The International Journal of Periodontics & Restorative Dentistry

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 253

Connective Tissue Graft Stabilization by

Subperiosteal Sling Suture for Periodontal
Plastic Surgery Using the VISTA Approach

Jonathan H. Do, DDS1 Although the coronally advanced

flap (CAF) combined with a connec-
tive tissue graft (CTG) is well docu-
mented and considered the gold
standard for root coverage of local-
ized Miller Class I and II recession
This report describes a minimally invasive surgical approach using the defects,1–5 it is susceptible to flap
vestibular incision subperiosteal tunnel access and a suture called the retraction,6 which can result in in-
subperiosteal sling (SPS) to stabilize the connective tissue graft (CTG) for complete root coverage. Advance-
periodontal plastic surgery. The SPS suture engages only the CTG and
ment of a CAF alone 1 to 2 mm
stabilizes the CTG against the tooth independent of the overlying tissue,
which minimizes the risk of graft mobility caused by muscle movement. Int J beyond the cementoenamel junc-
Periodontics Restorative Dent 2019;39:253–258. doi: 10.11607/prd.3529 tion (CEJ) has been demonstrated
to allow the gingival margin to settle
apically at the CEJ during healing
and increase the predictability of
complete root coverage.7 Removal
of the labial submucosal tissue has
been demonstrated to reduce flap
retraction and improve root cover-
age outcome of anterior mandibular
labial recessions treated with CAF
combined with CTG.6 However, not
all recession sites, such as those
located in the mandibular lingual
anterior region, are amenable to
coronal flap advancement. Further-
more, coronal advancement of sites
with deep recession can potentially
alter the mucogingival junction and
compromise gingival esthetics.
The use of CTG with envelopes
UCLA School of Dentistry, Los Angeles, California, USA;
1 and tunnels maintains intact mar-
Private Practice Limited to Periodontics and Dental Implants, Poway, California, USA. ginal and papillary tissue,8,9 which
reduces the risk of tissue retrac-
Correspondence to: Dr Jonathan H. Do, 10833 Le Conte Avenue,
CHS 53-039, Los Angeles, CA 90095, USA. tion during healing. With these ap-
Email: [email protected] proaches, the CTG can be stabilized
 Submitted July 31, 2017; accepted November 14, 2017.
to the overlying soft tissue by means
 ©2019 by Quintessence Publishing Co Inc. of adhesive8 or sutures.9 Grafts

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254

stabilized to the overlying tissue are The denuded root surfaces are Subperiosteal Sling Suture
susceptible to mobility due to mus- scrubbed and decontaminated for 1 for Connective Tissue Graft
cle movement at the recipient site.10 minute with gauze soaked in doxy­ Stabilization
Sutures suspended over interdental cycline slurry (powder from doxy-
contact points11,12 or anchored coro- cycline 100 mg capsule suspended The CTG is inserted into the tun-
nally on the midlabial surface of a in sterile saline). The teeth are then nel and stabilized with a single SPS
tooth13 have been described to im- thoroughly rinsed with sterile saline. suture without engaging the soft
prove graft stability. These suturing tissue at the recipient site, using
techniques can be cumbersome and 6-0 polypropylene suture with a
require the use of composite resin to Recipient Site Preparation C-3 needle (PSN8695P, Hu-Friedy),
suspend or anchor the sutures. Even as follows. The needle is inserted
with these suturing techniques, pre- A 6-mm vertical incision is made through the sulcus of the tooth to
cise and controlled placement of the with a no. 15 scalpel in the mucosa, be augmented, and exits through
graft over the denuded root surface starting at the mucogingival junc- the vertical incision (Fig 1a). The su-
can be challenging. tion in the interdental area mesial or ture engages the CTG with a hori-
This report describes a minimal- distal to the site to be augmented. zontal mattress suture (Fig 1b). The
ly invasive surgical approach using If the interdental area adjacent to needle enters and exits the CTG
the vestibular incision subperiosteal the recession is narrow, the inci- from the side with periosteum. The
tunnel access (VISTA)13 and a suture sion is made in the interdental area needle is then inserted into the ver-
called the subperiosteal sling (SPS) one tooth away. From this incision, tical incision and exits through the
to stabilize the CTG. Graft stabiliza- a full-thickness tunnel is created sulcus of the tooth to be augmented
tion by SPS suture minimizes the risk using a #1 Woodson periosteal el- (Fig 1c). The CTG is then inserted
of graft mobility caused by muscle evator (PFIWDS16, Hu-Friedy) and a into the tunnel through the vertical
movement and allows for the con- 4R/4L Columbia University curette incision with a U17 Utility Pick-Up
trolled placement and stabilization (SC4R/4L9E2, Hu-Friedy). The tun- Dressing Plier (Hu-Friedy). The CTG
of the graft in the coronal-most po- nel extends at least one tooth me- is inserted such that the periosteum
sition over the grafted site. sial and distal to the tooth to be side faces the tooth and bone, the
treated, and coronally under the coronal margin of the graft aligns
papillae to provide mobility of the with the gingival margin, and the
Technique soft tissue. two ends of the horizontal mattress
suture are positioned between the
Preoperative Care graft and the bone. The graft is then
Donor Tissue Procurement positioned as coronal as possible
The patient is premedicated with 4 inside the tunnel and stabilized by
capsules of amoxicillin 500 mg (or A CTG with periosteum is pro- slinging the polypropylene suture
clindamycin 150 mg), and 1 tablet of cured from the palate using a single around the tooth and tying the su-
ibuprofen 800 mg. straight horizontal incision 3 mm api- ture (Fig 1d). The vertical incision is
cal to the gingival margin from the closed with simple loop sutures us-
canine to the first molar. The CTG is ing 6-0 polypropylene without en-
Tooth Surface Preparation placed between saline-moistened gaging the underlying CTG (Fig 1e).
gauze while the donor site is sutured The vestibular simple loop sutures
The tooth to be treated and its ad- closed with vertical mattress sutures are removed at 1 week postopera-
jacent teeth are thoroughly scaled using 5-0 chromic gut (PSN687C, tive, and the SPS suture is removed
and planed with Gracey curettes. Hu-Friedy). at the 3-week postoperative visit.

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 255

Periosteum

a b c

Fig 1  (a) The SPS suture begins with the needle entering
through the gingival sulcus and exiting through the vertical
incision. (b) It engages the CTG with a horizontal mattress
suture; the needle enters and exits the graft from the side with
periosteum. (c) The needle then enters through the vertical
incision and exits through the gingival sulcus. (d, e) The SPS
suture is used to guide the CTG into the tunnel through the
vestibular incision. The suture is slung around the tooth and
tied to stabilize the CTG in the coronal-most position inside
the full-thickness tunnel. The SPS suture engages only the
CTG and not the soft tissue at the recipient site. d e

Postoperative Care cal examination confirmed a 6-mm and 2g), the lingual gingival margin
Miller Class III recession on the lin- on the mandibular left lateral inci-
Patients are prescribed amoxicillin gual side of the mandibular left lat- sor remained at a position similar
500 mg (or clindamycin 150 mg) tid eral incisor (Fig 2a). Indentation of to the coronal margin of the CTG
for 7 days and ibuprofen 800 mg the Hawley retainer was visible in the at the time of surgery—at the same
every 8 hours for 4 days and every lingual mucosa (Fig 2b). level as the gingival margins of the
8 hours as needed thereafter. Pa- The patient was sent to the or- two adjacent teeth—and the prob-
tients are instructed to brush twice thodontist to replace the Hawley ing depth at the midlingual surface
daily with an extra-soft Nimbus retainer with a fixed lingual retainer. of the mandibular left lateral inci-
toothbrush with toothpaste of their The lingual recession on the man- sor was 1 mm. Additionally, 5 mm
choice, and to avoid brushing at the dibular left lateral incisor was treat- of root coverage was obtained, the
recipient site for the first week. ed with the technique described amount of keratinized tissue was in-
above (Figs 2c to 2e). No attempt creased, and the biotype was thick-
was made to completely cover the ened.
Case Report denuded lingual root surface of the
mandibular left lateral incisor, nor to
A 66-year-old woman was referred completely submerge the CTG by Discussion
by her general dentist for evalua- coronally advancing the overlying
tion and treatment of gingival re- gingival tissue. The objectives of the technique pre-
cession on the lingual surface of Healing was uneventful. The sented here are to simplify the sta-
the mandibular left lateral incisor. two simple loop sutures that closed bilization of the CTG at the recipient
The patient reported the recession the vertical vestibular incision were site, to have control of the coronal
occurred within the last 6 months removed at the 1-week postopera- placement of the CTG inside a full-
since she completed traditional tive visit, and the SPS suture was re- thickness tunnel, to minimize the
orthodontic treatment and began moved at the 2-week postoperative effects of muscle and tissue move-
wearing a Hawley retainer. Clini- visit. At the 1-year follow-up (Figs 2f ment at the recipient site, and to

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256

Fig 2  (a) A Miller Class III lingual recession

of the mandibular left lateral incisor. (b) The
outline of the retainer is visible in the
mucosa (arrows). (c) Recipient site following
preparation. (d) CTG harvested from the
left palate. (e) Recipient site following
connective tissue stabilization and closure
of the vertical incision. The connective
a b tissue over the denuded root surface
is left exposed. (f, g) Healing at 1-year:
5 mm of root coverage was obtained, the
keratinized tissue was increased (f), and the
biotype thickened (g).

c d

e f g

have predictability in root coverage. 1.5 mm thick.8,9 For the technique thelialize and increase the width of
The objectives are met with the use presented here, a graft with a thick- keratinized tissue, which is desirable.
of a full-thickness tunnel through ness of ≥ 3 mm that spans at least The author is not aware of any pub-
the VISTA approach, a thick and one tooth mesial and distal to the lication that specifically determines
large CTG, and a SPS suture to sta- tooth with recession is desired. how much of the CTG can be left
bilize the CTG at the recipient site. CTG stabilization by SPS suture exposed with tunneling or envelope
The VISTA approach facilitates the is unique in that graft stability for techniques. A study of 40 single re-
insertion of a large and thick CTG a single recession site can be ob- cession sites treated with the CTG
into the full-thickness tunnel. A large tained with only one SPS suture, and and envelope technique reported a
and thick CTG prevents the CTG the SPS suture only engages the change in keratinized tissue of 3.75 ±
from dislodging through the gingi- CTG and not the soft tissue at the 0.95 mm at 1-year of follow-up.15 It is
val sulcus if the recession is deep recipient site. The SPS suture allows assumed that the gain in keratinized
and wide8; maximizes the ratio of the graft to be anchored around the tissue is the amount of exposed CTG
submerged CTG to exposed CTG, tooth in the most coronal position, that survived and epithelialized.
which enhances the survival of the while the overlying soft tissue pas- According to recent systematic
exposed portion of the CTG14; and sively drapes over the CTG. No at- reviews16,17 chemical root surface
thickens the biotype. Success of the tempt is made to coronally advance biomodification provides neither
technique presented significantly the overlying tissue to completely detriment nor benefit to root cov-
depends on the size of the CTG. submerge the CTG to ensure pas- erage. The use of a doxycycline
For CAF, envelope, and tunnel ap- sivity and minimize retraction. Any slurry on the root surface in the tech-
proaches, the CTG is typically 1.0 to exposed portion of the CTG will epi- nique described is intended to help

The International Journal of Periodontics & Restorative Dentistry

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 257

decontaminate the root surface.

Doxycycline is a tetracycline, and
inexpensive in comparison to tet-
racycline hydrochloride. At high
concentration, it can be effective
at removing the smear layer on the
a b
root surface.18
The 6-0 polypropylene suture
is preferred at the recipient site as
it is hydrophobic and does not at-
tract bacteria or induce an inflam-
matory response, which minimizes
scarring.10 During healing, as the tis-
sue swells, the polypropylene suture c d
sinks into the tissue. As such, it is ad- Fig 3  (a) Miller Class III recessions on the maxillary canine, first and second premolars,
visable to leave ≥ 6 mm of tails to and first molar. (b) The canine and premolars were grafted with a CTG utilizing one vertical
access incision and three SPS sutures. Healing at (c) 6 months and (d) 1 year.
facilitate removal of sutures and to
remove the vestibular simple loop
sutures at the 1-week postoperative
visit. Although in the case report apical to the mesial and distal inter- complicated. Furthermore, the size
the SPS suture was removed at the dental bone, the coronal margin of of the CTG will limit how many teeth
2-week postoperative visit, the au- the CTG will be coronal to the CEJ can be treated. As such, sites involv-
thor recommends removing the SPS and complete root coverage is an- ing more than four teeth should be
suture at the 3-week postoperative ticipated. If the CEJ at the midlabial treated more practically by using
visit to allow adequate stabilization surface is coronal to the mesial and two vertical access incisions and two
of the CTG. Based on the author’s distal interdental bone, the coronal grafts, or a different technique.
experience performing this tech- margin of the CTG will most likely While the main objective of root
nique, removal of the SPS suture be apical to the CEJ and complete coverage is to obtain complete root
at the 3-week postoperative visit root coverage is not anticipated. For coverage, this is not always pos-
minimizes the risk of tissue retrac- lingual recessions, the relationship sible due to loss of interdental tis-
tion, especially at sites with strong is the CEJ at the midlingual surface sue.19 In these instances, the goals
muscle movements. with respect to the mesial and distal of therapy should be to obtain the
Due to the stability of the CTG interdental bone. most root coverage possible and
and the passivity of the overlying tis- The surgical approach present- to thicken the biotype and increase
sue at the recipient site, it appears ed is applicable for both teeth and the width of keratinized tissue to fa-
that the coronal margin of the CTG dental implants, and for sites with cilitate hygiene and to make the site
at the time of surgery closely resem- multiple recessions (Fig 3). Up to more resistant to future recession.20
bles the gingival margin following four adjacent teeth can be treated These goals were achieved for the
healing. The amount of root cover- through one vertical access inci- Miller Class III lingual recession case
age obtained with this technique sion. One SPS suture is required per presented here.
depends on the location of the CEJ tooth, and all the SPS sutures must Although the number of re-
at the mid-tooth surface with re- engage the graft before it is inserted ports21–26 on treatment of lingual
spect to the mesial and distal inter- into the tunnel. When more than four recessions is limited in the literature,
dental bone. For labial recessions, if SPS sutures are involved, manage- success of lingual root coverage
the CEJ at the midlabial surface is ment of all the SPS sutures becomes procedures can be attained if the

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258

surgical principles of blood supply  2. Tatakis DN, Chambrone L, Allen EP, et 14. Yotnuengnit P, Promsudthi A, Teparat
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© 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.