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Global Translational Medicine Evolution of tunneling techniques

A B C

D E F

G H I

Figure 9. Multi-surface tunnel preparation for the connective tissue graft wall technique. (A) Lingual recession at mandibular central incisors. The left central
incisor exhibited 9-mm probing depths at the mesiolingual and direct lingual aspects. (B) Intrasulcular incisions were made with ophthalmic microblades,
and a lingual subperiosteal tunnel was established to facilitate debridement of the defect, thorough root planing, and positioning of a de-epithelialized
gingival graft (DGG). (C) The tunnel preparation extended to the interproximal and facial surfaces to permit complete instrumentation of the affected
root surfaces and coronal advancement of the midline papilla. (D) Appearance of the root surface after debridement. (E) The DGG was harvested from
the palate, de-epithelialized extraorally, and tailored to the dimensions of the site. (F) A demineralized freeze-dried bone allograft (DFDBA) was applied
through the facial tunnel access against the lingual connective tissue graft wall. The DFDBA helped maintain the midline papilla in a coronal position.
The DGG and lingual tunnel flap were stabilized using a subpapillary continuous sling suture (7-0 polyglycolic acid). (G) Immediate post-operative
appearance, facial view. The two mandibular central incisors were splinted, and occlusion was adjusted to avoid excessive force on the affected tooth.
(H) 3 months following the procedure, all probing depths were ≤3 mm. (I) Facial view of mandibular anterior teeth 3 months following the procedure.

Evidence supporting tunnel-based ARA procedures is Despite generally consistent reports that tunneling can
limited to case reports/series. 14-18 However, positive results favorably influence PROMs, available evidence does
documented in initial reports suggest that controlled not imply that tunnel procedures should completely
clinical studies are warranted. The most common post- replace more established methods. Thus, students must
operative complication of GBR is wound dehiscence and become proficient in using both conventional and tunnel
membrane exposure at the incision line. It is possible flap designs. However, tunnel-based procedures may
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that accomplishing GBR without the need for a horizontal be more technique-sensitive and thus challenging for
incision at the alveolar crest may reduce the occurrence of inexperienced operators. A reasonable approach may be to
wound dehiscence. Achieving ARA using a subperiosteal start new residents using conventional flaps and introduce
tunnel may also simplify closure, reduce the procedure tunneling after the students have gained additional surgical
duration, and limit patient morbidity. experience and confidence.
Tunnel applications in regenerative periodontal surgery Multiple tunnel-based procedures have utilized
represent iterations of prior minimally invasive procedures specialized surgical instruments. For example, in
that have been validated through long-term clinical the modified microsurgical tunnel technique, Zuhr
investigation. 3,41,42 All these procedures balance two critical et al. utilized special tunneling knives during tunnel
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concerns—clot stability and access to the root surface for preparation. Meanwhile, Chao and Chao et al. utilized
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addressing the etiology. Additional controlled clinical a specialized transmucosal papilla elevator to accomplish
research and comparative analyses are needed to define the pinhole procedure for root coverage. Both the MiTT
the relative efficacy of emerging techniques. In principle, and the MCAT relied upon specifically designed tunneling
however, the conditions for periodontal regeneration instruments. 9,13,24 Certainly, it is possible to establish a
that clinicians must establish intraoperatively have not tunnel preparation without the benefit of specialized
changed. 37,38 Tunneling is merely a means of establishing instrumentation. Nevertheless, such instruments may
these conditions. augment the operator’s ability to achieve adequate flap
Integrating tunnel-based techniques into graduate reflection and release without causing undue trauma to the
dental education presents a dilemma for educators. delicate marginal gingiva.

Volume 4 Issue 3 (2025) 46 doi: 10.36922/GTM025220048