Treatment of multiple gingival recessions with vista technique: A case series.

Gingival recession is a common manifestation in most populations. Gingival recession is clinically manifested by an apical displacement of the gingival tissues, leading to root surface exposure. Gingival recession may be a concern for patients for a number of reasons such as root hypersensitivity, erosion, root caries, and esthetics (Wennstrom 1996). Recently, new techniques have been suggested for the surgical treatment of multiple adjacent recession type defects. These are mainly derived from the coronally advanced flap, a supraperiosteal envelope technique in combination with a subepithelial connective tissue graft, or its evolution as a tunnel technique. The current case reports introduce a novel, minimally invasive approach applicable for both isolated recession defects as well as multiple contiguous defects in the maxillary anterior region. Access to the surgical site is obtained by means of an approach referred to as vestibular incision subperiosteal tunnel access.

INTRODUCTION

Esthetics represents an inseparable part of today's oral therapy.[1] Gingival recession, due to trauma, inflammatory conditions or anatomic factors is defined as partial denudation of the root surface due to apical migration of the gingival margin.[23] Indications including esthetics, defect progression, hypersensitivity, or difficulties with oral hygiene support the use of periodontal plastic surgical procedures.[3] Current case reports introduce a novel, minimally invasive approach, i.e. vestibular incision subperiosteal tunnel access (VISTA). This entails making an access incision in the maxillary anterior frenum, followed by elevation of a subperiosteal tunnel. VISTA provides access and allows coronal repositioning of gingival margins [Figure 1].[4]

Figure 1

Case-1 - Preoperative view

CASE REPORTS

Case 1

A case of Millers class I and class II multiple gingival recession in the maxillary anterior region extending from 13 to 23 was reported to the Department of Periodontics [Figure 2], The Oxford Dental College and Hospital, Bangalore. At the initial visit, thorough scaling and root planing was performed, patient was put on strict oral hygiene maintenance and recalled after 1-week. The VISTA approach began with a vestibular access incision in the midline of the maxillary frenum [Figure 3], which provided access to the entire anterior maxilla [Figure 4]. Subperiosteal tunnel was created by passing the incision through the periosteum and inserting a periosteal elevator between the periosteum and bone through the vestibular access incision. To mobilize gingival margins and facilitate coronal repositioning, the tunnel was extended at least one or two teeth beyond the teeth requiring root coverage. In order to achieve a low-tension coronal repositioning of the gingiva, the tunnel was sufficiently elevated beyond the mucogingival junction as well as through the gingival sulci of the teeth being augmented. Subperiosteal tunnel extension was carried out interproximally also below each papilla without making any surface incisions. Freshly prepared platelet-rich fibrin (PRF) membrane was then trimmed to fit the dimensions of the recipient site and the width was adjusted to extend at least 3-4 mm beyond the bony dehiscence's overlying the root surfaces. The PRF membrane was then carefully inserted into the subperiosteal tunnel and repositioned below the gingival margin of each tooth. The membrane and mucogingival complex were then advanced coronally and stabilized in the new position with a coronally anchored suturing technique. Direct interrupted sutures at approximately 2-3 mm apical to the gingival margin of each tooth were placed using 3-0 silk suture. Sutures were tied, and the knots positioned at the mid coronal point of each tooth and stabilized at that position by placing composite stops. Periodontal dressing was placed to cover the surgical site [Figure 5]. Patient was prescribed analgesics and was put on strict oral hygiene maintenance. Suture removal was done after 10 days. After 6 months of follow-up, it was noticed that 91% of root coverage was achieved [Figure 6].

Figure 2

Case-1 - Insertion of platelet rich fibrin

Figure 3

Case 1 - Coronally anchored suture with composite stops

Figure 4

Case-1 - Periodontal dressing placed

Figure 5

Case-1 - Vestibular access incision in maxillary midline frenum

Figure 6

Case-1 - 1-year postoperative view

Case 2

Case 2 was a 50-year-old man who presented with Millers class II gingival recession defects, ranging from 2 to 4 mm, on all four maxillary anterior teeth [Figure 7]. Usage of VISTA technique to treat gingival recession in this case was similar to the above case report described [Figure 8]. Only difference was in suturing technique. Horizontal mattress sutures were placed, and the knot was placed on the palatal aspect with a coronally anchored suturing technique [Figure 9].

Figure 7

Case-2 - Preoperative view

Figure 8

Case-2 - Subperiosteal tunnel preparation

Figure 9

Case-2 - Coronally anchored sutures on the palatal aspect

Composite stops which more plaque retentive was thereby interfering in the healing process and affecting esthetics were avoided in this case. After 12 months of follow-up, 96% root coverage was noted for all four treated teeth, along with 1-2 mm of gain in width of keratinized gingiva [Figure 10].

Figure 10

Case-2 - 1-year postoperative view

DISCUSSION

Periodontal therapy has historically been directed primarily at the elimination of disease and maintenance of a functional healthy dentition and supporting tissues.[3] However, more recently periodontal therapy, consistent with dental therapy in general, is increasingly directed at esthetic outcomes for patients, which extend beyond tooth replacement and tooth color to include the soft tissue component framing the dentition.[3]

Gingival recession is clinically manifested by an apical displacement of gingival tissues, leading to root surface exposure, which often causes poor esthetics,[56] increased susceptibility for root caries[7] and dentinal hypersensitivity.[8]

Treatment of gingival recessions has become an important therapeutic issue due to the increasing number of cosmetic requests from patients.[9] Patient's esthetic demands, due to exposure during smiling or function, of portions of the root surface are the main indication for root coverage procedures.[9] Thus, complete root coverage up to the cementoenamel junction is the goal to be achieved when the patient complains about esthetic appearance of teeth.[9] Furthermore, even if complete root coverage is surgically accomplished; the result may not be completely satisfactory in the case of excessive thickness of gingiva or poor blending of the area.[9] This happens very frequently when free or connective tissue graft is harvested from the palate and utilized for root coverage.[9]

Another factor to be considered is that gingival recession is very seldom localized to a single tooth.[9] More frequently gingival recessions affect group of adjacent teeth. In order to minimize the surgeries and to optimize the esthetic result, all the contiguous recessions should be treated at the same time.[9]

Treatment of isolated or multiple gingival recessions with different surgical procedures depends on many factors such as defect size, presence or absence of keratinized tissue adjacent to the defect, and thickness of the gingiva which are related to the defect and/or patient.[2]

Arrays of therapeutic options are available for treatment of gingival recession defects, though many of these are better suited for treatment of isolated defects.[4] Some of the limitations of the current techniques include need for harvesting of autogenous donor tissues and their associated morbidity, as well as scar formation at the recipient site resulting from surface incisions. Moreover, muscle pull during healing often leads to incomplete root coverage or relapse of the recession.[4]

The minimally invasive VISTA approach presented in these case reports, combined with a broad wound-healing growth factor, affords a number of unique advantages to the successful treatment of multiple recession defects.[4] The VISTA approach overcomes some of the short-comings of intrasulcular tunneling techniques used for periodontal root coverage.[4] The remote incision reduces the possibility of traumatizing the gingiva of the teeth being treated.[4] Critical to the success of VISTA is a careful subperiosteal dissection that reduces the tension of the gingival margin during coronal advancement while at the same time maintaining the anatomical integrity of the interdental papillae by avoiding papillary reflection.[4]

Placement of the initial incision and a tunnel entrance within the maxillary frenum results in little to no visible scarring, assisting in maximizing the esthetic outcome in this critical restorative area.[4]

An important technical difference between the VISTA and other tunneling approaches and more classical techniques of gingival augmentation is the degree of coronal advancement of the gingival margin advocated during the procedure.[4] As noted earlier, the gingival margin, with its membrane, is advanced to the most coronal level of the adjacent interproximal papillae rather than to the cementoenamel junction. Sutures are then secured to the facial/palatal aspect of each tooth; effectively preventing apical relapses of the gingival margin during the initial stages of healing. In both the cases presented here, apical migration of the gingival margin over relatively long periods of follow-up was either minimal or nonexistent with this tunnel procedure.

The rigid fixation of the gingival margins introduced with the present coronally anchored suturing technique minimizes micromotion of the regenerative site.[4] Reduction of micromotion has proven to be a major advantage of the present technique over conventional methods, where gingival margin may be subject to displacement during facial movements.[4] In VISTA technique, it was also possible to treat multiple recession defects without requiring secondary harvesting procedures.

In a study by Zadeh, they used Bioguide as a membrane in the VISTA technique.[4] Use of PRF in these case reports has several advantages over other membranes or grafts like they play multiple vital roles in early wound-healing, development, and maturation of a normal vasculature, cost effective and eliminates any chances of immune reaction.

CONCLUSION

An array of treatment options exists for treatment of gingival recession, some of which are better suited for localized recession defects.[4] Multiple contiguous gingival recession defects, however pose significant functional and esthetic problems to large numbers of the population.[4] The need to simultaneously address multiple recession defects is often problematic and hampered by inherent short-comings of some of the current procedures. The present VISTA technique potentially speaks to these short-comings.[4] Although VISTA has been applied in other regions, its application is most advantageous in the esthetic zone.[4]

Thus, to conclude, this technique can be used successfully in the treatment of multiple gingival recessions, and further studies with larger numbers of patients will provide further data and evidence.