobacco smoking on the outcomes achieved by rootcoverage pr ocedures : a systematic r eview. J Am Dent Assoc 2009;140:294-306.
Coatoam GW, Behrents RG, Bissada NF. The width of keratinized gingiva during orthodontic treatment : its significance and impact on periodontal status. J Periodontol 1981;52:307-313.
Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001 ;72:559-569.
Guiha R, el Khodeiry S, Mota L, Caffesse R. Histological evaluation of healing and revascularization of the subepithelial connective tissue graft. J Periodontol 2001;72:470-408.
Harris RJ. The connective tissue with partial thickness double pedicle graft : the r esults of 100 consecutively-tr eated defects. J Peri odontol 1994;65:448-461.
Hwang D, Wang HL. Flap thickness as a predictor of root coverage : a systematic review. J Periodontol 2006;77:1625-1634.
Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-225.
Lost C. Depth of alveolar bone dehiscences in relation to gingival recessions. J Clin Periodontol 1984;11:583-589.
Martins AG, Andia DC, Sallum AW, Sallum EA, Casati MZ, Nociti Júnior FH. Smoking may affect root coverage outcome : a prospective clinical study in humans. J Periodontol 2004;75:586-591.


McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and e ither enamel matrix deriv ative or connective tissue. Part 1. Comparison of clinical parameters. J Periodontol 2003;74:1110-1125.
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.
Modaressi M, Wang HL. Tunneling procedure for root coverage using acellular dermal matrix : a case series. Int J Periodontics Rest orative Dent 2009;29:395-403.
Müller HP, Schaller N, Eger T, Heinecke A. Thickness of masticatory mucosa. J Clin Periodontol 2000;27:431-436.
Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival r ecession. A systematic r eview. Ann Periodonto l 2003;8:303-320.
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. J Periodontol 2000;71:188-201.
Raetzke PB. Covering localized areas of root exposure employing the « envelope » technique. J Periodontol 1985;56:397-402.
Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions : a systematic review. J Clin Periodontol 2002;29:178-194.
Serino G, Wennström JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival r ecession in subjects with a high standar d of oral hygiene. J Clin Periodontol 1994;21:57-63.
Thalmeir T, Fickl S, Hinze M, Bolz W, Wachtel H. Tunneltechnik bei multiplen Rezessionen – vorläufige Ergebnisse einer prospektiven Untersuchung. Parodontologie 2010;21:292.
Wennström JL. The significance of the width and thickness of the gingiva in orthodontic treatment. Dtsch Zahnarztl Z 1990;45:136-141.
Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.
Woofter C. The prevalence and etiology of gingival er cession. Periodontal Abstr 1969;17:45-50.
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. Int J Periodontics Restorative Dent 1999;19:199206.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-1514.
Zuhr O, Fickl S, Wachtel H, Bolz W, Hürzeler MB. Covering of gingival recessions with a modified microsurgical tunnel technique: case report. Int J Periodontics Restorative Dent 2007;27:457-463.

S e n d re p r i n t s re q u e s t s t o Priv.-Doz. Dr. Jamal M. Stein, MSc.: Praxiszentrum für Implantologie, Parodontologie und Prothetik – Schumacherstrasse 14 – 52062 AACHEN – GERMANY – [email protected]

Journal de Parodontologie & d’Implantologie Orale - Vol. 31 N°1