联合隧道式冠向推进瓣（TCAF）与内层系带切除-前庭切口骨膜下隧道入路（IF-VISTA）治疗下颌前牙牙龈退缩：一项技术报告。

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中文摘要

引言： 下颌前牙区牙龈退缩（GR）缺损在牙周成形手术中是一个特别具有挑战性的情形，原因在于软组织表型薄、角化组织极少、前庭深度有限，以及常存在突出的唇系带。尽管下颌前牙的根面覆盖手术已取得显著进展，但在单一微创手术中同时处理这些共存的解剖因素仍是一项临床挑战。
方法： 本技术报告描述了联合应用隧道式冠向推进瓣（TCAF）与内层系带切除-前庭切口骨膜下隧道入路（IF-VISTA）及结缔组织移植，治疗两名全身及牙周健康、不吸烟患者的多处下颌前牙GR。TCAF框架指导位点特异性的龈乳头处理，而IF-VISTA通过单一微创切口提供内层系带切除、前庭加深和扩大的骨膜下入路。
结果： 愈合顺利，术后并发症有限。在10-12个月时，两例中大多数治疗位点观察到完全根面覆盖，并伴有软组织表型增加、龈乳头充盈和牙本质过敏缓解。
结论： TCAF + IF-VISTA联合术式在单一手术中处理了下颌前牙区最常影响预后的多种解剖因素，包括下颌中线系带牵拉、前庭深度有限和手术入路受限。两种方法之间的协同作用促进了无张力瓣推进、精确移植物插入、同期系带消除和龈乳头完整性的保留。需要前瞻性对照研究来验证该技术的长期结局和可重复性。
要点： 隧道式冠向推进瓣（TCAF）与内层系带切除-前庭切口骨膜下隧道入路（IF-VISTA）的联合使临床医生能够在单一手术中处理与下颌前牙牙龈退缩最常相关的多种解剖因素，包括前庭深度有限、下颌中线系带附着位置高和手术入路受限。IF-VISTA的内层系带切除部分通过闭合、无瘢痕的方法消除下颌中线系带附着，避免了传统开放式系带切除相关的并发症，同时增强了冠向瓣动度和无张力组织推进。TCAF决策框架允许根据龈乳头形态和局部解剖对瓣设计进行位点特异性调整——选择性切开或隧道化每个龈乳头——使这种联合方法灵活且适用于下颌前牙区不同的临床表现。
通俗语言总结： 牙龈退缩发生在牙龈组织从牙齿上剥离、暴露根面时，可引起敏感、美观问题以及牙齿和周围组织的长期损害。在下前牙，治疗牙龈退缩尤其困难，因为该区域的牙龈组织天生较薄，牙龈与唇之间的空间有限，且一条称为系带的小组织带常附着过高并牵拉牙龈，使获得稳定结果更加困难。本报告描述了一种将两种现有技术结合为单一微创手术的外科方法：一种技术指导如何对每颗牙齿周围的牙龈组织进行个体化管理，另一种技术从内部去除系带而不留下可见瘢痕。还使用一小块取自口腔顶部的组织来加强和增厚牙龈。在接受该方法治疗的两名患者中，术后10至12个月时大多数牙齿显示完全牙龈覆盖和组织厚度改善，恢复期间不适轻微。需要更大患者群体的未来研究来证实这些有希望的结果。

英文摘要

INTRODUCTION: Gingival recession (GR) defects in the mandibular anterior region represent a particularly challenging scenario in periodontal plastic surgery, owing to a thin soft tissue phenotype, minimal keratinized tissue, limited vestibular depth, and the frequent presence of a prominent labial frenum. While significant advances have been made in root coverage procedures for the anterior mandible, simultaneously addressing these coexisting anatomical factors in a single, minimally invasive procedure remains a clinical challenge.
METHODS: This technique report describes the combined application of the tunneled coronally advanced flap (TCAF) with the internal frenectomy-vestibular incision subperiosteal tunnel access (IF-VISTA) and connective tissue graft for the treatment of multiple mandibular anterior GRs in two systemically and periodontally healthy, non-smoking patients. The TCAF framework guided site-specific papilla management, while the IF-VISTA provided internal frenectomy, vestibular deepening, and expanded subperiosteal access through a single minimally invasive incision.
RESULTS: Healing was uneventful, with limited postoperative morbidity. At 10-12 months, complete root coverage was observed at most treated sites in the two cases, accompanied by an increase in soft tissue phenotype, papilla fill, and resolution of dentinal hypersensitivity.
CONCLUSIONS: The TCAF + IF-VISTA combination addresses, within a single procedure, the multiple anatomical factors most commonly compromising outcomes in the mandibular anterior region, including mandibular midline frenum pull, limited vestibular depth, and restricted surgical access. The synergy between the two approaches facilitates tension-free flap advancement, precise graft insertion, simultaneous frenulum elimination, and preservation of papillary integrity. Prospective controlled studies are needed to validate the long-term outcomes and reproducibility of this technique.
KEY POINTS: The combination of tunneled coronally advanced flap (TCAF) with the internal frenectomy-vestibular incision subperiosteal tunnel access (IF-VISTA) allows clinicians to address, in a single surgical procedure, the multiple anatomical factors most commonly associated with mandibular anterior gingival recessions, including limited vestibular depth, high mandibular midline frenum insertion, and restricted surgical access. The internal frenectomy component of IF-VISTA eliminates the mandibular midline frenum attachment through a closed, scarless approach, avoiding the morbidity associated with conventional open frenectomy while simultaneously enhancing coronal flap mobility and tension-free tissue advancement. The TCAF decision-making framework allows site-specific adaptation of the flap design-selectively incising or tunneling each papilla based on its morphology and the local anatomy-making this combined approach flexible and adaptable to varying clinical presentations in the mandibular anterior region.
PLAIN LANGUAGE SUMMARY: Gum recession occurs when the gum tissue pulls away from the teeth, exposing the root surface, and can cause sensitivity, esthetic concerns, and long-term damage to the tooth and surrounding tissues. In the lower front teeth, treating gum recession is particularly difficult because the gum tissue in this area is naturally thin, there is limited space between the gum and the lip, and a small band of tissue called the frenum is often attached too high and pulls on the gum, making it harder to achieve stable results. This report describes a surgical approach that combines two existing techniques into a single minimally invasive procedure: one technique guides how the gum tissue is managed around each tooth individually, while the other removes the frenum from the inside without leaving visible scars. A small piece of tissue taken from the roof of the mouth is also used to reinforce and thicken the gum. In two patients treated with this approach, most teeth showed complete gum coverage and improved tissue thickness at 10 to 12 months after surgery, with minimal discomfort during recovery. Future studies with larger patient groups are needed to confirm these promising results.