Coronally Advanced Tunnel with De-epithelialized Free Gingival Graft: advantages of the Inverted Graft: A Case Series.

Background: Various surgical options have been described for gingival recession management, namely the coronally advanced flap (CAF) or tunnel (TUN) surgical techniques, combined or not with connective tissue grafts (CTG) - CTGs can be obtained by de epithelializing a free gingival graft (dFGG). Nevertheless, none of them are exempt from postoperative complications, particularly when dFGG is combined with TUN techniques. Most common complications include the re-epithelialization of the marginal graft, resulting in undesirable esthetic outcomes. This paper describes the modified orientation of the dFGG under the tunnel, with the lamina propria layer facing the tooth's root (inverted graft), aiming to minimize the risk of esthetic complications.

Methods: 10 non-smoking patients with no comorbidities, presenting a total of 15 Miller class I/II (RT1) gingival recessions cases, were subjected to root coverage surgical treatment with the introduced technique (TUN+ inverted dFGG). After 6-months, each case was accessed using the root coverage esthetic score (RES).

Results: Regarding soft tissue integration parameters, the score was 3 out of 3 for all cases. Mean amount of root coverage was 97%. 13 recession defects (86%) achievedcomplete root coverage. The mean RES was 9.6, ranging from 7 to 10. 13 recession defects (86%) achieved a RES of 10.

Conclusions: The orientation of the dFGG under the tunnel, with the lamina propria layer facing the tooth's root (inverted graft), seems to present a promising aesthetic root coverage procedure and may be considered to minimize the risk of major esthetic complications when a dFGG is used under the TUN technique. Further studies are needed to address this proof of principle.