Tunneling Technique with CTG for Gingival Recession with NCCLs
Yes, the tunneling technique with CTG is viable for treating gingival recession from toothbrush abrasions with NCCLs, but the coronally advanced flap (CAF) with CTG is superior and should be your first choice. 1, 2
Primary Recommendation: CAF with CTG Over Tunneling
The coronally advanced flap with connective tissue graft remains the gold standard, achieving 70-92% root coverage with superior long-term stability compared to tunneling techniques. 1 When directly compared using the same graft material (CTG or acellular dermal matrix), CAF demonstrates higher rates of complete root coverage than tunneling. 2
Why CAF Outperforms Tunneling
- CAF with CTG achieves complete root coverage in a higher percentage of cases when the same graft materials are compared head-to-head. 2
- Long-term stability is superior with autogenous CTG approaches, maintaining 89.35% coverage at 5 years. 3, 1
- The critical determinant of success is achieving gingival thickness ≥1.46mm at 6 months, which predicts long-term gingival margin stability regardless of technique. 3, 1
When Tunneling May Be Considered
The tunneling technique can be viable in specific scenarios:
- For multiple adjacent recession defects, where tunneling shows mean root coverage of 87.87 ± 16.45%. 2
- In maxillary defects and Miller Class I-II recessions, where tunneling demonstrates superior outcomes. 2
- When microsurgical approach with split-thickness flap preparation is used, as this enhances tunneling outcomes. 2
Tunneling Performance Data
- Overall mean root coverage with tunneling is 82.75 ± 19.7% for localized defects and 87.87 ± 16.45% for multiple recessions. 2
- Tunneling and CAF show comparable outcomes only when different graft materials are used between groups, making direct comparison difficult. 2
Critical Success Factors for Either Technique
Tissue Thickness Requirements
You must achieve at least 1.46mm gingival thickness at 6 months to ensure long-term stability, as thin soft tissue will recede regardless of bone level or initial coverage achieved. 3, 1
- At least 1.5mm of keratinized tissue width is required in addition to adequate thickness. 3, 1
- Soft tissue phenotype modification is more important than periodontal regeneration for preventing long-term recession relapse. 3
Managing the NCCL Component
Restore the NCCL prior to surgery to create a smooth surface for graft adaptation:
- Nanofilled composite resin or resin-modified glass ionomer cement both achieve approximately 71% defect coverage when combined with CTG. 4
- Partial restoration (crown zone plus 1mm of NCCL) combined with CTG achieves 70% ± 20.2% combined defect coverage. 5
- For deep cervical abrasions >1mm, consider double CTG technique without additional tooth grinding to avoid hypersensitivity. 6
Surgical Protocol Essentials
Technique-Specific Considerations
- If using tunneling, employ split-thickness flap preparation and microsurgical approach to optimize outcomes. 2
- For CAF with CTG, this achieves complete root coverage and resolution of hypersensitivity with stable 19-year follow-up data. 6
- Initial keratinized tissue width ≥2mm significantly improves outcomes, with mean root coverage of 83% and 50% complete coverage rates. 7
Post-Operative Management
Restrict to soft food with no biting/chewing in treated area for 1 week, and rinse with 0.12% chlorhexidine twice daily for at least 3 weeks starting day 3. 1
Critical Pitfalls to Avoid
Do not proceed with either technique in thin phenotype cases without planning for adequate tissue thickness augmentation, as this leads to significant recession recurrence over 5 years. 3, 1
- Thin soft tissue is prone to recede with inflammation and traumatic toothbrushing regardless of underlying bone level. 3
- Growth factor approaches (rhPDGF-BB) show significant reduction from 89.85% coverage at 6 months to 74.10% at 5 years, making them inferior to autogenous CTG. 3, 1
- Giomer restorations may be less effective than composite or RMGI for combined surgical/restorative treatment. 4