Pinhole Surgical Technique: A 10-year evaluation of root coverage

Gingival recession is a soft-tissue problem affecting 88% of adults in the United States aged 65 and older and 50% of adults aged 18–64.¹ Gingival recession is defined as the displacement of the marginal tissue apical to the cementoenamel 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 gingival recession include toothbrush and oral hygiene abrasion, periodontal tissue loss, calculus, high frenum attachments, position of the tooth in the arch, trauma, orthodontic movement, smoking and tobacco products, genetically thin tissue, subgingival restorations, poorly fitting dentures, and chemical abrasion from medications/drug use.³

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

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

Figure 2: Specialized instruments used in PST to advance soft tissue

To avoid these problems, minimally invasive surgical techniques that utilize vestibular incisions and subperiosteal tunneling were created.⁷ This article will describe one type of this minimally invasive surgical method that has been used for more than a decade with success—the Chao Pinhole Surgical Technique (PST).

Pinhole Surgical Technique

Introduced by Dr. John Chao in 2012, the PST is a minimally invasive soft-tissue grafting approach using microincisions (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 recession defects. Graft material, typically porcine collagen membrane (Geistlich Bio-Gide), is inserted

Figure 3: Bio-Gide collagen strips inserted into the pinhole incision

into the pinhole incisions (figure 3) to increase the thickness of the tissue as well as support the new advanced height of the tissue.Advantages of this technique include not having to use a scalpel, no damage to intrasulcular papillary tissues, no sutures required, and minimal postoperative complications. Bleeding, pain, and better healing occur due to minimal manipulation of the soft tissue. Because no donor tissue is required and flap advancement is better when more teeth need to be treated, multiple areas of recession can be addressed at one treatment time. In addition, because there is no need for a donor site and minimal, if any, sutures are required, surgical treatment time is reduced.

Figure 4: Advanced recession case with hard- and soft-tissue loss

Decreases in treatment time have been correlated with decreases in postoperative pain. One study suggests that if a surgical procedure can be shortened by 10 minutes, moderate to severe postoperative pain can decrease as much as 40%.⁸ Limitations of the PST include it is technique sensitive, the patient must be on a soft food restricted diet for multiple weeks postsurgery, and the technique has its best success when early to moderate recession cases are treated. Advanced recession cases (with bone loss and gum tissue loss) are not indicated with traditional PST, but there are case series in the literature that have used PST in combination with both hard- and soft-tissue grafts (figures 4–6) and

Figure 5: PST surgery using hard- and soft-tissue grafting and sutures

that have had success with advanced recession defects (Miller class III and class IV recession).

Research about 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 with no bone loss (class I and class II Miller recession defects), recession was reduced about 94% and complete root coverage was

Figure 6: Stable result two years after PST and cosmetic dentistry

achieved in 81% of the treated teeth.Since that study, others have found similar percentages of root coverage with

one case series finding 96% mean root coverage for class I and class II Miller defects,⁹ and another case series with similar mean root coverage percentages showing that results were stable over time (figures 7 and 8).^10,11

Conclusion

The PST has been shown to have excellent results over a long-term period and is comparable to other soft-tissue grafting techniques. Advantages include a

Figure 8: Stable result six years after PST

decrease in pain, treatment time, and the need for posttreatment analgesics; more teeth can be treated during surgery; increase in tissue thickness; and excellent color-match. Limitations of this technique include the complexity of the technique, technique sensitivity, food restrictions, postoperative instructions that need to be closely followed, and the efficacy in severe recession defects or recession around dental implants has not been thoroughly tested.

Author’s note: Dr. Scott Froum is not a paid consultant and does not have any financial interest in any company mentioned in this article.

Editor's note: This article appeared in the May 2022 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.

References

Miller AJ, Brunelle JA, Carlos JP, Brown LJ, Löe H. Oral health of United States adults. The National Survey of Oral Health in U.S. Employed Adults and Seniors: 1985-1986, NIH publication no. 87-2868.
Glossary of Periodontal Terms. AAP Connect. American Academy of Periodontology. https://members.perio.org/libraries/glossary
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Chambrone L, Tatakis DN. Long-term outcomes of untreated buccal gingival recessions: a systematic review and meta-analysis. J Periodontol. 2016;87(7):796-808. doi:10.1902/jop.2016.150625
Goyal L, Gupta ND, Gupta N, Chawla K. Free gingival graft as a single step procedure for treatment of mandibular Miller class I and II recession defects. World J Plast Surg. 2019;8(1):12-17. doi:10.29252/wjps.8.1.12
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
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 Periodontics Restorative Dent. 2011;31(6):653-660.
Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures. J Periodontol. 2006;77(12):2070-2079. doi:1902/jop.2006.050296
Reddy SSP. Pinhole Surgical Technique for treatment of marginal tissue recession: a case series. J Indian Soc Periodontol. 2017;21(6):507-511. doi:10.4103/jisp.jisp_138_17
Agarwal MC, Kumar G, Manjunath RGS, Karthikeyan SSS, Gummaluri SS. Pinhole Surgical Technique — a novel minimally invasive approach for treatment of multiple gingival recession defects: a case series. Contemp Clin Dent. 2020;11(1):97-100. doi:10.4103/ccd.ccd_449_19
Mostafa D, Al Shateb S, Thobaiti B, et al. The pinhole technique in the treatment of gingival recession defects. A long-term study of case series for 5.1–19.3 years. Adv Dent Oral Health. 2020;13(1):555855. doi:10.19080/ADOH.2020.13.555855