Rise of minimally invasive techniques for soft tissue augmentation – A tale of promise and pitfalls

Periodontal plastic surgery, periodontal soft tissue surgery, or mucogingival surgery as it is sometimes referred to was originally the playground of only accomplished and dedicated periodontal surgeons who thought beyond pocket depths and bone loss. However, with the passing of decades, the spotlight has shifted to aesthetics in dentistry, and aesthetics in the mouth cannot be achieved without tending the gingiva. The advent and mainstreaming of dental implants brought with it another set of conundrums with regard to the gingiva and the realization that implant longevity and health depended not just on bone but most often on 1-2 mm of healthy keratinised soft tissue. This automatically made soft tissue surgeries the norm rather than the exception catapulting it into the limelight where the focus has now shifted how to achieve the best results with minimal trauma.

Over the past decades, we have traversed through the free gingival graft technique, the coronally advanced flap, The coronally advanced flap in combination with a connective tissue graft, the semilunar technique and the Multiple coronally advanced flap amongst others. The coronally advanced flap combined with a connective tissue graft still remains the gold standard for gingival recession coverage. However, the focus definitely seems to have shifted to procedures that do not involve vertical incisions and separation of the papilla which in theory make the procedure much less invasive. These involve the Tunnelling technique (Allen 1994), Modified Tunnelling Technique (Mahn 2001), VISTA (Zadeh 2011), and The Pinhole technique (Chao 2012).

The techniques used to harvest the connective tissue graft have also evolved towards procedures that do not involve healing by secondary intention and minus vertical incisions. The various procedures are the trap door technique with vertical incisions (Edel 1974), The double incision technique ( Langer and Calagna, 1982) The envelope technique (Raetzke, 1985) (Langer and Lager 1985), and the single incision technique (Hurzler and Weng, 1999). The de-epithelized Free gingival graft ( Zucchelli et al., 2003) remains the only modern technique that has gone against the flow and involves healing by secondary intention.

Advantages: Minimally invasive techniques for soft tissue augmentation offer several advantages over traditional approaches, including:

1. Reduced patient discomfort: Minimally invasive techniques typically involve smaller and fewer incisions resulting in less trauma to the surrounding tissues.
2. Faster healing times: With less tissue disruption, minimally invasive procedures claim to promote quicker healing compared to traditional surgical methods.
3. Reduced risk of complications: Minimally invasive techniques minimize the risk of complications such as excessive bleeding, infection, and nerve damage associated with more invasive procedures. The reduced trauma to the tissues also lowers the likelihood of postoperative swelling and bruising.
4. Enhanced aesthetic outcomes: The lack of vertical incisions precludes any scar formations resulting in aesthetically pleasing outcomes.

Disadvantages: The disadvantages must be discussed in as much detail as the advantages:

1. Steep learning curve: There is a steeper learning curve with these techniques as visibility is limited and the tunnel preparation requires a great degree of control and skill.
2. Investment: A specialised armamentarium is required over and above the microsurgical blades and sutures already mandatory for soft tissue surgeries.
3. Technique sensitive: Most techniques are quite unforgiving. The perforation of the flap during tunneling would lead not only to an abandonment of the current procedure undertaken but preclude reverting to a conventional technique like a coronally advanced flap as well. Complications such as tissue ischemia, flap necrosis, and suture dehiscence were inherent risks associated with minimally invasive procedures.
4. Anatomical variations: Graft harvesting from the palate via a single incision technique requires a depth of tissue upwards of 3 mm to get an adequate and good quality connective tissue graft.

Interestingly some studies have shown that despite the minimally invasive nature of tunneling techniques the pain perception postoperatively was higher in the tunneling group+ Sub epithelial connective tissue graft (SeCTG) in comparison to the coronally advanced flap combined with the SeCTG. Chair time was also significantly higher in the tunneling group.

Overall, we could conclude that minimally invasive techniques for soft tissue augmentation offer a minimally traumatic, efficient, and patient-friendly alternative to traditional surgical methods. Even the most cooperative and phobia-free patients prefer a comfortable procedure and hence the quest to develop a technique that marries predictability to minimal morbidity is not without merit however practicality, reproducibility, and flexibility must not be sacrificed at the altar of comfort.

The surgical technique must be accommodative of a surgeon’s skill set and learning potential. By embracing a balanced perspective, and honing our skills in multiple techniques we will be better suited to provide our patients with better care – thereby maximizing the benefits of each technique while minimizing their risks.

References:

1. Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontology 2000. 2015 Jun;68(1):333-68.
2. Puri K, Kumar A, Khatri M, Bansal M, Rehan M, Siddeshappa ST. 44-year journey of palatal connective tissue graft harvest: A narrative review. J Indian Soc Periodontol. 2019 Sep-Oct;23(5):395-408. doi: 10.4103/jisp.jisp_288_18. PMID: 31543611; PMCID: PMC6737854.
3. Gobbato L, Nart J, Bressan E, Mazzocco F, Paniz G, Lops D. Patient morbidity and root coverage outcomes after the application of a subepithelial connective tissue graft in combination with a coronally advanced flap or via a tunneling technique: a randomized controlled clinical trial. Clin Oral Invest. 2016 Jan 27;1–14.

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