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Global Translational Medicine Evolution of tunneling techniques

integrated minimally invasive techniques into the clinically gingiva and crestal soft tissue at edentulous sites remain
accessible repertoire of procedures. Multiple examples can intact but may be freed from the alveolar bone. The
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be found in periodontics. Few studies have assessed clinical surgeon may employ intrasulcular incisions only or add
efficacy and long-term stability following laser periodontal limited vertical vestibular incisions that do not extend to
therapy. However, this minimally invasive procedure the gingival margin. Specialized suturing techniques or
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aims to provide definitive periodontitis treatment despite implantation of biomaterials may coronally position the
accessing intrabony defects (IBDs) through the gingival tunnel flap. Irrespective of the procedure type, the rationale
sulcus only, without any external incisions. In contrast, the for selecting a tunnel flap usually includes enhancement
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modified minimally invasive surgical technique (M-MIST) of patient-reported outcome measures (PROMs), such as
involves the use of limited incisions and minimal reflection reduced post-operative swelling and discomfort, improved
of the defect-associated papilla to access the alveolar bone esthetics in the short term, and early return to normal
and root surface. Long-term follow-up of a randomized activities.
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controlled clinical trial demonstrated that IBDs treated Across all tunnel-based procedures in periodontics,
with M-MIST alone or M-MIST and regenerative materials the main limitation is the paucity of evidence confirming
exhibited periodontal stability over a 10-year observation superior or equivalent clinical outcomes compared
period. 3 with procedures that rely on classic flap designs. Direct
Tunnel flaps comprise a broad subset of minimally clinical comparisons between tunnel and conventional
invasive techniques utilized within the field of periodontics flaps are rare, and contradictory results appear in the
(Figure 1). Derivations have been applied in periodontal literature. Nevertheless, outcomes achieved with tunnel-
plastic surgery, regenerative treatment of periodontitis, based periodontal surgeries are generally positive, and
and alveolar ridge augmentation (ARA) (Table 1). The consistently, the procedures are well accepted by patients.
unifying feature of a tunnel flap is the avoidance of The purpose of this report is to review the tunnel flaps
crestal incisions that establish distinct buccal/facial and that have been applied in periodontics and suggest further
palatal/lingual mucoperiosteal flaps. The interdental derivations of the technique.

Figure 1. Evolution of tunnel flaps in periodontics for root coverage, alveolar ridge augmentation, and periodontal regeneration. Image created by the
authors.
Abbreviations: MiTT: Mixed-thickness tunnel access; NIPSA: Non-incised papilla surgical approach; SCTG: Subepithelial connective tissue graft;
SMART: Subperiosteal minimally invasive esthetic ridge augmentation technique; VISTA: Vestibular incision subperiosteal tunnel access.

Volume 4 Issue 3 (2025) 37 doi: 10.36922/GTM025220048