Root Coverage With Connective Tissue Graft Associated With VISTA Versus Tunnel Technique

Overview

Several techniques were proposed in the literature to solve the problems associated with gingival recession. Root coverage was mainly indicated for esthetic concern, however, it might also be indicated for treatment of root hypersensitivity and maintaining adequate plaque control by keratinized tissue augmentation. These proposed surgical techniques were well-documented with successful outcomes. Each technique had its own advantages, disadvantages and indications. Various factors affected the most suitable technique. These factors were either related to the dimensions of gingival recession defect, or related to the surgeon experience or to the patient himself . Nowadays, the scope of scientific research is concerned with designing surgical techniques that are more predictable, high esthetic, less invasive and patient centered In this way, continuous modification of surgical techniques aroused to result in a more reproducible outcomes; such as the attempt to advance pedicle flaps without vertical releasing incisions, as in the modified coronally advanced flap and the modified microsurgical tunnel technique. However, controversy still exist in the literature regarding the best technique for root coverage. Coronally advanced flap is the most commonly reported technique in research, with lack of researches on tunneling techniques.

Nowadays, esthetic demands increased greatly where all seek a Hollywood smile with a white well-aligned teeth and pink healthy gingiva. Therefore, the demand on treatment of gingival recession increased. Since most gingival recession cases are generalized or involve multiple sites so, current research is focusing on how treatment of multiple recession defects can be efficient and less traumatic. Several modifications of tunnel technique have been described in order to preserve esthetics, avoid relapse of gingival recession and maintain papillary integrity. These modifications also attend to avoid scar formation and delayed healing related to vertical releasing incision. Although tunneling technique excluded vertical incisions with its drawbacks, tunneling was still a sensitive and a blind technique with increased trauma to sulcular epithelium which eventually resulted in unfavorable healing outcomes. So evolution of a newer approach known as Vestibular Incision Subperiosteal Tunnel Access (VISTA) was proposed to avoid some of the potential complications occurring with other intrasulcular tunneling techniques. Moreover, a study by Cairo et al., 2009 reported increased incidence of post-operative pain and increased chair side time with tunneling in comparison to coronally advanced flap. However, the evidence in literature is minimal on VISTA technique and there is no enough data comparing patient morbidity and root coverage outcomes between intrasulcular tunneling and vestibular tunneling except for few case reports. Therefore, this study aim to do a randomized clinical trial in order to assess the efficacy of VISTA technique in treatment of multiple gingival recession and compare it to tunneling technique. The use of connective tissue graft seems to be a key of success in treatment of gingival recession regardless of the surgical technique used. Although there are numerous studies focusing on the effect of subepithelial connective tissue graft for the treatment of localized gingival recessions, but still more studies are needed to focus on the treatment of multiple recession defects. Therefore, this study will monitor the effect of tunneling and VISTA techniques together with connective tissue graft on patient morbidity and root coverage outcomes.