Page 46 - GTM-4-3

Global Translational Medicine Evolution of tunneling techniques

Table 1. Evolution of tunneling procedures in periodontics

Year Authors Procedure
Periodontal plastic surgery
1985 Raetzke 4 Envelope technique. Applicable to isolated recession defects.
1994 Allen 5 Supraperiosteal envelope. Applicable to single and multiple adjacent recession defects. Sharp dissection when
tissue thickness permitted.
1999 Zabalegui et al. 6 Tunnel subepithelial connective tissue graft. Partial-thickness dissection beyond the mucogingival junction. Use
of sutures for graft positioning.
2007 Zuhr et al. 7 Modified microsurgical tunnel technique. Use of specialized tunneling knives with sharp edges toward the periosteum.
2010 Allen 8 Subpapillary continuous sling suturing method. Use of a single continuous suture to stabilize both the acellular
dermal matrix and the overlying tunnel flap.
2010 Aroca et al. 9 Modified coronally advanced tunnel. Composite stops at proximal contact areas to facilitate suturing. Use of a
specialized knife-elevator instrument for tunnel preparation. Application of ethylenediaminetetraacetic acid and
enamel matrix derivative. Papillae are freed from the interproximal alveolar crest. Mucoperiosteal dissection
extended beyond the mucogingival junction.
2011 Zadeh 10 Vestibular incision subperiosteal tunnel access (VISTA) technique. Use of vertical vestibular incisions to facilitate
subperiosteal tunnel reflection. Use of polypropylene sutures bonded to the facial surfaces of the teeth.
2012 Chao 11 The pinhole surgical technique. Use of specialized transmucosal papilla elevators to reflect full-thickness
mucoperiosteal flaps through small incisions in the alveolar mucosa. Stabilization of marginal tissue in coronal
position by implanting absorbable porcine collagen membrane strips.
2020 Allen 12 Papilla access tunnel. Reflection of papilla to facilitate tunnel preparation in the presence of shallow recession
defects and thin tissue.
2023 Marques et al. 13 Mixed-thickness tunnel access. Vertical incisions terminating apical to the mucogingival junction. Split-thickness
separation of the alveolar mucosa from the underlying muscles. Full-thickness tunnel flap reflected from the
mucogingival junction to the gingival margin. Papilla tip intact.
Alveolar ridge augmentation
2007 Kfir et al. 14 Use of a tunnel created using a series of balloon inflations for guided bone regeneration (GBR).
2009 Nevins et al. 15 Tunneling technique for alveolar ridge augmentation involving vestibular incisions to create subperiosteal
pouches into which recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and various
biomaterials were implanted. No barrier membrane.
2017 Lee 16 Subperiosteal minimally invasive esthetic ridge augmentation technique. Similar to the method described by
Nevins et al. Implantation of anorganic bovine bone mineral (ABBM) and rhPDGF-BB. No barrier membrane.
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2018 Johnson and Tunnel access for GBR in the maxillary anterior. Intrasulcular and vestibular incisions to facilitate subperiosteal
Baron 17 tunnel preparation. Use of a dense polytetrafluoroethylene membrane and an allogeneic bone derivative.
2020 Karmon et al. 18 GBR tunneling technique involving placement of a subperiosteal bag—a perforated, folded, and sutured collagen
membrane filled with ABBM.
Regenerative periodontal surgery
2017 Aslan et al. 19 Entire papilla preservation technique. A “tunnel-like” approach to papillae at intrabony defect (IBD) sites.
2018 Moreno Rodríguez Non-incised papilla surgical approach. Defect-associated papillae remain completely intact. IBDs are accessed
and Caffesse 20 through a single horizontal or oblique incision in the alveolar mucosa.
2023 Pohl and Buljan 21 VISTA approach to periodontal regeneration. IBDs are accessed through a single vertical vestibular incision.

2. Tunnel flaps in periodontal plastic epithelium, the root surface was scaled and planed, and
surgery citric acid was applied to condition the root. A partial
thickness envelope was created, extending apically several
2.1. Early tunnel flap techniques millimeters beyond the gingival margin and laterally to
Although not originally termed a tunnel flap, the the line angles of adjacent teeth. A small subepithelial
“envelope” technique, introduced by Raetzke in 1985, connective tissue graft (SCTG) was harvested, tailored to
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involved maintenance of the integrity of the interdental the dimensions of the recipient site, implanted within the
gingiva. In this technique, the marginal gingiva adjacent envelope, and stabilized with a tissue adhesive rather than
to the recession defect was excised to remove the sulcular sutures. After treating 12 recession defects in 10 patients,

Volume 4 Issue 3 (2025) 38 doi: 10.36922/GTM025220048