The Internationai Journal of Penodonlics & Restorative Dentistry

471

The Bilateral Pedicle Flap-Tunnei

Technique: A New Approach to
Cover Connective Tissue Grafts

Rafaei Juan Blanes. DDS, MS' The ultimate gool in the treotment
Edward Patrick Aiien. DDS, PhD" of the soff tissue marginal reces-
sion is the complete coverage of
the denuded root, resulting in on
esthetic ond naturol appeor-
A new surgical technique for the treatment of adjacent soft tissue marginol
recession is presented. This technique cambines the use of a tunnei proce-
ance ofthe newiy gained tissue.'
dure with doublQ lateral pedicle flaps ta cover a connective tissue graft. To occomplish this objective
This approach combines the advantages af the tunnei technique with the many surgioal techniques have
inoreosed blaod supply ond protection pravided by pedicle flaps. been described.^'^ The first
Indications include adjacent Class i and II deep, wide recessions: however, approach, the ioteral siiding flap
the procedure may aiso be applied to miid Class lii reoessions. Two case by Grupe and Worren,^ dates
reports are presented to illustrate this new technique. (Int J Periodontics baok to 195Ó. Although innovo-
Restorative Dent 1999,19:471-479.) tive, ttie technique did not pro-
vide predictable root coverage,
with only 65% to 75% mean root
ooveroge reported.'" Further-
more, it wos inodequate in oases
with a shaiiow vestibule or insutfi-
cient gingival dimensions Iateroi
to the site of recession.
Langer ond Coiagna* intro-
duced q new approach to treot
marginoi tissue recession, the
subepitheiiai oonnective tissue
graft. This technique used a con-
nective tissue groft covered with
•Graduate Resident, Department of Periodontics, Baylor College of
Dentistry Dolías, Texas.
o repositioned spiit-thickness Hap.
"Clinical Protessor, Department of Periodontics, Baylor College of The success reported with this sur-
Dentistry. Dolías, Texas. gioal approach wos attributed to
the double blood supply at the
Reprint requests: Dr Ratoel Juon Blones, 8335 Walnuf Hill Lone, Suite
210, Dallas, Texas 75231.
recipient site trom the underlying

Volume 19, Number 5,1999

472
connective tissue base and the
overiying recipient fiap. ivlodifi-
cations of this fechnique have
been reported, wifh aiferafions in
fhe connecfive fissue flap cover-
age. Raetzke'' designed the
"enveiope" technique, in which
the connective tissue graft was
seafed in an envelope that is cre-
ated in the fissue around fhe
denuded root surface with an
undermining partial-fhickness inci-
sion. The author reported 80%
mean rootcoverage.Alien" pro-
posed a coronaiiy positioned split-
thickness flap in 1993. Nelson,^ in
1987, described a full fhickness-
dcuble papilla flap to cover the
graft. This mefhod was modified
in 1992 by Harris,'^who performed
a spiit thickness-double papiiia
flap, in a later pubiicaticn the
same author reporfed the use cf
the fechnique in 100 consecu-
tiveiy treafed defects with a
mean root coverage of 97.1%.'^^ combined to compensate for fhe
The advanfages of fhe latter 2
techniques inciude highiy pre-
dictable root coveroge and fhe
possibilify of covering the con-
nective tissue graft in situations in
which the coronally positioned
fiap may be contraindicafed,
such as in sites with a shaliow
vestibuiar depth. Allen,' in a mod-
ification of Raetzke's technique,
described the "tunnel"technique,
in which no horizontal or vertical
incisions are made, in sites with 2
adjacent recessions a tunnel
underneath the interproximal
pdpiila is created and the con-
nective tissue graft is drawn
fhrough fhe tunnel and sutured to
The International Journol of Periodantics & Restorative Dentistry
the recipient bed. The use of fhis
technique enabled the author fo
accomplish predictabie roof cov-
erage in shaiiow, narrow reces-
sions with 97% mean root cover-
age, but as fhe depfh and widfh
of the recession increased the
predictability decreased. Mean
root coverage decreased to 75%
when the depth was > 4 mm and
to 76% when the width was
greater than 3 mm.'"Reasons for
fhis incompiete root coverage
might be related to the lack of
biood supply over the exposed
coronal portion of the connec-
tive tissue graft. The coliaterol
biood supply provided by the
enveiope may be sufñcienf in shai-
iow, narrow recessions but not in
wider and deeper recessions.
The purpose of fhis arficie is to
describe a periodontai plastic
surgery procedure where a bilat-
eral pedicle flap and a tunnel are
lack of blood supply fhat fhe fun-
nel technique offers in deep or
wide adjacenf recessions.

fig la Recipient site preparation. Hori-
zontal incisions are pioced at fhe ievel
of the cementoenamei junction. Verfi-
cai incisions at the end of the homantai
incisions extend approximafeiy Wto 12
mm apically. Split-thiciiness laterai pedi-
cie naps are reflected without disturb-
ing the interpraximai papiiia at the mid-
line. The interproximal pdpiiid is under-
mined by sharp dissect ion.
Surgicai procedure
Recipienf and donor site
preparation
Two adjacent Class Hi soft tissue
marginai recessions are pre-
sented as an example, initially the
root surtaces are planed, follov/ed
by citric acid appiicaticn for 30
seconds. After saline irrigation, two
horizontol incisions are piaced ot
the level of the cementoenamei
junction distal to the teeth Vi/ith
recession, extending towdrd the
adjdcent tooth. Vertical incisions
ore piaced at each end of fhe
horizonfal incisions, extending
approximately 10 to 12 mm api-
cally into the alveolar mucosa.
Fig Ib Gratt placement. The graft IS
drawn underneath the papiiia and
sutured wäh interrupted sutures apically
and coronaily. Siing sutures may be
used to secure the graft coronaliy.
Suicuiar incisions are made, stop-
ping at the interproximal papilla.
Spiit-thickness laferai pedicle flaps
are elevated by sharp dissection
without disturbing the midline
interproximal pdpilla. Next, the
midline interproximai popiiia is
undermined by sharp dissection
to oredte a tunnel (Fig 1 a).
A conneotive tissue grdff is
harvested from fhe premolar
region of the right palate foiiow-
ing the technique described by
Bruno.^^
Graft piacemenf
The grdft is positioned over
the recipient site to evdiuafe
473
Fig Ic Lateral pedicle flops are rotat-
ed mesidiy and sutured over the taciai
aspect of fhe rocts wifh siing sufures. The
mesial borders ot the iateroi pedicle
flaps may be sutured to the interproxi-
mal papiiia wifh Interrupted sutures.
adequatefit:the graft is trimmed
as needed. The graff is then
drawn underneath the papilla
with the oid of a suture plooed in
the distal end ot the connective
tissue graff end o tissue forceps af
the other end. Interrupted sutures
pidced both apioaliy and coro-
naliy ore used to secure the graft
to the recipient bed (Fig 1 b). Sling
sutures may be used to addpf fhe
groft coronaily The laterai pedicle
fidps are rotated mesially and
sutured v/ith chromic # 5-0 sling
sutures to cover the entire con-
nective tissue graft (Fig Ic).
Inferrupfed sutures may be used
to secure the pedicle flaps to the
interproximai popula and fo
reduce the Iateroi groft exposure.
Volume 19. Number 5,1999
474
Fig 2a Case I • a 5ó-year-oid patient
with 3-mm mdrginal tissue recession
and a iack of attached gingiva facial
to mandibuiar centrai incisors.
Fig 2d Suturing of the graft to the
recipient bed.
Case 1
A 56-year-old Caucasian waman
presented to fhe Department of
Periodontics at Baylor Ccllege of
Dentistry suffering from discom-
fort upon brushing the mandibu-
iar central incisors. Oral exami-
nation revealed a 3-mm Class lii
recession faciai to these teeth.
There was inadequate attaohed
gingiva and plaque deposits
over the root surfaces of both
The International Journal of Periodontics & Restorative Dentistry
Fig 2b incision design.
Fig 2e Closure Of the pedicle flaps.
teeth (Fig 2a).The etioiogy of the
recession was related to a history
of infiammatory periodontai dis-
ease in the presence of a fhin
periodontium. Initiai therapy,
which Inciuded scaiing, raot
pianing, and poiishing, wifh the
introduction of fhe modified
Stiiiman brushing method, did not
resoive the patient's discomfort.
A connective tissue graft com-
bined with a biiateral pedicle
flap-funnel fechnique was used
Fig 2c Placement of the graft onto
the recipient bed.
Fig 2t Note the root coverage (95%)
and the adequate band af keratinized
tissue 3 months posttieatment.
to correct the mucogingivol
probiem (Figs 2b to 2e), Post-
operative care inciuded chior-
hexidine as a mauthrinse and in
a topical applicatian with a cot-
ton swab twice a day.The patient
was foiiowed up every 2 weei<s
during the firsf month and month-
ly thereafter up to 8 months. Each
recail inciuded removai of
plaque deposits with a prophy
cup and evaluation of healing.
One week after the surgery the

Fig 3a Cose 2: mandibular central
incisors with Class III marginai tissue
recession and a iack af attaohed gingi-
vo in a äö-year-old patient.
Fig 3d No retraction of the flap or graft
hos occurred 2 weeks postoperative.
fig 3e (rigtit) Complète root coverage
has been achieved 6 months postoper-
ative.
graffed area showed fhe typical
pestsurgicoi edema. The resuits
qt the 8-menth evqiuation dis-
cicsed almost cempiete root
coverage and an adequate
band of qffqched gingiva facial
fo bofh teeth (Fig 2f).The petient
reported more comfcrtable
toothbrushing and a satistoctory
Fig 3b Recipient site preparation.
esthetic result. Since thickened
gingivei contours were present
at the final follow-up, a gingivo-
plesty was offered to fhe pafient
to accomplish a more natural
appearance. However, the
patient was satisfied with the
resuits and declined further treot-
ment.
475
Fig 3c Piaoement of the gratt and
ciosure of fhe flaps.
Case 2
A 45-year-old femóle dentist pre-
sented in private practice com-
plaining of e progressive reces-
sion of fhe merginal fissue fociol to
the mandibular central incisors
(Fig 3e). Orei examinatien show-
ed 3-mm Class Hi recession with
Volume 19, Number 5,1999
47Ó
insuffioienf oftaohed gingiva on
fhe fociol aspecfs ot fhese teeth.
Oral hygiene was exceilent ond
the tissues were free of inflam-
mation. A connective tissue graft
harvested from the tuberosity re-
gion was used with the biioteral
pedicle flap-tunnel technique to
treot this probiem (Figs 3b and
3c). The patient was advised to
ovoid brushing ond mostiootion
at the grafted site for 3 weeks and
was evaiuated at 2 weeks and 1,
2, 3, and ó months postsurgiool.
Compiete survivai of the graft
without retraction of the tlap wos
nofed at 2 weeks (Fig 3d) and
complete root coveroge was
apparent and remained through
ó months (Fig 3e).
Discussion
Predictabie root ooverage in
shaiiow (< 3 mm), narrow Class I
to li recessions with the suprope-
riosteal pouch technique has
been shown to be excellent, with
97% mean root coverage.'''
However, as the depth ond width
of the recession increased the
prediotabiiity deoreased. Mean
root coverage deoreased to 75%
when the depth was greoter
thqn 4 mm and to 7ó% when the
width was greater than 3 mm.
The teohnique described in this
article is o modification of the
supraperiosteal pouch tech-
nique to provide a greoter blood
supply to the graft and thus more
predictable root coverage. This
modification includes the use of
The Internationol Journal ot Periodontics & Restorative Dentistry
2 iateroi pedicle tiaps distal to the
adjacent recessions. This aiter-
ation in the teohnique provides
biood supply to the entire surfooe
of the groff; the original suprape-
riosteal pouch technique pro-
vides double blood supply in the
apicai portion of the groft, but no
blood supply for the exposed por-
tion of the grotf overiying the root
surface. The presenf orficle
presents a combined bilateral
pedicie-tunnel oonneotive tissue
graft thot has resulted in opprox-
imately 95% root ooverage in ó
potients followed for at leqsf ó
months. This new approach to
cover oonnective tissue graffs
offers the foliowing advantoges:
• increased biood supply to the
connective tissue grqft by
covering the grqft compietely
with bilateral pedicle flaps
• Better adaptation and stobility
ot the graft to fhe recipient site
as q resuit of the compressing
etfect of the tunneled infer-
proximal papilla
• Complefe coverage of the
grqft when the coronolly posi-
tioned flap is contrqindi-
coted, such as in a shallow
vestibuie
Prevention of qpicol retrqo-
tion of the overlying flap, os is
commonly seen in the man-
dibular incisor region ond
other sites with q shoiiow
vestibule
• Less surgicql trquma and
more rapid healing by pre-
serving the interproximai
pqpillq

After fhe palafal harvesfing
of fhe connecfive fissue graft a
collar of epitheiium normally
remains as part of fhe graft. In our
coses we ieft the epithelium
undisturbed. Some aufhors hove
hypofhesized thaf when cover-
ing the epithelium with the flap
there is a possibility of cysf forma-
fion.i^ On the other hand, Bouch-
ord and Etienne^' sfudied fhe ef-
fect of ieaving the epithelium
exposed compared fo removing
ttie epifhelium and covering the
entire graft wifh fhe facial flap.
They found betfer esthetic results
with the latter approach, al-
though more keratinized tissue
was gained by leaving the epi-
thelium exposed. No data were
presented when the epithelium
was leff intact and entireiy cov-
ered by the facial flap, as pre-
sented in ihis study. Since there is
no evidence-based dota on the
esthetic and histoiogic impact of
fhis epithelium remnant on the
finol oufcome of fhe grafting pro-
cedure, if is the opinion ot fhe au-
thors that the elimination of the
epifhelium is nat d necessary sur-
gical step. In addition, there is not
certainty that the entire epithe-
lium has been removed when
using a blade for removal.
A partial-fhiokness dissection
of fhe recipienf site was used in
these cases because it was con-
sidered to offer a better blood
supply and ftierefore faster revas-
cularization af fhe connective fis-
sue graff ."^
Allen''' expressed concern
with the use of verfical and
477
horizonfal incisions because fhey
could interfere with the nourish-
ment of the facial flap. He sug-
gesfed thaf lateral and, to a
lesser extent paplllory biocd sup-
ply may be enough fo enhance
graff nutrition to the exposed por-
tion of the graft when using the
tunnel technique. However, fur-
fher blood supply may be
needed in deep and wide reces-
sions to achieve o complete root
coverage, '"^ ond for thot reason
the tunnel procedure may ben-
efit from the use of a pedicle flap.
A coronally positioned flap has
fhe disadvantage of being more
difficult fo combine wifh a funnel
prooedure and sfiii ochieve com-
piefe coverage of fhe graft,
especiaily in deep recessions
with d shallow vestibule. Lateral
pedicle flaps seem to be a bet-
ter selection since they are easy
to combine with the tunnel tech-
nique and require minimal peri-
osteal release, which facilitâtes
their use in a shallow vestibule.
It could be argued that a
double pedicle fiap would be o
more simple procedure to
achieve root coverage. However,
the use of double pedicie flaps
aione in adjacenf recessions
could be contraindicated in
cases where fhe inferproximal
papilla is too narrow, in those ciin-
icai sifuaficns the creation of the
mesial pedicle flaps may ieave
fho flaps more slender, which may
complicafe sufuring and jeopar-
dize their blood supply By com-
bining a tunnel and distal pedicle
flaps, trauma to the interproximal
Volume 19, Number 5,1999
478
papula is minimized, providing
better blood supply to the graft.
"Butt joint" inoisions are pre-
ferred to the beveied graff edges
fhot were advocated in the su-
praperiosteal enveiope tech-
nique.' According to that author,
beveled incisions provide inti-
mate bilaminar oontoot with the
invoived fissues, ensuring better
loterai biood suppiy to fhe graft.
The use of beveled graft edges
seems to be important in the
supraperiosteal envelope tech-
nique since the only biood supply
orises trom the edges of the graft.
With the moditication presented
in this article there is no need fo
bevel fhe edges of fhe graft
since biiaminar biood supply is
provided over the entire graft. In
addition, a butt joint relationship
to ttie recipient site was preferred
fo achieve better marginai
dddptotion of fhe graft to the
reoipient bed. to ensure uniform
connective tissue thickness
throughout the graft, and to pre-
vent any tearing of the graff af
the time ot suturing.
Thickening of the recipient
site after connective tissue graft-
ing has been documenfed.'^
Thdf effect was seen to some
degree in this study, A gingivo-
piasty procedure was offered to
one patient to smooth fhe gingi-
vai contours. The patient, how-
ever, declined that aiternotive
since her concerns were resolved
wifh the firsf surgical procedure.
The indicdfions for fhe use of
the bilaterai pedicie flap-tunnel
technique are: (1) Ciass I to II
The international Journal of Pericdontics & Restorative Dentistry
deep and Vi/ide adjocent soft tis- compietely cover the connec-
sue marginai recession vi/ith shal- tive tissue graff. This opproach
iow vestibuiar depth: (2) Cioss i fo offers a better biood suppiy to
ii deep dnd wide adjdcenf soft fhe graff, vi/hich could enhance
tissue mdrgind! recession with a the predicfabiiity of the tech-
norrow interproximal pdpiiia; or nique in treating Class I and II
(3) Class 111 adjacent soft tissue recessions > 3 mm deep and > 2
marginal recession where some mm wide.
gain in papillary height may be
attempted—this is a c c o m -
plished by undermining the inter-
proximoi tissue and roising it with
o siing suture.
Soft tissue marginai reces-
sions in the mandibular onterior
teeth represent an excelient oiin-
ical indication for this surgioai
technique. The mondibulor ante-
rior sextont normaiiy displays a
shdliow vestibule, a thin peri-
odontium, and multipie adjaoent
soft tissue marginal recessions.
The disruption of the interproxi-
mai papulae could jeopardize
wound heaiing by eariy fiap
retroction ond therefore jeopar-
dize graft survivai. The use ot a
conservative approach such as
the biiateral pedicle fiap-tunnel
technique could improve the
clinicai predictobiiity of com-
plete roof coverage.The resuifs of
fhese ó cases v^^arrant furfher
research to evaiuate the pre-
dictobiiity of this technique in
Ciass i to il deep and wide reces-
sions ond early Ciass ili soft tissue
marginal recessions using a lorger
sample population.
A modification of the previ-
ously described supraperiosteai
envelope connective tissue graft
technique is presented, where bi-
lateral pedicie flaps are used to

References
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Volume 19, Number 5,1999