A NOVEL MODIFIED-VISTA TECHNIQUE WITH CONNECTIVE TISSUE GRAFT IN THE TREATMENT OF

GINGIVAL RECESSION-A CASE REPORT.

P. Charishma Chowdary*, Post graduate

Y. Sandhya Pavankumar*, Professor

K. Raja V Murthy*, Professor and Head

Trinath Kishore D*, Professor

*
Department of Periodontics and Oral Implantology, GITAM Dental College and

Hospital, Visakhapatnam, Andhra Pradesh, India.

Corresponding author

P. Charishma Chowdary,

Address for correspondence: P. Charishma, Department of Periodontics and Oral

Implantology, GITAM Dental College and Hospital, Pin- 530045, Visakhpatnam, Andhra

Pradesh, India.

Email- [email protected]

Authors contribution statement: All the authors have contributed substantially to

conception and design; acquisition, analysis and interpretation of data; in drafting the article

and in the final approval of the version to be published.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/cap.10135.

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Word Count- 980

Number of Figures- 11

Number of References – 15

Short Running Title- Minimally Invasive Therapy of Visible Recession.

Key findings- M-VISTA and CTG seems to be a promising method for root coverage.

ABSTRACT:

Introduction:

The increasing esthetic demands from patients has required that clinicians sharpen their

skills and adopt newer and more novel techniques to satisfy these demands. In periodontal

therapy, periodontal plastic surgery poses a substantial challenge to the clinician, both

because it is technique sensitive and also because it includes a wide array of procedures

and their variations. Conventional plastic procedures have provided satisfactory results in

the treatment of gingival recession but there is, presently, a greater need for more advanced

procedures that cause less surgical morbidity as also provide improved results. Minimally

invasive surgery has been harnessed in periodontics for this purpose and has been

extensively used in multiple indications, including root coverage. Modified-Vestibular Incision

Supra-periosteal Tunnel Access (M-VISTA) applies the principles of minimally invasive

surgery to provide satisfactory results in root coverage.

Case presentation: A 28-year-old male patient presented with multiple Miller Class I/II

buccal recession defects and associated high labial frenum on right maxillary anterior teeth.

M-VISTA technique allowed coronal repositioning of gingival margin, which was then

stabilized by orthodontics bracket assisted suturing technique. The V-shaped incision in the

region of the frenal attachment allowed for conducting both the M-VISTA and frenectomy

techniques simultaneously. Connective tissue graft was inserted in the supra-periosteal

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tunnel and vertical incision was sutured. Complete root coverage was achieved and

maintained at 9 months with excellent esthetic outcomes.

Conclusion: The use of connective tissue graft along with M-VISTA technique allows the

clinician to successfully treat multiple recession defects.

Key words: Connective tissue graft; gingival recession; mucogingival surgery; plastic

periodontal surgery; cosmetic periodontal surgery.

Background

A wide range of therapeutic options are available in the management of marginal recession

defects, including soft tissue tunnelling.1 Various Tunnelling techniques were proposed to

preserve esthetics, prevent relapse, maintain papillary integrity and prevent the scarring

resulting from vertical releasing incisions.2,3 Tunnelling is a widely accepted but highly

sensitive and blind technique causing trauma to the sulcular epithelium, resulting in less than

acceptable outcomes. Modified-Vestibular Incision Supra-periosteal Tunnel Access (M-

VISTA)4 was proposed to avoid the potential complications occurring with tunnelling

techniques. The M-VISTA technique incorporates a supra-periosteal flap design instead of

the original sub-periosteal approach.

Autogenous sub-epithelial connective tissue graft (SCTG) is effective in providing long-term

root coverage, proper color match and increasing the width of keratinized tissue and

continues to be the gold standard therapeutic option in root coverage procedures.5,6

The aim of the present clinical case report is to describe the M-VISTA technique, combined

with CTG, in the treatment of gingival recession.

Clinical presentation

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 7
A 28-year-old, healthy (ASA I) male reported on June 18th, 2019, to the Department of

Periodontics and Oral Implantology, Gandhi Institute of Technology and Management

(GITAM) Dental College, Visakhapatnam, India, with a chief complaint of receding gums,

poor esthetics and sensitivity in relation to the right upper front teeth. The patient was a non-

smoker with no history of periodontal disease. Clinically class I/II Miller gingival recession

defects were observed at teeth #6-8, without concomitant papillary loss, root caries or

radiographic interproximal bone loss (Fig.1). The treatment plan included oral prophylaxis

implemented four weeks prior to the surgical procedure. Written informed consent was

obtained from the patient.

Case Management

Under sterile conditions, local anesthesia was given. As tension test was positive for

maxillary labial frenum (Fig.1), frenectomy was performed by giving a triangular incision with

a 15c blade (Fig. 2). The resulting tissue opening provided access to the buccal recession

defects on teeth #6-8. A split-thickness tunnel was then prepared supra-periosteally, leaving

the periosteum intact (Fig. 3a & 3b). An intrasulcular incision was given at teeth #6-8 to

provide continuity with the supra-periosteal tunnel. To prevent tension during coronal

advancement, the dissection was carefully extended beyond the mucogingival junction (Fig.

4).

Following recipient bed preparation, a connective tissue graft was harvested from the palate

by “trap door” technique (Figs. 5 and 6)8 and compression sutures were placed (Fig. 7). This

CTG was tucked with the aid of a suture into the prepared tunnel through the frenectomy

opening (Fig. 8). The graft was stabilized on the periosteum using interrupted sutures

(Polyglycolic acid #5-0). The sutures were then horizontally passed across the gingiva,

coronally advancing the gingival margin 2mm beyond the cemento-enamel junction (CEJ),

and stabilized by orthodontic brackets (Fig. 9). The frenectomy opening was sealed using

interrupted sutures (Fig. 9). Periodontal dressing was given. The patient was asked to refrain

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from brushing for 2 weeks; Ibuprofen 400mg for postoperative pain and chlorohexidine

mouthwash (0.12%) was prescribed. The brackets were debonded after two weeks. The

patient was followed up at two weeks, one, three, six and nine months.

Clinical Outcomes

Healing was uneventful. Complete root coverage and an intact papilla was observed at one

month (Fig. 10) which was subsequently maintained (Fig. 11). Apical shift of maxillary frenal

attachment was also achieved, with subsequent increase in keratinized tissue. The probing

depths, mid-bucally on the treated teeth, were limited to 1mm. The root coverage esthetic

score for both the clinician and the patient ranged between 9 to 10 with respect to color

match and texture.9 The surgical site demonstrated an increase in both gingival thickness

and width of the keratinized gingiva. The patient’s hypersensitivity resolved completely.

Discussion

In this era of patient centred esthetic outcome, restoring the ideal pink and white esthetics is

a prime requisite. A high labial frenum and esthetic improvement could be the challenges for

the clinician in the maxillary anterior area. The M-VISTA technique differs from the original

VISTA in incision design, supra-periosteal tunnel access, the graft used and suturing.10

A “V- shaped” incision given for frenectomy provided adequate access to prepare a supra-

periosteal tunnel and relieve the frenum pull. The improved visual access allowed for a more

meticulously executed surgery, reducing surgical time, and increasing patient comfort. As

opposed to the original VISTA technique, the supra-periosteal tunnel left the periosteum

intact over the facial bone, maintaining its vascularity and preventing further bone loss.4,11,12

Periosteum retention provides early revascularisation of the connective tissue graft. The

embedding of the SCTG between two vascular rich surfaces helps in immediate reperfusion

and graft survival, leading to perfect tissue blending in terms of color and texture. 11,13 In

addition, studies have implied that the lamina propria consists of genetic information that

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dictates the keratinization of the overlying surface.14

In tunnelling through the small sulcular access there is increased risk of traumatizing

and perforating the sulcular tissues, potentiating possible unfavorable healing outcomes. M-

VISTA provides improved access and is minimally invasive compared to the tunnelling

technique. Critical to the success of M-VISTA is supra-periosteal dissection which avoids

tension on coronally positioned gingival margin and preserves papillary integrity.

The use of patient’s own connective tissue rather than other substitutes in this case report

may have contributed to provided improved clinical outcomes.15 A key aspect of successful

root coverage is graft stabilization. In this study, the graft was stabilized to the periosteum;

the tension free flap was coronally advanced using orthodontic bracket assisted sutures.

Undisturbed healing resulted in good results with no relapse.

Conclusion

The M-VISTA resulted in patient centred esthetic outcome, reduced surgical visits, time

(both frenectomy and root coverage done simultaneously) and patient discomfort. The

supra-periosteal tunnel provided greater vascularity to the CTG and the orthodontic bracket

anchored sutures offered a tension free advancement. Hence, this minimally invasive

surgical technique may allow the clinicians to attain functionally and esthetically pleasing

root coverage in the maxillary anterior area. Future comparative studies may be undertaken

to prove its efficacy over time.

Summary

Why is this case new information?  The supra-periosteal tunnel provides

increased access and predictable graft

survival, resulting in an improved patient

centred esthetic outcome.

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  Minimally invasive surgical technique with

reduced intra-surgical time and increased

patient comfort.

What are the keys to successful  Supra-periosteal tunnel access

management of this case?  Tension free coronal flap advancement

 Graft stabilization

What are the primary limitations to  Very thin biotype carries risk of flap

success in this case? perforation

 Cases with shortened vestibule

Acknowledgments

The authors report no conflicts of interest related to this case report.

Conflict of interest

The authors report no conflicts of interest related to this case report.

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13. Caffesse RG, Burgeft FG. Nasjieti CE. Costelli WA. Healing of free gingival grafts with

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Figure Legends

Figure 1- Initial Presentation

Figure 2- Frenectomy and Sulcular Incision

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 Figure 3a & 3b- Supra-periosteal Tunnelling

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 Figure 4- Tension Free Coronal Advancement of Flap

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 Figure 5- Procuring Connective Tissue Graft Using Trap Door Technique

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 Figure 6- Connective Tissue Graft After Harvesting

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 Figure 7- Compression Sutures at Donor Site

Figure 8- Connective Tissue Graft Tucked into The Supra-periosteal Tunnel

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 Figure 9- Orthodontic Bracket Assisted Coronally Advanced Flap

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 Figure 10- Healing at One Month

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 Figure 11- Healing at Nine Months

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Exemplary images

 Baseline

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  9th Month postoperative

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