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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: jdo@dentistry.ucla.edu 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
susceptible to mobility due to mus-
cle movement at the recipient site.10
Sutures suspended over interdental
contact points11,12 or anchored coro-
nally on the midlabial surface of a
tooth13 have been described to im-
prove graft stability. These suturing
techniques can be cumbersome and
require the use of composite resin to
suspend or anchor the sutures. Even
with these suturing techniques, pre-
cise and controlled placement of the
graft over the denuded root surface
can be challenging.
This report describes a minimal-
ly invasive surgical approach using
the vestibular incision subperiosteal
tunnel access (VISTA)13 and a suture
called the subperiosteal sling (SPS)
to stabilize the CTG. Graft stabiliza-
tion by SPS suture minimizes the risk
of graft mobility caused by muscle
movement and allows for the con-
trolled placement and stabilization
of the graft in the coronal-most po-
sition over the grafted site.
Technique
Preoperative Care
The patient is premedicated with 4
capsules of amoxicillin 500 mg (or
clindamycin 150 mg), and 1 tablet of
ibuprofen 800 mg.
Tooth Surface Preparation
The tooth to be treated and its ad-
jacent teeth are thoroughly scaled
and planed with Gracey curettes.
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The denuded root surfaces are
scrubbed and decontaminated for 1
minute with gauze soaked in doxy­
cycline slurry (powder from doxy-
cycline 100 mg capsule suspended
in sterile saline). The teeth are then
thoroughly rinsed with sterile saline.
Recipient Site Preparation
A 6-mm vertical incision is made
with a no. 15 scalpel in the mucosa,
starting at the mucogingival junc-
tion in the interdental area mesial or
distal to the site to be augmented.
If the interdental area adjacent to
the recession is narrow, the inci-
sion is made in the interdental area
one tooth away. From this incision,
a full-thickness tunnel is created
using a #1 Woodson periosteal el-
evator (PFIWDS16, Hu-Friedy) and a
4R/4L Columbia University curette
(SC4R/4L9E2, Hu-Friedy). The tun-
nel extends at least one tooth me-
sial and distal to the tooth to be
treated, and coronally under the
papillae to provide mobility of the
soft tissue.
Donor Tissue Procurement
A CTG with periosteum is pro-
cured from the palate using a single
straight horizontal incision 3 mm api-
cal to the gingival margin from the
canine to the first molar. The CTG is
placed between saline-moistened
gauze while the donor site is sutured
closed with vertical mattress sutures
using 5-0 chromic gut (PSN687C,
Hu-Friedy).
Subperiosteal Sling Suture
for Connective Tissue Graft
Stabilization
The CTG is inserted into the tun-
nel and stabilized with a single SPS
suture without engaging the soft
tissue at the recipient site, using
6-0 polypropylene suture with a
C-3 needle (PSN8695P, Hu-Friedy),
as follows. The needle is inserted
through the sulcus of the tooth to
be augmented, and exits through
the vertical incision (Fig 1a). The su-
ture engages the CTG with a hori-
zontal mattress suture (Fig 1b). The
needle enters and exits the CTG
from the side with periosteum. The
needle is then inserted into the ver-
tical incision and exits through the
sulcus of the tooth to be augmented
(Fig 1c). The CTG is then inserted
into the tunnel through the vertical
incision with a U17 Utility Pick-Up
Dressing Plier (Hu-Friedy). The CTG
is inserted such that the periosteum
side faces the tooth and bone, the
coronal margin of the graft aligns
with the gingival margin, and the
two ends of the horizontal mattress
suture are positioned between the
graft and the bone. The graft is then
positioned as coronal as possible
inside the tunnel and stabilized by
slinging the polypropylene suture
around the tooth and tying the su-
ture (Fig 1d). The vertical incision is
closed with simple loop sutures us-
ing 6-0 polypropylene without en-
gaging the underlying CTG (Fig 1e).
The vestibular simple loop sutures
are removed at 1 week postopera-
tive, and the SPS suture is removed
at the 3-week postoperative visit.
 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
Patients are prescribed amoxicillin
500 mg (or clindamycin 150 mg) tid
for 7 days and ibuprofen 800 mg
every 8 hours for 4 days and every
8 hours as needed thereafter. Pa-
tients are instructed to brush twice
daily with an extra-soft Nimbus
toothbrush with toothpaste of their
choice, and to avoid brushing at the
recipient site for the first week.
Case Report
A 66-year-old woman was referred
by her general dentist for evalua-
tion and treatment of gingival re-
cession on the lingual surface of
the mandibular left lateral incisor.
The patient reported the recession
occurred within the last 6 months
since she completed traditional
orthodontic treatment and began
wearing a Hawley retainer. Clini-
cal examination confirmed a 6-mm
Miller Class III recession on the lin-
gual side of the mandibular left lat-
eral incisor (Fig 2a). Indentation of
the Hawley retainer was visible in the
lingual mucosa (Fig 2b).
The patient was sent to the or-
thodontist to replace the Hawley
retainer with a fixed lingual retainer.
The lingual recession on the man-
dibular left lateral incisor was treat-
ed with the technique described
above (Figs 2c to 2e). No attempt
was made to completely cover the
denuded lingual root surface of the
mandibular left lateral incisor, nor to
completely submerge the CTG by
coronally advancing the overlying
gingival tissue.
Healing was uneventful. The
two simple loop sutures that closed
the vertical vestibular incision were
removed at the 1-week postopera-
tive visit, and the SPS suture was re-
moved at the 2-week postoperative
visit. At the 1-year follow-up (Figs 2f
and 2g), the lingual gingival margin
on the mandibular left lateral inci-
sor remained at a position similar
to the coronal margin of the CTG
at the time of surgery—at the same
level as the gingival margins of the
two adjacent teeth—and the prob-
ing depth at the midlingual surface
of the mandibular left lateral inci-
sor was 1 mm. Additionally, 5 mm
of root coverage was obtained, the
amount of keratinized tissue was in-
creased, and the biotype was thick-
ened.
Discussion
The objectives of the technique pre-
sented here are to simplify the sta-
bilization of the CTG at the recipient
site, to have control of the coronal
placement of the CTG inside a full-
thickness tunnel, to minimize the
effects of muscle and tissue move-
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.
The objectives are met with the use
of a full-thickness tunnel through
the VISTA approach, a thick and
large CTG, and a SPS suture to sta-
bilize the CTG at the recipient site.
The VISTA approach facilitates the
insertion of a large and thick CTG
into the full-thickness tunnel. A large
and thick CTG prevents the CTG
from dislodging through the gingi-
val sulcus if the recession is deep
and wide8; maximizes the ratio of
submerged CTG to exposed CTG,
which enhances the survival of the
exposed portion of the CTG14; and
thickens the biotype. Success of the
technique presented significantly
depends on the size of the CTG.
For CAF, envelope, and tunnel ap-
proaches, the CTG is typically 1.0 to
1.5 mm thick.8,9 For the technique
presented here, a graft with a thick-
ness of ≥ 3 mm that spans at least
one tooth mesial and distal to the
tooth with recession is desired.
CTG stabilization by SPS suture
is unique in that graft stability for
a single recession site can be ob-
tained with only one SPS suture, and
the SPS suture only engages the
CTG and not the soft tissue at the
recipient site. The SPS suture allows
the graft to be anchored around the
tooth in the most coronal position,
while the overlying soft tissue pas-
sively drapes over the CTG. No at-
tempt is made to coronally advance
the overlying tissue to completely
submerge the CTG to ensure pas-
sivity and minimize retraction. Any
exposed portion of the CTG will epi-
thelialize and increase the width of
keratinized tissue, which is desirable.
The author is not aware of any pub-
lication that specifically determines
how much of the CTG can be left
exposed with tunneling or envelope
techniques. A study of 40 single re-
cession sites treated with the CTG
and envelope technique reported a
change in keratinized tissue of 3.75 ±
0.95 mm at 1-year of follow-up.15 It is
assumed that the gain in keratinized
tissue is the amount of exposed CTG
that survived and epithelialized.
According to recent systematic
reviews16,17 chemical root surface
biomodification provides neither
detriment nor benefit to root cov-
erage. The use of a doxycycline
slurry on the root surface in the tech-
nique described is intended to help

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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
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
sinks into the tissue. As such, it is ad-
visable to leave ≥ 6 mm of tails to
facilitate removal of sutures and to
remove the vestibular simple loop
sutures at the 1-week postoperative
visit. Although in the case report
the SPS suture was removed at the
2-week postoperative visit, the au-
thor recommends removing the SPS
suture at the 3-week postoperative
visit to allow adequate stabilization
of the CTG. Based on the author’s
experience performing this tech-
nique, removal of the SPS suture
at the 3-week postoperative visit
minimizes the risk of tissue retrac-
tion, especially at sites with strong
muscle movements.
Due to the stability of the CTG
and the passivity of the overlying tis-
sue at the recipient site, it appears
that the coronal margin of the CTG
at the time of surgery closely resem-
bles the gingival margin following
healing. The amount of root cover-
age obtained with this technique
depends on the location of the CEJ
at the mid-tooth surface with re-
spect to the mesial and distal inter-
dental bone. For labial recessions, if
the CEJ at the midlabial surface is
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257
a b
c d
Fig 3  (a) Miller Class III recessions on the maxillary canine, first and second premolars,
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.
apical to the mesial and distal inter- complicated. Furthermore, the size
dental bone, the coronal margin of of the CTG will limit how many teeth
the CTG will be coronal to the CEJ can be treated. As such, sites involv-
and complete root coverage is an- ing more than four teeth should be
ticipated. If the CEJ at the midlabial treated more practically by using
surface is coronal to the mesial and two vertical access incisions and two
distal interdental bone, the coronal grafts, or a different technique.
margin of the CTG will most likely While the main objective of root
be apical to the CEJ and complete coverage is to obtain complete root
root coverage is not anticipated. For coverage, this is not always pos-
lingual recessions, the relationship sible due to loss of interdental tis-
is the CEJ at the midlingual surface sue.19 In these instances, the goals
with respect to the mesial and distal of therapy should be to obtain the
interdental bone. most root coverage possible and
The surgical approach present- to thicken the biotype and increase
ed is applicable for both teeth and the width of keratinized tissue to fa-
dental implants, and for sites with cilitate hygiene and to make the site
multiple recessions (Fig 3). Up to more resistant to future recession.20
four adjacent teeth can be treated These goals were achieved for the
through one vertical access inci- Miller Class III lingual recession case
sion. One SPS suture is required per presented here.
tooth, and all the SPS sutures must Although the number of re-
engage the graft before it is inserted ports21–26 on treatment of lingual
into the tunnel. When more than four recessions is limited in the literature,
SPS sutures are involved, manage- success of lingual root coverage
ment of all the SPS sutures becomes procedures can be attained if the
Volume 39, Number 2, 2019
258
surgical principles of blood supply
and graft stabilization are respect-
ed. The mobility of the floor of the
mouth and the tongue poses a ma-
jor challenge to wound stabilization
in the lingual mandible.16,18,19 The
surgical approach presented here is
a minimally invasive technique that
stabilizes the CTG against the tooth
and reduces the effects of muscle
movement on graft stabilization,
which can make root coverage of
lingual recessions predictable.
Conclusions
The technique described here ap-
pears to be promising and suitable
for the treatment of localized root
recession. For single recessions,
a single SPS suture appears to be
adequate to stabilize the CTG in-
side a full-thickness tunnel. Clinical
studies are required to understand
the predictability and limitations
of this technique and to determine
long-term professional and patient-
oriented outcomes.
Acknowledgments
The author reported no conflicts of interest
related to this study.
References
 1. Chambrone L, Tatakis DN. Periodontal
soft tissue root coverage procedures:
A systematic review from the AAP Regen-
eration Workshop. J Periodontol 2015;
86(suppl 2):s8–s51.
The International Journal of Periodontics & Restorative Dentistry
© 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.
 2. Tatakis DN, Chambrone L, Allen EP, et
al. Periodontal soft tissue root cover-
age procedures: A consensus report
from the AAP Regeneration Workshop.
J Periodontol 2015;86(suppl 2):s52–s55.
  3. Cairo F, Nieri M, Pagliaro U. Efficacy of
periodontal plastic surgery procedures
in the treatment of localized facial gin-
gival recessions. A systematic review.
J Clin Periodontol 2014;41(suppl 15):
s44–s62.
  4. Tonetti MS, Jepsen S; Working Group 2
of the European Workshop on Periodon-
tology. Clinical efficacy of periodontal
plastic surgery procedures: Consensus
report of Group 2 of the 10th European
Workshop on Periodontology. J Clin
Periodontol 2014;41(suppl 15):s36–s43.
 5. Roccuzzo M, Bunino M, Needleman I,
Sanz M. Periodontal plastic surgery for
treatment of localized gingival reces-
sions: A systematic review. J Clin Peri-
odontol 2002;29(suppl 3):s178–s194.
 6. Zucchelli G, Marzadori M, Mounssif I,
Mazzotti C, Stefanini M. Coronally ad-
vanced flap + connective tissue graft
techniques for the treatment of deep
gingival recession in the lower incisors:
A controlled randomized clinical trial.
J Clin Periodontol 2014;41:806–813.
  7. Pini Prato GP, Baldi C, Nieri M, et al. Cor-
onally advanced flap: The post-surgical
position of the gingival margin is an im-
portant factor for achieving complete
root coverage. J Periodontol 2005;76:
713–722.
 8. Raetzke PB. Covering localized areas
of root exposure employing the “enve-
lope” technique. J Periodontol 1985;56:
397–402.
 9. Allen AL. Use of the supraperiosteal
envelope in soft tissue grafting for root
coverage. I. Rationale and technique. Int
J Periodontics Restorative Dent 1994;14:
216–227.
10. Allen EP. Subpapillary continuous sling
suturing method for soft tissue graft-
ing with the tunneling technique. Int J
Periodontics Restorative Dent 2010;30:
479–485.
11. Azzi R, Etienne D. Recouvrement radicu-
laire et reconstruction papillaire par gref-
fon con jonctif enfoui sous un lambeau
vestibulaire tunnelisé et tracté coronaire-
ment. J Parodontol Implant Orale 1998;
17:71–77.
12. Zuhr O, Rebele SF, Thalmair T, Fickl S,
Hürzeler MB. A modified suture tech-
nique for plastic periodontal and implant
surgery: The double-crossed suture. Eur
J Esthet Dent 2009;4:338–347.
13. Zadeh HH. Minimally invasive treatment
of maxillary anterior gingival recession
defects by vestibular incision subperios-
teal tunnel access and platelet-derived
growth factor BB. Int J Periodontics Re-
storative Dent 2011;31:653–660.
14. Yotnuengnit P, Promsudthi A, Teparat
T, Laohapand P, Yuwaprecha W. Rela-
tive connective tissue graft size affects
root coverage treatment outcome in
the envelope procedure. J Periodontol
2004;75:886–892.
15. Abundo R, Corrente G, des Ambrois
AB, Perelli M, Savio L. A connective tis-
sue graft envelope technique for the
treatment of single gingival recessions:
A 1-year study. Int J Periodontics Restor-
ative Dent 2009;29:593–597.
16. Oliveira GH, Muncinelli EA. Efficacy of
root surface biomodification in root cov-
erage: A systematic review. J Can Dent
Assoc 2012;78:c122.
17. Karam PS, Sant’Ana AC, de Rezende ML,
Greghi SL, Damante CA, Zangrando MS.
Root surface modifiers and subepithelial
connective tissue graft for treatment of
gingival recessions: A systematic review.
J Periodontal Res 2016;51:175–185.
18. Madison JG 3rd, Hokett SD. The effects
of different tetracyclines on the dentin
root surface of instrumented, periodon-
tally involved human teeth: A com-
parative scanning electron microscope
study. J Periodontol 1997;68:739–745.
19. Miller PD Jr. Root coverage  using the
free soft tissue autograft following cit-
ric acid application. III. A successful and
predictable procedure in areas of deep-
wide recession. Int J Periodontics Re-
storative Dent 1985;5:14–37.
20. Wennström JL. The significance of the
width and thickness of the gingiva in
orthodontic treatment. Dtsh Zahnärztl Z
1990;45:136–141.
21. Wilcko MT, Wilcko WM, Murphy KG, et
al. Full-thickness flap/subepithelial con-
nective tissue grafting with intramarrow
penetrations: Three case reports of lin-
gual root coverage. Int J Periodontics
Restorative Dent 2005;25:561–569.
22. Zucchelli G, Bentivogli V, Ganz S, Bel-
lone P, Mazzotti C. The connective tissue
graft wall technique to improve root cov-
erage and clinical attachment levels
in
lingual gingival defects. Int J Esthet
Dent 2016;11:538–548.
23. Dorfman HS, Kobs JH 3rd. The lingual
pedicle: Case reports. J Periodontol 1979;
50:316–319.
24. Parra C, Jeong YN, Hawley CE. Guided
tissue regeneration involving piercing-
induced lingual recession: A case report.
Int J Periodontics Restorative Dent 2016;
36:869–875.
25. Soileau KM. Treatment of a mucogingival
defect associated with intraoral piercing.
J Am Dent Assoc 2005;136:490–494.
26. Assis G, Nevins M, Kim DM. The use of
autogenous gingival graft for treatment
of lingual recession on mandibular ante-
rior teeth. Int J Periodontics Restorative
Dent 2017;37:667–671.