Minimally Invasive Treatment of Soft Tissue Deficiency Around an Implant-Supported Restoration in the Esthetic Zone: Modified VISTA Technique Case Report
The horizontal and vertical soft tissue dimension around an implant-supported restoration in the maxillary anterior is one of the determining factors for achieving an esthetic result. In this case report, the patient presented with a deficiency in both dimensions around a single-tooth implanted-supported restoration in the anterior maxilla. The soft tissue defects were augmented with a connective tissue graft that was placed underneath the buccal peri-implant tissue using a frenum access incision and a supraperiosteal tunneling approach (modified vestibular Incision supraperiosteal tunnel access [VISTA] technique). This novel technique resulted in an increase in tissue height and width, which suggests its potential use around implant-supported restorations.
Figure 1. (a) Patient presents with a high smile showing all gingival margins and papillae. (b and c) The left upper maxillary incisor (#9) had a fistula and a horizontal fracture (periapical radiograph). Keratinized tissue was approximately 4 mm wide, and the patient‘s periodontal tissue type was determined to be thin. In addition, #9 had a facial recession of 0.5 mm.The papilla between #8 and #9 was slightly deficient due to interproximal bone loss visible on the periapical radiograph. Figure 2. Clinical presentation before soft tissue augmentation. (a) Before the modified VISTA (vestibular incision subperiostal tunnel approach) procedure, the gingival margin was more than 1 mm apical to the margin of the adjacent tooth. (b) The horizontal tissue dimension was reduced and appeared sunken in, especially in the coronal aspect. Both deficiencies were severe enough to be noticeable when the patient smiled.
Modified VISTA (vestibular incision subperiostal tunnel approach) soft tissue augmentation procedure. (a) A frenectomy was performed with a triangular incision using a scalpel with a 15c blade. (b) The buccal area was accessed through the frenum incision in the vestibule, and a split thickness tunnel flap was prepared. The tunnel flap extended toward the gingival sulcus and the lateral incisor. (c) A connective tissue was harvested and placed underneath the split thickness flap envelope. (d) The connective graft was stabilized with interrupted sutures, and the mucogingival flap was advanced coronally.
Figure 4. (a) Before the start of the surgical procedure, the cement enamel junction of the crown was moved 2 mm coronally and the crown profile was flattened to create additional space for the advancement of the flap. A frenectomy was performed with a triangular incision using a scalpel with a 15c blade. (b) Using an Allen end cutting intrasulcular knife, the buccal area was accessed and a split thickness tunnel flap was prepared. Figure 5. Healing after soft tissue augmentation and prosthetic phase. (a) The patient was seen 6 months after soft tissue augmentation. The picture depicts uneventful healing and a stable gingival margin. (b and c) The final abutment was tried in and the fit verified. Figure 6. Follow-up after placement of final restoration (frontal and occlusal view). (a and b) The patient was seen 1 year after soft tissue augmentation and 4 months after crown placement. The gingival margins remained stable. The overall soft tissue architecture was now close to the one before removal of tooth #9.
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