Modified Coronally Advanced Tunnel for Mandibular Lingual Root Coverage

Clinical Outcomes of Modified Coronally Advanced Tunnel Technique With Deepithelialized Connective Tissue Graft for Mandibular Lingual Root Coverage: A Case Series

This study will follow adults who have gum recession on the tongue side of the lower teeth. Participants will receive a gum surgery called the Modified Coronally Advanced Tunnel technique with a connective tissue graft taken from the roof of the mouth. The study will include 20 participants and will follow them for up to 24 months after surgery. The main outcome is how much of the exposed root is covered 6 months after surgery. The study will also measure gum thickness, gum width, tooth sensitivity, healing, patient comfort, satisfaction, and three-dimensional soft tissue changes using intraoral scans.

Study Overview

• Status: Not yet recruiting
• Conditions: Gingival Recession; Mucogingival Deformity - Insufficient Keratinized Tissue
• Intervention / Treatment: Procedure: Modified Coronally Advanced Tunnel with Connective Tissue Graft

Detailed Description

This is a single-site prospective case series at the University of Pittsburgh School of Dental Medicine. Adults with single or multiple Cairo RT1 lingual gingival recessions of at least 3 mm on mandibular incisors, canines, or premolars will be enrolled if they meet the study eligibility criteria.

All participants will receive the same surgical treatment. During the procedure, the surgeon will create a tunnel under the gum tissue on the tongue side of the affected lower tooth or teeth. A small piece of tissue will be taken from the palate, prepared as a connective tissue graft, placed under the gum tissue, and stabilized with sutures to help cover the exposed root surface.

Participants will have study visits before surgery, on the day of surgery, during early healing, and at scheduled follow-up visits through 24 months after surgery. The primary outcome will be assessed at 6 months after surgery.

At follow-up visits, the study team will collect gum measurements, assess tooth sensitivity, record healing or post-operative complications, and collect patient-reported outcomes about pain, discomfort, function, appearance, and satisfaction. Intraoral photographs and intraoral scans will also be collected to document healing and measure three-dimensional soft tissue changes over time.

• Study Type: Interventional
• Enrollment (Estimated): 20
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Carla Sanchez, MS; Phone Number: 4126241179; Email: cab28@pitt.edu
• Study Contact Backup: Name: Andrea Ravida, DDS, MS, PhD; Phone Number: 4126488595; Email: andrearavida@pitt.edu

Study Locations

• United States
  • Pennsylvania
    • Pittsburgh, Pennsylvania, United States, 15261
      • University of Pittsburgh School of Dental Medicine
      • Contact: Carla Sanchez, MS; Phone Number: 4126241179; Email: cab28@pitt.edu
      • Contact: Andrea Ravida, DDS, MS, PhD; Phone Number: 412-648-8595; Email: andrearavida@pitt.edu
      • Principal Investigator: Andrea Ravida, DDS, MS, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 18-65 years
• Single or multiple Cairo RT1 lingual gingival recessions ≥3 mm on mandibular incisors, canines, or premolars
• Identifiable CEJ on the lingual aspect
• Vital uniradicular teeth
• Full-mouth plaque score <20%
• Smokes less than 10 cigarettes per day
• Adequate mouth opening for lingual access
• Sufficient palatal donor tissue thickness (≥2 mm at 2-3 mm from gingival margin)

Exclusion Criteria:

• Positive urine pregnancy test or self-reported lactation
• Smoker more than 10 cigarettes per day
• Uncontrolled systemic diseases, at the discretion of the PI (diabetes HbA1c >7%, cardiovascular disease, immunocompromised)
• Use of medications affecting periodontal tissues (phenytoin, calcium channel blockers, immunosuppressants)
• Use of blood thinners
• Previous root coverage surgery at treated sites
• Teeth with cervical restorations or caries on lingual surfaces
• Inadequate attached gingiva (<1 mm)
• Prominent lingual frenum attachment requiring frenectomy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Modified Coronally Advanced Tunnel with Connective Tissue Graft; Adults with single or multiple Cairo RT1 mandibular lingual gingival recessions of at least 3 mm on mandibular incisors, canines, or premolars who will receive standardized Modified Coronally Advanced Tunnel surgery with a deepithelialized connective tissue graft and will be followed for up to 24 months.

Procedure: Modified Coronally Advanced Tunnel with Connective Tissue Graft; The procedure consists of lingual tunnel preparation without vertical releasing incisions, followed by placement of a deepithelialized connective tissue graft harvested from the palate. Root surface conditioning may be performed with EDTA gel before graft placement. The graft is positioned to cover the exposed root surface, and the lingual flap is advanced coronally and secured with sutures to achieve stable, tension-free coverage.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Change in Root Coverage from Baseline at 6 Months	Mean root coverage will be calculated as baseline recession depth minus recession depth at 6 months post-surgery. Recession depth will be measured in millimeters from the cementoenamel junction to the gingival margin at the mid-lingual aspect using a UNC-15 periodontal probe by a calibrated examiner blinded to baseline measurements	Baseline and 6 months post-surgery.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage Root Coverage at 6 Months	Percentage root coverage will be calculated as [(baseline recession depth minus 6-month recession depth) / baseline recession depth] × 100. Additional measurements will be collected at 3, 12, 15, 18, 21, and 24 months post-surgery for descriptive analyses.	6 months post-surgery
Frequency of Complete Root Coverage at 6 Months	Recession depth will be measured in millimeters from the cementoenamel junction to the gingival margin at the mid-lingual aspect using a UNC-15 periodontal probe.	6 months post-surgery
Change from Baseline in Recession Depth at 6 Months	Recession depth will be measured from the cementoenamel junction to the gingival margin at the mid-lingual aspect using a UNC-15 periodontal probe.	Baseline and 6 months post-surgery
Change from Baseline in Recession Width at 6 Months	Recession width will be measured as the mesiodistal width of the recession defect at the cementoenamel junction level.	Baseline and 6 months post-surgery
Change from Baseline in Clinical Attachment Level at 6 Months	Clinical attachment level will be measured from the cementoenamel junction to the base of the sulcus at the treated lingual site using a UNC-15 periodontal probe.	Baseline and 6 months post-surgery
Change from Baseline in Probing Depth at 6 Months	Probing depth will be measured from the gingival margin to the base of the sulcus at the treated lingual site using a UNC-15 periodontal probe.	Baseline and 6 months post-surgery
Change from Baseline in Keratinized Tissue Width at 6 Months	Keratinized tissue width will be measured from the gingival margin to the mucogingival junction using a UNC-15 periodontal probe.	Baseline and 6 months post-surgery
Change from Baseline in Gingival Thickness at 6 Months	Gingival thickness will be measured 2 mm apical to the gingival margin using a #15 endodontic file with a rubber stop under local anesthesia.	Baseline and 6 months post-surgery
Surgical time (minutes)	Surgical time will be recorded in minutes from incision to final suture.	Day of surgery
Number of Participants with Early Post-operative Complications Within 2 Weeks	Early complications will include graft exposure, wound dehiscence, infection, bleeding, or other post-operative complications documented during early healing.	Up to 2 weeks post-surgery
Post-operative Pain Score on Visual Analog Scale at Day 7	Post-operative pain will be assessed using a 100-millimeter visual analog scale, where 0 represents no pain and 100 represents extreme pain. Additional pain assessments will be collected on Days 1 and 3 post-surgery for descriptive analyses.	Day 7 post-surgery
Functional Impairment Score on Visual Analog Scale at Day 7	Functional impairment related to speaking, swallowing, or eating will be assessed using a 100-millimeter visual analog scale, where 0 represents no impairment and 100 represents extreme impairment. Additional assessments will be collected on Days 1 and 3 post-surgery for descriptive analyses.	Day 7 post-surgery
Aesthetic Satisfaction Score on Visual Analog Scale at 6 Months	Patient satisfaction with the appearance of the treated area will be assessed using a 100-millimeter visual analog scale, where 0 represents extremely unsatisfied and 100 represents extremely satisfied. Additional assessments will be collected at 12 and 24 months post-surgery for descriptive analyses.	6 months post-surgery
Overall Treatment Satisfaction Score on Visual Analog Scale at 6 Months	Overall satisfaction with the treatment outcome will be assessed using a 100-millimeter visual analog scale, where 0 represents extremely unsatisfied and 100 represents extremely satisfied. Additional assessments will be collected at 12 and 24 months post-surgery for descriptive analyses.	6 months post-surgery
Willingness to undergo the procedure again (VAS 0-100 mm; higher score = better outcome)	Participants will rate their willingness to undergo the procedure again using a 100-mm visual analog scale, where 0 represents would not undergo the procedure again and 100 represents definitely would undergo the procedure again.	24 months post-surgery
Change from Baseline in Root Hypersensitivity Score on Visual Analog Scale at 6 Months	Root hypersensitivity will be assessed using a 100-millimeter visual analog scale after an air blast test, where higher scores indicate greater hypersensitivity. Additional assessments will be collected at 12 and 24 months post-surgery for descriptive analyses.	Baseline and 6 months post-surgery
Three-Dimensional Soft Tissue Volume Change at 6 Months	Soft tissue volume change will be assessed using intraoral scans exported as STL files. Baseline and 6-month scans will be superimposed, and the absolute volumetric difference within a standardized region of interest will be calculated in cubic millimeters. Additional scans will be collected at 3, 12, and 24 months post-surgery for descriptive analyses.	Baseline and 6 months post-surgery
Mean Soft Tissue Thickness Change from Intraoral Scans at 6 Months	Mean tissue thickness change will be calculated as the average perpendicular distance between superimposed baseline and 6-month intraoral scan surfaces within the defined region of interest. Additional scans will be collected at 3, 12, and 24 months post-surgery for descriptive analyses.	Baseline and 6 months post-surgery
Long-term Stability of Root Coverage at 24 Months	Long-term stability will be measured as the change in recession depth from baseline to 24 months post-surgery, expressed in millimeters. This outcome assesses whether the root coverage achieved at the 6-month primary endpoint is maintained over the extended follow-up period.	Baseline and 24 months post-surgery

Collaborators and Investigators

• Sponsor: University of Pittsburgh
• Investigators: Principal Investigator: Andrea Ravida, DDS, MS, PhD, University of Pittsburgh, Department of Periodontics and Preventive Dentistry

Publications and helpful links

General Publications

• Zuhr O, Baumer D, Hurzeler M. The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and execution. J Clin Periodontol. 2014 Apr;41 Suppl 15:S123-42. doi: 10.1111/jcpe.12185.
• Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015 Feb;86(2 Suppl):S8-51. doi: 10.1902/jop.2015.130674.
• Tavelli L, Barootchi S, Nguyen TVN, Tattan M, Ravida A, Wang HL. Efficacy of tunnel technique in the treatment of localized and multiple gingival recessions: A systematic review and meta-analysis. J Periodontol. 2018 Sep;89(9):1075-1090. doi: 10.1002/JPER.18-0066. Epub 2018 Aug 13.
• Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: a 6-month study. J Periodontol. 2009 Feb;80(2):244-52. doi: 10.1902/jop.2009.080253.
• Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage esthetic score: a system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol. 2009 Apr;80(4):705-10. doi: 10.1902/jop.2009.080565.
• Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study. J Clin Periodontol. 2011 Jul;38(7):661-6. doi: 10.1111/j.1600-051X.2011.01732.x. Epub 2011 Apr 20.
• Scheyer ET, Sanz M, Dibart S, Greenwell H, John V, Kim DM, Langer L, Neiva R, Rasperini G. Periodontal soft tissue non-root coverage procedures: a consensus report from the AAP Regeneration Workshop. J Periodontol. 2015 Feb;86(2 Suppl):S73-6. doi: 10.1902/jop.2015.140377.
• Jepsen S, Caton JG, Albandar JM, Bissada NF, Bouchard P, Cortellini P, Demirel K, de Sanctis M, Ercoli C, Fan J, Geurs NC, Hughes FJ, Jin L, Kantarci A, Lalla E, Madianos PN, Matthews D, McGuire MK, Mills MP, Preshaw PM, Reynolds MA, Sculean A, Susin C, West NX, Yamazaki K. Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018 Jun;89 Suppl 1:S237-S248. doi: 10.1002/JPER.17-0733.
• Barootchi S, Tavelli L, Zucchelli G, Giannobile WV, Wang HL. Gingival phenotype modification therapies on natural teeth: A network meta-analysis. J Periodontol. 2020 Nov;91(11):1386-1399. doi: 10.1002/JPER.19-0715. Epub 2020 Jun 12.
• Cortellini P, Bissada NF. Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Periodontol. 2018 Jun;89 Suppl 1:S204-S213. doi: 10.1002/JPER.16-0671.
• Assis G, Nevins M, Kim DM. The Use of Autogenous Gingival Graft for Treatment of Lingual Recession on Mandibular Anterior Teeth. Int J Periodontics Restorative Dent. 2017 Sep/Oct;37(5):667-671. doi: 10.11607/prd.3263.
• Soileau KM. Treatment of a mucogingival defect associated with intraoral piercing. J Am Dent Assoc. 2005 Apr;136(4):490-4. doi: 10.14219/jada.archive.2005.0205.
• Wilcko MT, Wilcko WM, Murphy KG, Carroll WJ, Ferguson DJ, Miley DD, Bouquot JE. Full-thickness flap/subepithelial connective tissue grafting with intramarrow penetrations: three case reports of lingual root coverage. Int J Periodontics Restorative Dent. 2005 Dec;25(6):561-9.
• Zucchelli G, Bentivogli V, Ganz S, Bellone P, Mazzotti C. The connective tissue graft wall technique to improve root coverage and clinical attachment levels in lingual gingival defects. Int J Esthet Dent. 2016;11(4):538-548.
• Mehrotra VK, Triveni MG, Tarun Kumar AB, Chandra RV. Minimally invasive treatment of mandibular anterior lingual defects by vestibular incision subperiosteal tunnel access technique and connective tissue graft: a case report. Clin Adv Periodontics. 2017;7(4):195-200.
• Alves JP, Marques TM, Malta Santos NB, Correia Sousa M, Coutinho Alves C, Correia AR. Lingual Incision Subperiosteal Tunnel Access: Proof of Concept 18-Month Follow-Up. Clin Adv Periodontics. 2019 Dec;9(4):196-202. doi: 10.1002/cap.10072. Epub 2019 Sep 26.
• Yadav VS, Kamra P, Singh N, Chandra RV. Treatment of multiple lingual gingival recession defects in mandibular incisors with modified coronally advanced tunnel technique. Contemp Clin Dent. 2018;9(Suppl 2):S345-9.

Study record dates

Study Major Dates

• Study Start (Estimated): June 1, 2026
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): December 1, 2028

Study Registration Dates

• First Submitted: May 1, 2026
• First Submitted That Met QC Criteria: May 8, 2026
• First Posted (Actual): May 15, 2026

Study Record Updates

• Last Update Posted (Actual): June 4, 2026
• Last Update Submitted That Met QC Criteria: June 2, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Tooth Sensitivity; Gingival Recession; Tissue Grafts
• Additional Relevant MeSH Terms: Periodontal Atrophy; Periodontal Diseases; Mouth Diseases; Stomatognathic Diseases; Tooth Diseases; Gingival Diseases; Dentin Sensitivity; Gingival Recession
• Other Study ID Numbers: STUDY26020003

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No