Dealing with complications
Treatment of recessions around implants with the VISTA technique
Recessions around implants are a common problem. A systematic review revealed that 11% of immediately placed implants develop buccal mucosal dehiscence (Khzam et al., 2015). Another study focused on conventionally placed implants and found that the incidence of mucosal recession over 1mm was 61% (Oates et al., 2002). It can therefore be concluded that this is a frequent complication.
Recessions around implants pose severe aesthetic complications. Recessions have a considerable negative impact on the aesthetic result, as the patient considers it completely unacceptable and the problem requires further treatment (Cosyn et al., 2012; Sculean et al., 2017).
Treatment methods for root coverage around teeth have evolved over the years. They have become increasing predictable and currently employ a combination of tunnel access or coronally advanced flaps together with connective tissue grafts or soft tissue substitutes (Cortellini et al., 2012). Around implants, however, it is not yet clear which technique is the ‘gold standard’ (fig 6–7).
The evidence found in the literature is still limited and the results reported are variable. So far, the use of a coronally advanced flap combined with a connective tissue graft is considered the best option, with a success rate of around 90%. But these results should be taken with caution as they may be due to the operator’s skill and may depend on rigorous case selection (i.e. only single, healthy implants with adjacent teeth without interproximal attachment loss).
VISTA: a remote surgical access technique
The vestibular incision subperiosteal tunnel access (VISTA) technique was first described in 2011 (Zadeh et al., 2011). Unlike conventional tunnelling approaches, which use only a small intrasulcular incision, VISTA adopts an approach from a remote surgical access in the vestibule. A vertical incision is made in the vestibule, followed by the elevation of a subperiosteal tunnel towards the gingival margin. The tunnel releases the tension of the flap so a graft can be placed inside. The dissected tunnel is then coronally repositioned by horizontal mattress sutures bonded to the buccal surface of the teeth that anchor such coronal advancement and maintain it during the healing period (fig 8).
It has been shown that predictable root coverage and gingival volume gain can be achieved by the VISTA procedure; these results have been digitally measured and recently published (Gil et al., 2018; Gil et al., 2019). Results have also shown that initial root prominence is associated with less root coverage.
Case selection is crucial for good results. Risk factors for implant margin recessions have been well documented. There are anatomical factors (buccal position, thin biotype, lack of keratinised mucosa), pathological (peri-implantitis) and behavioural factors (smoking) which have been documented (Mazzoti et al., 2018).
Removing the implant may be the only solution in unfavourable cases
Some cases should not be selected for treatment. This is because recessions are highly dependent on underlying risk factors (i.e. implants positioned too buccally, narrow inter-implant distance or peri-implantitis).
When indicated (the implant is healthy, the placement is in the right position and the bone anatomy around the implant is favourable), however, VISTA can be an appropriate approach for treating implant recessions, due to its:
- remote surgical access, which does not disturb the delicate scar-like mucosal margin around an implant
- capacity to increase mucosal thickness in a predictable way with a connective tissue graft (placed properly on a secure bed) or a soft tissue substitute
- coronal flap displacement, which can be achieved by anchored sutures
- understanding the aetiology of the defect is key in case selection and treatment choice
- the evidence supporting surgical treatment is limited
- VISTA is a predictable technique for treating multiple recessions on teeth
- VISTA can also be used to manage implant recessions, although an RCT is needed to validate it