Volume 8, Issue 7, July – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

A Case Report on Combination of Vista

with Connective Tissue Graft as A Predictable
Surgical Approach in Management of Multiple
Gingival Recession
Dr. Shivani1 Dr. Madhu S. Ratre2
1 2
Post graduate student, Department of Periodontology, Professor & Head, Department of Periodontology,
Government College of Dentistry, Indore, Government College of Dentistry, Indore,
Madhya Pradesh, India (452001) Madhya Pradesh, India (452001)

Dr. Shaleen Khetarpal3 Dr. Shreyansh Ahirwar 4

3 4
Reader, Department of Periodontology, Post graduate student, Department of Periodontology,
Government College of Dentistry, Indore, Government College of Dentistry, Indore,
Madhya Pradesh, India (452001) Madhya Pradesh, India (452001)

Abstract:- Gingival recession, a common occurrence movement by orthodontic forces and some periodontal
across various populations, is characterized by the surgeries by conventional/or chemicals methods can lead to
displacement of gingival tissues towards the root, leading the apical shift of the gingival margin. Gingival recession
to exposure of the root surface. This condition can raise exposes the root surface resulting in hypersensitivity,
concerns for patients due to root hypersensitivity, formation of plaque retentive area, root caries and poor
erosion, root caries, and aesthetic reasons. In recent aesthetics particularly in the anterior aesthetic zone [1].
times, novel techniques for surgically treating multiple
adjacent recession type defects have been proposed. Evidence suggest that gingival recession mostly affects
These techniques are primarily based on the coronally individuals with age 30 years or more. Furthermore, it has
advanced flap approach, which involves a supra- or been observed that at least 40% of young adults and 88% of
subperiosteal tunnel technique combined with a older adults experience gingival recession in at least one
subepithelial connective tissue graft, graft substitutes or area with marginal tissue recession of 1 mm or more [2,3].
growth factors. The aim of the the present case reports is
to outline a minimally invasive approach known as Different surgical techniques incorporating soft tissue
vestibular incision subperiosteal tunnel access along with grafts i.e., Free gingival graft (FGG), sub-epithelial
connective tissue graft, which overcomes the drawbacks connective tissue graft (CTG), guided tissue regeneration
of other conventional tunneling techniques or classic root (GTR) membrane, enamel matrix derivative (EMD),
coverage procedures. Overall, this innovative technique acellular dermal matrix allograft (ADM), xenogenic
offer promising solutions for addressing gingival collagen matrix (XCM), platelet-rich fibrin (PRF) etc. have
recession and its associated concerns, providing potential been proposed for the management of gingival recession [4].
benefits to patients seeking treatment for this condition. CTG technique has been considered as the gold standard for
the management of gingival recession. It has yielded
Keywords:- Coronally Advanced Flap, Gingival Recession, predictable and reproducible results with the dual advantage
Root Coverage, Subepithelial Connective Tissue Graft, of optimal donor site healing as well as outstanding color
Vestibular Incisional Sub Periosteal Tunnel Access. matching of the tissues.

I. INTRODUCTION The efficacy and predictability of various root

coverage procedures rely on several factors including the
The gingiva is a crucial part of the periodontium, that anatomy of the defect site, the width of attached gingiva, the
encircles the cervical portion of the teeth and the alveolar height of interdental papilla, the vestibular depth and the
processes of the jaws. The gingival tissues are closely type of frenulum attachment [5]. The treatment of recession
adapted in a healthy state, thus offering excellent defense defects associated with multiple teeth poses a greater
against physical injuries and bacterial infiltration. challenge to clinicians as avascular root surface area is more
Additionally, it plays a vital role in maintaining esthetics. extensive. The vestibular incision subperiosteal tunnel
access (VISTA) approach was introduced with the aim to
Multiple factors like the presence of plaque and avoid the complications of the conventional treatment
calculus, tooth malposition, high frenal attachment, procedures for root coverage[6].
improper tooth brushing, faulty restorations, smoking, tooth

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Volume 8, Issue 7, July – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
The purpose of the present case report is to outline and CTG was harvested from the right premolar-molar
discuss the effectiveness of the VISTA technique in region of the hard palate using the trap door technique (Fig.
combination with CTG in the management of multiple 4). The palatal donor site was sutured and protected with an
gingival recession defects. adhesive intraoral band-aid (Fig. 5). The graft was trimmed
to fit the dimensions of the recipient site and carefully
II. CASE REPORT inserted inside the subperiosteal tunnel (Fig. 6). Measures
were also taken to place the graft just below the gingival
A 32 year old female patient reported to the margin of each tooth with its apicocoronal extent of at least
Department of Periodontology, with a chief complaint of 3-4 mm beyond the bony dehiscences over the root surfaces
receding gums and sensitivity in the upper right front and to ensure the adequate blood supply to the graft.
back tooth region. The patient’s general health status was
fair with no relevant medical and dental history. She was The graft along with the mucogingival and the gingivo-
using the horizontal scrub technique for tooth brushing. On papillary complex were then stabilized in the new coronal
intraoral examination, miller class I recession defect was position using the coronally anchored suturing technique
present w.r.t 13,14,15,16 (Fig. 1). On radiographic using 6-0 polypropylene sutures. This suturing technique
evaluation, there was no bone loss interproximally. incorporates modified horizontal mattress sutures, knots of
which is positioned at the coronal third of the tooth crown.
A. Pre-Surgical Phase: The knots are then stabilized at that position by using
Phase I therapy was caried out and the patient was composite buttons which prevents the apical pull of the
educated for plaque control. Moreover, the patient was also gingival margin during the initial healing. The vertical
motivated to modify her brushing habit. She was instructed access incision was approximated and sutured using 6-0
to follow the vertical oriented roll method instead of the polypropylene suture (Fig. 7). Analgesics (ibuprofen 400
horizontal scrub technique to minimize toothbrush trauma as mg) and antibiotics (amoxicillin 500mg) three times a day
advocated by Wennström and Zucchelli [7]. Basic blood for 5 days were prescribed. Cold fermentation was also
investigations were done which were in the normal range. prescribed in on and off mode at the surgical site in the
The patient was recalled after 4 weeks to evaluate the initial 24 hours. All the sutures were removed after 14 days.
gingival health status. VISTA technique was planned in The follow-up was done at 3 weeks, 1 month and 3 months
combination with CTG w.r.t 13,14,15,16 for the postoperatively (Fig. 8).
management of gingival recession.

Fig 2 Vestibular Access Incision Mesial to the Defect and

Subperiosteal Tunneling using Microsurgical Periosteal
Fig 1 Pre-Operative Photograph; Miller Class I Recession Elevator
Evident w.r.t 13,14,15,16

B. Surgical Phase:
After taking patient’s consent and obtaining profound
anesthesia, a vestibular access incision was made through
the periosteum mesial to the recession defect. A
subperiosteal tunnel was prepared using a microsurgical
periosteal elevator thus exposing the buccal bone plate and
root dehiscences (Fig.2) The gingival sulcus of each tooth to
be treated was connected via the tunnel. The extended well
beyond the mucogingival junction, so as to allow for tension
free coronal advancement of the gingiva. Interproximal
extention of the tunnel was also carried out to mobilize the
gingivo-papillary complex as far as the embrasure space
permitted. No surface incisions were made through the Fig 3 The Gingival Sulcus of each Tooth to be Treated was
papillae (Fig.3). Connected via the Tunnel

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Volume 8, Issue 7, July – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Fig 8 :- 03 Months follow-Up

Fig 4 CTG Harvested from the Palate C. Result:
Both the recipient site and the donor site healed
uneventfully. A satisfactory clinical outcome was achieved
in terms of the amount of root coverage achieved
postoperatively. The tooth sensitivity was reduced and the
patient was satisfied with the improved esthetics as well.
The post-operative pain and swelling were also minimal.

III. DISCUSSION

One of the most critical components of a person’s

attractive personality is a pleasing smile. With this rationale,
improving the esthetics in addition to restoring the
functional integrity of the periodontium has become an
Fig 5 Palatal Donor Site Suturing and Protected with integral part of periodontal therapy [8]. Gingival recession
Adhesive Intraoral Dressing occurs due to the apical shift of the gingival margin,
exposing the root surface, which ultimately leads to
compromised esthetics, increased susceptibility for root
caries and dentinal hypersensitivity are the chief indications
for root coverage procedures [1].

Many therapeutic options have been suggested for the

treatment of gingival recession, most of which are more
suitable for isolated defects. But in clinical scenarios,
gingival recession is very rarely localized to a single tooth,
rather it involves a group of adjacent teeth. Multiple
contiguous recessions should be treated simultaneously to
minimize the surgeries and optimize the esthetic result [9].

Most of the conventional therapies pose limitations like

Fig 6 CTG Secured Inside the Tunnel reduced blood supply and scar formation at the recipient site
resulting from surface incisions and muscle pull during
healing often leading to incomplete root coverage or
recurrence of the recession [6].

The VISTA technique was originally described by

Dr. Homa Zadeh which was further modified and improved
by Dr. Chris Chang [6]. This technique either alone or in
combination with CTG or other soft tissue graft alternatives,
GTR membrane, EMD, or a broad wound-healing growth
factor like PRF or PDGF-BB has several of advantages in
the successful management of multiple recession defects.
The subperiosteal dissection done in the VISTA approach
reduces the tension of the marginal gingiva during the
coronal advancement. It also maintains the integrity of the
interdental papillae by avoiding papillary reflection. A
Fig 7 Double Mattress Suturing at the Recipient Site
remote incision enhances the esthetic outcome in the
Stabilized with the Help of Composite Stops
surgical area by resulting in little to no visible scarring [6].

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Volume 8, Issue 7, July – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
An important technical difference between the VISTA multiple gingival recession defects as there is minimum
and other tunneling approaches or other classical techniques trauma to the recipient site. Furthermore, CTG being the
of root coverage is the amount of coronal advancement of gold standard for root coverage procedures, when combined
the gingival margin that could be achieved during the with the VISTA technique seems to yield superior clinical
procedure. Moreover, the coronally anchored suturing outcomes. Further multicentric studies are required to
technique minimizes micromotion of the regenerative site [6]. validate the observations of the present case report.
In the present case, advancement of the gingival margin
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