A Comparison between the Tunnel Technique with Autogenous Grafts and Coronally Advanced Flap for Root Coverage of Multiple Gingival Recessions: A Randomized Clinical Trial
Abstract
Objectives: The purpose of this study was to compare the clinical performance of coronally advanced flap (CAF) with connective tissue graft (CTG) and vestibular incision subperiosteal tunnel access (VISTA).
Materials and Methods: The statistical population of this randomized clinical trial consisted of 24 healthy non-smokers with Miller Class I or II gingival recession (GR) defects, equally divided into two groups of 12 to receive either a CAF or the VISTA technique. Clinical parameters including the clinical attachment level (CAL), gingival biotype, pocket probing depth (PPD), recession height (RH), recession width (RW), root coverage (RC), and keratinized tissue width (KTW) were measured and compared between the two groups using ANCOVA, Fisher's exact test, independent samples t-test, Mann-Whitney U test, and repeated-measures ANOVA (alpha=0.05).
Results: The CAF group showed a significantly higher RC percentage (97.22%±9.62%) than the VISTA group (77.22%±24.28%%). Both techniques exhibited similar performance in terms of reducing the PPD and increasing the KTW and gingival attachment. However, the CAF group experienced a significantly greater reduction in CAL, RW, and RH than the VISTA group (P<0.05).
Conclusion: The VISTA and CAF groups showed a complete root coverage (CRC) percentage of 33.3% and 91.7%, respectively, indicating higher effectiveness of CAF than VISTA.
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2. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol. 2015 Feb;86:S8-S51..
3. Jordan HV, Sumney DL. Root surface caries: Review of the literature and significance of the problem. J Periodontol. 1973 Mar;44(3):158-63.
4. Bittencourt S, Del Peloso Ribeiro É, Sallum EA, Sallum AW, Nociti Jr FH, Casati MZ. Comparative 6‐month clinical study of a semilunar coronally positioned flap and subepithelial connective tissue graft for the treatment of gingival recession. J Periodontol. 2006 Feb;77(2):174-81.
5. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc. 2003 Feb;134(2):220-5.
6. Modica F, Pizzo MD, Roccuzzo M, Romagnoli R. Coronally advanced flap for the treatment of buccal gingival recessions with and without enamel matrix derivative. A split‐mouth study.
J Periodontol. 2000 Nov;71(11):1693-8.
7. Aroca S, Molnár B, Windisch P, Gera I, Salvi GE, Nikolidakis D, et al. Treatment of multiple adjacent Miller class I and II gingival recessions with a Modified Coronally Advanced Tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol. 2013 Jul;40(7):713-20.
8. Allen EP, Miller Jr PD. Coronal positioning of existing gingiva: short term results in the treatment of shallow marginal tissue recession. J Periodontol. 1989 Jun;60(6):316-9.
9. 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 Feb;71(2):188-201.
10. Moraschini V, Calasans-Maia MD, Dias AT, de Carvalho Formiga M, Sartoretto SC, Sculean A, et al. Effectiveness of connective tissue graft substitutes for the treatment of gingival recessions compared with coronally advanced flap: a network meta-analysis. Clin Oral Investig. 2020 Oct;24(10):3395-406.
11. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a systematic review. J Clin Periodontol. 2008 Sep;35:136-62.
12. de Sanctis M, Zucchelli G. Coronally advanced flap: a modified surgical approach for isolated recession-type defects: three-year results. J Clin Periodontol. 2007 Mar;34(3):262-8.
13. Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent. 2011 Nov-Dec;31(6):653.
14. Zuhr O, Akakpo D, Eickholz P, Vach K, Huerzeler MB, Petsos H, et al. Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 5‐year results of an RCT using 3D digital measurement technology for volumetric comparison of soft tissue changes. J Clin Periodontol. 2021 Jul;48(7):949-61.
15. Mayta-Tovalino F, Barboza JJ, Pasupuleti V, Hernandez AV. Efficacy of Tunnel Technique (TUN) versus Coronally Advanced Flap (CAF) in the Management of Multiple Gingival Recession Defects: A Meta-Analysis. Int J Dent. 2023 Apr;2023.
16. SilnessJ, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964 Feb;22:121‑35
17. De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol. 2009 May;36(5):428-33.
18. Pini Prato GP, Baldi C, Nieri M, Franseschi D, Cortellini P, Clauser C, et al. Coronally advanced flap: The post‐surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol. 2005 May;76(5):713-22.
19. Zucchelli G. Mucogingival Esthetic Surgery. 1st ed: Quintessence; 2013.
20. Gobbato L, Nart J, Bressan E, Mazzocco F, Paniz G, Lops D. Patient morbidity and root coverage outcomes after the application of a subepithelial connective tissue graft in combination with a coronally advanced flap or via a tunneling technique: a randomized controlled clinical trial.Clin Oral Investig. 2016 Nov;20(8):2191-202.
21. González-Febles J, Romandini M, Laciar-Oudshoorn F, Noguerol F, Marruganti C, Bujaldón-Daza A, et al. Tunnel vs. coronally advanced flap in combination with a connective tissue graft for the treatment of multiple gingival recessions: a multi-center randomized clinical trial. Clin Oral Investig. 2023 Jul:1-12.
22. Salem S, Salhi L, Seidel L, Lecloux G, Rompen E, Lambert F. Tunnel/pouch versus coronally advanced flap combined with a connective tissue graft for the treatment of maxillary gingival recessions: four-year follow-up of a randomized controlled trial. J Clin Med. 2020 Aug;9(8):2641.
23. Rasperini G, Acunzo R, Pellegrini G, Pagni G, Tonetti M, Pini Prato GP, et al. Predictor factors for long‐term outcomes stability of coronally advanced flap with or without connective tissue graft in the treatment of single maxillary gingival recessions: 9 years results of a randomized controlled clinical trial. J Clin Periodontol. 2018 Sep;45(9):1107-17.
24. Zuhr O, Rebele SF, Schneider D, Jung RE, Hürzeler MB. Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: a RCT using 3D digital measuring methods. Part I. Clinical and patient‐centred outcomes. J Clin Periodontol. 2014 Jun;41(6):582-92.
25. Azaripour A, Kissinger M, Farina VSL, Van Noorden CJ, Gerhold‐Ay A, Willershausen B, et al. Root coverage with connective tissue graft associated with coronally advanced flap or tunnel technique: a randomized, double‐blind, mono‐centre clinical trial. J Clin Periodontol. 2016 Dec;43(12):1142-50.
26. Ivanova V, Chenchev I, Gavrailov T. Clinical Comparison of Three Methods for Vestibuloplasty in the Anterior Part of the Mandibule. J of IMAB. 2018 Oct-Dec;24(4):2223-7.
27. Reddy S, Prasad M, Bhowmik N, Singh S, Pandit H, Vimal S. Vestibular incision subperiosteal tunnel access (VISTA) with platelet rich fibrin (PRF) and connective tissue graft (CTG) in the management of multiple gingival recession-A case series. Int J Appl Dent Sci. 2016 Sep;2(4):34-7.
28. Fahmy RA, Taalab MR. Modified tunnel technique for management of gingival recession in esthetic zone using acellular dermal matrix versus connective tissue graft. Future Dental Journal. 2019; 5(2):1-5
2. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol. 2015 Feb;86:S8-S51..
3. Jordan HV, Sumney DL. Root surface caries: Review of the literature and significance of the problem. J Periodontol. 1973 Mar;44(3):158-63.
4. Bittencourt S, Del Peloso Ribeiro É, Sallum EA, Sallum AW, Nociti Jr FH, Casati MZ. Comparative 6‐month clinical study of a semilunar coronally positioned flap and subepithelial connective tissue graft for the treatment of gingival recession. J Periodontol. 2006 Feb;77(2):174-81.
5. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc. 2003 Feb;134(2):220-5.
6. Modica F, Pizzo MD, Roccuzzo M, Romagnoli R. Coronally advanced flap for the treatment of buccal gingival recessions with and without enamel matrix derivative. A split‐mouth study.
J Periodontol. 2000 Nov;71(11):1693-8.
7. Aroca S, Molnár B, Windisch P, Gera I, Salvi GE, Nikolidakis D, et al. Treatment of multiple adjacent Miller class I and II gingival recessions with a Modified Coronally Advanced Tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol. 2013 Jul;40(7):713-20.
8. Allen EP, Miller Jr PD. Coronal positioning of existing gingiva: short term results in the treatment of shallow marginal tissue recession. J Periodontol. 1989 Jun;60(6):316-9.
9. 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 Feb;71(2):188-201.
10. Moraschini V, Calasans-Maia MD, Dias AT, de Carvalho Formiga M, Sartoretto SC, Sculean A, et al. Effectiveness of connective tissue graft substitutes for the treatment of gingival recessions compared with coronally advanced flap: a network meta-analysis. Clin Oral Investig. 2020 Oct;24(10):3395-406.
11. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a systematic review. J Clin Periodontol. 2008 Sep;35:136-62.
12. de Sanctis M, Zucchelli G. Coronally advanced flap: a modified surgical approach for isolated recession-type defects: three-year results. J Clin Periodontol. 2007 Mar;34(3):262-8.
13. Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent. 2011 Nov-Dec;31(6):653.
14. Zuhr O, Akakpo D, Eickholz P, Vach K, Huerzeler MB, Petsos H, et al. Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 5‐year results of an RCT using 3D digital measurement technology for volumetric comparison of soft tissue changes. J Clin Periodontol. 2021 Jul;48(7):949-61.
15. Mayta-Tovalino F, Barboza JJ, Pasupuleti V, Hernandez AV. Efficacy of Tunnel Technique (TUN) versus Coronally Advanced Flap (CAF) in the Management of Multiple Gingival Recession Defects: A Meta-Analysis. Int J Dent. 2023 Apr;2023.
16. SilnessJ, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964 Feb;22:121‑35
17. De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol. 2009 May;36(5):428-33.
18. Pini Prato GP, Baldi C, Nieri M, Franseschi D, Cortellini P, Clauser C, et al. Coronally advanced flap: The post‐surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol. 2005 May;76(5):713-22.
19. Zucchelli G. Mucogingival Esthetic Surgery. 1st ed: Quintessence; 2013.
20. Gobbato L, Nart J, Bressan E, Mazzocco F, Paniz G, Lops D. Patient morbidity and root coverage outcomes after the application of a subepithelial connective tissue graft in combination with a coronally advanced flap or via a tunneling technique: a randomized controlled clinical trial.Clin Oral Investig. 2016 Nov;20(8):2191-202.
21. González-Febles J, Romandini M, Laciar-Oudshoorn F, Noguerol F, Marruganti C, Bujaldón-Daza A, et al. Tunnel vs. coronally advanced flap in combination with a connective tissue graft for the treatment of multiple gingival recessions: a multi-center randomized clinical trial. Clin Oral Investig. 2023 Jul:1-12.
22. Salem S, Salhi L, Seidel L, Lecloux G, Rompen E, Lambert F. Tunnel/pouch versus coronally advanced flap combined with a connective tissue graft for the treatment of maxillary gingival recessions: four-year follow-up of a randomized controlled trial. J Clin Med. 2020 Aug;9(8):2641.
23. Rasperini G, Acunzo R, Pellegrini G, Pagni G, Tonetti M, Pini Prato GP, et al. Predictor factors for long‐term outcomes stability of coronally advanced flap with or without connective tissue graft in the treatment of single maxillary gingival recessions: 9 years results of a randomized controlled clinical trial. J Clin Periodontol. 2018 Sep;45(9):1107-17.
24. Zuhr O, Rebele SF, Schneider D, Jung RE, Hürzeler MB. Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: a RCT using 3D digital measuring methods. Part I. Clinical and patient‐centred outcomes. J Clin Periodontol. 2014 Jun;41(6):582-92.
25. Azaripour A, Kissinger M, Farina VSL, Van Noorden CJ, Gerhold‐Ay A, Willershausen B, et al. Root coverage with connective tissue graft associated with coronally advanced flap or tunnel technique: a randomized, double‐blind, mono‐centre clinical trial. J Clin Periodontol. 2016 Dec;43(12):1142-50.
26. Ivanova V, Chenchev I, Gavrailov T. Clinical Comparison of Three Methods for Vestibuloplasty in the Anterior Part of the Mandibule. J of IMAB. 2018 Oct-Dec;24(4):2223-7.
27. Reddy S, Prasad M, Bhowmik N, Singh S, Pandit H, Vimal S. Vestibular incision subperiosteal tunnel access (VISTA) with platelet rich fibrin (PRF) and connective tissue graft (CTG) in the management of multiple gingival recession-A case series. Int J Appl Dent Sci. 2016 Sep;2(4):34-7.
28. Fahmy RA, Taalab MR. Modified tunnel technique for management of gingival recession in esthetic zone using acellular dermal matrix versus connective tissue graft. Future Dental Journal. 2019; 5(2):1-5
| Issue | Vol 22 (Continuously Published Article-Based) | |
| Section | Original Article | |
| DOI | https://doi.org/10.18502/fid.v22i21.18815 | |
| Keywords | ||
| Connective Tissue Gingiva Gingival Recession Randomized Controlled Trial Surgical Flaps | ||
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Yaghini J, Mahmoudzadeh M, Afshari Z, Farmohammadi A, Mogharehabed A. A Comparison between the Tunnel Technique with Autogenous Grafts and Coronally Advanced Flap for Root Coverage of Multiple Gingival Recessions: A Randomized Clinical Trial. Front Dent. 2025;22.
