Modified Vestibular Incision Supraperiosteal Tunnel Access in Recession Type 2 with Thin Phenotype: A Report of Two Cases
Correspondence Address :
Sakshi Malhotra,
Ex Postgraduate Student, Department of Periodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India.
E-mail: sakshi1828@gmail.com
Gingival Recession Type 2 (RT2) presents complexity in achieving complete Root Coverage (RC) and associated parameters such as interproximal attachment loss and bone loss further have a negative influence on the stability of achieved RC. Complete RC might be attainable in RT2, though certain factors like tooth malposition, avascular root surface area, frenal pull, and thin Periodontal Phenotype (PP) may limit the amount of RC. Vestibular Incision Subperiosteal Tunnel Access (VISTA) technique proposed in the last decade has been promising in the maxillary anterior region in the management of Miller Class I/RT1 and even some RT2 gingival recession. In this case report, two systemically healthy female patients, having RT2 gingival recession in mandibular incisors labially positioned/rotated with thin PP were treated with Modified-vestibular incision supraperiosteal tunnel access (m-VISTA) along with Subepithelial Connective Tissue Graft (SCTG). Fifty percent RC was achieved in case-1 and 100% in case 2. The results were maintained during the follow-up period of nine months in case 1, and one year in case 2. Gingival RT2 with malpositioned tooth may be successfully treated with m-VISTA and SCTG as demonstrated in achieving stability of percentage RC and patients’ satisfaction in terms of aesthetics and resolution of hypersensitivity in the present case report.
Aesthetics, Connective tissue, Dentin hypersensitivity, Gingival recession, Regeneration
Case 1
A 27-year-old systemically healthy female patient reported with the chief complaint of mild hypersensitivity and aesthetic concern due to exposed root surface of lower front teeth for two years. On clinical examination isolated Miller class III or RT2 (1) was found in relation to rotated labially positioned mandibular left central incisor (Table/Fig 1)a,b.
Clinical parameters included Probing Pocket Depth (PPD) (2), Clinical Attachment Loss (CAL) (2), Recession Depth (RD) (2), Recession Width (RW) (2), percentage Root Coverage (RC%=RD (preoperative-postoperative)/RD (preoperative)×100) (3), Gingival Thickness (GT) measured using a digital vernier calliper (4), PP based on periodontal probe translucency (5), Root Aesthetic Score (RES) (6), and patient- based evaluation of hypersensitivity and aesthetics using visual analogue scale (details of clinical findings are summarised in (Table/Fig 2),(Table/Fig 3)). A periodontal probe (PCP-UNC 15, Hu-Friedy, Chicago, USA) was used to measure periodontal parameters. Radiographic examination revealed interdental alveolar bone loss (Table/Fig 1)c. Level of alveolar bone crest from cementoenamel junction was calculated by using Image-J software (7).
Thorough scaling and root planing were performed and modified (m) VISTA technique using SCTG was planned after obtaining written and informed consent. Root prominence was reduced with the burs (Mani Dia Burs, India)/curettes (Hu Friedy, Chicago, USA)
[Table/Fig-1d]. After achieving local anaesthesia, a vertical incision was made with #15 blade (Surgeon blades and medical devices private limited, Gujrat, India), slightly distal to frenal area and beyond the mucogingival junction, through the periosteum to elevate a supraperiosteal tunnel using tunnelling instruments (GDC, India) (Table/Fig 1)e. The tunnel was extended mesially and distally of the tooth to be treated (Table/Fig 1)g. An intrasulcular incision was performed using surgical blade (#15 C, Hu-friedy, Chicago, USA) to detach the papillae and to mobilise gingival margin (Table/Fig 1)f. The SCTG of adequate thickness and approximately three times the width of the recession defect was harvested from the palate through single incision technique (8), and inserted inside the prepared tunnel (Table/Fig 1)h. Graft and mucogingival-papillary complex were then advanced coronally and stabilised with a coronally anchored suture (5-0 Vicryl, Ethicon, Johnson & Johnson private limited, India) using composite resin (Charisma, Kulzer Mitsui chemicals group, Germany). The access vertical incision was also sutured using interrupted sutures
(Table/Fig 1)i.
Postoperative instructions were given and amoxicillin (Almox, Alkem laboratories Ltd., India) 500 mg 3/day×5 days, ibuprofen (Brufen, Abbott, India), 400 mg 3/day×3 days and 0.2% chlorhexidine (0.2% Hexidine, ICPA Health Product Ltd., India) mouthwash twice daily×14 days were prescribed. Patient was advised not to use mechanical means of plaque control until suture removal. The sutures were removed after 12-14 days (Table/Fig 1)j. Postoperative healing was uneventful and no complications were observed. After three months of surgery, 50% of RC was achieved (Table/Fig 1)k and remained stable till nine months of follow-up (Table/Fig 1)l.
Case 2
An 18-year-old female patient reported with the chief complaint of mild hypersensitivity and aesthetic concern due to exposed root surface in relation to lower front teeth since one year. On clinical examination, isolated RT2 recession was found in relation to rotated labially positioned mandibular left central incisor (Table/Fig 4)a. Clinical parameters included were same as described above in case 1 (Table/Fig 2),(Table/Fig 3). Radiographic examination revealed interdental alveolar bone loss in relation to mandibular left central incisor (Table/Fig 3),(Table/Fig 4)b. Thorough scaling and root planing was performed and surgery for recession coverage was planned after obtaining written and informed consent. The m-VISTA technique was used along with SCTG which was harvested from palate using single incision technique (Table/Fig 4)c-f. Postoperative instructions were given, same as described above in case 1. The sutures were removed after 12-14 days (Table/Fig 4)f,g. Complete RC was achieved at six months of follow-up (Table/Fig 4)h and remained stable till one year of follow-up (Table/Fig 4)i.
Intricacy in achieving complete RC in RT2 gingival recession may be due to certain crucial factors like interproximal soft tissue integrity, avascular root surface areas, and the dimension of the gingival recession along with interproximal attachment loss/bone loss (1),(9). VISTA technique proposed in the last decade has been promising in the maxillary anterior region in the management of Miller class 1/RT1 and even some RT2 gingival recession (Table/Fig 5) (10),(11),(12),(13),(14),(15).
Zadeh HH et al., introduced VISTA approach, revealing several advantages of this minimally invasive approach by preparing a tunnel beyond the mucogingival junction with a single incision within the frenum which in turn (10), facilitates the low-tension coronal positioning of the gingival margins, maintaining the anatomical integrity of the interdental papillae and improves the aesthetic outcome. Modifications of this technique by Fernandez-Jimenez A et al., in treating multiple Miller class III recession included placement of composite bridges in the interproximal sites for suturing before the preparation of the surgical bed, vertical incision to the periosteum at the centre of the extension of treated teeth extending slightly beyond the mucogingival junction, intrasulcular incisions which extend to the papillae, and performing multiple vertical double-crossed sutures on the interdental composite sutures (15). Chowdhary PC et al., reported a different modification in cases of Miller class I/II gingival recession by performing V-shaped incision in the frenal area for conducting both the m-VISTA and frenectomy techniques simultaneously and inserting SCTG in the supraperiosteal tunnel (14). Gil A et al., conducted a retrospective study and reported percentage mean linear recession coverage of 84.3±14.4% in Miller class III in relation to different tooth type, performing VISTA using SCTG which was harvested from different sites and with use of other graft materials (12). In a case series, Spate US and Lee CT utilised VISTA technique with volume stable collagen matrix for recession coverage in two premolars having gingival recession Miller class III. Volume stable collagen matrix is easy to perform with single operating site however, it is not cost-effective (13).
In the present case report, m-VISTA approach with SCTG was used to treat isolated RT2 gingival recession in mandibular anterior tooth, with an implementation of a vertical incision distant from the gingival margin, distal to the frenum to avoid tissue tear during the preparation of supraperiosteal tunnel in thin PP. After that, an intrasulcular incision was performed to disengage interdental papillae, which enables coronal repositioning of the whole papillary mucogingival unit, and a coronally anchored suture using composite resin was given to stabilise the graft and mucogingival- papillary complex. Underlying frenal fibres were completely relieved. Root prominence was also reduced for the proper adaptation of SCTG without creating a dead space between the grafts and underlying root surfaces. SCTG may be considered as gold standard for gingival recession coverage and at the recipient site, it provides good colour match and aesthetics.
The results showed the possibility of achieving stable RC and optimal aesthetics with m-VISTA technique along with SCTG performed to treat isolated RT2 gingival recession in malaligned mandibular anterior with thin PP.
DOI: 10.7860/JCDR/2023/64327.17955
Date of Submission: Mar 29, 2023
Date of Peer Review: Apr 21, 2023
Date of Acceptance: Apr 26, 2023
Date of Publishing: May 01, 2023
Author declaration:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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