The concept and technique of the pinhole surgical procedures has been a debated topic in dentistry in recent years. This paper consists of a mini review of the literature available on pinhole surgical technique. This review shows that pinhole surgical technique allows us to reposition the gums quickly and easily, with the less invasive method, a decreased patient discomfort, a shorter treatment and recovery time and much less pain.
Gum recession refers to the loss of gum tissue along the gum line. This can occur as a result of periodontal disease (gingivitis, periodontitis, advanced periodontitis), the natural aging process, or abrasive habits when it comes to brushing the teeth. When gum recession occurs, the root structure of the tooth becomes exposed and loses of the tissues covering the root. This means that tooth decay and other problems can affect the teeth along the gum line and beneath it. Since healthy gums are essential for a healthy mouth, getting gum recession treated is important for lasting dental wellness [1-3]. The surgeons are now interested in more user-friendly, less invasive, esthetically favorable patient oriented surgeries as they now aim at/prioritize patient comfort, satisfaction, and patient centered outcomes. The concept of “extension for prevention” has now changed to “conserve to preserve.” The concept of “minimally invasive surgery (MIS)” is one such peculiar and innovative approach which aims to produce minimal wounds, minimal flap reflection, and gentle handling of the soft and hard tissues . Wickham and Filtz described the techniques of using smaller incisions as “MIS” which were later defined by medical subject headings as those procedures that avoid the use of open invasive surgery in favor of closed or local surgery. Hunter and Sackier described the same as “the ability to miniaturize our eyes and extend our hands to perform microscopic and macroscopic operations in places that could previously be reached only by large incisions .” In recent years a novel surgical approach to root coverage, called the pinhole surgical technique, has been gaining exposure. Chao introduced it for Miller class I, II, and III recession defects and reported favorable predictability for root coverage and defect reduction up to 18 months following
the procedure . Miller introduced his classification system . The author related the extent of the soft tissue recession to the location of the mucogingival junction as well as the height of interproximal clinical attachment adjacent to the surface affected by the recession.
Pub Med databases were used to search for published articles about pinhole surgical technique. Clinical studies and cases using this technique were included. Letters to the Editor, historical reviews, and unpublished articles were not sought. Some articles were directly excluded after reading only their titles. At this stage there were 9 to 10 articles included, and the inclusion and exclusion criteria were defined. Thirteen articles were included for full-text reading. After reading these, three more articles were excluded, as they did not fulfill the inclusion criteria. These articles were included in introduction and discussion in addition to that, more reviews of literature had been included regarding pinhole surgical technique.
This treatment offers a more conservative alternative to common periodontal treatments, such as gum grafting. With the Pinhole Surgical Technique, the clinician makes a small hole in the gums, the size of a needlepoint, and then manipulates the tissue to correct recession and other issues. In addition, for some cases, a biocompatible collagen agent is inserted, filling the space between gingival tissue and the roots, which helps heal the area and allow healthy tissue to attach to the teeth. Most of the selected studies considered different benefits, including cosmetic
improvement, arresting further breakdown, no need for scalpels
or sutures, preservation of natural gum tissue, and reduced risk of
periodontal problems [6,8-13].
Zucchelli and Sanctis conducted a case series study to evaluate
root coverage with a new surgical approach to the coronally
advanced flap procedure for treatment of multiple recession
defects in patients with esthetic demands at 1 year examination.
The results showed 88% complete root coverage and greater
reductions in recession in cases with less amount of keratinized
tissue apical to recession defect . In 2005 zucchelli et al. 
conducted a long term case series (5 years) for treatment of
Multiple Adjacent Recession Defects (MRTD) using envelope
type coronally advanced flap and the 5 year follow up showed,
increased in keratinized tissue and 85% of treated recessions
defects showed complete root coverage. Chambrone et al. 
conducted a systematic review of periodontal plastic surgery in
the treatment of multiple recession type defects and concluded
that the mean width of keratinized tissue increased significantly
and mean root coverage achieved ranged from 94% - 98% and
the need for more randomized controlled trials to identify the
indication for each surgical technique. A split mouth study
randomized controlled was conducted by pini prato et al.  in
2010 to evaluate coronally advanced flap versus connective tissue
graft in the treatment of multiple gingival recessions with a 5
year follow up and concluded that 52% sites showed completed
root coverage when treated with coronally advanced flap and
connective tissue graft in comparison to 35% coverage in coronally
advanced flap treated sites. A new minimally invasive treatment
of multiple gingival recession defects in maxillary anterior region
was achieved by zadeh  as a case series by vestibular incision
subperiosteal tunnel access technique. The result showed good
outcome in esthetic zones.
A randomized controlled trial for treatment of multiple
recession defects was conducted by ozcelik et al.  using
coronally advanced flap combined with orthodontic button
application and the result showed 84% complete root coverage
and high patient satisfaction with esthetic demands. A novel
approach for treatment of multiple recession defects using a Pin
Hole Surgical Technique was introduced by John Chao . The
Author concluded that 94% mean defect reduction was obtained
along with minimum post-operative complications and optimal
patient based outcome. The Chao Pinhole Surgical Technique
(PST) is a minimally invasive option for treating gum recession.
Unlike traditional grafting techniques, PST is incision and suture
free. Traditional gum recession treatments involve the use of
donor tissue or soft tissue grafts in order to rebuild the gum line.
This soft tissue would be sutured in place and would join with
existing gum tissue as it healed. During the Chao Pinhole Surgical
Technique, a needle is used to make a small hole in the patient’s
existing gum tissue. Through this pinhole, special instruments
are used to gently loosen the gum tissue. These tools help expand and slide the gum line to cover the exposed root structure. There
are no grafts, no sutures, and no incisions needed with the Chao
Pinhole Surgical Technique. It simply involves the adjustment of
the existing tissue.
Chao conducted different benefits of the Pinhole Surgical
Less discomfort for the patient after treatment.
Faster recovery for the patient than traditional grafting.
No need for scalpels or invasive surgical tools.
No need to take donor tissue from the patient’s palate.
Excellent, natural-looking, long-lasting results.
The Pinhole Surgical Technique, is an incision-free, suturefree
procedure for treating gum recession. Through a small
pinhole made by a needle and uses specially designed instruments
to gently loosen the gum tissue and glide it over the receded part
of the tooth. Since there is no incision or suturing, patients can
expect minimal post-operative symptoms (pain, swelling and
Pinhole surgical technique is one such novel technique which
holds promise as a minimally invasive, predictable, efficient, time
and cost-effective procedure for recession coverage in Millers
Class I and Class II recession defects mainly occur in buccal
areas and the main etiologic factors include trauma from tooth
brushing, malposition of teeth, ectopic insertion of frenum and
muscle attachment. There is a need for more long term research to
be carried out to analyze the success of pinhole surgical technique
in management of single or multiple recession defects.