Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up
Abstract
:1. Introduction
2. Materials and Methods
2.1. Eligibility Criteria
- Healthy individuals;
- Non-smokers;
- Non-diabetics;
- Diagnosed with gingival recession type 1 or 2 (RT1 or RT2) [16].
- Patients with a poor standard of plaque control and demonstrating a lack of ability to maintain a good level of oral hygiene (full-mouth plaque score ≥ 20%);
- Bleeding on probing (BoP) > 10%;
- Questionable long-term prognosis of patient dentition;
- Any mobility;
- Pregnancy;
- Severe cardiovascular disease;
- Taking any medication that may interfere with the healing;
- Malignancy;
- Bleeding disorders.
2.2. MiTT Technique—Preparation Steps
- Systemic health condition compatible with a healthy patient or with controlled disease;
- Non-pregnant;
- If using any medication, it must not harm healing or cause excessive bleeding;
- Adequate blood pressure (lower than 140/90 mmHg recommended);
- The width of the local keratinized tissue width (KTW) remnant is suggested to be at least 1 mm;
- Whether it is a single tooth or multiple teeth with gingival recessions, evaluate the best site for the primary incision or, if necessary, more than one incision;
- Identify the type of recession (RT) [13], which can help with the prediction of the results;
- Verify if there is a step and visible cement–enamel junction (CEJ) [17];
- Verify gingival thickness;
- Verify if there is any bone or soft tissue defect close to the recession(s);
- Periodontal diagnosis;
- Verify if there is a rotated, tilted, or crowded tooth associated with the area of the recession
- BoP—recommended ≤ 10%.
2.3. MiTT Technique—Surgical Steps
- (1)
- Vertical incision on the mucosa (around 1–2 mm apical to the MGJ), lateral to the papilla base (Figure 1D). It is mandatory not to perform this incision in the center of the papilla’s base, which might damage any vascular supply or risk damage to the papilla. In multiple recessions, it is recommended to perform two vertical incisions; and if extremely necessary, more vertical incisions can be performed, always in mucosa and lateral in the papilla’s base.
- (2)
- (3)
- It is permitted (but not mandatory) to perform intrasulcular incisions, including up to one adjacent tooth (Figure 1H), which can facilitate the procedure to connect the tunnel. Avoid causing any damage to the gingival margin.
- (4)
- From the MGJ, subperiosteal access to raise the full-thickness tunnel is performed (Figure 1I), involving one adjacent tooth, to keep the local vascularization. The access is subperiosteal, and it is essential to act gently in this stage.
- (5)
- Confirm the tissue detachment until the gingival sulcus area (free gingival margin) and also in the papilla’s base (Figure 1J), keeping the papilla’s tip intact.
- (6)
- After CTG is harvested (either subepithelial or de-epithelialized), it will be inserted in the desired site through the linear incision or intrasulcularly (Figure 1K,L).
- (7)
- The CTG will be adjusted to cover the recession (Figure 1l) and must be coronally advanced at least 1 mm coronal to the CEJ.
- (8)
- Then, MiTT should be sutured according to the personally preferred technique. It is suggested that the suture techniques slightly pull the tunnel coronal (anchored with composite or double-crossed suture [18]). The vertical incision must be sutured with one or two single sutures. It is suggested to stabilize the soft tissues using interrupted sutures, and it may be used as adjunctive material, such as a biological glue. It is suggested that the suture be removed between 7 and 14 days.
2.4. Statistical Analysis
3. Results
4. Discussion
4.1. Evolution of Tunnel Techniques
4.2. Pros and Cons of the MiTT Technique and Limitations of This Study
Author Contributions
Funding
Institutional Review Board Statement
Data Availability Statement
Conflicts of Interest
References
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“Envelope” Technique | Modified Envelope Technique | Tunnel Technique | Modified Tunnel Technique | VISTA | PST | m-VISTA | GDT | |
---|---|---|---|---|---|---|---|---|
Authors/Year | Raetzke (1985) [4] | Allen (1994) [6,7] | Zabalegui et al. (1999) [2] | Tözüm & Dini (2003) [3] | Zadeh (2011) [5] | Chao (2012) [8] | Lee et al. (2015) [14] | Tuttle et al. (2018) [9] |
Advantages | - Simple technique (without coronal displacement) with minimal trauma. - Does not detach papillae. | - Can be performed on multiple sites. - Simple technique (without coronal displacement) with minimal trauma. | - Does not detach papillae - Simple technique (without coronal displacement). - Partial dissection. | - Without vertical incisions. - Full-thickness dissection at the mucogingival area (in a coronoapical direction) to supply more blood vessels. - Does not detach papillae. | - Does not detach papillae. - Incision in mucosa facilitating the access. - Easier detachment of the soft tissue (subperiosteal). | - Does not detach papillae. - Incision in mucosa facilitating the access. - Full-thickness dissection (reduced risk of fenestration). | - Double vascular surfaces for revascularization of the graft. - Lower risk of graft necrosis and scarring. - Better capillary ingrowth. - Does not detach papillae. | - Minimally invasive. - Places holes in mucosa to permit the access. - Reduced risk of fenestration-full-thickness tunnel (subperiosteal access). - Does not detach papillae. |
Disadvantages | - Higher risk of necrosis of the CTG (exposed). - Used in isolated areas (single tooth). - Lower level of root coverage for gingival recessions greater than 3 mm. - Supraperiosteal approach (higher risk of fenestration). | - Supraperiosteal approach—higher risk of fenestration. - Higher risk of necrosis of the CTG (exposed). | - Only intrasulcular incisions. - Supraperiosteal approach (higher risk of fenestration. - CTG has a small exposition—elevated risk of necrosis. | - Only intrasulcular incisions. - CTG has a small exposition (around 50%)—elevated risk of necrosis. | - Expensive biomaterial was used (membrane complex (β-TCP hydrated with rhPDGF-BB)). - More invasive. | - Collagen stripes placed (increase the cost due to the biomaterial). - Specific instruments to perform the technique. - More invasive. | - Access is only through the frenum area, “V-shaped” incision. - Simultaneous frenectomy. - Difficult level for thin phenotypes (risk of fenestration). - More invasive. | - Substitution of the “gold standard” (CTG) for the A-PRF and i-PRF. - Rapid resorption of the PRF compared with the CTG. - More invasive. |
Classification | Gender | Tooth/Teeth with REC | Initial REC Height (mm) | Initial REC Width (mm) | Initial PD (mm) | Initial KTW (mm) | Final REC Height (mm) | Final PD (mm) | Final KTW (mm) | % RC | p-Value | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Baseline | 6-Month Follow-up | |||||||||||
Case 1 | RT2 | M | 41 | 6.2 | 2.5 | 1.0 | 0.3 | 1.1 | 2.0 | 4.3 | 82.25 | REC: p < 0.0001 PD: p = 0.2771 KTW: p = 0.1013 |
Case 2 | RT1 | F | 31 | 3.3 | 1.7 | 0.5 | 0.3 | none | 1.0 | 3.7 | 100 | |
Case 3 | RT1 | F | 41 | 1.2 | 2.1 | 1.0 | 3.3 | none | 0.5 | 7.3 | 100 | |
Case 4 | RT1 | F | 41 31 | 1.4 1.2 | 2.1 1.8 | 1.0 0.5 | 3.1 2.9 | none | 1.0 0.5 | 3.7 4.0 | 100 100 | |
Case 5 | RT1 | M | 43 | 1.5 | 2.3 | 1.0 | 1.3 | none | 1.5 | 4.4 | 100 | |
Case 6 | RT1 | F | 43 44 45 | 1.2 2.1 1.4 | 2.6 3.1 2.8 | 2.0 1.5 1.0 | 3.0 3.8 3.8 | none | 1.5 1.0 1.0 | 2.1 2.8 5.3 | 100 100 100 | |
Case 7 | RT1 | F | 12 11 21 22 | 1.1 1.5 2.4 1.5 | 1.5 3.0 4.0 2.0 | 1.0 2.0 1.5 2.0 | 5.4 5.0 6.3 6.9 | none | 1.0 2.5 2.5 1.5 | 4.3 5.7 6.0 6.3 | 100 100 100 100 | |
Case 8 | RT2 | F | 42 41 31 32 | 2.2 3.4 3.2 1.2 | 2.3 2.5 3.0 2.7 | 0.5 0.5 0.5 1.0 | 2.4 1.9 1.5 3.5 | 0 0.6 0.6 0.5 | 1.5 1.0 1.0 1.0 | 3.6 2.9 2.1 3.3 | 100 82.35 81.25 58.34 | |
Case 9 | RT1 | F | 12 13 | 1.3 2.1 | 2.2 2.3 | 1.5 2.0 | 4.4 5.3 | none | 2.5 1.5 | 4.6 5.2 | 100 100 |
MITT | |
---|---|
Advantages | - Simple technique with reduced risk of fenestration. |
- Does not detach papillae. | |
- Easier access. | |
- Greater mobility of the tunnel. | |
- No exposition of the graft, reduced risk of necrosis. | |
Disadvantages | - Reduced vascularization, complete detachment. |
Differences | - Lower risk of necrosis for the flap and graft. |
- Used in single or multiple recessions. | |
- It can be used in shallow or deep recessions. | |
- More predictable release of the tunnel. | |
- It is not performed only in the frenum area. |
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Marques, T.; Santos, N.B.M.d.; Sousa, M.; Fernandes, J.C.H.; Fernandes, G.V.O. Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up. Dent. J. 2023, 11, 235. https://doi.org/10.3390/dj11100235
Marques T, Santos NBMd, Sousa M, Fernandes JCH, Fernandes GVO. Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up. Dentistry Journal. 2023; 11(10):235. https://doi.org/10.3390/dj11100235
Chicago/Turabian StyleMarques, Tiago, Nuno Bernardo Malta dos Santos, Manuel Sousa, Juliana Campos Hasse Fernandes, and Gustavo Vicentis Oliveira Fernandes. 2023. "Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up" Dentistry Journal 11, no. 10: 235. https://doi.org/10.3390/dj11100235
APA StyleMarques, T., Santos, N. B. M. d., Sousa, M., Fernandes, J. C. H., & Fernandes, G. V. O. (2023). Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up. Dentistry Journal, 11(10), 235. https://doi.org/10.3390/dj11100235