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It is often difficult to perform the tunnel technique for root coverage and soft tissue augmentation in the mandibular anterior region where there is shallow recession and thin soft tissue, particularly when accompanied by prominent roots and alveolar undercuts. The aim of this report is to present a papilla access technique that facilitates tunnel site preparation and graft placement in such sites. This surgical access method may also be applied to sites where there is moderate to severe recession of the mandibular central incisors, and extension of the tunnel to include both the lateral incisors and canines is desired for augmentation. The papillary access provides improved surgical access for both site preparation and graft placement with reduced risk of perforation or injury to thin tissue.

Covering exposed roots becomes more and more difficult as the gingiva becomes thinner and the vestibule becomes more shallow. Also, the outcome becomes less predictable. In addition, where there is high frenal attachment or muscle pull, such as the mentalis muscle in the mandibular anterior region, secondary retraction of a coronally advanced flap will likely occur. Therefore, a transplanted connective tissue graft may not completely cover the recession. This case series presents a technique where the roots are covered with a combination epithelialized-subepithelial connective tissue graft. The epithelialized portions of the graft are positioned directly over the exposed roots to aid in resistance to the environment of the mouth, and there is no displacement of the mucogingival junction or flattening of the vestibule.

This paper describes a new suturing method, the subpapillary continuous sling suture, for use with soft tissue grafts in tunnel procedures to treat gingival recession. This method combines the graft suture and the sutures used to advance the pouch margins over the graft into a single continuous sling suture. It is indicated particularly for sites with shallow recessions and those treated for augmentation rather than root coverage because of a lack of graft access for standard suture placement. The single-suture method may also be used for sites with moderate to severe recession. The advantages of this method include elimination of the need to place additional sutures for coronal advancement of the pouch, resulting in reduced suturing time and reduced opportunity to inadvertently cut the continuous suture with the needle when suturing the pouch.