Page 52 - GTM-4-3

Global Translational Medicine Evolution of tunneling techniques

In 2020, Karmon et al. introduced a tunneling EPPT completely avoided reflection of any portion of the
18
technique for horizontal ARA using a subperiosteal bag. IBD-associated papilla. 19,45 Instead, a vertical incision was
The technique involved folding, suturing, and perforating shifted to an adjoining tooth. A small full-thickness flap
19
a collagen membrane containing a deproteinized bovine was reflected between the vertical incision and the IBD, and
bone derivative. A vertical vestibular incision was placed the defect-associated papilla was approached in a “tunnel-
adjacent to the alveolar ridge deficiency, through which a like” fashion. Microsurgical scissors and mini-curettes
subperiosteal tunnel was reflected. The bag containing a were used to remove the interproximal granulation tissue.
particulate xenograft was then implanted in the tunnel with Two additional tunneling techniques have been devised
the perforated side facing the alveolar bone. Three patients to access deep IBDs without incision of the defect-associated
received ARA using this technique. Each procedure papilla. Moreno Rodríguez and Caffesse developed the
20
resulted in sufficient alveolar ridge volume for implant non-incised papilla surgical approach (NIPSA). In this
placement, and all patients reported minimal discomfort. procedure, one apical horizontal or oblique incision was

4. Tunnel flaps in regenerative periodontal made within the alveolar mucosa. Through this access,
the granulation tissue was removed, the root surfaces
therapy were debrided, and biomaterials/EMD were implanted. 20,48
In regenerative periodontal surgery, a clear trajectory from In a comparative analysis including NIPSA and MIST
conventional flap techniques toward minimally invasive procedures, the two techniques produced similar clinical
methods has emerged over the last half-century. From the late results. However, NIPSA resulted in lower recession and
20
1960s to the late 1980s, reports were published confirming superior soft-tissue preservation. 20,48 Meanwhile, Pohl and
histologic periodontal regeneration—formation of new Buljan introduced the VISTA technique for regenerative
21
bone, cementum, and periodontal ligament—at intrabony treatment of IBDs. The technique combined VISTA access
periodontal defect sites treated with autogenous bone with application of a bone allograft, EMD, and an SCTG.
implants, bone derivatives, and guided tissue regeneration. 34-37 Favorable clinical outcomes and PROMs were observed.
In subsequent years, skilled clinician–researchers carefully
identified patient-, tooth-, defect-, procedure-, and operator- 5. New tunneling applications in
related factors relevant to the establishment of periodontal periodontics
regeneration. Wound closure, space maintenance, and clot 5.1. Circumferential tunneling in periodontal plastic
38
stability were recognized as surgical prerequisites. 39,40 In the surgery
1990s, variations of conventional mucoperiosteal flaps were
developed to maximize wound closure for primary intention Gingival recession caused by mechanical factors, such as
healing over barrier membranes and biomaterials implanted tooth brushing, is typically restricted to the facial surfaces of
at IBD sites. 41,42 teeth, whereas recession caused by periodontitis can occur
in a circumferential pattern and may be irreversible. 49,50
Later, Dr. Cortellini and Tonetti 43,44 advocated for Nevertheless, clinicians occasionally encounter teeth
increasingly less invasive surgical methods, introducing exhibiting both oral and facial gingival recession defects
43
44
first the MIST, then the M-MIST. Compared with that are not attributable to periodontitis. Although the
conventional flap techniques, these procedures limited vertical height of the interproximal alveolar crest may be
access to the root surface for debridement but emphasized normal, dehiscence defects at oral and facial surfaces may
wound closure and clot stability. 43,44 The M-MIST be present, and the interproximal bone may be thin and
represented a refinement of the original technique to delicate. In such situations, circumferential tunneling is
reduce patient morbidity further, minimize collapse of a potential treatment option for achieving root coverage
the interproximal gingiva, maximize space maintenance, at both facial and palatal/lingual surfaces (Figure 8).
44
and enhance wound/clot stability. It involved reflection Controlled clinical research is needed to establish the
of only a buccal/facial papillary flap. The oral papilla predictability of this method.
remained intact, and the granulation tissue was sharply
dissected from the lingual soft tissue and bone using a 5.2. Multi-surface tunnel preparation in the
microblade and removed using a mini-curette. Favorable treatment of periodontitis
periodontal stability after 10 years of follow-up has been Incorporating gingival augmentation into regenerative
observed at IBDs treated with the M-MIST alone, M-MIST periodontal therapy at periodontal defect sites that
+ EMD, and M-MIST + EMD + bone derivative. 3 demonstrate soft tissue deficiency has been recommended.
51
The M-MIST evolved further with the advent of the Dr. Zucchelli et al. 52,53 proposed the use of the connective
entire papilla preservation technique (EPPT). 19,45-47 The tissue graft wall technique to replace a deficient or missing

Volume 4 Issue 3 (2025) 44 doi: 10.36922/GTM025220048