CLINICAL ARTICLE

Modified Tunnel Technique Combined with Enamel Matrix

Derivative: A Minimally Invasive Treatment for Single or
Multiple Class I Recession Defects
SÉVERINE VINCENT-BUGNAS, DDS, PHD*, YVES CHARBIT, DDS, PHD†, JULIE LAMURE, DDS, MSC‡,
PATRICK MAHLER, DDS, PHD§, MICHEL M. DARD, DDS, PHD¶

ABSTRACT
Purpose: Gingival recession is a significant problem in the esthetic zone. Connective tissue grafts have been considered
the gold standard, but they need a donor site that increases morbidity and discomfort for the patient.The purpose of
the present study was to evaluate the clinical results of a modified tunnel technique that consists of replacing the
connective tissue graft by enamel matrix derivative, in the treatment of Miller Class I recession defects.
Materials and Methods: Twenty-six teeth in 14 subjects with Miller Class I recessions were treated using the tunnel
procedure plus enamel matrix derivative. The gingival recession, probing depth, clinical attachment level, and the width
of the keratinized gingival tissue were recorded.
Results: There was a statistically significant reduction in gingival recession (88% of root coverage) and a gain in clinical
attachment level (3.1 mm) between baseline and 24 months post-operatively, whereas the change in width of
keratinized tissue and in probing depth was not statistically significant. All patients were satisfied with the esthetic
appearance and would undergo the same surgery again.
Conclusion: This technique could be successfully used as an alternative to connective tissue grafts, with the advantage
of avoiding the discomfort and morbidity of connective tissue harvesting.

CLINICAL SIGNIFICANCE
This modified tunnel technique using enamel matrix derivative potentially represents a clinically and esthetically
satisfactory treatment of Miller Class I recession defects.
(J Esthet Restor Dent 27:145–154, 2015)

INTRODUCTION pedicle grafts,4 double papillae flaps,5 coronally

Gingival recession (GR) is an important challenge in
creating a natural-looking smile. Several techniques
have been proposed for root coverage, such as free
gingival grafts,1 guided tissue regeneration,2
subepithelial connective tissue grafts (SCTG),3 lateral
advanced flaps (CAF),6 and acellular dermal matrix
grafts.7 Among them, the tunnel connective tissue graft
was presented as an alternative due to its less invasive
approach and quick healing aspects for root coverage.8
However, this procedure requires a second surgical site
to harvest the tissue and therefore is associated with

*Associate Professor, Pole of Odontology, Department of Periodontology, Nice University Hospital, Nice, France. Nice-Sophia Antipolis University, MICORALIS EA7534,
Nice, France
†
Head of Department of Periodontology, Associate Professor, Pole of Odontology, Department of Periodontology, Nice University Hospital, Nice, France
‡
Assistant Professor, Pole of Odontology, Department of Periodontology, Nice University Hospital, Nice, France. Nice-Sophia Antipolis University, MICORALIS EA7534,
Nice, France
§
University Professor, Pole of Odontology, Department of Periodontology, Nice University Hospital, Nice, France
¶
University Professor, Department of Periodontology and Implant Dentistry, College of Dentistry, New York University, NY 10010, USA

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 TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al
undesirable side effects like post-operative pain,
discomfort, and potential post-operative bleeding.
Currently, quantitative root coverage is no longer the
ultimate treatment goal of recession defects: qualitative
criteria of success, such as the chromatic and texture
integration of the covering tissues, the marginal tissue
contour or scar tissue formation, and the satisfaction of
patients, are parameters to be considered and
evaluated.9 In fact, a good result is now described as
complete root coverage associated with minimal
probing depths (PDs) and pleasing esthetics.10–12
In order to perform surgery in the treatment of GR as
atraumatically as possible at the recipient and donor
site, the use of enamel matrix derivative (EMD)
(Emdogain®, Straumann, Basel, Switzerland) has been
reported as an adjunct to periodontal plastic surgery.
This device is composed of freeze-dried enamel matrix
proteins obtained from the developing crown of a
6-month-old piglet. These proteins are industrially
isolated, treated, and, after their final purification stage,
solubilized under the form called EMD within a
hydrogel. This proteins complex is reported to stimulate
and promote the formation of new connective tissue,
alveolar bone, periodontal ligament. and cementum.13
Periodontal regeneration through the application of
EMD is thought to occur by mimicking the
embryological events leading to the normal
development of periodontal tissues.14,15
The application of EMD on root surfaces, in surgical
therapy, results in substantial regeneration of
periodontal tissues thus improving the clinical
outcomes in intrabony defects, recessions, and Class II
furcation defects.16 Recent characterization of the
molecular composition of EMD confirms that
amelogenin proteins, including their enzymatically
cleaved and alternatively spliced fragments, dominate
the protein complex (>95%). A small presence of
ameloblastin fragments has been reported too, and
cumulative evidence indicates that EMD can affect and
enhance gene expression, protein production,
proliferation, and differentiation of various cell types,
146 Vol 27 • No 3 • 145–154 • 2015 Journal of Esthetic and Restorative Dentistry
particularly for periodontal ligament and osteoblastic
cells.17
Moreover, EMD may promote superoxide production
and chemotaxis but reduces matrix metalloproteinase-8
expression by polymorphonuclear leukocytes that
suggest potential for enhancement of wound healing,
bacterial and tissue debris clearance, and suppress
tissue damage and degradation.18
The bioactive component EMD results in significant
stimulation of microvascular primary endothelial cell
proliferation and so acts as a proangiogenic factor in
vitro and, as such, might contribute to periodontal
tissue healing and regeneration by stimulation of vessel
formation. It is likely that EMD stimulates angiogenesis
directly by affecting the production of angiogenic
factors via periodontal ligament cells.19 A recent in vivo
study confirmed the angiogenic activity of EMD on
wound-healing sites.20
The following study describes minimally invasive plastic
surgery using the tunnel technique, complemented by
the application of EMD in the treatment of Miller Class
I single or multiple recession defects, with a clinical
follow-up of 24 months post-operatively.
MATERIALS AND METHODS
Patients
Fourteen patients, eight females, and six males (22–58
years old), in good general health and all non-smokers,
were recruited in the Department of Periodontology at
the Nice University Hospital, from January 2010 to
January 2012. After giving informed consent, the
procedure was conducted in accordance with the
Helsinki declaration of 1975, as revised in 2000.
All patients selected for the study had from Miller Class
I recession defects and requested surgical root coverage
procedure for esthetic reasons, and sometimes
hypersensitivity. None of them showed signs of
destructive periodontal diseases and all received oral
hygiene instructions.
DOI 10.1111/jerd.12170 © 2015 Wiley Periodicals, Inc.

Clinical Measurements
Before surgery, supragingival plaque was calculated
according to the plaque index (PI) systems, and only
patients with a PI lower than 0.6 qualified for the
operation.
All clinical examinations were performed by the same
periodontist at baseline (immediately before surgery)
and at 6, 12 and 24 months post-surgery (Table 1). The
following measurements were recorded using a UNC
probe to nearest 0.5 mm.
The height of GR was measured from the
cementoenamel junction to the gingival margin. The
PD of the buccal side of the teeth was measured
between the gingival margin and the bottom of the
pocket. The clinical attachment level (CAL) was the
distance between the cementoenamel junction and the
bottom of the pocket. The width of keratinized tissue
(KT) was measured between the gingival margin and
the mucogingival junction.
Surgical Procedure
All the patients were treated with the same procedure,
which is illustrated by the clinical case in Figure 1. After
local infiltration of 2% lidocaine containing 1:200,000
epinephrine (Astra, Westborough, MA, USA), the
exposed root was scaled and planed with periodontal
curettes and ultrasonic hand instruments. If necessary,
the root surfaces were reshaped with a smooth
diamond bur and polished. The preparation of the
recipient bed for adjacent areas of recession was based
on the construction of a tunnel under the gingival
tissue with minimal trauma.
The sole incision at each recession site was made
through the sulcus with a 15°C surgical blade, without
any external incisions, thus without affecting the
gingival papillae.
The tunnel was formed by partial thickness dissection
apical to the mucogingival junction in order to
coronally advance the flap. It was then extended
laterally through the papillae with a papilla elevator,
© 2015 Wiley Periodicals, Inc. DOI 10.1111/jerd.12170
TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al
3 mm mesially and distally from the lateral teeth, while
keeping the tip of the interproximal papillae attached to
the teeth apical to the proximal contact point. The
exposed root surface was treated with a 24%
ethylenediaminetetracetic acid gel for 2 minutes
(PrefGel®, Straumann, Basel, Switzerland) and rinsed
copiously with sterile saline solution. Then suspended
pre-sutures, using 5.0 bioabsorbable sutures (Vicryl®,
Ethicon, Inc., Somerville, NJ, USA), were placed for
each recession area. The sites were carefully dried by
inserting small pieces of gauze in the pouch created by
the flap (Figure 2). The gauze was then removed just
before applying EMD on the root surface, inside the
tunnel, and in an apico-coronal direction so that no
blood was then present (Figure 3). The flap was
advanced to the cementoenamel junction level and the
suspension pre-sutures were tied (Figure 4).
Post-operative care consisted of a rinsing with 0.12%
chlorhexidine gluconate twice daily for 2 weeks and
analgesic medication (acetaminophen 1,000 mg
prescribed and taken by the patients, as necessary). The
patients were advised not to brush in the area of
surgery until the removal of the sutures at 2 weeks.
Patients were subsequently examined at 3, 6, 12, and 24
months post-surgically (Figures 5 and 6). At 6 and 24
months post-operatively, the treated areas were
evaluated for GR, PD, CAL, and width of KT just as
performed at baseline. Patients were asked if they were
satisfied with the appearance of the operated site, and if
they would undergo the same surgery again.
Statistical Analysis
Statistical analysis was performed using software
(Statview® 5.0, Statview for Windows; SAS Institute Inc.
Copyright©, Cary, NC, USA). The unpaired t-test was
used to check the significance of the change between
baseline and at 24 months. A 95% confidence level was
considered with p = 0.05.
RESULTS
In our study, five patients had single tooth recession, six
patients had two adjacent teeth recessions, and three
patients needed coverage for three adjacent teeth. For
Journal of Esthetic and Restorative Dentistry Vol 27 • No 3 • 145–154 • 2015 147
148
TABLE 1. Clinical parameters of each patient at baseline, 6 months, and 24 months

Vol 27 • No 3 • 145–154 • 2015

Patient  Tooth  Baseline 6 months 24 months Change at 24 months

GR PD CAL KT GR PD CAL KT GR PD CAL KT GR PD CAL KT

1 10 2.5 1.5 4 3 0 1 1 3.5 0 1 1 3 2.5 0.5 3 0

11 3 1 4 2 0 1 1 3 0 1 1 3 3 0 3 1

2 12 4 2 6 2 1 1.5 2.5 2 1 1 2 3 3 1 4 1

3 10 4 1 5 3 0.5 1 1.5 4 1 1 2 4 3 0 3 1

11 3 2.5 5.5 4 1 2 3 5 0.5 2 2.5 5 2.5 0.5 3 1

Journal of Esthetic and Restorative Dentistry

4 27 3.5 1 4.5 3 0 1 1 4 1 1 2 4 2.5 0 2.5 1
TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al

28 4 2 6 3 0.5 2 2.5 4 0 1 1 4 4 1 5 1

5 6 3 1 4 2 1 1 2 3 0.5 1 1.5 3 2.5 0 2.5 1

5 3.5 2 5.5 3 0.5 2 2.5 3 0 2 2 3 3.5 0 3.5 0

4 3.5 1 4.5 3 0.5 1 1.5 3 0.5 1 1.5 3 3 0 3 0

6 11 2.5 1 3.5 3 0 1 1.5 2 0 1 1.5 2 2.5 0 2 0

12 3 2 5 4 0 2 2 4 0 1 1 4 3 1 4 0

13 2.5 2 4.5 4 0 1 1 4 0 1 1 4 2.5 1 3.5 0

7 5 3 1.5 4.5 3 0 1 1 3 0 1 1 4 3 0.5 3.5 1

DOI 10.1111/jerd.12170
4 3 1.5 4.5 3 0 1 1 3 0 1 1 3 3 0.5 3.5 0

© 2015 Wiley Periodicals, Inc.

© 2015 Wiley Periodicals, Inc.
TABLE 1. Continued

Patient  Tooth  Baseline 6 months 24 months Change at 24 months

GR PD CAL KT GR PD CAL KT GR PD CAL KT GR PD CAL KT

DOI 10.1111/jerd.12170
8 6 4 2 6 2 1 1 2 3 1 1 2 3 3 1 4 1

9 29 3.5 2.5 6 2 0.5 2 2.5 3 1 2 3 3 2.5 0.5 3 1

10 10 2 1 3 2 0 1 1 2 0 1 1 2 2 0 2 0

11 3 1 4 2 1 1 2 2 0 1 2.5 2 3 0 1.5 0

11 13 4 1.5 5.5 3 0 1.5 1.5 4 0.5 1 1.5 4 3.5 0.5 4 1

12 7 2 1.5 3.5 2 0 1.5 1.5 2 0 1.5 1.5 2 2 0 2 0

6 3 1.5 4.5 2 0.5 1.5 2 2 0.5 1.5 2 2 2.5 0 2.5 0.5

5 3 1.5 4.5 3 0 1 1 3 1 1.5 2.5 3 2 0 2 0

13 27 3.5 2 5.5 2 0 1 1 2 0 1 1.5 2 3.5 1 3 0

14 11 4 1.5 5.5 3 0 1 1 3 0 1 1 3 4 0.5 4.5 0

12 3 1 4 3 0 1 2 3 0 1 1.5 3 3 0 2.5 0

GR = gingival recession (mm); PD = pocket depth (mm); CAL = clinical attachment level (mm); KT = keratinized tissue (mm).

Journal of Esthetic and Restorative Dentistry

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149
 TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al
FIGURE 1. Miller Class I recession on the upper right first
premolar.
FIGURE 3. Enamel matrix derivative (EMD) application
inside the envelope flap.
the five patients with only one recession, we performed
a pouch technique, and for the other nine, a tunnel
technique. We pooled the results because of the
similarity of the two procedures (the tunnel is only the
succession of several pouches), and the homogeneity
of the initial recessions: 3.2 mm ± 0.6 mm. The values
and changes for the clinical parameters at baseline
and 24 months post-operatively are reported in
Table 2.
Height of GR
The baseline mean recession depth of 3.2 mm ± 0.6 mm
was reduced to 0.3 mm ± 0.4 mm at 24 months
(p < 0.0001). This indicates a reduction of
150 Vol 27 • No 3 • 145–154 • 2015 Journal of Esthetic and Restorative Dentistry
FIGURE 2. Root surface dried with a piece of gauze.
Pre-sutures are done.
FIGURE 4. Coronally advanced flap with sutures.
2.9 mm ± 0.6 mm at 24 months, with mean root
coverage of 93% at the end of the study.
PD
PD remained shallow over time. It changed from
1.6 mm ± 0.5 mm to 1.2 mm ± 0.3 mm at 24 months
with a mean reduction of 0.4 mm ± 0.4 mm (p = 0.05).
CAL
The mean value at baseline was 4.7 mm ± 0.9 mm and
1.6 mm ± 0.6 mm at 24 months. So there was a
statistically significant gain in CAL of 3.1 mm ± 0.9 mm
at the end of the study (p < 0.0001).
DOI 10.1111/jerd.12170 © 2015 Wiley Periodicals, Inc.

FIGURE 5. Twelve months post-operative.
FIGURE 6. Twenty-four months post-operative.
Width of KT
Keratinized gingiva increased from 2.7 mm ± 0.7 mm to
3.1 mm ± 0.8 mm at 24 months. The mean gain was
0.4 mm ± 0.5 mm in 24 months; however, this
difference was not statistically significant
(p = 0.19).
Overall, there was a statistically significant reduction in
GR and a gain in CAL between baseline and the
24-month post-operative visit, whereas the change
in PD and in width of KT was not statistically
significant.
All patients reported minimal discomfort in the
post-operative period.
© 2015 Wiley Periodicals, Inc. DOI 10.1111/jerd.12170
TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al
Satisfaction
All patients were very satisfied with the esthetic
appearance and would undertake the surgery again, if
necessary, on another tooth.
DISCUSSION
Recent advances in periodontal plastic surgery have
encouraged a reassessment of the tunnel technique (for
multiple adjacent recessions) and its modified version,
the pouch technique (for single-tooth recession):21
tunnel techniques are one method of protecting the
papillae and improving esthetics. The graft was placed
directly on the exposed root surface, inserted into a
recipient bed prepared by split-thickness dissection
without external incisions and flap elevation. The
“tunnel flap” could then be sutured to its initial
position,8 or coronally positioned22 in order to cover the
graft totally. The use of EMD in less invasive root
coverage procedures such as pedicle flaps was proposed
as an alternative to connective tissue grafts to treat
GR.23
In 2011, a meta-analysis based on 22 randomized
controlled clinical trials with a follow-up superior or
equal to 6 months, and including 320 patients,
evaluated 16 procedures of Miller Class I or II root
coverage. SCTG, matrix grafts, and EMD procedures
were superior to CAF in achieving complete root
coverage, but SCTG showed the best predictability.24
Recently, a consensus report of the 10th European
Workshop on Periodontology showed that for single
recessions, the addition of autologous SCTG or EMD
under CAF improves complete root coverage and may
be considered the procedure of choice for maxillary
anterior and premolar teeth.25
Moreover, a systematic review including 53 articles,
corresponding to 1,574 patients and 1,744 recessions,
showed that EMD is a useful biomaterial in current
periodontal plastic surgery, which improves the efficacy
of CAF alone and which is supported by large evidence
in modern periodontal plastic surgery.26
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 TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al
TABLE 2. Measurement of clinical parameters at baseline and 24 months
Clinical parameters Initial examination
(mm; mean ± SD)
Gingival recession depth (mm) 3.2 ± 0.6
Probing depth (mm) 1.6 ± 0.5
Clinical attachment level (mm) 4.7 ± 0.9
Keratinized tissue width (mm) 2.7 ± 0.7
*Statistically significant at p < 0.05.
Similarly, a meta-analysis has shown that additional use
of EMD with a CAF for recession coverage gives
superior results in comparison to control, but is as
effective as a connective tissue graft.27
The results of a randomized controlled clinical study
comparing treatment of Miller Class I and II recessions
showed that over 2 years, complete root coverage could
be maintained in 53% of the EMD group versus 23% in
the control group.28 Furthermore, 47% of the recessions
in the control group deteriorated again in the second
year after therapy compared with 22% in the EMD
group, thus suggesting that EMD may provide better
long-term results.
In 2012, McGuire and colleagues showed in a
split-mouth randomized controlled trial over 10 years
that treatment with either CAF + EMD or CAF + SCTG
for Miller Class I and II recessions appears stable,
clinically effective, and similar to each other on all
measured parameters.29
Comparable results were reported in a subsequent
randomized controlled clinical study30 where the test
sites demonstrated significantly better root coverage
compared with the control groups (i.e., 92.9% root
coverage at the test sites versus 66.8% in the controls at
6 months). The same outcomes were also obtained by
other groups with a root coverage in test and control
groups respectively of 84% versus 67%,28 84% versus
54%,31 88.6% versus 62.2%,23 and 93.8% versus 66.5%.32
We found a mean root coverage rate of 93%, which is
consistent with these data.
152 Vol 27 • No 3 • 145–154 • 2015 Journal of Esthetic and Restorative Dentistry
Final examination Changes (mm; mean ± SD) p value
(mm; mean ± SD) in clinical parameters at
baseline and at 24 months
0.3 ± 0.4 −2.9 ± 0.6 p < 0.0001*
1.2 ± 0.3 −0.4 ± 0.4 p = 0.05
1.6 ± 0.6 +3.1 ± 0.9 p < 0.0001*
3.1 ± 0.8 +0.4 ± 0.5 p = 0.19
Moreover, a number of reports published on recession
treatment emphasize the size of the pre-surgical defect
and its effect on clinical outcomes; in other words, the
deeper and narrower the defect, the greater the
achieved root coverage. Deeper recessions (i.e., 4 mm
or more) had greater attachment level gains than
shallow recessions. In our study, we have only included
Miller Class I recessions, with a mean recession
depth of 3.2 mm ± 0.6 mm, i.e., shallow recessions,
which generally have a worse prognosis of root
coverage. In the present investigation, we possibly could
have had even better results by including deeper
recessions. Despite the results of Cordaro and
colleagues, which showed that the use of EMD does
not significantly improve the results of a CAF
procedure for the root coverage of multiple recessions,33
the available data suggest that the application of
EMD may enhance the outcome of root coverage
procedures, and the additional application of a
connective tissue graft seems to further enhance
the formation of KT.34 To date, a connective tissue
graft is still considered the gold standard for root
coverage and results in a significant gain of keratinized
gingiva.26
In this study, we suggest modifying the tunnel
technique or pouch technique by replacing the
connective tissue graft with EMD, which is injected into
the created recipient area of the flap and thus simplifies
the approach to correction. Our preliminary results
indicate that this single procedure can produce
significant improvement in the studied clinical
parameters, with mean root coverage of 88%, and
DOI 10.1111/jerd.12170 © 2015 Wiley Periodicals, Inc.

allows for a satisfactory esthetic outcome. However, the
width of keratinized gingiva remains limited.
A recent study has shown that plasma proteins from
blood alter the ability of EMD to adsorb to root
surfaces.35 In our opinion, this modified procedure led
to good wound healing partly thanks to the high
vascularization of the flap but also because, with this
minimal procedure, excessive bleeding is prevented and
therefore EMD is in direct contact with the root to be
covered. Moreover, thanks to the design of the tunnel,
the EMD remains close to the root and excessive
leakage of the gel out of the surgical site is avoided.
Treating multiple teeth in a single appointment is
also possible using this tunnel technique plus EMD.
Finally, it is less traumatic for the patient, requiring
only one surgical site, is quicker and easier to perform
for the practitioner, and presents low patient morbidity
and discomfort. All of the patients were satisfied
and would repeat the procedure elsewhere if
necessary.
CONCLUSIONS
This study deals with the use of an original, minimally
invasive, periodontal plastic surgery variation of the
tunnel technique, with the addition of EMD in the
treatment of Miller Class I recession defects. This single
procedure provides root coverage and gain of clinical
attachment with esthetic results at 24 months.
Moreover, it does not require a second surgical site.
Avoiding harvesting from the palatal donor site
decreases post-operative morbidity; therefore, recovery
is simplified, with minimal pain reported by patients.
Lastly, chair time is decreased for the surgeon
because of the ease of this procedure. Within the limits
of this study, this technique could be successfully
used as an alternative to connective tissue grafts to
cover Class I single or multiple recession defects.
Although only a few cases were treated using this
procedure, the results are encouraging. Further studies
that compare results of this technique with already
established protocols are necessary to support its
regular use.
© 2015 Wiley Periodicals, Inc. DOI 10.1111/jerd.12170
TUNNEL TECHNIQUE PLUS EMDOGAIN Vincent-Bugnas et al
DISCLOSURE AND ACKNOWLEDGEMENTS
The authors do not have any financial interest in the
companies whose materials are included in this article.
We also thank Ms. Jane Fenner-Magnaldo, University of
Nice-Sophia Antipolis, for writing assistance and
manuscript review in English.
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Reprint requests: Séverine Vincent-Bugnas, DDS, PhD, Pole of
Odontology, Department of Periodontology, Nice University Hospital, 5
Rue Pierre Dévoluy, Hôpital Saint Roch, Pôle Odontologie, 06000 Nice,
France; email: severine.vincent@unice.fr
DOI 10.1111/jerd.12170 © 2015 Wiley Periodicals, Inc.