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Treatment of multiple gingival recession defects with VISTA: 2D-analysis

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Treatment of multiple gingival recession defects with VISTA: 2D-analysis

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Content 1
Treatment of Multiple Gingival Recession Defects with VISTA: 2D-Analysis

A Thesis Presented to the
Faculty of the Ostrow School of Dentistry of University of Southern California
In Partial Fulfillment of the Requirements for the Degree
Master of Science in Craniofacial Biology

August 2019

Author
Jasveen Wadia DDS
Department of Advanced Periodontology; Herman Ostrow School of Dentistry of USC

2

Table of Contents

Title 1
List of Tables and Figures 3
Abstract 4
Introduction 5
Material and Methods 7
Results 10
Discussion 12
Conclusion 16
References 17
Tables and Figures 21

3
List of Tables and Figures

Table 1 Clinical Characteristics of Included Subjects and Teeth

Figure 1 Diagram of 2D Imaging Technique and Quantitation Protocol

Figure 2 Intraclass and Interclass Correlation Coefficient Scores

Figure 3 Mean Root Coverage and Complete Root Coverage Percentages of Treated Sites

Figure 4 Mean Root Coverage Percentage of Mandible versus Maxilla Treated Sites

Figure 5 Complete Root Coverage Percentage of Mandible versus Maxilla Treated Sites

Figure 6 Mean Root Coverage Percentage of Anterior versus Posterior Treated Sites

Figure 7 Complete Root Coverage Percentage of Anterior versus Posterior Treated Sites

Figure 8 Mean Root Coverage Percentage of RT1 versus RT2 Type Recession Defects

Figure 9 Complete Root Coverage Percentage of RT1 versus RT2 Type Recession Defects

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Abstract

Objective: The primary objective of this retrospective study was to validate a 2D quantitative
method to measure the surface area of exposed roots in sites with gingival recession defects, as
well as the root coverage achieved after treatment. We hypothesized that the intraclass
correlation coefficient (Intra-CC) and interclass correlation coefficient (Inter-CC) scores will
substantiate 2D analysis of gingival recession, supporting the use of 2D analysis to investigate
the efficacy of VISTA in the treatment of mucogingival deformities.

Material and Methods: Gingival Recession (GR) and papilla surface areas were measured
using Adobe Photoshop® on patients treated with Vestibular Incision Subperiosteal Tunnel
Access (VISTA). Pre- and post-operative digital photographs were superimposed as separate
layers. The opacity of the post-op images was adjusted to allow simultaneous viewing of both
layers. The proportions of the post-op images were adjusted, using fixed reference points such as
incisal edges, embrasure line angles, etc. The surface areas of recession defects of pre- and post-
op images were calculated, using image analysis tool. Five different blinded examiners made
quantitative digital measurements on clinical photographs for Intra- and Inter-CC scores before
evaluating the efficacy of VISTA with 2D analysis technique.

Results: For the Inter-CC and Intra-CC Analysis 5 blinded examiners performed repeated
measurements on 12 patients contributing 58 recession defects. The average Intra-CC and Inter-
CC scores for pre-operative measurements was 64 and 89, respectively. The average Intra-CC
and Inter-CC scores for 1 year follow up (38 recession defects measured) was 87 and 92,
respectively, indicating excellent reproducibility. This retrospective study analyzed a total of 43
patients meeting the inclusion/exclusion criteria, contributing 202 recession defects treated by
VISTA in a private practice. The average mean root coverage at 1 year follow up was 111.80%
and the average complete root coverage over 1 year follow up was 60.38%. The subgroup
analysis compared 118 maxillary versus 84 mandibular teeth, 132 anterior versus 70 posterior
teeth, and 90 RT1 type defects versus 112 RT2 type defects. The average mean root coverage
and complete root coverage over 1 year follow up period for mandibular teeth was 97.98% and
45.45%, respectively. The average mean root coverage and complete root coverage over 1 year
follow up period for maxillary teeth was 118.05% and 67.12%, respectively. The average mean
root coverage and complete root coverage over the 1 year follow up period for anterior teeth was
114.60% and 64.47%, respectively. The average mean root coverage and complete root coverage
over 1 year follow up period for posterior teeth was 104.5% and 48.39%, respectively. The
average mean root coverage and complete root coverage over 1 year follow up period for RT1
recession defects was 111.14% and 60.00%, respectively. The average mean root coverage and
complete root coverage over 1 year follow up period for RT2 recession defects was 112.49% and
76.32%, respectively.

Conclusions: Multiple gingival recession defects were effectively treated with VISTA with
values of root surface area coverage above 100%. The reason for the root coverage above 100%
is because the gingival margins were positioned at least 2mm coronal to the CEJ. Analysis of
treatment outcomes using the simple 2D analysis method provided a useful and practical tool for
research, which can be applied in future prospective studies.

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Introduction
The ultimate goals of periodontal regenerative therapy are clinical attachment gain, probing
pocket depth reduction, bone gain in osseous defects, and prevention of soft tissue recession
(Cortellini et al., 2015). Knowledge and understanding of the etiology and treatment of
periodontal recession have increased significantly in recent years. Periodontal recession,
particularly in the anterior segment, significantly impacts function and esthetics. Thus, several
surgical techniques have been developed to optimize esthetic outcomes of dental treatment
(Takei et al., 1985; Cortellini et al., 1999; Nyman et al., 1994; Cortellini et al., 2008; Lehmann
et al., 2011).

The management of multiple contiguous gingival recession (GR) defects is even more
problematic since all the defects should be treated simultaneously to achieve an optimal esthetic
outcome. In 1994, Allen et al. (1994) reviewed Raetzke’s envelope technique and presented
supraperiosteal tunneling for multiple GR management. Similarly, Zabalegui et al. (1999),
introduced another significant modification by eliminating the internal bevel incision, avoiding
the loss of the most critical marginal gingival tissue. Generally, creating supra- or subperiosteal
access via the gingival sulcus is technically challenging, and graft positioning becomes relatively
difficult, with an increased risk of perforation, traumatizing the delicate marginal tissues and
leading to unfavorable healing. In 2011, Zadeh introduced an approach called vestibular incision
subperiosteal tunnel access (VISTA) (Zadeh, 2011). In this procedure, the subperiosteal tunnel is
created via a vestibular access incision, effectively mobilizing the entire mucogingival complex
with ease. VISTA offers the advantages of easy access and trauma reduction in multiple GR
management (Rajeswari et al., 2018). Such advances in surgical techniques reflects on the
clinical improvements for the majority of root coverage procedures (Chambrone and Pini Prato,
2019). Because such treatments rely on the accurate clinical diagnosis of periodontal recession,
several clinical classifications are available (Miller 1985; Nordland et al., 1998; Cardaropoli et
al., 2004).

According to a new to a classification proposed in 2011 (Cairo et al., 2011), gingival recessions
without loss of interproximal attachment were considered as RT1 defects, representing defects
most likely associated with traumatic toothbrushing only in healthy periodontal tissue. Gingival
6
recessions associated with the presence of clinical attachment loss were divided into classes RT2
and RT3, thus clustering defects associated with periodontal disease. While RT2 defects showed
an amount of interproximal attachment loss less than or equal to the buccal site (i.e. a gingival
recession associated with horizontal bone lone loss), RT3 recessions showed higher
interproximal attachment loss than the buccal site (i.e. a gingival recession associated with an
interproximal infrabony defect). This differential diagnosis may help clinicians in selecting the
proper treatment.

Classically, periodontal recession is assessed visually with a periodontal probe, and height and
width are defined by recording vertical and horizontal distances of the gingival margin from the
cementoenamel junction (CEJ). However, this method has several disadvantages and is subject to
a multitude of errors (Abbas et al., 1982; Baderstem et al., 1984; Bulthis et al., 1998). Variations
in probe design (tip diameter, tip shape and flexibility) and force have presented obstacles to the
reproducibility of probing depth measurements. Other confounding factors include the difficulty
in the detection of the cemento-enamel junction (CEJ) in many cases, and observer-dependent
factors, such as the location and angle of probe insertion (Mayfield et al.,1996; Lehmann et al.,
2011). Even the use of a stent to guide the angulation of the probe does not necessarily overcome
these limitations (Watts,1987).

Furthermore, different types of periodontal probes are characterized by horizontal markings at
defined intervals (e.g., at each 1, 2, or 3 mm) for visual measurements, and values are usually
rounded to the next millimeter. Therefore, a measurement error of approximately 1 mm or more
can result from rounding the value, which has been described in several studies assessing
periodontal pocket depths clinically. When assessing the effect of different therapeutic
modalities, this methodological error may have significant impact on the outcomes, potentially
leading to some misinterpretation of treatment outcomes. Thus, more precise techniques for
clinical measurements are still warranted allowing for a more accurate data collection and
interpretation of even minute changes of the periodontal or peri-implant conditions (Schneider et
al., 2014).

7
Digital imaging technology have been introduced in dentistry for different purposes. Commonly,
they are used for computer-aided design of prosthetic components, optical surface scanning,
radiographic data analysis, computer-assisted implant planning, surgical guide production, etc.
Objects in images obtained from optical surface scanning can be magnified and viewed from
different directions, and even measurements including linear and volumetric analyses are
possible (Windisch et al., 2007; Schneider et al., 2014). However, the use of 3D evaluation
techniques requires additional training with specific software and equipment, which may not be
available in a standard clinical practice. Additionally, these techniques often require additional
steps and time for proper evaluation. The present investigation attempts to introduce a novel,
accessible, and manageable 2D analysis technique to measure gingival recession defects with a
high degree of reliability and reproducibility.

The primary objective of this retrospective study was to validate a 2D quantitative method to
measure the surface area of exposed roots in sites with gingival recession defects, as well as the
root coverage achieved after treatment. We hypothesized that the intraclass correlation
coefficient (Intra-CC) and interclass correlation coefficient (Inter-CC) scores will substantiate
2D analysis of gingival recession, supporting the use of 2D analysis to investigate the efficacy of
VISTA in the treatment of mucogingival deformities.

Material and Methods

A- Characteristics of Study Participants

The protocol for this retrospective study was reviewed and approved by the Institutional Review
Board (IRB) of the University of Southern California. All patients were treated by the same
periodontist (H.H.Z.) in private practice setting, as part of their routine care. The following
inclusion and exclusion criteria were used for the study population.
Inclusion criteria:
- The presence of multiple gingival recession defects on a minimum of two adjacent
teeth, with 2 mm or more recession on at least one of those teeth;
- Availability of pre- and post-operative photographs of sufficient quality; ie.
angulation and exposure to allow superimposition of the images
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- Minimum of 6 months follow-up

Exclusion Criteria were:
- Absence of clearly identifiable CEJ in the photographs
- Cervical restorations extending apical to the CEJ

B- Clinical Intervention

All patients were treated using VISTA technique, using various graft material that was deemed
appropriate based on the initial conditions, as well as patient and therapist preferences. Briefly,
after administering local anesthesia through infiltration and/or block anesthesia, the exposed root
surfaces were debrided by scaling and root planing and odontoplasty to reduce excessive root
prominences in cervical areas. A vertical vestibular incision of sufficient length was made in a
suitable location to allow access to the surgical area. The typical location of this incision in the
anterior maxilla was at the midline frenum. For the posterior maxilla, as well as any location in
the mandible, the position of the initial incision was between the canine and lateral incisor. A
subperiosteal tunnel was elevated, extending from the vestibule to the gingival margin. The
tunnel was released sufficiently to advance the gingival margins coronal to the CEJ with minimal
tension. A simple interrupted suture or double horizontal mattress sutures (6.0 polypropylene
with C3 needle) were positioned approximately 3 mm apical to the gingival margin. The teeth
were then etched for 10 seconds. If crown restorations were present, etching was done for 1
minute with porcelain etchant (9% hydrofluoric acid). Each gingival margin was then
repositioned at least 2 mm coronal to the CEJ of the tooth and every suture knot was bonded in
position to the facial surface of the teeth with flowable composite.

The clinician selected an appropriate graft material, based on clinical considerations, such as the
presence and thickness of the pre-operative zone of keratinized gingiva, esthetic demand, number
of recessions treated and root prominence. The graft materials used included autogenous
connective tissue from palate or tuberosity, acellular dermal matrix (ADM) allograft (Perioderm,
Musculoskeletal Tissue Foundation, Edison, NJ, USA), or xenogenic collagen matrix (XCM,
Mucograft; Geistlich Pharma, Wolhusen, Switzerland) in combination with platelet derived
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growth factor (PDGF; GEM21S, Osteohealth, Shirley, NY, USA). The graft material was
inserted in the tunnel and stabilized to the overlying mucosa by placement of 6.0 polypropylene
suspensory sutures. The initial vertical incision was approximated with 5,0 chromic gut sutures.
The sutures were removed 3 weeks post-surgically. Patients were prescribed antibiotics
(Amoxicillin or Clindamycin), Naproxen Sodium 500 mg every 12 hours, as needed and
Chlorhexidine rinse 0.12% twice a day for three weeks.

C- Digital Image Analysis

The pre- and post-operative photographs for each site were imported into Adobe Photoshop CC.
The program’s layering tool was used to superimpose the two images to adjust their overall
proportions using various anatomic landmarks such as the incisal edges and embrasure line
angles. To ensure that the placement on the second image was accurate, the opacity of the second
(post-operative) photograph was changed to enable simultaneous viewing of both images.

After the two images were overlaid and their proportions were adjusted, the recession surface
area in the pre-operative image was outlined using the “Lasso Tool.” After outlining the area of
exposed roots to the cementoenamel junction (CEJ), the “Record Measurements” tool was used
to count the number of pixels within that region. A pre-operative recession boundary mask was
again traced with the Lasso Tool to create a pre-operative recession boundary layer. This
boundary layer was then placed over successive superimposed post-operative images so that root
coverage surface areas could be traced and pixels of recession coverage could be counted. The
boundary layer served as the pre-operative gingival margin, and the area between this border and
the new location of the gingival margin served as the area of root coverage. The resultant
measurements of pre- and post-operative recession represent a quantification of the exposed root
surfaces, expressed as an arbitrary unit of area (AUA) (Figure 1). Using pre- and post-operative
AUA values, percentages of root coverage were calculated.

In order to first assess the validity of this technique, 5 blinded examiners made two repeated
measurements on the first 12 subjects, equating to 58 test sites. Both intraclass scores (Intra-CC)
and interclass scores (Inter-CC) were obtained validating study methods. After reliability of
10
technique was verified, the same investigator [JW] performed all the image manipulation and
measurement, taking care to use the same protocol for every pair of images measured.
The percentage of root coverage achieved at each time point was calculated using the formula
100 X (Post-Op AUA at specific follow up/Pre-Op AUA). The data was then analyzed in terms
of evaluating percent root coverage, and percent complete root coverage at different follow up
periods. The data was also further subdivided comparing anterior versus posterior, mandibular
versus maxillary, and by RT type.

D- Statistical Analysis

Descriptive statistics were calculated for all variables of interest. Continuous measures were
summarized using means and standard deviations whereas categorical measures were
summarized using counts and percentages. Inter-CC and intra-CC reliability were assessed for
percentage of root coverage. Shrout-Fleiss reliability coefficients were calculated for this
purpose. All analyses were carried out using SAS Version 9.4 (SAS Institute, Cary, NC, USA).

Results

This retrospective study analyzed a total of 43 patients contributing 202 recession defects treated
by VISTA in a Los Angeles based private practice. Table 1 shows the characteristics of the study
participants. The mean age of the study participants was 49 ± 9.27 years, 10 males and 33
females were included. The mean follow-up was 30 ± 28.75 months. A total of 118 maxillary
teeth versus 84 mandibular teeth and a total of 132 anterior versus 70 posterior teeth were
studied. Furthermore, the sites were divided to RT1 and RT2 differential diagnosis (90 RT1
versus 112 RT2 sites).

Before any measurements on Mean Root Coverage and Percent Complete Root Coverage were
made, 5 blinded examiners performed repeated measurements (N=12 patients, 58 recession
defects) for the Inter- and Intra-CC Analysis. The Inter-CC and Intra-CC scores are demonstrated
in Figure 2. Based on the statistical analysis used for Inter- and Intra-CC, scores of 0.4 to 0.75
indicated fair to good reproducibility and scores greater than 0.75 indicates excellent
reproducibility. The average Intra-CC and Inter-CC scores for pre-operative measurements was
11
64 and 89, respectively. The average Intra-CC and Inter-CC scores for 1 year follow up (38
recession defects measured) was 87 and 92, respectively. Thus the Inter-CC and Intra-CC scores
using this 2D method to analyze gingival recession defects for both pre- and post-operative
demonstrated excellent reproducibility, serving as an important step to validate study
methodology.

The effectiveness of root coverage achieved using VISTA was examined by comparing the
digital photographs taken at pre- and post-operative visits to quantify the exposed root surface.
To minimize the confounding effects of the distortion of photographic images, pre- and post-
operative photographs were digitally superimposed in Adobe Photoshop ® utilizing dental
landmarks such as incisal edges, marginal ridges, and embrasure line angles. The surface area of
exposed roots at pre- and post-operative visits were compared in order to calculate the percent
root coverage. Figure 3 shows the mean overall percentage of root coverage and complete root
coverage at the follow up appointments, 6 months to 10 years. The average mean root coverage
at 1 year follow up was 111.80% and the average complete root coverage at 1 year follow up was
60.38%.

Adobe Photoshop ® technology was then used to analyze the efficacy of VISTA by comparing
different subgroups. Figures 4 and 5 evaluate mandibular versus maxillary teeth. The average
mean root coverage and complete root coverage over the 1 year follow up period for mandibular
teeth was 97.98% and 45.45%, respectively. The average mean root coverage and complete root
coverage over 1 year follow up period for maxillary teeth was 118.05% and 67.12%,
respectively. Figures 6 and 7 evaluate anterior teeth versus posterior teeth. The average mean
root coverage and complete root coverage over 1 year follow up period for anterior teeth was
114.6% and 64.47%, respectively. The average mean root coverage and complete root coverage
over 1 year follow up period for posterior teeth was 104.5% and 48.39%, respectively. Figures 8
and 9 evaluate RT1 versus RT2 recession type defects. The average mean root coverage and
complete root coverage over 1 year follow up period for RT1 recession defects was 111.14% and
60.00%, respectively. The average mean root coverage and complete root coverage over 1 year
follow up period for RT2 recession defects was 112.49% and 76.32%, respectively.

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Discussion

A critical aspect of assessing the outcome of clinical interventions is accurate and reproducible
measurements. From an analysis perspective, errors during data acquisition may lead to
misinterpretation of the efficacy of different treatment modalities or otherwise falsifying the
results of studies. This area is particularly challenging in interpreting the results of mucogingival
surgery, because mucosal tissues do not provide fixed and reliable landmarks. Accurate
measurements of gingival recession and papilla height are of great importance in clinical
research, e.g., when comparing different methods for recession coverage, stability of mucosal
margins or alterations of papilla height over time (Schneider et al., 2014). To date, clinical intra-
oral measurements with periodontal probes were frequently used for linear measurements of
recession depth and width (Rams et al., 1993; Hull et al., 1995; Eickholz et al., 2001; Roccuzzo
et al., 2002; Oates et al., 2003). Often times recession defects present with complex
morphologies which may not be accurately represented solely by conventional linear methods.
Furthermore, using the periodontal probe to clinically evaluate gingival recession also contains
other inherent measurement errors from a range of sources, including: 1) measurements that at
best are at 1mm intervals, making it impossible to detect small changes; 2) lack of clear fixed
references and 3) inter- and intra-examiner variability (Lehmann et al., 2011). Various attempts
have been made to improve the reliability of these measurements, including fabrication of stents
(Watts, 1987). Reading errors based on different visual angles and projections of the scale of the
instrument are also possible. Moreover, values are usually rounded to the next millimeter
(Schneider et al., 2014).

To address these concerns, the present study utilized digital technology to quantify recession
surface areas while evaluating the outcome of root coverage procedures. This approach enables
much more precise measurement of the typically geometrically complex recession areas. Unlike
direct clinical measurements, digital measurements offer the advantage of better accessibility to
the relevant area. Measurements can be performed in a nonclinical environment without time
restrictions. They can be repeated several times if necessary and with the use of various tools,
such as with magnification, not suitable for intra-oral application (Schneider et al., 2014). There
have been only few studies which have utilized digital image for evaluation of the outcome of
root coverage procedures. Linear analysis of pre- and post-operative digital photographs of sites
13
treated with root coverage procedure has been reported (Kerner et al., 2008). The difference
between the two studies is that in the Kerner (2008) study, linear measurements were made on
pre-operative and post-operative images. In contrast, in the present study, the images at two time
points were superimposed to calculate the percentage of root surface area coverage. Apical
migration of the gingival margin in sites with recession assumes different contours, which cannot
simply be represented by linear measurements. However, before any claims as to the benefits of
using digital tools can be made, the validation of their accuracy must be made. The results of the
present study suggest that using 2D photographic superimposition analysis can produce excellent
reproducibility and low variance of measurements as demonstrated by Interclass and Intraclass
Correlation Coefficient Scores.

The ultimate goal of dental and periodontal care is to maintain the health, comfort, function, and
esthetics of the natural dentition. This includes the treatment of gingival recession defects to
restore proper soft tissue anatomy and thus minimize GR-associated complications. GR, defined
as the migration of the marginal soft tissue apical to CEJ, is accompanied by alveolar bone
dehiscence and a potential reduction in the gingival tissue surrounding the tooth. GR is
encountered commonly in adults aged > 30 years. The exposure of the tooth root and the loss of
hard and soft tissue supporting structures ultimately increases the likelihood that the patient will
experience: 1) dentinal hypersensitivity; 2) soft tissue discomfort; 3) root surface caries; 4)
esthetic concerns; 5) interference with the performance of adequate mechanical plaque control;
and 6) greater susceptibility to inflammatory insult (Richardson et al., 2015).

Moreover, gingival recession defects present clinicians with significant therapeutic challenges,
including restoration of the protective anatomy of the mucogingival complex, reestablishment of
the esthetic balance between soft tissues and adjacent tooth structures, and ideally, regeneration
of the lost cementum, periodontal ligament, and supporting alveolar bone. Such therapeutic
challenges become even greater when clinicians confront multiple contiguous recession defects,
where issues of limited tissue availability and post harvesting morbidity are magnified. In
addition, the need for optimizing esthetic results through simultaneous treatment of contiguous
defects tends to further challenge therapeutic success (Zucchelli et al., 2000; Cetiner et al., 2004;
Carvalho et al., 2006; Zadeh, 2011)
14

Accomplishing complete root coverage (CRC) in multiple-teeth recession defects is more
challenging than in single recession type defects. Chambrone et al., (2015) conducted a
systematic review of the literature to evaluate the treatment of multiple recession-type defects
through different periodontal plastic surgery techniques. Their initial database search retrieved
632 articles, but after screening only four case series met the inclusion criteria of patients having
multiple recession defects treated with periodontal plastic surgery with at least 6 months of
follow up. Analysis of the four studies revealed mean root coverage ranged from 94% to 98%,
and CRC was achieved in 68% to 90% of the patients. Additionally, there were improvements in
other clinical parameters such as mean recession, clinical attachment levels, and probing depths.

The outcome of CTG in conjunction with coronally advanced flap (CAF) for the treatment of
Miller Class I or Class II multiple recession defects has been studied (Cetiner et al., 2004). The
12-month postsurgical results of mean root coverage was 96%, with 80% of the sites achieving
complete root coverage. Chambrone et al., 2015, further reported treatment results limited to
Miller Class I or Class II multiple recession defects. The mean percentage root coverage was
96% and CRC was 71%. Additionally, most of the previous published studies have limited their
therapy to the maxillary arch. Zabalegui et al. (1999) found mean root coverage and complete
root coverage of 92% and 67%, respectively. Zucchelli and De Sanctis (Zucchelli and De
Sanctis, 2000) found mean root coverage and complete root coverage of 97% and 88%,
respectively. The respective findings of Tözum and Dini (Tozum and Dini, 2003) were 95% and
92%, while Cetiner et al., (Cetiner, Bodur et al., 2004) found 96% and 80%, respectively. In
summary, coronally advanced flaps combined with connective tissue grafts for the treatment of
multiple Miller Class I and Class II gingival recession defects achieved superior outcomes in the
maxilla versus the mandible (Chambrone and Chambrone, 2006).

The results of the current study regarding treatment of multiple gingival recession defects with
the VISTA approach recession are consistent with these previous publications, demonstrating a
high degree and stability of root coverage. The average mean root coverage over 1 year follow
up period was 111.80% and the average complete root coverage percentage over 1 year period
was 60.38%. In a recent retrospective analysis (Pini Prato et al., 2015), treatment was only
15
considered truly successful if the exposed root surface is complete covered by soft tissue and is
associated with the gingival margin lying coronal to the CEJ, over the crown enamel. Clinically
this would result in a crevice probing depth, which is coronal to the CEJ and would render the
CEJ invisible on visual inspection. The clinical outcome is measurable by clinicians and
researchers and is reflective of an anatomic restitution ad integrum of the lost periodontal
tissues. Thus this can account for the greater than 100% root coverage calculations of VISTA for
the treatment of multiple gingival recession defects, precisely measured with 2D analysis.

The minimally invasive VISTA approach affords a number of unique advantages to the
successful treatment of multiple gingival recession defects. The vestibular incision can provide
access to an entire region, including visual access to the underlying bone and root dehiscences.
The remote incision also reduces the possibility of traumatizing the gingiva of the teeth being
treated. Critical to the success of VISTA is a careful subperiosteal dissection that reduces the
tension of the gingival margin during coronal advancement while at the same time maintaining
the anatomical integrity of the interdental papillae by avoiding papillary reflection.

An important technical difference between the VISTA and other tunneling approaches and more
classical techniques of gingival augmentation is the degree of coronal advancement of the
gingival margin advocated during the procedure. The gingival margin, with its attached collagen
membrane, is advanced to the most coronal level of the adjacent interproximal papillae rather
than to the cementoenamel junction. Polypropylene sutures are then secured to the facial aspect
of each tooth, effectively preventing apical relapse of the gingival margin during the initial
stages of healing but compensating for some degree of apical migration during the healing
period. One of the major obstacles to regenerative healing is micromotion, which promotes
formation of scar tissue. The rigid fixation of gingival margins introduced with the present
coronally anchored suture technique minimizes micromotion of the regenerative site. Reduction
of micromotion has proven to be a major advantage of the present technique over conventional
methods, where the gingival margin may be subject to displacement during facial movements
(Zadeh, 2011). Taken together, the novel features of using VISTA to treat multiple recession
defects could account for the high degree of success and stability elucidated by the results of this
retrospective analysis.
16
Conclusion

The present study utilized photographic images to quantify recession surface areas while
evaluating the outcome of VISTA procedure. Disadvantages of this methodology include the fact
that photographic images are subject to distortion, the images may not be taken with the same
settings, and the photographs may not be taken with the same angulations. These inherent
differences in the imported photographs make it difficult to standardize calculations for Adobe
Photoshop arbitrary unit area. Despite these limitations, the use of 2D technology for quantifying
recession surface area pre- and post-operatively showed excellent reproducibility of
measurements within one individual and between different investigators, validating
methodology. Furthermore, using 2D measuring technology, this retrospective analysis
demonstrated the durability of VISTA in the treatment of multiple recession defects.

17
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21
Tables and Figures

Table 1: Clinical characteristics of included subjects and teeth. I-Incisors, P-Premolars, M-
Molars

Patient
Gender Male
(N=10)
Female (N=33) Total (N=43)
Mean Age (Years) 51.70 ± 8.49 48.18 ± 9.46 49 ± 9.27
Mean Follow Up (Months) 29.4 ± 25.99 30.18 ± 29.90 30 ± 28.75
Mean Number of
Recession/Patient
3.40 5.09 4.70
Site
Anatomic Location Maxillary (N=118) Mandibular (N=84) Total (N=202)
Anatomic Location Anterior (N=132) Posterior (N=70) Total (N=202)
Tooth type Maxillary
I (N = 87)
P (N = 26)
M (N = 5)
Mandibular
I (N = 45)
P (N = 31)
M (N = 8)
Total
I (N = 132)
P (N = 57)
M (N = 13)
RT Class I
(N=90)
II
(N=112) Total (N=202)
22
Figure 1: Diagram illustrating the two-dimensional imaging technique and quantitation protocol.
A & B. Pre-operative photograph of teeth #8 and 9; C. Pre-operative photograph with masks
overlaid to define the boundaries of exposed root surfaces and gingival tissues.; D. Pre-operative
recession outline mask; E. 1 Year Post Op #8 and #9. Recession Defects treated with CTG +
VISTA approach; F & G. Superimposition of Figure 1A and Figure 1E; H & I. Pre Operative
recession outline mask superimposed on 1 year post op (Fig 1E) J. Post-treatment recession
coverage measured from pre operative recession outline mask to gingival margin location of soft
tissue.

23
Figure 2: Intra- and inter-rater reproducibility scores for gingival recession surface areas
measured by 5 examiners, who performed repeated measurements (N=12 patients, 58 teeth) at 7
time points. The ICC scores of our measurements demonstrated a high degree of reproducibility,
serving as an important step to validate study methodology. ICC scores 0.4 to 0.75 indicates fair
to good reproducibility and ICC scores greater than 0.75 indicates excellent reproducibility.

24
Figure 3: The efficacy of VISTA in treating multiple gingival recession defects measured via 2D
analysis. Bar graphs demonstrating Mean Root Coverage and Complete Root Coverage
measured at 6 months post operatively to 10 years post operatively. A total of 43 patients
contributing 202 recession defects were used for this retrospective analysis.

Follow
Up
Time
(Years)
0.5 1 2 3 4 5 7 10
Number
of Sites
46 106 16 16 52 5 9 3

25
Figure 4: VISTA approach to treat gingival recession defects, measured via 2D analysis. Bar
graphs demonstrating Mean Root Coverage of Mandibular Teeth (N=84) versus Maxillary Teeth
(N=118), for a follow up period up to 10 years.

Follow
Up Time
(Years)
0.5 1 2 3 4 5 7 10
Number
of Sites
Mandible
23 33 7 3 26 0 1 1
Number
of Sites
Maxilla
23 73 9 13 26 5 8 2

26
Figure 5: VISTA approach to treat gingival recession defects, measured via 2D analysis. Bar
graphs demonstrating Complete Root Coverage of Mandibular Teeth (N=84) versus Maxillary
Teeth (N=118), for a follow up period up to 10 years.

27
Figure 6: VISTA approach to treat gingival recession defects, measured via 2D analysis. Bar
graphs demonstrating Mean Root Coverage of Anterior Teeth (N=132) versus Posterior Teeth
(N=70), for a follow up period up to 10 years

Follow
Up Time
(Years)
0.5 1 2 3 4 5 7 10
Number
of Sites
Anterior
37 76 12 9 33 2 9 3
Number
of Sites
Posterior
9 30 4 7 19 3 0 0

28
Figure 7: VISTA approach to treat gingival recession defects, measured via 2D analysis. Bar
graphs demonstrating Complete Root Coverage of Anterior Teeth (N=132) versus Posterior
Teeth (N=70), for a follow up period up to 10 years.

29
Figure 8: VISTA approach to treat gingival recession defects, measured via 2D analysis. Bar
graphs demonstrating Mean Root Coverage of RT1 (N=90) versus RT2 (N=112), for a follow up
period up to 10 years.

Follow
Up
Time
(Years)
0.5 1 2 3 4 5 7 10
Number
of Sites
Type
RT1
28 54 8 11 19 5 6 0
Number
of Sites
Type
RT2
18 52 8 5 33 0 3 3

30
Figure 9: VISTA approach to treat gingival recession defects, measured via 2D analysis. Bar
graphs demonstrating Complete Root Coverage of RT1 (N=90) versus RT2 (N=112), for a
follow up period up to 10 years

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Creator Wadia, Jasveen Singh (author)

Core Title Treatment of multiple gingival recession defects with VISTA: 2D-analysis

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 08/05/2019

Defense Date 05/22/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag 2D analysis,Adobe Photoshop,anterior,complete root coverage,correlation coefficient analysis,correlation coefficient scores,dental,dental esthetics,gingival augmentation,gingival recession,interclass,intraclass,mandible,maxilla,mean root coverage,Miller classification,multiple gingival recession defects,OAI-PMH Harvest,periodontal probe,periodontology,posterior,recession,root coverage,RT,RT classification,Teeth,tunneling,vestibular incision subperiosteal tunnel access,Vista

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Advisor Bakhshalian, Neema (committee chair), Chen, Casey (committee member), Sedghizadeh, Parish (committee member)

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