CASE REPORT

Tunnel Access for Guided Bone Regeneration in the Maxillary Anterior

Thomas M. Johnson∗† and Dmitry Baron‡

Introduction: Minimally invasive surgical techniques in periodontics, including methods for ridge augmentation, have
been shown to achieve surgical goals while minimizing swelling, decreasing postoperative discomfort, and enhancing soft
tissue architecture. The present case illustrates a minimally invasive guided bone regeneration technique for augmentation
of a deficient alveolar ridge in the esthetic zone.
Case Presentation: A 30-year-old patient received localized ridge augmentation utilizing tunnel access for
guided bone regeneration with a dense polytetrafluoroethylene membrane and a freeze-dried bone allograft. The patient
experienced minimal postoperative swelling and discomfort, and the procedure resulted in favorable ridge dimensions for
implant placement.
Conclusions: The tunnel access for guided bone regeneration presented in this case may offer advantages similar to
other minimally invasive ridge augmentation techniques. Further controlled clinical study is warranted. Clin Adv Periodontics
2018;8:27–32.
Key Words: Allografts; alveolar ridge augmentation; bone regeneration; minimally invasive surgical procedures; orthodontics;
polytetrafluoroethylene.

Background exposure may lead to bacterial contamination, little or

no bone regeneration, loss of bone height and thickness
Many dental implant sites can be enhanced through
on adjoining proximal tooth surfaces, flattened papil-
bone regeneration, soft tissue augmentation, or both, and
lae, and irregular soft tissue architecture.5 – 7 Recently a
often, implant placement cannot proceed until ridge defi-
ridge augmentation technique was introduced utilizing a
ciency is corrected.1 – 3 Guided bone regeneration (GBR)
remote incision, laparoscopic tunnel access to the deficient
is among the most widely used methods for augment-
ridge, and establishment of a subperiosteal pouch with-
ing a deficient ridge for subsequent implant placement.4
out advancing a traditional mucoperiosteal flap.8 This
However, flap contraction and wound dehiscence can
technique combines a xenograft with recombinant human
occur during the early postoperative period. Membrane
platelet-derived growth factor (rhPDGF-BB) and requires
∗ United
States Army Advanced Education Program in Periodontics,
no membrane.8 The technique described in the present
Fort Gordon, GA case may similarly preserve soft tissue contours and reduce
† Department
risk of wound dehiscence, utilizing a nonresorbable bar-
of Periodontics, Army Postgraduate Dental School, Uni-
rier/allograft combination rather than a xenograft with
formed Services University of the Health Sciences, Fort Gordon,
GA rhPDGF-BB.
‡ Department of Periodontics, Bavaria Dental Health Activity, Stuttgart
Dental Clinic, Stuttgart, Germany
Clinical Presentation
Received May 8, 2017; accepted July 23, 2017 A periodontally and systemically healthy 30-year-old
white male presented June 18, 2012, to Tingay Dental
doi: 10.1902/cap.2017.170032 Clinic, Fort Gordon, Georgia, congenitally missing teeth

Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 27

C A S E R E P O R T

position. The virtual implant placement exhibited ade-

quate facial bone at the platform level. Apically, the pro-
posed fixture protruded through the facial bone (Fig. 3).
The Chief Resident (DB) discussed treatment alternatives
with the patient, who elected GBR in preparation for
implant placement. Vertical incisions were placed in the
midline labial frenum and between teeth #11 and #12
(Fig. 4), and intrasulcular incisions were made on the
immediate proximal and facial surfaces of teeth adjacent
to the #10 site. A tunneling kit was used to create sub-
periosteal tunnel access to the deficient ridge (Fig. 5). A
dense polytetrafluoroethylene (dPTFE) membrane¶ was
tailored to the surgical site and placed in the tunnel access
FIGURE 1 Facial view in maximum intercuspation after the orthodon- (Figs. 6 and 7), and the surgical site was thoroughly irri-
tic phase. Because of the relatively distal position of the maxillary gated with normal saline. A midcrestal incision the width
central incisors and the adjacent ridge deficiency, thin bone at the
distofacial line angle of tooth #9 was a concern. The gingival zeniths of a #15 blade was made to assure proper membrane
on the maxillary central incisors were also positioned toward the positioning, and a 1.5-mL freeze-dried bone allograft#
distal, creating an angular appearance rather than a smooth arc. The (FDBA) hydrated in normal saline was placed beneath
gingival margin at the distofacial line angle of tooth #9 was positioned
approximately at the cemento enamel junction. the barrier. A graft syringe∗∗ was used to precisely apply
allograft at the crest (Fig. 8). Incisions were closed with 4-
0 expanded polytetrafluoroethylene sutures†† (Figs. 9 and
10). The patient received postoperative analgesics as well
as a 1-week course of amoxicillin (500 mg three times
daily). Toothbrushing in the surgical area was withheld
for 2 weeks, and the patient utilized chlorhexidine plaque
control until normal oral hygiene measures could be
reinstated.

Clinical Outcomes
One week following surgery, incisions were closed, and the
patient reported minimal discomfort limited to the first 2
postoperative days without need for narcotic analgesics.
FIGURE 2 Occlusal view after the orthodontic phase. Tooth #6 The facial and distal gingival margins on tooth #9 were
has been moved into the #7 position, teeth #8 and #9 have been coronally positioned compared with baseline (Figs. 1 and
positioned for porcelain veneers according to a diagnostic wax-up,
11). Papilla-sparing incisions were used for ø3.5 × 11.5
and the edentulous span between teeth #9 and #11 measured ≈7
mm mesiodistally at the alveolar crest. mm implant‡‡ placement 7 months post-GBR. Subep-
ithelial connective tissue graft (SCTG) augmentation and
immediate provisional restoration placement were com-
#7 and #10. A diastema was present between teeth #8 pleted concomitantly (Fig. 12). Four months after implant
and #9. The patient reported no allergies, no medications, placement, the ridge contour appeared favorable, with
and no surgical history. Examination revealed a minimally thick peri-implant mucosa (Fig. 13). Definitive restora-
restored dentition with no caries lesions. Gingiva was tions (#7 to #10 positions) are shown in Figure 14, and
pink and firm generally, with periodontal probing depths radiographic peri-implant bone levels at 8 months are
ranging from 1 to 3 mm. Bleeding upon probing was shown in Figure 15.
virtually absent.

Discussion
Case Management Minimally invasive procedures accomplish surgical
Orthodontic treatment was used to move tooth #6 into the goals while minimizing invasiveness, risk of untoward
#7 position, optimally space teeth #8 and #9 for porcelain
veneers, and create proper space in the #10 position for  Salvin Tunneling Kit, Salvin Dental Specialties, Charlotte, NC.
implant placement (Figs. 1 and 2). After the orthodontic ¶ Cytoplast, Osteogenics Biomedical, Lubbock, TX.
phase, planning software§ was used to determine implant # Oragraft, Lifenet Health, Virginia Beach, VA.
∗∗ Ring Handle Syringe 4.5 mm, Salvin Dental Specialties.
†† GORE-TEX (P5K17A), W.L. Gore and Associates, Newark, DE.
§ 3D Accuitomo 170, J. Morita, Irvine, CA. ‡‡ Replace Select Tapered, Nobel Biocare, Kloten, Switzerland.

28 Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 Tunnel Guided Bone Regeneration Technique
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FIGURE 3 Cone-beam computed tomography: sagittal view of #10 area (3a) and volume
rendering (3b). In the intended implant position, facial bone thickness measured ≈3 mm.
However, the virtual implant apex protruded through the facial cortical plate. The radiographic
guide was modified slightly and converted to a surgical guide. Radiopaque material was applied
to the guide at the approximate level of the gingival margin, and the virtual implant platform was
placed 3.5 mm apical to this opacity.

FIGURE 4 Vertical incisions in the midline labial frenum and between

teeth #11 and #12 extended from the depth of the vestibule to 3 to 4 FIGURE 5 Intrasulcular incisions were made on the facial of teeth #9
mm coronal to the mucogingival junction. and #11 as well as the proximal tooth surfaces adjoining the #10 area.
Full-thickness reflection with periosteal elevators proceeded to establish
a tunnel between the two vertical incisions. Care was taken to reflect to
the alveolar crest. The gingival margin was freed and positioned coronally
compared with baseline.
outcomes, and surgical trauma.8 – 18 In periodontics,
minimally invasive techniques in the treatment
material facilitated membrane positioning within the tun-
of periodontitis,9 ridge augmentation,8,10 – 14 and
nel access. A mineralized biomaterial (FDBA) was selected
corticotomy procedures15 have received clinical interest.
to hold the overlying gingiva in a coronal position and
Tunneling techniques for mucogingival surgery have been
support space maintenance under the membrane for bone
shown to enhance esthetics and decrease postoperative
formation.
morbidity and discomfort.16 – 18 Reported advantages of
Surgical goals in the present case were to augment the
subperiosteal tunneling techniques for ridge augmentation
apical ridge deficiency in the planned implant location,
include decreased postoperative swelling and discomfort
maintain or improve bone thickness at the line angles
as well as preserved or enhanced soft tissue contours.8,12
of adjacent teeth, and maintain or enhance gingival con-
Tunneling techniques specifically for GBR have been
tours. The vertical height of bone on the teeth adjacent
described in two reports, each a case series utilizing
to a dental implant is a primary determinant of papilla
resorbable membranes.10,14 One report described tunnel
height between a natural tooth and an implant-supported
access for GBR in the maxillary anterior.14 However, the
crown.19 However, bone thickness in this critical area
ultimate effect of the treatment on gingival architecture
is also of paramount importance. Horizontally deficient
after implant restoration in the esthetic zone was not
bone at the facial line angle of a tooth adjacent to a dental
evaluated.14
implant can lead to a disharmonious angular appearance
Selection of a bioabsorbable membrane in this case
of the gingival margin, a deficient papilla, or gingival
would have eliminated disruption of the site at membrane
recession. In the present case, tooth #9 bordered a site of
removal. However, the rigidity and resilience of the dPTFE

Johnson, Baron Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 29

C A S E R E P O R T

FIGURE 9 Facial view of closure with nonresorbable sutures.

FIGURE 6 dPTFE membrane customized to the surgical site. Ridge
augmentation at the line angles of adjacent teeth was desired.

FIGURE 10 Occlusal view upon completion of the GBR procedure.

Note the enhanced alveolar ridge contour.
FIGURE 7 dPTFE membrane inserted through the midline labial
frenum incision and positioned in the #10 area. A midcrestal incision
the width of a #15 blade was made in the #10 area to assure proper
membrane positioning. A membrane fixation screw or tack could have
been placed through this access. In this case, membrane fixation was
not used.

FIGURE 11 Healing 1 week following GBR. The facial gingival margin

remained coronally positioned on tooth #9. The patient reported min-
imal discomfort limited to the first 2 postoperative days. No swelling
was evident at the 1-week assessment.

FIGURE 8 FDBA placement. A graft syringe was used to precisely

apply biomaterial at the crest. Biomaterial placement supported coro- was a concern. The technique used appeared to minimize
nal positioning of the gingival margin. Note the more rounded gingival risk of membrane exposure and resorption of critical
contour on tooth #9. line-angle bone. Controlled clinical study is warranted to
determine if this technique consistently produces favor-
ridge deficiency secondary to tooth agenesis. Accordingly, able clinical and patient-centered outcomes comparable
the potential for thin bone at the mesio-facial line angle with results reported by Lee.8 

30 Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 Tunnel Guided Bone Regeneration Technique
 C A S E R E P O R T

FIGURE 14 Definitive restorations 7 months after implant placement.

FIGURE 12 Dental implant (ø3.5 × 11.5 mm) placement 7 months Porcelain veneers were placed in the #7 to #9 positions, and an
after GBR. The tightly adherent dPTFE membrane was carefully freed implant-supported crown was placed in the #10 area.
from the underlying tissue and removed through a small incision
in the midline labial frenum. Gingival augmentation with a SCTG
and immediate provisional restoration were completed at the time of
implant placement (not shown).

FIGURE 13 The peri-implant mucosa was assessed 4 months after

implant placement during preparation of tooth #6 (in the #7 position)
and the maxillary central incisors for veneers. The alveolar ridge con-
tour in the #10 area appeared favorable, and the facial peri-implant
mucosa measured 3 to 4 mm in thickness. The distal papilla-sparing
incision line made at implant insertion remained discernible.
FIGURE 15 Periapical radiograph #10 area 8 months after
implant placement exhibiting stable peri-implant bone lev-
els located approximately at the first implant thread.

Johnson, Baron Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 31

C A S E R E P O R T

Summary

Why is this case new  The authors could identify no other report documenting soft tissue
information? contours after subperiosteal tunnel access for GBR.

What are the keys to successful  Careful reflection with a tunneling kit appears helpful for preserving
management of this case? periosteum integrity and limiting surgical trauma.

What are the primary limitations  This technique appears most useful at apically located deficiencies.
to success in this case? When significant augmentation is needed at the crest, direct access
may be necessary to assure proper membrane positioning and
placement of adequate biomaterial.

Acknowledgments 7. Jensen AT, Jensen SS, Worsaae N. Complications related to bone

augmentation procedures of localized defects in the alveolar ridge.
The authors thank Dr. Ronald W. Bice, United States Army A retrospective clinical study. Oral Maxillofac Surg 2016;20:
Dental Health Activity, Fort Gordon, GA, for completing 115-122.
the orthodontics in this case as well as CPT Kerin M. 
8. Lee EA. Subperiosteal minimally invasive aesthetic ridge augmentation
technique (SMART): A new standard for bone reconstruction of the
Jamison, United States Army Advanced Education Pro- jaws. Int J Periodontics Restorative Dent 2017;37:165-173.
gram in Prosthodontics, Fort Gordon, GA, for providing 9. Cortellini P, Tonetti MS. Improved wound stability with a modified
the restorative treatment. The views expressed in this minimally invasive surgical technique in the regenerative treatment of
isolated interdental intrabony defects. J Clin Periodontol 2009;36:157-
manuscript are those of the authors and do not necessarily 163.
reflect the official policy of the Department of Defense, 10. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive guided bone
Department of Army, United States Army Medical regeneration. J Oral Implantol 2007;33:205-210.
Department, Uniformed Services University of the Health 11. Xuan F, Lee CU, Son JS, Fang Y, Jeong SM, Choi BH. Vertical ridge aug-
Sciences, or the United States Government. The authors mentation using xenogenous bone blocks: A comparison between the
flap and tunneling procedures. J Oral Maxillofac Surg 2014;72:1660-
report no conflicts of interest related to this case report. 1670.
12. Nevins ML, Camelo M, Nevins M, et al. Minimally invasive alveolar
CORRESPONDENCE ridge augmentation procedure (tunneling technique) using rhPDGF-BB
Dr. Thomas M. Johnson, 320 E. Hospital Rd., Fort Gordon, GA 30905. in combination with three matrices: A case series. Int J Periodontics
E-mail: [email protected] Restorative Dent 2009;29:371-383.
13. Block MS, Kent JN, Ardoin RC, Davenport W. Mandibular augmenta-
tion in dogs with hydroxylapatite combined with demineralized bone.
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32 Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 Tunnel Guided Bone Regeneration Technique