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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 427-431

The management of Miller’s class I gingival recession: Vestibular incision subperiosteal tunnel access (VISTA) in combination with acellular dermal matrix: A case report

1 Department of Periodontics, Universitas Airlangga, Mayjend Prof. Dr. Moestopo 47, Surabaya, Indonesia
2 Periodontics Residency Program, Faculty of Dental Medicine, Universitas Airlangga, Mayjend Prof. Dr. Moestopo 47, Surabaya, Indonesia

Date of Submission10-Feb-2022
Date of Decision23-Jun-2022
Date of Acceptance27-Jun-2022
Date of Web Publication29-Aug-2022

Correspondence Address:
Dr. I Komang Evan Wijaksana
Department of Periodontics, Faculty of Dental Medicine, Universitas Airlangga, Mayjend Prof. Dr. Moestopo 47, Surabaya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIOH.JIOH_43_22

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The vestibular incision subperiosteal tunnel access (VISTA) has many advantages for successfully treating multiple recession defects. Soft-tissue regeneration is generally achieved by either free gingival or connective tissue grafts. In recent years, various investigations have evaluated the outcome of acellular dermal matrix (ADM) for mucogingival surgery with encouraging outcomes. A 26-year-old male presented with a chief complaint of unattractive appearance in the upper left teeth. Miller’s class I gingival recession presented in 23, 24, and 25 teeth. The VISTA approach combined with ADM affords a number of unique advantages to the successful treatment of multiple recession defects on this case report. The VISTA method was selected to manage this condition. During coronal advancement, subperiosteal dissection reduces gingival margin tension while maintaining blood flow to the interdental papillae. The increase of keratinized gingiva is notable, and after 1 year, soft tissue stability is apparent. The management of Miller class I gingival recession with the VISTA could achieve a commendatory result. ADM (Mucoderm) is a suitable alternative for connective tissue graft to augment gingival thickness.

Keywords: Acellular Dermal Matrix, Gingival Recession, Health Outcomes, VISTA

How to cite this article:
Wijaksana I K, Wiyono N, Ulfah N, Rubianto M. The management of Miller’s class I gingival recession: Vestibular incision subperiosteal tunnel access (VISTA) in combination with acellular dermal matrix: A case report. J Int Oral Health 2022;14:427-31

How to cite this URL:
Wijaksana I K, Wiyono N, Ulfah N, Rubianto M. The management of Miller’s class I gingival recession: Vestibular incision subperiosteal tunnel access (VISTA) in combination with acellular dermal matrix: A case report. J Int Oral Health [serial online] 2022 [cited 2023 Sep 22];14:427-31. Available from:

  Introduction Top

Gum recession and associated tooth sensitivity are common in dentistry. Knowing the correct sequence of treatment is critical for dentists to successfully treat these conditions. It is critical to first understand the etiology of gingival recession and associated tooth sensitivity. Causes include poor plaque control, forceful brushing, daily use of high relative dentin abrasivity toothpaste, periodontitis, oral piercings, and orthodontic treatment.[1],[2] If the cause is not treated, any treatment for the patient may fail. Once the cause is identified, it must be addressed by eliminating or treating the factor. Non-surgical treatment options can then be implemented, such as testing various sensitive toothpastes and in-office desensitizers. Adhesives are another non-surgical treatment option for patients when these avenues are fully explored. In the event the non-invasive treatment options such as sensitive toothpaste, in-office desensitizers, and bonding agents fail to relieve a patient’s symptoms, more invasive treatments may be considered.[1],[3]

Periodontal plastic surgery encompasses a broad range of procedures for treating and preventing periodontal recession. Periodontal recession should be surgically treated to achieve complete root coverage with sufficiently wide keratinized gingiva (2 mm) for an esthetic result and gingival physiology. Although root covering procedures have been shown to reduce dentin hypersensitivity, they should not be used solely to treat this symptom. We must keep in mind that surgical procedures are far more dangerous than non-surgical treatment options. When more invasive procedures are required, periodontal plastic surgery may be an option.[1],[4]

Tunnel technique is an approach that improves aesthetic aspects as this procedure left the interdental papilla intact and absence of vertical incisions.[5] However, unfavorable healing consequences due to trauma to sulcular epithelium are the prominent disadvantages of this technique-sensitive procedure. In order to prevent those conditions, the VISTA approach was introduced.[6] The surgical technique for gingival recession is generally achieved by either free gingival or connective tissue grafts.[7],[8] Recently, numerous researches have assessed the effect of acellular dermal matrix (ADM) for mucogingival surgery. The advantages of using ADM are avoiding using human donor tissue, higher availability, and being harvested in large quantities.[9]

  Case History Top

A 26-year-old male patient presented to the Department of Periodontology with the chief complaint of unattractive appearance and dental hypersensitivity on the upper left teeth. This condition has been observed by the patient for 1 year. The clinical examination presented Miller’s class I gingival recession in 23, 24, and 25 teeth [Figure 1]. The patient refused to have a connective tissue harvesting procedure in the palatal area. Thus, to cover such recession, a tunneling technique with ADM insertion was performed.
Figure 1: Patient showing Miller’s class I gingival recession

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  Case Management Top

The patient initially underwent scaling and root planing procedures. The surgery was performed 1 month after phase I periodontal therapy. After a thorough discussion of the procedures, the patient gave his informed consent. The surgical design was VISTA technique with the Mucoderm (Bottis) as autogenous soft tissue graft substitute and scaffold. The exposed root surfaces were scaled and root planed. A 17% EDTA was used as a root bio-modifier before incision. Once local anesthesia (lidocaine HCl 2% with epinephrine 1:100,000) was administered, the vestibular access incision was made with a surgical blade no. 15, mesial to the recession. The subperiosteal tunnel was created with tunneling knives and a periosteal elevator, exposing the facial osseous plate and root dehiscence. The tunnel was lengthened along one to two teeth adjacent to the treated tooth to mobilize gingival margins and to facilitate coronal repositioning. Mucoderm was rehydrated in sterile saline for 10 min and then placed inside the tunnel. The gingival margin was repositioned 2 mm coronal to the desired final position and held in that position with a 4-0 monofilament nylon suture and composite at the buccal of the teeth [Figure 2]. Post-operative pharmacological treatment comprised 500 mg amoxicillin (for 5 days) and 500 mg mefenamic acid (for 3 days). The patient was informed about revisiting on days 1, 3, 7, and 14 for post-surgery for monitoring [Figure 3]. The suture was removed 1 month after the surgical procedure, and the patient was recalled once a month for maintenance. After a 1-year recall, the stability of the soft tissue was confirmed [Figure 4].
Figure 2: Surgical procedure: (A) anesthesia, (B) root surfaces were mechanically treated with curettes, (C) EDTA 17% was used as a root bio-modifier, (D) vestibular incision, (E) subperiosteal tunnel from vestibular access, (F) coronal reposition of the gingival margin, (G) Mucoderm insertion, and (H) vestibular incision suturing

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Figure 3: Follow-up after surgery: (A) baseline, (B) 1 week after surgery, (C) 1 month after surgery, (D) 4 months after surgery, and (E) 1 year after surgery

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Figure 4: Before and after surgery: (A) gingival recession measurements before surgery and (B) gingival recession measurements after surgery

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  Discussion Top

The tunneling technique is an approach that optimizes aesthetics and predictability because of its ability to avoid the release of critical papillae and to maintain a high level of vascularity at the surgical site to support the grafts as well. These treatments, however, are technique-dependent, and some investigations have found that tissue damage to the sulcular epithelium leads to unsatisfactory healing results. The vestibular incision subperiosteal tunnel access (VISTA) approach aims to avoid these complications.[2],[6],[7]

The VISTA technique is considered significantly advantageous to treat multiple recession defects. The vertical incision on the mesial to the lesion minimizes the likelihood of damaging the gingiva of the treated teeth. Subperiosteal dissection is able to overcome gingival margin tension created during coronal advancement and maintains blood supply to interdental papillae. In the VISTA technique, the advancement of the gingival margin and the connective tissue graft or ADM is fixed in a stable position to prevent relapse in the earlier stage of healing, thus resulting in better outcomes in gingival recession coverage.[2],[8],[9]

The surgical technique for gingival recession is generally achieved by either free gingival or connective tissue grafts. However, the morbidity associated with the surgical procedure to harvest palatal-tissue autograft is the main limitation of this technique. Moreover, a more challenging procedure has to be performed in patients with shallow palate or thin palatal tissues. This case may require multiple surgeries to obtain additional donor tissue. Moreover, harvesting a palatal graft is precarious due to the risk of damaging the palatal artery. Thus, a rigorous pre-operative evaluation of the maximal dimension of the palatal tissue is required.[3],[4] Recently, a novel derived collagen matrix (Mucoderm) has been established as a soft tissue graft replacement and a potential substitute to connective tissue graft in periodontal plastic surgery. As an alternative to human donor tissue, ADM is considered beneficial due to its greater availability. The ADM is prepared by eliminating cellular antigenic elements without generating any damage to the tissue structure, thus conserving the structural integrity of the entire extracellular collagenous matrix. The intact extracellular collagenous matrix may play as a three-dimensional scaffold to support fibroblast proliferation, re-epithelization, and angiogenesis.[5]

Within the limitations of this case report, VISTA in conjunction with ADM is a predictable approach for treating Miller’s class I multiple recession defects. The use of AMD as a scaffold for the treatment of class I recession defects improves the gingival phenotype and provides long-term stability in terms of recession depth reduction. In contrast, more studies with a large sample size and a long follow-up period are still needed.


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Conflicts of interest

There are no conflicts of interest.

Authors’ contributions

Not applicable.

Ethical policy and Institutional Review Board statement

Not applicable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

Not applicable.

  References Top

Garg S, Arora SA, Chhina S, Singh P Multiple gingival recession coverage treated with vestibular incision subperiosteal tunnel access approach with or without platelet-rich fibrin—A case series. Contemp Clin Dent 2017;8:464-8.  Back to cited text no. 1
Cortellini P, Bissada NF Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations. J Periodontol 2018;89(Suppl. 1):204-13.  Back to cited text no. 2
Jepsen S, Caton JG, Albandar JM, Bissada NF, Bouchard P, Cortellini P, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of Workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol 2018;89(Suppl. 1):S237-48.  Back to cited text no. 3
Dandu SR, Murthy KR Multiple gingival recession defects treated with coronally advanced flap and either the VISTA technique enhanced with GEM 21S or periosteal pedicle graft: A 9-month clinical study. Int J Periodont Restorative Dent 2016;36:231-7.  Back to cited text no. 4
Lino Aguilar V, González Estrella IZ, Martínez Hernández R, Hurtado Sánchez A, Lino Aguilar V, González Estrella IZ, et al. Treatment of multiple Miller class I and III gingival recessions by means of sub-epithelial connective tissue graft and tunnel technique. Revista Odontológica Mexicana 2018;22:46-50.  Back to cited text no. 5
Subbareddy BV, Gautami PS, Dwarakanath CD, Devi PK, Bhavana P, Radharani K Vestibular incision subperiosteal tunnel access technique with platelet-rich fibrin compared to subepithelial connective tissue graft for the treatment of multiple gingival recessions: A randomized controlled clinical trial. Contemp Clin Dent 2020;11:249-55.  Back to cited text no. 6
Menceva Z, Dimitrovski O, Popovska M, Spasovski S, Spirov V, Petrushevska G. Free gingival graft versus mucograft: Histological evaluation. Open Access Maced J Med Sci 2018;6:675-9.  Back to cited text no. 7
Pabst AM, Happe A, Callaway A, Ziebart T, Stratul SI, Ackermann M, et al. In vitro and in vivo characterization of porcine acellular dermal matrix for gingival augmentation procedures. J Periodontal Res 2014;49:371-81.  Back to cited text no. 8
Stein JM, Hammächer C The modified tunnel technique—Options and indications for mucogingival therapy. J Parodontol 2012;31:1-13.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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