The tunneling technique as a treatment for gingival recessions: a case series

A técnica de tunelização como tratamento para recessões gengivais: série de casos

ABSTRACT

Gingival recession is an increasingly common condition in dental practice, affecting about 50% of the general population, regardless of their oral hygiene standards. It is characterized by the apical migration of the gingival margin in relation to the cementoenamel junction, leading to root exposure and clinical attachment loss, mainly on the buccal surfaces of teeth. Patients frequently report unfavorable aesthetics, dentin hypersensitivity and non-carious cervical lesions, with the aesthetic concern being a growing focus within dentistry. Treatment consists in surgical root coverage procedures when a favorable prognosis is expected, or gingival augmentation procedures in order to prevent the progression of mucogingival defects by increasing the width of keratinized tissue. In this context, the tunneling technique combined with a subepithelial connective tissue graft is considered versatile and highly efficient, not only for root coverage procedures but also for gingival augmentation and corrections in the peri-implant mucosal area, making it a widely adopted technique in periodontology and implantology. Therefore, the aim of this study is to present three clinical cases on the treatment of gingival recessions using the tunneling technique and its variations, associated with a subepithelial connective tissue graft. Stable results were observed after 3, 6 and 12-month postoperative follow-ups, with improved gingival phenotype, gain of keratinized tissue, and satisfactory root coverage in all cases. Thus, the tunneling technique and its variations are highly versatile and effective for treating gingival recessions, even in complex mucogingival defects.

Indexing terms
Esthetics, dental; Gingival recession; Periodontics

RESUMO

A recessão ou retração gengival é uma condição cada vez mais presente dentro da clínica odontológica, compreendendo cerca de 50% da população geral, independente do seu padrão de higiene oral. É caracterizada pela migração da margem gengival mais apicalmente à junção amelocementária, causando exposição radicular e perda de inserção clínica principalmente nas faces vestibulares dos dentes. Os sinais e sintomas mais relatados são estética desfavorável, hipersensibilidade dentinária e lesões cervicais não cariosas, sendo o primeiro um fator de atenção crescente dentro da odontologia. Seu tratamento consiste em procedimentos cirúrgicos de recobrimento radicular, quando se espera prognóstico favorável para tal, ou procedimentos para aumento da faixa de mucosa ceratinizada, quando o objetivo é impedir o agravamento dos defeitos mucogengivais. Neste contexto, a técnica de tunelização associada ao enxerto de tecido conjuntivo subepitelial tem apresentado bons resultados clínicos, não somente para procedimentos de recobrimento radicular, mas também para aumento gengival e correções peri-implantares, sendo uma técnica muito difundida na área da periodontia e implantodontia. Portanto, o objetivo do presente trabalho é apresentar três casos clínicos sobre o tratamento de recessões gengivais utilizando-se da técnica de tunelização e suas atuais variações, associadas ao enxerto de tecido conjuntivo subepitelial. Foram observados resultados estáveis após acompanhamentos de 3, 6 e 12 meses pós-operatório, com melhora do fenótipo gengival, ganho de tecido queratinizado e recobrimento radicular satisfatório em todos os casos, concluindo que a técnica de tunelização e suas variações são altamente versáteis e eficazes para o tratamento de recessões gengivais, mesmo em defeitos mucogengivais complexos.

Termos de indexação
Estética dentária; Retração gengival; Periodontia

INTRODUCTION

Gingival recession is defined as the apical migration of the gingival margin regarding the cementoenamel junction, leading to root exposure or clinical attachment loss, primarily on the buccal surfaces of teeth, though it can also affect lingual/palatal or interproximal surfaces [¹]. This phenomenon occurs in populations with both high and low standards of oral hygiene and is increasingly more common among patients in general, affecting about 50% of the population [²,³].

Despite its multifactorial nature, the most prevalent etiological factors include mechanical trauma from tooth brushing, a thin gingival phenotype, plaque-induced inflammatory lesions and orthodontic movements [²,³]. Patients frequently report unfavorable aesthetics, dentin hypersensitivity and non-carious cervical lesions, with the aesthetic concern being a growing focus within dentistry [¹]. Treatment consists in surgical root coverage procedures when a favorable prognosis is expected, or gingival augmentation procedures in order to prevent the progression of mucogingival defects by increasing the width of keratinized tissue [⁴].

Clinical evaluation is paramount, thereby the classification of gingival recession proposed by Miller [⁵] takes into account the recession length, according to its relation with the mucogingival junction, and the involvement of interproximal tissues, which can be associated to the expected outcome for the intended treatment:

• Class I: Gingival recession that does not extend to the mucogingival junction, with no interdental soft tissue or bone loss.

• Class II: Gingival recession that extends to or beyond the mucogingival junction, with no interdental soft tissue or bone loss.

• Class III: Gingival recession that extends to or beyond the mucogingival junction, with interdental soft tissue or bone loss.

• Class IV: Gingival recession that extends to or beyond the mucogingival junction, with severe interdental soft tissue or bone loss.

Another recent classification proposed by Cairo [⁶], summarizes the previous categorization by considering only the buccal or lingual recession and its relation to the interdental attachment loss:

• Recession Type 1 (RT1): Gingival recession without interdental attachment loss.

• Recession Type 2 (RT2): Gingival recession with interdental attachment loss lesser than or equal to the buccal attachment loss.

• Recession Type 3 (RT3): Gingival recession with interdental attachment loss greater than the buccal attachment loss.

According to the classifications proposed by Miller [⁵] and Cairo [⁶] complete root coverage can be expected in cases where Classes I and II defects or RT1 defects are present. However, in Class III or RT2 gingival recessions, complete root coverage is unpredictable and may only be achieved in some cases with less severe interdental attachment loss. For cases designated as Class IV or RT3 defects, complete root coverage is considered unattainable [⁷].

In addition to the defect classification, other factors that influence the prognosis must be taken into consideration when choosing the right treatment or technique to be employed. These include patient-related factors (e.g. smoking, hygiene habits, age, systemic conditions), local factors (e.g. anatomy and location of the defect, vestibule depth, frenum or muscle insertion, clinical attachment level, width of keratinized tissue), and technique-related factors (e.g. flap tension, tissue trauma, flap thickness and design, graft thickness) [⁸-¹¹].

Several root coverage techniques have been described in the literature, such as the coronally positioned flap associated with a subepithelial connective tissue graft, considered for many years as the “gold standard” technique [⁸,⁹]. However, some authors reported that the use of vertical incisions to advance the flap coronally have the potential to affect the blood supply or cause scar formation in certain cases [¹⁰]. Consequently, as an alternative to open-flap procedures, flapless surgical techniques (i.e. tunnel or envelope) initially described by Raetzke [¹²] have been extensively studied and modified, offering excellent aesthetic results on the subject matter.

Currently, tunneling procedures associated with a subepithelial connective tissue graft harvested from the palate are considered versatile and highly effective, not only for root coverage but also for soft tissue augmentation around teeth and implants, being a well-established procedure in periodontology and implantology [¹⁰]. Therefore, this study aims to present three clinical cases of gingival recession treatment using different tunneling techniques associated with a subepithelial connective tissue graft.

CASES REPORTS

Case Report 1

Patient 1, female, 44 years old, was referred to the Periodontology Clinic at the State University of Ponta Grossa with the chief complaint of deficient aesthetics around a tooth and an implant. Intraoral clinical examination showed that the patient presented multiple gingival recessions, notably on the upper right canine (#13), which exhibited 3mm of recession on the buccal surface without interproximal tissue loss, classified as a Class II per Miller [⁵] or a RT1 recession per Cairo [⁶]. Additionally, the peri-implant mucosa of the element #14 presented a grayish aspect buccally, with a light exposure of the metal collar (figure 1A). Based on the clinical analysis, a periodontal surgery for root coverage and peri-implant gingival augmentation was chosen, utilizing the intrasulcular tunneling technique associated with a subepithelial connective tissue graft harvested from the palate.

Figure 1
Case report 1. (A) Initial aspect. (B) Tunnel flap prepared from lateral incisor to molar. (C) Tissue release checking. (D) Subepithelial connective tissue harvested from the palate. (E) Immediate postoperative. (F) 14 Days follow-up. (G) Lateral view after 1 year. (H) Frontal view after 1 year.

Immediately before the procedure, extraoral antisepsis was performed with 10% PVP-I, followed by a 1-minute rinse with 0.12% Chlorhexidine Gluconate for intraoral antisepsis. Local infiltrative anesthesia of the right anterior, middle, and posterior superior alveolar nerves, as well as the major palatine nerve were administered with 4% Articaine + 1:100,000 Epinephrine (Articaine 100, DFL, Rio de Janeiro, Brazil). Scaling and root planing of teeth #13 were performed with Gracey curettes, also 17% ethylenediaminetetraacetic acid (EDTA) was gently applied during 1 minute and then abundantly rinsed with saline for root decontamination and collagen fibers exposure. Subsequently, a tunnel flap was prepared from the lateral incisor to the first molar using tunneling instruments (ICE Instrumentos Cirúrgicos Esmeralda Ltda., São Paulo, Brazil), and tissue release was checked using a periodontal probe (Thimon Instrumentos Cirúrgicos Ltda., São Paulo, Brazil) (figure 1B, 1C).

Once the recipient bed was prepared, the subepithelial connective tissue graft was harvested from the palate performing the trap door technique. Incisions were initiated 3 mm from the gingival margin extending mesio-distally according to the required graft size, with a #15C blade (Solidor, Lamedid, São Paulo, Brazil) mounted on a #5 scalpel handle (Golgran Instrumentais Odontológicos, São Paulo, Brazil). The first superficial incision was made in a “U” shape, followed by a split-thickness dissection between the epithelial and connective tissue, with pendulum movements of the blade parallel to the bone. After visualizing the connective tissue, 1mm depth incisions are done perpendicular to the bone, forming a rectangle. The graft was then removed with deeper horizontal incisions parallel to the bone, assisted by Dietrich forceps (Golgran Instrumentais Odontológicos). Immediately after removal, the connective tissue graft was immersed in 0.9% sterile saline and trimmed with a scalpel blade as necessary, removing any epithelial or adipose tissue remnants (figure 1D).

For suturing, simple interrupted sutures were used to stabilize the graft within the mucosal tunnel, as well as the donor site closure. Finally, sling sutures anchored in the papillae were performed with a 6-0 nylon suture thread (Ethicon Inc., New Jersey, USA) (figure 1E).

The patient was then instructed on postoperative care, more specifically to avoid brushing the operated area for two weeks, and to perform chemical biofilm control with a 0.12% Chlorhexidine Gluconate rinse for approximately 1 minute twice daily for fourteen days. For postoperative pain control, Ibuprofen 600mg and Dipyrone Monohydrate 1g were prescribed intercalated every 12 hours for three days. Sutures were removed fourteen days after the procedure (figure 1F).

After a 12-month postoperative follow-up, it was observed that complete root coverage as well as gingival augmentation were achieved eliminating the mucogingival defects in the canine and pre-molars region, thereby improving smile aesthetics (figure 1G-H).

Case Report 2

Patient 2, a 43 years old male, presented with the chief complaint of dentin hypersensitivity and discomfort when brushing a lower tooth. Clinical examination revealed gingival recessions of 3mm on the lower left central incisor (#31) and 6mm on the lower right central incisor (#41), with a slight interdental bone loss, classified as Miller Class III [⁵] or Cairo RT2 [⁶] recessions. Based on the clinical analysis, root coverage was proposed by a modified tunneled coronally advanced flap technique associated with a subepithelial connective tissue graft (figure 2A-B).

Figure 2
Case report 2. (A) Initial aspect. (B) Preoperative planning; Green: Tunneling; Light blue: Incisions and full-thickness flap; Dark Blue: Split-thickness flap. (C) Mucosal tunnel prepared from the right central incisor to the left lateral incisor. (D) Flap mobility. (E) Connective tissue harvested. (F) Immediate postoperative. (G) 14 Days follow-up. (H) 6 Months follow-up.

Antisepsis and local anesthesia, along with scaling and root planing plus 17% EDTA application were performed as previously described. Flap design consisted of a single releasing incision on the disto-buccal aspect of tooth #41, connected to a tunnel flap prepared from teeth #32 to #41. The flap was elevated using a mixed approach, with the attached gingiva mobilized as a full-thickness flap and the alveolar mucosa as a partial-thickness flap (figure 2C-D).

Once the recipient bed was prepared, the subepithelial connective tissue graft was harvested as described previously and stabilized with simple sutures just apical to the cementoenamel junction (figure 2E). A double-crossed suture was also placed between teeth #31 and #41, and a sling suture was used on the pediculated flap, positioning it coronally towards tooth #41 (figure 2F).

Sutures were removed fourteen days after the procedure (figure 2G). After a 6-month follow-up, satisfactory root coverage and a discrete interproximal soft tissue gain were observed in this complex mucogingival defect (figure 2H).

Case Report 3

Patient 3, a 31 years old female, presented with the chief complaint of sensitive gums and difficulty during brushing a lower tooth. During the initial clinical examination, gingival inflammation and calculus accumulation were observed in the anterior lower region, in addition to an absence of keratinized tissue around tooth #31 (figure 3A). Thirty days after initial periodontal therapy, it was noted that elements #31 and #41 presented 5 mm and 1 mm of gingival recession respectively, with slight interdental bone loss, being classified as Class III according to Miller [⁵] or RT2 according to Cairo [⁶] (figure 3B). Based on the clinical analysis, root coverage through a modified VISTA tunneling technique was suggested (figure 3C).

Figure 3
Case report 3. (A) Initial aspect. (B) After initial periodontal therapy. (C) Preoperative planning; Green: Tunneling; Blue: Intrasulcular incisions; Orange: VISTA incisions. (D) Mucosal tunnel prepared from lateral incisor to lateral incisor. (E) Connective tissue harvested. (F) Immediate postoperative. (G) 14 Days follow-up. (H) 3 Months follow-up.

Following antisepsis and local anesthesia, together with scaling and root planing plus 17% EDTA application, the recipient bed was prepared starting with two small vertical incisions in the alveolar mucosa next to the area of interest and intrasulcular incisions from elements #32 to #42, followed by a full-split-full-thickness approach tunneling through these incisions (figure 3D). A subepithelial connective tissue graft was then harvested from the palate and positioned just apical to the cementoenamel junction using interrupted sutures (figure 3E). Three double-crossed sutures were also performed in order to stabilize the flap and the graft in the desired position (figure 3F).

Sutures were removed fourteen days after the procedure (figure 3G). After a 3-month follow-up, satisfactory root coverage and modification of the gingival phenotype were observed in the operated region, despite the presence of interdental bone loss and patient’s deficient oral hygiene (figure 3H).

DISCUSSION

The choice of the best treatment for gingival recessions is complex, especially for Miller Class III [⁵] or Cairo RT2 [⁶] recessions where even experienced periodontists can struggle to accomplish stable results, as interdental supporting tissue loss often impairs treatment outcomes. Current literature shows considerable variability in the results for these types of recessions due to numerous factors that can affect prognosis, not only the mucogingival defect classification, but also patient-related, local, and technical factors that must be taken into account. Some patient-related habits such as tobacco use or poor oral hygiene, as well as systemic conditions including diabetes, commonly show limited clinical results; furthermore, surgical sites with pronounced frenum or muscle attachments, shallow vestibules, or a lack of keratinized tissue may also lead to compromised outcomes [⁸-¹¹].

Although patient-related and local factors are crucial to determine the prognosis, technique-related factors deserve special attention by the surgeon, as these are controllable. When elevating a flap, the operator must be careful not to compromise blood supply in the area, for instance avoiding executing vertical releasing incisions when possible. In cases where vertical incisions are necessary, they should be designed keeping a wide flap base to allow an adequate blood supply to the region [¹³].

Another important factor is flap thickness, directly related with the type of periosteal elevation. Full-thickness mucoperiosteal flaps generally have greater thickness and, therefore, better blood supply, which can be advantageous for both flap and graft healing. On the other hand, partial-thickness flaps allow for a better flap mobility, reducing tension and maintaining a better blood flow to the raised tissue after suture, often resulting in maintaining the desired position of the tissues [¹⁴,¹⁵]. The current literature supports that a mixed approach combining both full and partial-thickness flap elevation seems optimal for root coverage procedures.

Furthermore, Mörmann & Ciancio [¹⁵] stated that favorable root coverage results can only be expected if there is a passive adaptation of the flap over the exposed root surface; otherwise, the sutures will exert tension on the repositioned tissue, potentially causing ischemia and necrosis. The authors also concluded that, in addition to impaired circulation, residual flap tension can cause tissue retraction during the initial healing phases, negatively affecting treatment outcomes.

Burkhardt & Lang [¹⁶] evaluated the importance of blood supply by comparing macro- and micro-surgical techniques for root coverage, finding that the microsurgical group presented significantly better results after 12 months. The authors indicate that using thinner and more delicate instruments, along with atraumatic suture materials results in less tissue trauma in the operated area and, consequently, better blood supply, suggesting that micro-surgical techniques might be a more adequate approach for mucogingival surgeries.

Among the various root coverage techniques, the most studied and clinically proven by scientific evidence is the coronally positioned flap technique, as described by Allen & Miller [¹⁷] and Langer & Langer [¹⁸]. This is still considered the “gold standard” procedure due to its significant results in terms of root coverage percentage, attachment gain, and keratinized tissue gain [⁸,¹⁹].

Despite the excellent results of the coronally positioned flap technique, there’s a current concern among authors regarding scar and keloid formation, often present when vertical releasing incisions are executed, which compromise the aesthetic outcome of the treatment. Hence, flapless procedures have gained ground in periodontal plastic surgery, showing similar clinical results in terms of root coverage and superior aesthetic outcomes when compared to coronally advanced flap techniques and their modifications [¹⁰,²⁰]. Therefore, intrasulcular tunneling appears to be the approach of choice in cases of high aesthetic demand in single or multiple shallow gingival recessions, even in small peri-implant defects, as demonstrated in case report 1.

A meta-analysis by Tavelli et al. [²¹] found that the tunneling technique effectively treated isolated single gingival recessions. However, when compared to the coronally advanced flap technique using the same types of grafts, tunneling yielded inferior complete root coverage outcomes, although modifications to the technique could improve results [²²].

Conversely, a study by Tozum et al. [²³], analyzing 31 patients over 6 months, found superior results for the tunneling technique in terms of attachment gain and percentage of root coverage when compared to the technique described by Langer & Langer [¹⁸], both associated with subepithelial connective tissue grafts (96.4% and 75.5%, respectively). In parallel, Zuhr et al. [²⁴] analyzed 47 shallow gingival recessions and found statistically significant differences favoring the tunneling technique with a connective tissue graft for aesthetic outcomes and percentage of root coverage when compared to coronally positioned flap associated with enamel matrix derivative proteins (98.4% and 71.8%, respectively).

Within current tunneling techniques, a microsurgical approach is considered indispensable for all cases. Zuhr et al. [²⁵] suggested using specific tunneling instruments to reduce the risk of flap perforation and tissue trauma, as demonstrated in all clinical cases presented in this article. The “double-crossed” suture suggested by Zuhr et al. [²⁶], performed in cases reports 2 and 3, is indicated for tunneling procedures as it aims to provide greater stability for both the flap and the graft by anchoring them at the contact point of the teeth and the papillae.

Zadeh [²⁷] described a modification of the tunneling technique, introducing a subperiosteal access through a minimally invasive incision in the vestibular mucosa (VISTA, Vestibular Incision Subperiosteal Tunnel Access), advocated for aesthetic regions and labial frenum areas. According to the author, the VISTA approach not only facilitates access to the mucosal tunnel but also aids in coronal flap traction by eliminating muscle insertion. These effects were more recently supported by a systematic review and meta-analysis conducted by Sabri et al. [²⁸], which found superior results in terms of mean and complete root coverage for the VISTA technique when compared to other tunneling techniques, concluding that the VISTA technique is viable for treating multiple recessions.

Moreover, the modified VISTA technique (m-VISTA) associated with a connective tissue graft was analyzed in a case series by Fernández-Jiménez et al. [²⁹], potentially offering an interesting alternative for the treatment of Class III gingival recessions. As demonstrated in case report 3, modifications to the VISTA technique can be made according to each clinical scenario, especially in challenging cases with interproximal tissue loss. In the case at matter, two small vertical incisions were made in the alveolar mucosa near the area of interest and connected to intrasulcular incisions via a subperiosteal tunnel. This was subsequently stabilized with double-crossed sutures, allowing for better coronal traction of the papillae and the mucosal tunnel, along with proper stability.

Alternatively, in the second case report presented which involved a deep RT2 mucogingival defect, the Tunneled Coronally Advanced Flap (TCAF) technique was the procedure of choice. As described by Barootchi & Tavelli [³⁰], TCAF combines tunneling with a coronally advanced flap, performed with a single releasing incision and associated with a connective tissue graft, demonstrating that this technique can be a viable option for treating gingival recessions with deficient papillae.

CONCLUSION

Gingival recessions are increasingly more common in the general population, and surgical root coverage procedures are considered the best treatment option for cases with a favorable prognosis. Before selecting a specific root coverage technique, the surgeon must carefully analyze the classification of mucogingival defects and the various factors that can affect the therapy’s prognosis, subsequently choosing the most appropriate technique for each individual case. When correctly performed, tunneling is a very versatile and highly successful technique for treating gingival recessions, as demonstrated in this study. However, it requires attention to the technique’s details, its most current variations, and their respective indications in order to achieve the best possible clinical outcome.

• How to cite this article
  Laudelino LT, Pilatti GL. The tunneling technique as a treatment for gingival recessions: a case series. RGO, Rev Gaúch Odontol. 2026;74:e20260017. http://dx.doi.org/10.1590/1981-86372026001720250083

Data Availability

The research data are available in the body of the document.

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Edited by

• Assistant editor
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  27 July 2026
• Date of issue
  2026

History

• Received
  14 Oct 2025
• Accepted
  23 Dec 2025