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Gingival recessions (GRs) result in root hypersensitivity, root surface caries, and esthetic problems. Various root coverage surgeries are being developed for periodontal plastic therapy. The tunnel technique (TUN) is one of the most widely applied surgeries due to its features of being minimally invasive, practical, excellent outcomes and long-term stability; however, there are still some limitations of this technique. The history and evolution from the envelope flap to TUN, including its efficiency when compared with coronally advanced flaps with a connective tissue graft (CTG), are reviewed in this paper. The limitations of TUN are discussed in consideration of our clinical experience; for example, there is high technique sensitivity when TUN is applied in GR>5 mm because of the great difficulty in covering the grafts. The advantages of surgical access, including vertical incisions in the vestibule, “W” type and pinhole access, are discussed for different situations. Mattress sutures and sling sutures in a single tooth or multiple teeth are applied in TUN. The different types of grafts, such as CTG, platelet-rich plasma, articular dermal matrix and xenogeneic collagen matrix, are described. Mechanical, chemical and biological conditioning of the root surface are recommended during surgery. Protecting the surgical area and taking antibiotics postoperatively are also very important. Finally, the modifications when TUN is applied with other kinds of techniques are discussed, including lateral closed TUN, laterally positioned flaps, double papilla flaps and frenuloplasty. Minimally invasive, esthetic, long-term stability and simplified techniques are the development trends of TUN in the future.

Objective To compare the clinical effect of the tunnel technique (TUN) and vestibular incision subperiosteal tunnel access (VISTA) combining connective tissue grafts (CTGs) on recovering the exposed root surface in a case of gingival recession over the upper anterior teeth and then to provide clinical evidence for gingival recession treatment. Methods A case of gingival recession (Miller I type) over teeth 13-14 and 22-23 was treated using different techniques bilaterally. 22-23 were treated by a TUN combined CTG transplantation,while teeth 13-14 were treated by a VISTA technique combined with CTG transplantation. The gingival retraction height (GRH), gingival retraction width (GRW), keratinized gingival width (KW), root coverage aesthetic score (RES) and visual analog scale (VAS) were measured after operation. Results The effect of post-operation were ideal and complete ginglval recovering were achieved, the postoperative effects of the two methods were stable, GRH and GRW decreased, and KW increased. RES was 10. The VAS score of VISTA combined with CTG transplantation was 6, which was higher than that of TUN+CTG. Conclusion Gingival recession can be treated by TUN+CTG or VISTA+CTG with ideal prognosis. VISTA with an additional incision facilitates the operative procedure but leads to less comfort.

Rationale: Endodontic surgery, which includes apex resection, retro-fill and some regeneration procedures, is a traditional way to deal with apex fenestration. The endodontic surgery could bring large flap, curtate root length, non-healing mucosa and soft tissue deficiency in the apex area. Other treatment options might be considered according to different etiological factors. Mucogingival surgery provides some ideas in accumulation of soft and hard tissues, especially some unique methods such as "tunnel technique" bringing us a view of minimal invasive surgery approach. A novel surgery named "apical tunnel surgery" was reported here to resolve a root apex exposure with the tunnel-like technique., Patient Concerns: A young female complained about root exposure of upper right anterior tooth without history of trauma or orthodontic treatment., Diagnosis: The intraoral examination revealed a buccal root apex exposure about 3mm in diameter of #12 (FDI teeth numbering system). The tooth was slightly dark with Class 1 mobility. The periodontal situation was good and the occlusion check revealed no traumatic bite on #12. The cone-beam computed tomography (CBCT) showed a bone fenestration from the buccally lower 1/2 root surface to the apex and bone absorption around the apex. It also revealed a bone contour deficiency in #12 area., Interventions: Root canal treatment, root surface debridement, and soft tissue combined with hard tissue accumulation were carried out in one tunnel-like surgery., Outcomes: Examination of 12-month follow-up showed a healed and thickened mucosa in the buccally apical region and CBCT showed the continuous lamina dura occupied the buccal aspect of #12 root apex., Lessons: This new apical tunnel surgery provided soft and hard tissue accumulation in one minimal invasive way in the apex exposure case caused by bone fenestration and thin mucosa., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

When the use of root canal retreatment and apical surgery experiences difficulty in treating endodontic diseases, intentional replantation is an optional clinical technique used to retain the tooth. A 28-year-old female complained of chewing discomfort at the mandibular second molar after undergoing root canal treatment 3 month ago. History record and radiographic examination revealed that a C-shaped root canal system was filled with gutta-percha in the mandibular second molar. A radiolucency area existed at the root furcal area with a thin canal wall in the distal and mesial roots. Intentional replantation was used to treat this tooth. The clinical and radiographic results showed that intentional replantation and nano-biomaterial application facilitated infection control, tooth retention, and periodontal tissue regeneration.