PERIODONTICS, dentistry, root coverage VISTA, Periosteal Pedicle, Graft Multiple Gingival Recession Defects, Coronally Advanced Flap, GEM 21S, oA 9-Month Clinical Study

1. 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
Shruti Raju Dandu, Private Practice, Visakhapatnam, India.
K. Raja V. Murthy. Professor and Head of Department of Periodontology, GITAM Dental College and Hospital,
Visakhapatnam, India.
Int J Periodontics Restorative Dent 2016

2. INTRODUCTION.
• Gingival recession is defined as “the displacement of soft tissue
margin apical to CEJ with exposure of root surface.”
• Successful coverage of exposed roots for esthetic and functional
reasons has been the objective of various mucogingival
procedures.
• Multiple techniques have been developed to obtain predictable
root coverage.
• The purpose of developing new techniques is to increase
predictability, reduce patient discomfort, minimize the number of
surgical sites, and satisfy the patient’s esthetic demands, which
include the final color and tissue blend of the grafted area.

3. “Marginal tissue recession is defined as the displacement of
the soft tissue margin apical to the cement-enamel
junction.”-AAP 1999
“Gingival recession is defined as the location of gingival
margin apical to the cemento-enamel junction.” –GPT 2001
“Gingival recession is defined as the apical shift of the
gingival margin with respect to the cemento‐enamel
junction (CEJ); (Pini Prato et al Ann Periodontal 1999) it is
associated with attachment loss and with exposure of the
root surface to the oral environment” 2017 World
workshop.

5. The criteria for successful root coverage
are as follows:
The gingival margin is on CEJ in Class I,
Class II gingival recession, the depth of
gingival sulcus is within 2 mm, there is
no bleeding on probing, there is no
hypersensitivity, and color match with
adjacent tissue is esthetically
harmonious. ( Miller PD., Jr A
classification of marginal tissue
recession. Int J Periodont Rest
Dent. 1985)

6. techniques mainly CAF, Zuchelli’s technique and
pouch and tunnel techniques, the problems
associated are the compromised vascularity since
large surgical sites are involved , extensive avascular
surface, longer surgical time and increase in patient
morbidity, also the papillary integrity is not
maintained since there is a creation of surgical and
anatomic papillae, when there is tension during
coronal repositioning there are less success rates,
vestibular shortening and sometimes there is scar
formation at the vertical incisions

7. The extent and predictability of any root coverage procedure
for the treatment of recession defects is dependent on the
vascularity maintained at the surgical site. Since the
introduction of the supraperiosteal tunnel technique in 1994, it
has been used widely with a number of modifications to treat
isolated as well as multiple adjacent gingival recession. In cases
of MAGRD, especially in the anterior esthetic zone it is
important to maintain the integrity of the papilla thereby
maintaining esthetics and also the vascularity. The interdental
papilla has a very rich source of vascularity since it is supplied
from three sources, the supraperiosteal blood vessels, the
vessels from the PDL and the arterioles emerging from the crest
of the interdental bone. Also subperiosteal tunneling beyond
the mucogingival junction allows for low tension coronal
repositioning of the gingiva. A vestibular incision allows for easy
access for tunneling than the intrasulcular tunneling approach.
And hence keeping into consideration the above factors Zadeh
et al in 2011, gave vestibular incision subperiosteal tunnel

8. • Vestibular incision subperiosteal tunnel access (VISTA) is a more
recent, minimally invasive approach used for the treatment of
both isolated and multiple contiguous recession defects.
Zadeh et al.2011. Introduced a new surgical
technique - vestibular incision subperiosteal
tunnel access (VISTA). In this a access incision was
made in the maxillary anterior frenum area for
recessions crossing the midline. The access incision
was made adjacent to the teeth to be treated.
Elevation of a full thickness sub-periosteal is made
by tunneling with the VISTA instruments. Tunnel is
mobilized until low tension coronal repositioning
is achieved. A novel suturing technique of
coronally anchored suspensory sutures is used.
The author has used recombinant human platelet-
derived growth factor BB saturated onto a matrix
of beta–tricalcium phosphate over root
dehiscences for root coverage. Two documented
case showed successful root coverage and long
term stable results

9. Nevins et al reported
recombinant human platelet-
derived growth factor (rhPDGF)
as a potent mitogen and
chemotactic protein for
periodontal ligament fibroblasts
and alveolar bone cells.

10. • The periosteum has a rich vascular plexus, and its osteogenic
potential has received considerable attention as a grafting
material for repair of bone and joint defects.
• The use of a pedicle flap to cover the graft improves root
coverage predictability as it provides the graft with
additional blood supply and also improves the esthetic
result.
• The purpose of this study was to compare and evaluate the
clinical efficacy of the VISTA technique incorporating Bio-
Gide (Geistlich) membrane enhanced with GEM 21S
(Osteohealth) with periosteal pedicle graft and the coronal
advancement of the flap in the treat- ment of multiple
gingival recession defects.

11. Materials and methods
• A total of 15 patients (10 men and 5 women) with a mean age of
36.13 years and a chief complaint of dentinal hypersensitivity
and/or esthetic concern with bilateral Miller Class I or II gingival
recession defects were enrolled in the study.
• A single blinded, randomized, split- mouth clinical trial was
designed.
• A total of 30 sites in 15 patients were randomly divided into
experimental site A and experimental site B as per split-mouth
design using the coin toss method.

12. Inclusion criteria
• Men or women between 18 and 60 years of age
• Miller Class I or II gingival recession defects
• Good systemic health
• No history of smoking
• No history of surgical treatment in the delineated area for at
least 2 years prior to the study
• Vital teeth, free of faulty restorations
The study protocol involved a screening appointment, followed
by initial therapy, surgical therapy, and postoperative
evaluation after 3, 6, and 9 months.

13. Initial therapy and clinical
measurements
• Prior to surgery patients received
professional oral prophylaxis, oral
hygiene instructions, and occlusal
adjustments as per individual
requirements. Deep cervical defects were
restored with resin-modified glass-
ionomer cement (GC Fuji PLUS, GC
America).
• A customized acrylic stent was made with
guiding grooves on each experimental
tooth angled toward the deepest part (ie,
the midfacial part) of the recession.
• One trained examiner performed all the
clinical measurements on the midbuccal
aspect of the gingival recession defects
using a UNC-15 periodontal probe. Prior
to surgery and 9 months after surgery the
following clinical parameters were
assessed:
Resin ionomer materials have
many properties that allow the
successful restoration of NCCLs
and those in the subgingival area
including self-adhesion to dentin
and enamel, epithelial and
connective tissue adherence,
better mechanical strength, and
smoother surface than
conventional glass ionomers
Epithelial and connective tissue
adherence to resin ionomer
restorative materials is observed
during the healing process

14. • Probing pocket depth was measured from the
gingival margin to the base of the gingival sulcus.
• Vertical depth of the recession (RD) was measured as
the distance from the cementoenamel junction (CEJ)
to the gingival margin.
• Clinical attachment level (CAL) was measured from
the CEJ to the base of the gingival sulcus with the
help of UNC probing using the acrylic stent.
• Width of keratinized tissue (WKT) was measured
from the mucogingival junction to the gingival
margin.
• Percentage of root coverage was calculated as:
• Postsurgical discomfort levels were noted at the end
of 1 day, 1 week, and 1 month using a subjective pain
scale ranging from 0 (no pain) to 5 (worst possible
pain).

15. All the surgical
procedures were
performed by one
operator.
After extraoral
preparation with 5%
povidone iodine
solution, the patient
was asked to rinse with
10 mL of 0.2%
chlorhexidine
digluconate solution
for 1 minute.
The surgical site was
anesthetized by local
infiltration (2%
lidocaine with
adrenaline 1:80,000).
Surgical procedure

16. • Experimental site A was treated using the
VISTA technique with bioresorbable collagen
membrane (Bio-Gide) enhanced with re-
combinant human platelet-derived growth
factor BB (rhPDGF-BB) (GEM 21S) as
described by Zadeh.

18. Geistlich Bio-Gide® is designed with a smooth, compact upper layer which is an ideal
catalyst for the attachment of fibroblasts that lead to favorable healing of the gingival
tissue. The dense porous lower layer acts as a guide for osteoblasts, which become the
foundation for optimal bone formation and healing. These properties, in combination
with an optimally timed barrier function, prevent premature growth of soft-tissue into
the defect and create an environment for the appropriate cascade of biological events

20. BioMimetic Therapeutics, Inc. announced ON
7TH June 2006 that it has received approval from
the U.S. Food and Drug Administration (FDA) for
its lead product, GEM 21S(R).
The first BioMimetic product to be approved by
the FDA, GEM 21S is a fully synthetic
regeneration system for the treatment of
periodontal bone defects and associated
gingival recession.
GEM 21S is composed of the tissue growth
factor, recombinant human Platelet-Derived
Growth Factor (rhPDGF-BB), and a synthetic
bone matrix, Beta-tricalcium phosphate (a-TCP).
It is the first totally synthetic product combining
a purified recombinant growth factor with a
synthetic bone matrix to be approved by the
FDA for human application.

24. • A vestibular access incision was located at an
optimal position to gain access to the recession
defects. The incision was made through the
periosteum using a no. 11 surgical blade (Bard-
Parker) to elevate a subperiosteal tunnel, exposing
the facial osseous plate
• A periotome (PT2, Hu-Freidy) was used to elevate
the periosteum and create the subperiosteal
tunnel. It is important to extend the tunnel
elevation sufficiently beyond the mucogingival
margin as well as through the gingival sulci of the
teeth being augmented to allow for low-tension
coronal repositioning of the gingiva

26. • This tunnel was extended at least one or two
teeth beyond the teeth requiring root
coverage to mobilize gingival margins and
facilitate coronal repositioning.
• Additionally, the subperiosteal tunnel was
extended interproximally under each papilla
as far as the embrasure space permitted,
without making any surface incisions
through the papillae.
• A resorbable collagen membrane was then
trimmed to fit the dimensions of the surgical
area

27. • Prior to its insertion, the membrane was
saturated with 0.3 mg/mL rhPDGF- BB for a
minimum of 10 minutes in a sterile dappen
dish.
• A fine-tipped serrated forceps was used to
insert the collagen membrane inside the
subperiosteal tunnel.
• The membrane and mucogingival complex
were then advanced coronally and stabilized
in the new position with a coronally
anchored suturing technique

29. (a) Clinical photograph showing
gingival recession defect in relation to
the maxillary first right premolar.
(b) A partial thickness flap lifted to
expose the underlying periosteum
covering the alveolar bone.
(c) The periosteum which is
separated from the underlying
bone.
d) The periosteum is used as a pedicle
graft for covering the recession
defect.
( (e) The periosteal graft is covered with
the overlying coronally advanced flap
which is sutured using 4–0 silk suture.
. (f) Satisfactory
treatment outcome.

30. Experimental site B was treated
with a periosteal pedicle graft
(PPG) and coronally advanced flap
as described by Mahajan
An intrasulcular incision on the
buccal aspect of the involved tooth
was made with a no. 15 surgical
blade (Bard-Parker).
A horizontal right angle incision
was made into the adjacent
interdental papilla at or slightly
coronal to the level of the CEJ of
the tooth presenting the defect.
Two divergent vertical incisions
were made starting at least 0.5
mm from the gingival margin of
the adjacent teeth and extending
into the alveolar mucosa

31. The intrasulcular horizontal right angle incision and the vertical incisions were
connected, and a trapezoidal full-thickness flap was raised 3 to 4 mm apical to the
bone dehiscence.
From there, a partial-thickness dissection was performed to allow for coronal
positioning of the flap.
An incision was made through the periosteum, where the flap was still attached to
bone, to create a partial-thickness flap.
The partial-thickness flap was extended to expose a sufficient amount of the
periosteum, which was then separated from the underlying bone using a periosteal
elevator
The process of separating the periosteum was initiated at its apical extent, which
was then lifted slowly in a coronal direction.
The periosteum was not separated completely from the underlying bone; it
remained attached at its coronal end
De-epithelization of the papillae adjacent to the
defect was performed.

32. • The exposed affected root surface was scaled and planed
with a Gracey curette to produce a decontaminated,
smooth, flattened surface.
• The PPG thus obtained was then turned over the exposed
root surface and stabilized
• The flap was coronally positioned and sutured using the
sling suture technique.
• The releasing incisions were closed with interrupted sutures

34. Results
• All patients tolerated the surgical procedures well, experienced no
postoperative complications, and were compliant with the study protocol.
• Study teeth were free of visible plaque and gingival inflammation
throughout the study. The mean baseline recession depth, WKT, probing
depth, and CAL showed no statistical difference (P > .05) between the
experimental sites. Both study groups showed a statistically significant
reduction in mean recession depth (P < .001) at 3, 6, and 9 months when
compared with baseline. Statistically sig- nificant gain in the WKT (P <
.001) and CAL (P < .05) was obtained at 9 months when compared with
baseline in both groups. The mean reduction in recession depth was
statistically higher in site A when compared with site B at 3, 6, and 9
months (P < .05), similar to other clinical parameters such as gain in the
WKT and CAL. No statistically significant difference was observed in
probing depth from baseline to
• 9 months follow-up between the
• groups (P > .05) (Table 1).

36. • The mean percentage of root coverage achieved was 87.37 ±
17.78% and 71.84 ± 19.25% at 9
• months from baseline in VISTA- treated sites and PPG-treated
sites, respectively. Site A showed a significantly higher percentage
of root coverage compared with site B (P < .05)
• Postsurgical discomfort levels (PSDL) were assessed at day 1, at
the end of 1 week, and at the 1-month follow-up in both sites. In
the VISTA group on day 1, 10 subjects had a PSDL score of 2; 4
subjects scored 1, and 1 subject scored 3. At 1 week,
• 11 subjects scored 0 and 4 subjects scored 1. At the end of 1
month, all
• 15 subjects scored 0. In the PPG group on day 1, 9 subjects scored
3, 4 subjects scored 5, and 2 subjects scored 2. At 1 week, 10
subjects scored 1, 4 subjects scored 2, and 1 subject scored 3. At
the end of 1 month, 11 subjects scored 0 and 4 subjects scored 1.

37. Discussion
Chambrone et al have reported that the subepithelial connective tissue graft
(SCTG) seems to produce more predictable results when both root
coverage and WKT gain are expected.
The bilaminar technique using the subepithelial connective tissue graft is
considered the current gold standard technique for root coverage.
Its advantages over the conventional gingival graft procedure include good
gingival contour and less likelihood of keloid formation.
However, the limitations of SCTG include the need for harvesting at a distant
donor site, limited tissue availability when donor tissue thickness is
insufficient or the greater palatine neurovascular complex is in proximity
to the CEJ of the premolars, and increased potential for
post harvesting morbidity and discomfort.
In patients with multiple contiguous gingival recession defects these
disadvantages are even more pronounced, since optimizing esthetic
results in part depends on simultaneous treatment of all contiguous
recessions.
Other novel methods of root coverage are needed to overcome these
drawbacks.

38. VISTA allows management of multiple recession defects, maintains the
papillary integrity, and avoids vertical releasing incisions.
McGuire et al and McGuire and Scheyer, in comparing the
effectiveness of rhP- DGF-BB with SCTG, demonstrated clinically
significant improvements from baseline through week 24, with the
growth factor–mediated treatment approaching the efficacy of the
SCTG on parameters such as recession depth reduction and percent
root coverage

39. presence of cell-surface receptors for PDGF on PDL and alveolar bone
cells and elucidating PDGF’ has stimulatory effect on the proliferation
and chemotaxis of these cells. Additionally, recombinant human PDGF-
BB (rhPDGF-BB) has been shown to promote the regeneration of
periodontal tissue, including bone, cementum, and PDL
Beta tricalcium phosphate is a purified, multicrystalline, porous form of
calcium phosphate with a Ca:PO4 ratio similar to that of natural
bone mineral. When placed under a membrane, the þ-TCP prevents
membrane collapse against the root surface and provides a matrix or
scaffolding for new bone formation. It also facilitates the stabilization of
the blood clot.

40. • The VISTA technique incorporating the Bio- Gide membrane enhanced
with GEM 21S serves as an alternative to SCTG, as rhPDGF-BB with the
collagen barrier allows simultaneous treatment of multiple gingival
recession defects without requiring secondary harvesting procedures.
• The adult human periosteum is highly vascular and is known to contain
fibroblasts and osteoblasts, their progenitor cells, and mesenchymal stem
cells.
• In all age groups, the cells of the periosteum retain the ability to
differentiate into fibroblasts, osteoblasts, chondrocytes, adipocytes, and
skeletal myocytes.
• The results of this study demonstrated that both the VISTA technique
using Bio-Gide enhanced with GEM 21S and PPG, covered by a coronally
positioned flap, were effective in the treatment of gingival recession
defects≥ 2 mm.
• The presence of a resin- modified glass-ionomer restoration may not
interfere with the percentage of soft tissue coverage when a coronally
advanced flap is used for the treatment of Miller Class I and II gingival
recessions associated with noncarious cervical lesions.

41. • Both sites showed significant root coverage (87.37% and 71.84% for
VISTA and PPG, respectively), gain in the WKT, and clinical
attachment gain at 9 months postoperative.
• The difference in reduction in probing depth between the two
procedures was not statistically significant. VISTA- treated sites
resulted in a statistically significant increase in the percentage of
root coverage when compared to PPG-treated sites.
• Zadeh noted 100% root coverage for all growth factor–mediated,
minimally invasive VISTA–treated teeth, along with 1- to 2-mm
gains in keratinized gingiva at the end of the 12-month follow-up
period.

42. • At the end of 1 year, Mahajan in his case series incorporating the
periosteal pedicle flap observed 90.95% root coverage, with a
significant increase in the widths of keratinized and attached gingiva
no change was observed in probing depths
• In the VISTA technique, access is broader and is made in the
vestibule, where a single vestibular incision can provide access to an
entire region, including instrument access to the underlying alveolar
bone and root dehiscences.
• The remote incision reduces the possibility of traumatizing the
gingiva of the teeth being treated.

43. • Critical to the success of VISTA is a careful subperiosteal
dissection that reduces the tension of the gingival margin
during coronal advancement while maintaining the
anatomical integrity of the interdental papillae by avoiding
papillary reflection.
• Coronally anchored bonded sutures are retained for 3 weeks
to allow for immobilization of the gingival margin during
the initial healing phases.
• The gingival margin, with its attached collagen membrane,
is advanced to the most coronal level of the adjacent
interproximal papillae rather than to the CEJ

44. • The most critical phase of regenerative periodontal therapy is the
reattachment of collagen fibers to the root surface.
• During the inverted periosteal pedicle graft healing, the cells with
the potential to regenerate cementum and periodontal ligament are
the first to populate the root surface.
• Osteoblasts and their progenitor cells are immediately behind the
fibroblasts and populate the defect.
• The periosteal pedicle graft thus places the proper cells in the
proper location for regeneration of the defect.
• Any area without a firm barrier to tooth apposition is likely to allow
the invasion of gingival cells, resulting in surgical failure.
• The periosteum is a natural barrier membrane preventing fibrous
and epithelial cell invasion into the grafted site, allowing the
slower- proliferating osteoblasts to populate a scaffold

45. • The VISTA group presented better esthetics, especially in terms of
contour and texture, when compared with the PPG group.
• The color match was similar in both groups.
• When the results were compared in terms of patient satisfaction,
VISTA emerged as the preferred treatment option as it was rated
better in terms of comfort during and after the surgical procedure
and overall satisfaction by the subjects.
• The better patient satisfaction obtained by the VISTA may be
attributed to the less traumatic surgical procedure.
• This not only reduces intraoperative time but also favors
uneventful post- operative healing; in contrast, the PPG
techniques caused the patient more pain due to the need to
surgically open the site apically to obtain donor tissue.
• The study was limited by the absence of histologic assessment of
the type of attachment obtained and in being restricted to Miller
Class I and II gingival recession defects.

46. • Conclusions
• Within the limits of the study, it is reasonable to conclude that
VISTA may be deemed a predictable, effective, minimally
invasive, and viable alternative to the PPG technique for
obtaining optimal patient-based outcomes.
• In light of the potential benefits of VISTA to patients, further
histologic evidence is warranted. On the other hand, PPG is cost
effective and has the advantages of being an autogenous graft.

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