Pinhole surgical technique: a 10-year evaluation of root coverage

Receding gums are a soft tissue problem that affects 88% of adults in the United States ages 65 and older and 50% of adults ages 18-64.¹ Gingival recession is defined as displacement of marginal tissue apical to the cemento-enamel junction (CEJ), where the amount of tissue that is lost (apically displaced) between the CEJ and the gingival margin is the amount of recession present.²

Causes of receding gums include abrasion from toothbrush and oral hygiene, loss of periodontal tissue, tartar, high frenulum attachments, tooth position in the arch, trauma, orthodontic movements, smoking and tobacco products, genetically thin tissue, subgingival restorations, ill-fitting dentures, and chemical abrasion due to medication/drug use.³

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Consequences of untreated tissue recession include poor esthetics (long teeth), root hypersensitivity, root caries, plaque retention, bleeding, and continued tissue loss.⁴

There are various soft tissue graft surgical techniques to treat gingival recession including free gingival grafts, connective tissue grafts, pedicle grafts, rotational grafts, coronally advanced flaps, guided tissue regeneration, and others. modifications of these standard grafts.⁵ The disadvantages of many of these techniques are that they are invasive, may not result in a perfect tissue replacement color match, or may require a second donor site to harvest the grafted tissue.⁶

To avoid these problems, minimally invasive surgical techniques using vestibular incisions and a subperiosteal tunnel have been created.⁷ This article will describe one type of this minimally invasive surgical method that has been used successfully for over a decade – the Chao Pinhole Surgical Technique (PST).

Pinhole surgical technique

Introduced by Dr. John Chao in 2012, PST is a minimally invasive soft tissue grafting approach using micro-incisions (pinholes) in the vestibular tissue (Figure 1). Specialized transmucosal periosteal elevators (Figure 2) are then used to advance the existing soft tissue coronally to cover the recessional defects. The graft material, usually a porcine collagen membrane (Geistlich Bio-Gide), is inserted in the pinhole incisions (Figure 3) to increase tissue thickness as well as to support the new advanced tissue height.

The advantages of this technique include the absence of the use of a scalpel, the absence of damage to the intrasulcular papillary tissues, the absence of necessary sutures and a minimum of postoperative complications. Bleeding, pain and better healing occur due to minimal soft tissue manipulation. Since no donor tissue is required and flap advancement is better when more teeth need to be treated, multiple areas of recession can be treated at one time. Additionally, since there is no need for a donor site and minimal, if any, sutures are required, surgical treatment time is reduced.

The decrease in treatment time was correlated with the decrease in postoperative pain. A study suggests that if surgery can be shortened by 10 minutes, moderate to severe postoperative pain can decrease by up to 40%.⁸ Limitations of PST include that it is sensitive to the technique, that the patient must follow a restricted diet of soft foods for several weeks after surgery, and that the technique has its best success when cases of early to moderate recession are processed. Cases of advanced recession (with bone loss and loss of gum tissue) are not indicated with traditional PST, but there are case series in the literature that have used PST in combination with hard and soft tissue grafts ( Figures 4–6) and who have had success with advanced recessionary defaults (Miller Class III and Class IV recession).

Search on PST

In 2012, Dr. John Chao, the inventor of PST, published the first study using this technique on 121 recession defects. He noted that for teeth with early and moderate recession without bone loss (Miller Class I and Class II recession defects), recession was reduced by approximately 94% and complete root coverage was reached in 81% of treated teeth.

Since that study, others have found similar percentages of root coverage with a case series showing an average root coverage of 96% for Miller class I and class II defects,⁹ and another case series with similar average root coverage percentages showing that the results were stable over time (Figures 7 and 8).^10.11

Conclusion

PST has been shown to have excellent results over a long term period and is comparable to other soft tissue grafting techniques. Benefits include a decrease in pain, treatment time and need for post-treatment analgesics; more teeth can be treated during surgery; increase in tissue thickness; and excellent color matching. Limitations of this technique include the complexity of the technique, the sensitivity of the technique, dietary restrictions, postoperative instructions that must be followed closely, and effectiveness in severe recession defects or recession around dental implants n has not been thoroughly tested.

Author’s note: Dr. Scott Froum is not a paid consultant and has no financial interest in the companies mentioned in this article.

Editor’s note: This article originally appeared in the May 2022 print edition of Dental economy magazine. Dentists in North America can take advantage of a free print subscription. Register here.

References

1. Miller AJ, Brunelle JA, Carlos JP, Brown LJ, Löe H. Oral health of American adults. The National Survey of Oral Health in Employed Adults and Elderly in the United States: 1985-1986, NIH publication no. 87-2868.
2. Glossary of periodontal terms. AAP connection. American Academy of Periodontology. https://members.perio.org/libraries/glossary
3. Koppolu P, Rajababu P, Satyanarayana D, Sagar V. Receding gums: review and treatment strategies for recession. Case Rep Dent. 2012;2012:563421. doi:10.1155/2012/563421
4. Chambrone L, Tatakis DN. Long-term outcomes of untreated oral gingival recession: a systematic review and meta-analysis. J Periodontol. 2016;87(7):796-808. doi:10.1902/jop.2016.150625
5. Goyal L, Gupta ND, Gupta N, Chawla K. Single-stage free gingival grafting for the treatment of Miller class I and II mandibular recession defects. World J Plast Surg. 2019;8(1):12-17. doi:10.29252/wjps.8.1.12
6. Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontol 2000. 2001;27(1):72-96. doi:1034/j.1600-0757.2001.027001072.x
7. Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision, subperiosteal tunnel access, and platelet-derived growth factor BB. Int J Restorative Periodontics Tooth. 2011;31(6):653-660.
8. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications after gingival augmentation procedures. J Periodontol. 2006;77(12):2070-2079. doi:1902/jop.2006.050296
9. Reddy SSP. Pinhole surgical technique for the treatment of marginal tissue recession: a case series. J Indian Soc Periodontol. 2017;21(6):507-511. doi:10.4103/jisp.jisp_138_17
10. Agarwal MC, Kumar G, Manjunath RGS, Karthikeyan SSS, Gummaluri SS. Pinhole Surgical Technique – a new minimally invasive approach for the treatment of multiple gum recession defects: a case series. Contemp Clin Dent. 2020;11(1):97-100. doi:10.4103/ccd.ccd_449_19
11. Mostafa D, Al Shateb S, Thobaiti B, et al. The pinhole technique in the treatment of gingival recession defects. A long-term case series study for 5.1 to 19.3 years. Oral Health Adv Dent. 2020;13(1):555855. doi:10.19080/ADOH.2020.13.555855