Minimally invasive tunneling of a de-epithelialized connective tissue graft to improve gingival phenotype of lingual recession defects: A case report

Abstract

Background

This case report describes a minimally invasive technique to increase the functional resistance of mandibular anterior lingual recession defects to inflammation. There are only a few case reports that describe the soft tissue augmentation of lingual gingival recession, of which none describe a tunneling technique without coronal advancement of the flap to treat a long span of multiple recession defects. Soft tissue augmentation of lingual recession defects is challenging due to the proximity to the tongue, frenum, vital structures, pre-existing thin phenotype, and limited access during surgery.

Methods and Results

A 30-year-old male was referred for the treatment of gingival recession on the lingual surfaces of teeth #22–27, with a diagnosis of recession type 2 (RT2). Mucogingival surgery included the preparation of the recipient site with a tunneling protocol, where apical muscular attachment was left undisturbed to isolate the flap from the movement of the tongue during normal function. As the goal was to not coronally advance the tunneled flap, the interdental papillae were not elevated and left intact, further optimizing blood supply. A free gingival graft was harvested, de-epithelialized extra-orally, and the resulting connective tissue graft (CTG) was fed through the tunnel and stabilized with sling sutures. Partial root coverage was achieved ranging from 50% to 90% at 4 months, consistent with the initial diagnosis of RT2. There was also a visually appreciable increase in gingival thickness and in the vestibular depth.

Conclusion

A de-epithelialized CTG via tunneling without disturbing the deeper muscular attachment is a conservative method to improve phenotype of lingual recession defects.

Key points

Why is this case new information?

• There are only a few case reports that describe soft tissue augmentation of lingual recession defects, of which none describe a tunneling technique without coronal advancement of the flap to treat a long span of multiple recession defects. This case report introduces a minimally invasive technique to increase the functional resistance of mandibular anterior lingual recession defects to plaque and calculus.

What are the keys to successful management of this case?

• Control of gingival inflammation before and after surgery, with regular maintenance visits and oral hygiene instructions.
• Precise tunneling, leaving deeper muscular attachment on the floor of the mouth undisturbed.
• Connective tissue graft of even thickness that is fibrous in quality.

What are the primary limitations to success in this case?

• A shallow lingual vestibule will not allow the clinician to leave deeper muscular attachment apical to tunneling undisturbed.