Clinical Oral Investigations (2023) 27:7171–7187

https://doi.org/10.1007/s00784-023-05383-7

REVIEW

Clinical efficacy of Vestibular Incision Subperiosteal Tunnel Access

(VISTA) for treatment of multiple gingival recession defects:
a systematic review, meta‑analysis and meta‑regression
Hamoun Sabri1,2 · Fatemeh SamavatiJame1 · Farzin Sarkarat3 · Hom‑Lay Wang1 · Homayoun H. Zadeh4

Received: 14 October 2023 / Accepted: 12 November 2023 / Published online: 27 November 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023

Abstract
Objectives This study investigated the efficacy of Vestibular Incision Subperiosteal Tunnel Access (VISTA) compared to
other methods for treating multiple adjacent gingival recessions (MAGRs) through a systematic review and meta-analysis.
Materials and methods A systematic literature search was performed through June 2023, to identify clinical trials inves-
tigating VISTA for root coverage on MAGRs. A meta-analysis with meta-regression model was employed on the primary
outcomes of mean and complete root coverages (MRC, CRC), comparing VISTA with other techniques. Clinical efficacy of
various graft materials was assessed.
Results Fourteen studies were included, 8 of which met the criteria for quantitative assessment. The cumulative MRC
(88.15% ± 20.79%) and CRC (67.85% ± 21.72%) of VISTA were significantly higher compared to the tunneling technique
(SMD = 0.83 (95% CI [0.36, 1.30], p < 0.01). The baseline recession depth showed a negative correlation with CRC, whereas
baseline keratinized gingiva width exhibited a positive correlation with this outcome.
Conclusions The VISTA technique, particularly with acellular dermal matrix (ADM) or connective tissue graft (CTG) materi-
als, offers superior outcomes compared to the tunneling technique. The capacity of platelet-rich fibrin (PRF) to substitute for
connective tissue graft (CTG) in VISTA-root coverage was noteworthy, provided there is adequate keratinized tissue width.
Clinical relevance VISTA in concert with acellular dermal matrix or CTG resulted in improved root coverage, surpassing the
outcomes achieved through tunneling. PRF emerged as a viable alternative to CTG, when used in conjunction with VISTA,
demonstrating comparable mean root coverage. This is particularly evident in situations where sufficient keratinized gingiva
is available and when patient comfort is taken into consideration.

Keywords Periodontal plastic surgery · VISTA · Root coverage · Gingival recession · Tunneling · Vestibular incision

Introduction

Managing multiple adjacent gingival recession (MAGR)

defects presents a formidable challenge within periodontal
plastic surgery, characterized by intricate interactions among
* Homayoun H. Zadeh local, systemic, and patient-related factors [1]. To confront
homazadeh@gmail.com this clinical complexity, an array of flap techniques and
1 therapeutic innovations has emerged over time [2–4]. These
Department of Periodontics and Oral Medicine, University
of Michigan School of Dentistry, Ann Arbor, MI, USA include free gingival graft (FGG), coronally advanced flap
2 (CAF), and tunneling (TUN), to contemporary variations
Center for Clinical Research and Evidence Synthesis in Oral
Tissue Regeneration (CRITERION), Ann Arbor, MI, USA and adaptations of these conventional approaches [5–7].
3 These approaches have evolved in response to changing
Department of Oral and Maxillofacial Surgery, Gulf Medical
University, Ajman, UAE therapeutic objectives, progressing from strategies aimed
4 at augmenting the keratinized gingival zone to procedures
VISTA Institute for Therapeutic Innovations, 6325 Topanga
Canyon Blvd, Suite 101, Woodland Hills, Los Angeles, focused on root coverage and, more recently, phenotype
CA 91367, USA modification therapy to enhance gingival thickness and

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esthetics. The effectiveness of each technique varies based
on the specific therapeutic objectives, with differing success
rates documented for each approach [8].
The transition from “mucogingival surgery” to “periodon-
tal plastic surgery,” has aspired to align with general plastic
surgical concepts [9]. These efforts embraced minimally
invasive methods and improved blood supply preservation.
Introduced in 2011, the Vestibular Incision Subperiosteal
Tunnel Access (VISTA) technique presents novel flap design
and coronally anchored suture technique aimed to overcome
limitations of traditional approaches [10]. Application of
biomaterial as alternative to connective tissue grafts (CTG)
has aimed to reduce the morbidity associated with autog-
enous tissue harvesting [2, 11]. Beyond investigating root
coverage outcomes (mRC, cRC) to treat gingival recessions
(GRs), exploring the efficacy of minimally invasive methods
is crucial. While various pairwise and network meta-anal-
yses have examined root coverage procedures in MAGRs
[3, 4, 12–14], none has systematically studied the VISTA
technique. This study marks the first systematic review and
meta-analysis focusing on the efficacy of VISTA for the
treatment of MAGRs. Its primary aims encompass assess-
ing VISTA’s overall clinical outcomes with different graft
materials and identifying factors associated with higher suc-
cess rates using this technique.
Materials and methods
Protocol registration
This systematic review followed PRISMA guidelines.
Appendix A provides the checklist. The study protocol was
registered in PROSPERO (ID: CRD42023442855).
PICOS(T) and focused question
The focused question developed, aligning with the aims
and scope of this study, was the following: “What is the
clinical efficacy and overall evidence on the VISTA surgi-
cal technique in the treatment of MAGRs?”. Subsequently,
the following PICOS(T) domains were generated based on
this prompt:
Patients (P). Individuals with MAGRs requiring surgical
intervention to achieve periodontal root coverage.
Intervention (I). VISTA technique as described by Zadeh
in 2011 [10] combined with the use of various biomaterials
or graft substitutes.
Comparison (C). Treatment with other surgical tech-
niques (e.g., CAF, TUN technique).
Outcomes (O). Primary outcome of mRC and second-
ary outcomes of cRC, keratinized gingiva (KG) changes,
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Clinical Oral Investigations (2023) 27:7171–7187
probing pocket depth (PD) changes, clinical attachment level
(CAL) changes, esthetic scores, etc.
Studies (S). Randomized controlled trials (RCTs), non-
randomized controlled trials (CCTs).
Time (T). Follow-up duration of at least 6 months will
be considered.
Eligibility, inclusion, and exclusion criteria
Included were relevant study types with ≥ 6 months follow-
up without language or publication date limits. Excluded
were as follows: animal studies, editorials, conference
papers, reviews, letters, case series, case reports, short fol-
low-ups, and no pre-/post-op data.
Search strategy
The systematic review’s search strategy with specific
keywords is detailed in Appendix B. In summary, elec-
tronic searches were conducted in PubMed (MEDLINE),
EMBASE, Scopus, and Google Scholar databases in May
2023. Keywords used were as follows: (Vestibular inci-
sion subperiosteal tunneling access) OR (VISTA) AND
((Minimally Invasive Surgery) OR (Periodontal surgical
procedures) OR (oral surgical procedures) OR (periodontal
regeneration) OR (root coverage) OR (gingival recession).
Complementary manual search was conducted to explore the
references of the included articles.
Screening and selection phase
After calibrating on 20 titles, two reviewers (H.S, F.S) inde-
pendently screened titles and abstracts. On finding relevant
articles, a third reviewer (H.H.Z) resolved disagreements,
and full texts were obtained for final review.
Data extraction and outcomes
Articles meeting inclusion criteria underwent data extraction
by two examiners (H.S, F.SJ). A pre-organized spreadsheet
facilitated this process. Any disagreement or ambiguity con-
sulted a senior reviewer (H.HZ). For missing data, authors
were contacted, with a 4-week response window. Included
study variables gathered the following: author details,
study design, sample size, patient characteristics (gender,
age), procedure type (flap technique), materials, outcome
variables (mainly mRC, cRC, KGW, thickness, PD, CAL
changes), follow-ups, and conclusions.
Risk of bias assessment
Included RCTs underwent bias assessment using the
Cochrane RoB-2 tool [15]. Five domains were as follows:
Clinical Oral Investigations (2023) 27:7171–7187
bias from randomization and allocation concealment,
deviations from intended interventions (masked), missing
outcome data, outcome measurement, and result selec-
tion. Studies were categorized as follows: low risk (all low),
high risk (one or more high risk), or some concerns (one
or more “some concerns”).
Data synthesis and statistical analysis
Initially, we pooled all VISTA arms of included studies,
based on which weighted-cumulative mean percentages for
mRC and cRC were measured.
Meta‑analysis of randomized trials
Included RCTs underwent meta-analysis. Two models were
employed based on results: pair-wise meta-analysis compar-
ing VISTA with TUN and another for VISTA with different
grafts (CTG, PRF, CM, etc.) for root coverage in multiple
GRs.
For both analyses, outcomes (mRC, cRC, KGW, GT, PD,
CAL changes) were expressed as mean difference (MD) and
95% confidence intervals (95% CI). Standardized mean dif-
ference (SMD) was used if outcomes were reported in dif-
ferent scales.
Statistical analyses included chi-square test and I2 sta-
tistics. I2 assessed data heterogeneity, defined as moderate
(30–60%) or substantial (50–90%).
Results were combined using the fixed effect analysis;
the random-effects model used if significant heterogeneity.
Unit of analysis: recession defect site. Data was analyzed by
an experienced biostatistician (H.S) with RevMan software
and Rstudio (version 1.3.1073–1, “metafor” package) [16].
p < 0.05 was significant. Non-analyzable data were eluci-
dated through qualitative descriptions.
Meta‑regression
Meta-regression used lmer and lme4 packages [17] in Rstu-
dio for weighted multivariate mixed-models regression. The
aims were as follows: to explore cRC (%) and mRC (%)
relationship with baseline recession depth, KGW,accounting
for confounders. Dataset included variables and study IDs
for heterogeneity. Multivariate mixed models managed inde-
pendent variables’ correlation, graft materials’ effect, and
study ID’s random effects accommodated multiple arms.
The model weighed by recessions per study.
Certainty of the evidence
Certainty of evidence for significant outcomes was assessed
using the GRADE approach [18]. This systematic method
evaluates evidence systematically in categories (study
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design, bias risk, consistency, evidence directness, estimate
precision). Classifications were as follows: very low, low,
moderate, and high certainty.
Results
Study selection
The flow diagram of article selection based on the presented
search strategy is depicted in Appendix C. Out of 548 ini-
tial articles that were identified, 14 studies were included
in this systematic review out of which, 8 were entered into
the meta-analysis. List of excluded articles with reason for
exclusion is presented in Appendix D.
Characteristics of the included studies
Three RCTs [12, 19, 20] and one split-mouth CCT [21] com-
pared VISTA and Tunneling approaches. Additionally, four
RCTs assessed VISTA with CTG or PRF [22–25]. Three
RCTs compared VISTA with CAF or modifications using
different grafts [26–28]. Among other qualitative assessed
studies, one compared PRF vs. CM [29], another PRF + CM
vs. CM alone [30], and one compared buccal fat pad with
PRF [31]. Notably, these studies utilized VISTA for mul-
tiple recession coverage. Table 1 summarizes key charac-
teristics and clinical findings of all qualitatively assessed
articles (n = 14). All studies were single-center trials in a
university setting, with only two reporting research funding
[20, 22]. While one study included Miller’s class III (RT
2) defects [24], the other thirteen focused on class I and II
(RT 1) defects. Regarding oral location, eight trials covered
both jaws and anterior/posterior sites [20–22, 25, 28–31].
Three studies treated anterior sites in both jaws [12, 19, 26].
Maxillary anterior [23], maxillary canine/premolars [27],
and anterior mandible [24] were individually addressed in
separate studies.
Cumulative root coverage outcomes
Based on the data from the included studies (combining all
VISTA treatment arms from the trials), a cumulative mRC
of 88.15% ± 20.79% and cRC of 67.85% ± 21.72% were
calculated when employing the VISTA technique for root
coverage of multiple GRs within Miller’s class I/II (RT1)
defects. These results were irrespective of the graft material
used, and the follow-up period ranged from 6 to 9 months.
Figure 1 depicts the forest plot corresponding to the cumula-
tive mRC % among all included studies.
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 Table 1  Characteristics, summary of findings, and authors’ conclusion of the included studies to this systematic review
7174

Author, Year Country, Arms (test/control) N of subjects Recession GRD Complete Keratinized gin- Keratinized Other results Conclusion
University/ (T/C), N of type (clas- root cover- giva width (KG) mucosa thickness

13
Private, recession sification), age (CRC) changes (KTT)
Funding, (T/C), Age (multiple/
Design, (mean, range), single), Arch
Center Gender (m/f), (Max, Man),
Smokers Site (Ant/
(Y/N) Post)

Sery, 2022 Egypt, VISTA + PRF 24 (12/12) Miller’s BL, 2.71 ± 0.54 30.30% BL, 3.46 ± 1.22 NR PD BL, Both inter-
University, 92 (42/50) class III/ 6 M, 1.33 ± 0.35 6 M, 3.87 ± 0.57 1.64 ± 0.25 ventions
NR 25–50 RT2, M, 6 M, 1.69 ± 0.17 resulted in
RCT, Single, 10/18 Man, Ant CAL BL, significant
Parallel N 4.17 ± 0.52 improve-
6 M, 2.99 ± 0.38 ments in the
amount of
VISTA + CTG​ BL, 2.23 ± 0.51 60% BL, 2.89 ± 0.6 PD BL,
recession
6 M, 0.84 ± 0.56 9 1.86 ± 0.31
VISTA + CTG
6 M, 4.02 ± 0.82 6 M, 1.79 ± 0.5
gave overall
CAL BL, superior
4.12 ± 0.82 results
6 M, 2.67 ± 0.76
Mohamed, KSA, VISTA + ADM 10 (24/24) Miller’s BL, 3.1 ± 0.53 92.42 ± 9.32 BL, 2.10 ± 0.33 NR PD BL, VISTA
2020 University, 43 ± 9.37(34– class I or 6 M, 0.25 ± 0.29 6 M, 3.38 ± 0.37 1.31 ± 0.32 technique
NR 60) II, M, both, 6 M, 0.98 ± 0.10 was found
RCT, Single, NR both CAL BL, to be more
Split- N 4.38 ± 0.54 efficient than
mouth 6 M, 1.23 ± 0.26 Tun + ADM
BL, 3.06 ± 0.60 PD baseline, in treatment
6 M, 0.56 ± 0.43 1.42 ± 0.46 of Miller
6 M, 1.06 ± 0.37 class I and
CAL baseline, II gingival
4.44 ± 0.56 recessions
6 M, 1.63 ± 0.42 and led to
favorable
root cover-
age
Clinical Oral Investigations (2023) 27:7171–7187
 Table 1  (continued)
Author, Year Country, Arms (test/control) N of subjects Recession GRD Complete Keratinized gin- Keratinized Other results Conclusion
University/ (T/C), N of type (clas- root cover- giva width (KG) mucosa thickness
Private, recession sification), age (CRC) changes (KTT)
Funding, (T/C), Age (multiple/
Design, (mean, range), single), Arch
Center Gender (m/f), (Max, Man),
Smokers Site (Ant/
(Y/N) Post)

Geisinger, USA, VISTA + ADM 9 (13/ 16) Miller’s I or BL, 2.54 ± 0.52 69.20% BL, 2.77 ± 0.93 NR PD BL, Result of both
2022 University, NR II, M, both, 6 M, 0.4 ± 0.2 6 M, 1.74 ± 0.13 1.57 ± 0.76 VISTA and
Partial NR both 6 M, 1.22 ± 0.14 TUN are
RCT, Single, < 10/day Esthetic similar
Parallel 6 M, 7.41 ± 0.28
Clinical Oral Investigations (2023) 27:7171–7187

TUN + ADM BL, 2.31 ± 0.48 56.30% BL, 2.46 ± 0.97 PD BL,
6 M, 0.47 ± 0.15 6 M, 1.51 ± 0.16 1.85 ± 0.38
6 M, 1.6 ± 0.22
Esthetic
6 M, 7.31 ± 0.29
Patra, 2022 India, VISTA + PRF + CM 13 (20/20) Miller’s BL, 2.9 ± 0.71 1 M, 91.6% BL, 1.35 ± 0.48 BL, 1.65 ± 0.238 PD, VISTA
University, 36.7 ± 12.44 class I or 3 M, 0.95 ± 0.51 3 M, 81.6% 3 M, 2.9 ± 0.44 3 M, 2.53 ± 0.212 1.75 ± 0.44 mm technique
NR 7/6 II, M, both, 6 M, 1.3 ± 0.57 6 M, 67% 6 M, 2.75 ± 0.44 6 M, 2.46 ± 0.252 PD, along with
RCT, Single, VISTA + CM N both BL, 2.7 ± 0.86 1 M, 82.3% BL, 1.6 ± 0.5 BL, 1.62 ± 0.202 2.05 ± 0.6 mm collagen
Split 3 M, 0.5 ± 0.5 3 M, 66.4% 3 M, 3.5 ± 0.51 3 M, 2.02 ± 0.18 membrane
mouth 6 M, 0.9 ± 0.64 6 M, 53.95% 6 M, 3.4 ± 0.59 6 M, 1.91 ± 0.166 and inject-
able form of
platelet-rich
fibrin can be
successfully
used as a
treatment
Jain, 2021 India, Uni- VISTA + PRF 8 (10/10) Miller’s BL, 2.05 ± 0.83 NA BL, 4.40 ± 1.17 NA Better results
versity, No 18–50 class I or 6 M, 0.35 ± 0.53 3 M, 5.20 ± 1.01 were
RCT, Single, NR II, M, both, 6 M, 5.00 ± 1.55 obtained
Parallel VISTA + CM N both BL, 2.00 ± 0.33 NA BL, 4.30 ± 0.95 PPD-BL, when
6 M, 0.8 ± 0.59 3 M, 5.30 ± 1.18 0.90 ± 0.32 A-PRF was
6 M, 5.15 ± 1.06 6 M, 0.50 ± 0.00 used

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 Table 1  (continued)
7176

Author, Year Country, Arms (test/control) N of subjects Recession GRD Complete Keratinized gin- Keratinized Other results Conclusion
University/ (T/C), N of type (clas- root cover- giva width (KG) mucosa thickness

13
Private, recession sification), age (CRC) changes (KTT)
Funding, (T/C), Age (multiple/
Design, (mean, range), single), Arch
Center Gender (m/f), (Max, Man),
Smokers Site (Ant/
(Y/N) Post)

Gameel, Egypt, VISTA + CTG​ 20 (10/10) Miller’s 6 M, 74.6 NR NR NR Esthetic score: Both
2022 University, (NR/NR) class I and (± 12.1)% 6 M, 7.8 (7–9) approaches
NR 30–45 II, M, Ant, had signifi-
RCT, Single, TUN + CTG​ 8/12 both 6 M, 81.2 NR Esthetic Score: cant results.
Parallel NR (± 17.4)% 6 M, 7.5 (7–10) However,
the VISTA
group
showed less
pain and
discomfort
during early
healing
Subbareddy, India, Uni- VISTA + PRF 20 (10/10) Miller’s BL, 3.24 ± 1.19 69.67% BL, 2.03 ± 0.75 NR PD BL, VISTA with
2020 versity, No (33/25) class I and 6 M, 1.69 ± 1.59 6 M, 2.90 ± 0.99 2.65 ± 0.56 SCTG was
RCT, Single, 35.64 II, M, both, 6 M, 2.14 ± 0.39 distinctly
Parallel VISTA + CTG​ 13/7 both BL, 2.74 ± 0.72 60% BL, 2.24 ± 0.59 PD BL, superior to
N 6 M, 1.78 ± 0.30 6 M, 3.74 ± 1.00 2.44 ± 0.31 VISTA with
6 M, 2.10 ± 0.26 PRF in all
the param-
eters
Kamal. 2021 Egypt, VISTA + BFP 40 (20/20) Miller’s 6 M, NR 6 M, 6 M, 6M PRF group
University, 21–45 class II, M, 51.25 ± 36.53 5.20 ± 0.89 mm 1.8 ± 0.37 mm PD, has better
No NR both, both 1.70 ± 0.57 mm results
RCT, Single, N CAL, 2.45 ± 2.11 regarding
Parallel VISTA + PRF 6 M, 6 M, 6M the percent-
5.55 ± 0.99 mm 1.77 ± 0.25 mm PD age of root
1.85 ± 0.37 mm coverage
CAL, 1.25 ± 1.97 than the
NPBPF
group after
3- and
6-month
follow-up
Clinical Oral Investigations (2023) 27:7171–7187
 Table 1  (continued)
Author, Year Country, Arms (test/control) N of subjects Recession GRD Complete Keratinized gin- Keratinized Other results Conclusion
University/ (T/C), N of type (clas- root cover- giva width (KG) mucosa thickness
Private, recession sification), age (CRC) changes (KTT)
Funding, (T/C), Age (multiple/
Design, (mean, range), single), Arch
Center Gender (m/f), (Max, Man),
Smokers Site (Ant/
(Y/N) Post)

Dandu, 2016 India, VISTA + CM + Gem 15 (30) Miller’s 6 M, 87.37% NR BL, 2.75 (0.91) NR PD BL, 0.46 VISTA may
University, 21S (15/15) class I and 9 M, 6.30 (1.08) 9 M, 0.31 be deemed a
NR 36.13 II, M, both, CAL BL, 4.67 predictable,
RCT, Single, 10/5 Ant 9 M, 0.92 effective,
Split- N and mini-
Clinical Oral Investigations (2023) 27:7171–7187

mouth CAF + Periosteal 6 M, 71.84% BL, 2.63 (1.24) PD BL, 0.45 mally inva-
pedicle graft 9 M, 5.60 (1.53) 9 M, 0.41 sive to the
CAL BL, 4.57 periosteal
9 M, 1.37 pedicle graft
technique
Rajeswari, India, Uni- VISTA + PRF 16 (107)/NR Miller’s BL, 2.41 ± 0.908 NR BL, 3.35 ± 1.058 VISTA: PD BL, Patient
2021 versity, No 34.2 ± 9.2 class I or 18 M, 18 M, BL, 0.90 ± 0.097 1.50 ± 0.720 preference
RCT, Single, 6/10 II, M, both, 0.15 ± 0.267 3.67 ± 0.968 18 M, 6 M, 1.06 ± 0.482 was more
Split- N both 1.30 ± 0.173 CAL BL, inclined
mouth ZT: BL, 3.91 ± 1.281 toward
0.91 ± 0.149 6 M, 1.21 ± 0.515 VISTA,
Zucchelli’s Tech- BL, 2.47 ± 0.60 BL, 2.11 ± 0.752 18 M, PD BL, depicting
nique (CAF modi- 18 M, 18 M, 1.20 ± 0.246 1.41 ± 0.656 its superior
fication) + PRF 0.08 ± 0.225 2.56 ± 0.708 6 M, 1.19 ± 0.482 patient
CAL BL, acceptance
3.88 ± 0.881 on account
6 M, 1.26 ± 0.571 of its nomi-
nal morbid-
ity and early
satisfactory
esthetic
outcome

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 Table 1  (continued)
7178

Author, Year Country, Arms (test/control) N of subjects Recession GRD Complete Keratinized gin- Keratinized Other results Conclusion
University/ (T/C), N of type (clas- root cover- giva width (KG) mucosa thickness

13
Private, recession sification), age (CRC) changes (KTT)
Funding, (T/C), Age (multiple/
Design, (mean, range), single), Arch
Center Gender (m/f), (Max, Man),
Smokers Site (Ant/
(Y/N) Post)

Hegde, 2021 India, Uni- VISTA + PRF 10 (32) Miller’s 6 M, 1.75 ± 1.437 NR BL, 3.500 ± 0.873 NR Mean PD PRF being
versity, Yes (16/16) class I or 6 M, 6 M, 1.31 ± 0.60 rich in
RCT, Single, 16–64 II, M, both, 5.875 ± 1.784 RAL 6 M, growth fac-
Parallel NR both 5.25 ± 1.77 tors, when
N used in
VISTA + CTG​ 6 M, 2.06 ± 0.68 BL, 2.438 ± 0.964 Mean PD combination
6 M, 1.37 ± 0.5 with VISTA,
5.125 ± 0.885 RAL 6 M, can be an
6.5 ± 1.155 alternative
for treating
multiple
gingival
recession
defects
Chen, 2023 China, VISTA + CTG​ 24 (12/12) RT1, M, 6 M, 70.97% BL, 3.13 ± 1.45 BL, 1.36 ± 0.45 PD BL, Better esthetic
University, (59) (31/28) both, non- 91.13 ± 16.96% 6 M, 3.93 ± 1.64 12 M, 1.70 ± 0.66 1.58 ± 0.50 result in tun-
NR 36.65 ± 10.69 molar 12 M, 3.74 ± 1.32 12 M, 2.26 ± 0.63 nel approach
RCT, Single, 9/15 CAL BL, with CTG​
Parallel N 3.87 ± 0.87
12 M, 2.45 ± 0.84
TUN + CTG​ 6 M, 67.86% BL, 2.66 ± 1.28 BL, 1.19 ± 0.34 PD BL,
91.40 ± 13.53% 6 M, 3.30 ± 1.01 12 M, 1.88 ± 0.50 1.75 ± 0.65
12 M, 3.20 ± 1.18 12 M, 2.43 ± 0.79
CAL BL
4.29 ± 1.18
12 M, 2.68 ± 0.64
Clinical Oral Investigations (2023) 27:7171–7187
 Table 1  (continued)
Author, Year Country, Arms (test/control) N of subjects Recession GRD Complete Keratinized gin- Keratinized Other results Conclusion
University/ (T/C), N of type (clas- root cover- giva width (KG) mucosa thickness
Private, recession sification), age (CRC) changes (KTT)
Funding, (T/C), Age (multiple/
Design, (mean, range), single), Arch
Center Gender (m/f), (Max, Man),
Smokers Site (Ant/
(Y/N) Post)

Mansouri, Iran, Univer- VISTA + CTG​ 12 (24) RT1, M, BL, 1.21 ± 3.25 50% BL, 1.49 ± 2.66 BL PD, VISTA can
2019 sity, NR NR max, 6 M, 1.13 ± 1.25 6 M, 1.53 ± 4.00 0.51 ± 1.41 enhance root
RCT, Single, NR canine and 6 M, 0.51 ± 1.41 coverage,
Split- N premolar CAL BL, KTW, and
mouth 1.53 ± 4.00 CAL gain; it
Clinical Oral Investigations (2023) 27:7171–7187

6 M, 0.86 ± 2.25 can be used

as a substi-
CAF + CTG​ BL, 1.04 ± 1.00 33% BL, 2.63 ± 3.25 BL PD, tute for CAF
6 M, 0.99 ± 1.08 6 M, 2.62 ± 4.83 0.28 ± 1.08 with CTG​
6 M, 0.45 ± 1.25
CAL BL,
1.34 ± 4.00
6 M, 0.73 ± 2.00
Pandit, 2017 India, VISTA + PRF 27 (30) Miller’s BL, 2.62 (0.42) 100% BL, 2.21 (0.64) NR PD BL, 1.70 -
University, VISTA + CTG​ (15/15) class I or 6 M: 0 100% 6 M, 3.93 (0.77) (0.37)
NR 18–60 II, M, max, BL, 2.53 (0.35) BL, 2.24 (0.53) 6 M, 1.03 (0.13)
RCT, Single, NR both 6 M, 0 6 M, 4.27 (0.56) BL, 1.53 (0.4)
Parallel N 6 M, 0.97 (0.3)
CAL BL, 4.12
(0.8)
6 M, 1.03 (0.13)
BL, 3.93 (0.56)
6 M, 0.93 (0.26)

Abbreviations: N number, T test, C control, Max Maxilla, Man mandible, Ant anterior, Post posterior, GRD gingival recession depth, CRC​complete root coverage, MRC mean root coverage, KG
keratinized gingiva, KTT keratinized tissue thickness, N no, Y yes, NR not reported, BL baseline, M months

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7180
Fig. 1  Cumulative weighted mean root coverage percentage, includ-
ing all VISTA arms of the randomized and non-randomized con-
trolled clinical trials. The size of the nodes corresponds to the sample
size. The red dashed line indicates cumulative mean root coverage
Risk of bias of individual studies
Bias assessment occurred for sub-categories in included
publications. For VISTA vs. TUN meta-analysis, two stud-
ies [12, 20] were low risk, one [19] moderate, and one [21]
high risk. Fifty percent were high quality. For CTG vs. PRF
in VISTA, no low risk, three [22, 23, 25] high, and one [24]
moderate bias. Qualitative assessment (Appendices D and
E) showed only two of six [26, 30] as low bias. Figure 2
presents the results of risk of bias assessment.
Fig. 2  Risk of bias assessment of included trials (based on ROB-2
protocol) including the traffic light plots (right side) and weighted bar
plots of the distribution of risk-of-bias judgements within each bias
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Clinical Oral Investigations (2023) 27:7171–7187
Analyses on VISTA versus other flap techniques
Meta‑analysis on VISTA versus tunneling
This analysis included data from four RCTs [12, 19–21]
involving 156 MAGRs (78 in each group) with a 6-month
follow-up period. Figure 3 shows forest and funnel plots
comparing VISTA and TUN for mRC outcome. A random
effects model with standardized mean difference was used.
Subgroup analysis for CTG-only studies showed no signifi-
cant heterogeneity (τ2 = 0, p = 0.82, I2 = 0%) with an SMD of
0.30 (95% CI [− 0.15, 0.74]). Overall effect test did not reach
significance (p = 0.19). For ADM studies, no significant het-
erogeneity was found (τ2 = 0, p = 0.87, I2 = 0%) with an SMD
of 0.83 (95% CI [0.36, 1.30]). The overall effect test was
significant (p = 0.0005), favoring VISTA over TUN. Consid-
ering all studies, no significant heterogeneity was detected
(τ2 = 0, p = 0.44, I2 = 0%). Overall SMD estimate was 0.55
(95% CI [0.23, 0.87]), reaching significance (p = 0.0008).
Subgroup differences test indicated graft material (CTG
and ADM) did not significantly impact the result (p = 0.11,
I2 = 61.9%). VISTA showed significant mRC improvement
over TUN, especially with ADM. No significant differences
were found in other meta-analyses for parameters like GT,
KGW, PD, CAL changes, and esthetic scores. Results of
these analyses are in Appendices G to K.
VISTA versus other flap designs
Three studies compared VISTA and CAF. Mansouri et al. [27]
using CTG, reported 70.69 ± 34.85% and 67.22 ± 23.99% of
mRC in VISTA and CAF, respectively. While there was no
domain (left side). (a and b) studies comparing VISTA and TUN. (c
and d) studies compared CTG and PRF while VISTA is applied
Clinical Oral Investigations (2023) 27:7171–7187 7181

Fig. 3  a Forest plot comparing the mean root coverage outcome in VISTA versus TUN. b Funnel plot for the mean root coverage outcome
depicting potential publication bias in trials comparing TUN versus VISTA, demarcated by CTG- and ADM-only studies

significant difference in mRC between the groups, VISTA
demonstrated a significantly higher cRC at the 6-month follow-
up (p < 0.05). Other variables such as KGW and CAL did not
exhibit significant differences. Rajeswari et al. [28] compared
VISTA and modified CAF, using PRF, reaching 93.95% and
96.84% of mRC, respectively. They reported a statistically sig-
nificant difference in patient esthetic score and surgical mortal-
ity score favoring the VISTA group. Lastly, Dandu and Murthy
[26] reported significantly higher mRC with VISTA + CM and
PDGF (87.37 ± 17.78%), as compared with CAF with peri-
osteal pedicle graft (71.84 ± 19.25%). Similarly, KGW and
CAL gain were significantly higher in the VISTA group.
Analyses of different graft materials with VISTA
approach
Meta‑analysis on connective tissue graft
versus platelet‑rich fibrin
A random-effects model was employed to explore the mean
difference between CTG and PRF graft materials, when
using the VISTA technique for root coverage. Figure 4a
depicts the corresponding forest plot for the mRC outcome.
A total of four studies were included in the analysis [22–25],
which collectively involved 212 multiple GR sites (106 in

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7182
Fig. 4  Forest plots corresponding to the main outcomes of studies
comparing CTG versus PRF when VISTA is performed. a mRC. b
KGW changes. c CAL changes. d The network graph of available evi-
dence and respective quality and direct/indirectness of the trials on
the VISTA technique and testing different biomaterials and graft sub-
each treatment group). The overall analysis showed that
there was no significant difference in mRC between CTG
and PRF. No heterogeneity was detected among the studies
(τ2 = 0, I2 = 0%). The chi-square test for overall effect also
confirmed the lack of statistically significant difference (MD,
0 (95% CI [− 0.12, 0.12]), p = 0.98). Based on the available
evidence, there was no significant difference (MD = 0 mm)
in mRC between CTG and PRF, when using the VISTA
approach.
13
Clinical Oral Investigations (2023) 27:7171–7187
stitutes. (Note: size of the nodes corresponds to the number of sample
size, the thickness of the connecting lines represents the number of
available trials (directness), and the color of the nodes corresponds to
the risk of bias level. CM, collagen matrix; PRF, platelet-rich fibrin;
CTG, connective tissue graft)
On the other hand, the meta-analyzed evidence indicated
that CTG yielded significantly higher KGW gain, as well
as CAL gain (Fig. 4b and c). The MD for KGW gain out-
come was − 0.57 mm (95% CI [− 0.82, − 0.32]) favoring
CTG (p < 0.001). A moderate heterogeneity was detected
(I2 = 43%, p = 0.15). Similarly, CTG demonstrated superior
outcomes in CAL gain as well (MD: 0.27 mm (95% CI [0.22,
0.32]), p < 0.001). No heterogeneity was detected for this
outcome (I2 = 0, p = 0.38).
Clinical Oral Investigations (2023) 27:7171–7187 7183

Furthermore, the analysis did not reveal any significant
difference in other secondary outcomes, including GT
gain and PD changes. Complete results of meta-analysis,
including relative forest plots are presented in Appendices
L and M.
Table 2  Mixed-models, multi-variate meta-regression model on out-
come of complete root coverage cRC % at 6 M following VISTA
approach for multiple gingival recession treatment. Note that the
model was controlled for impact of different graft materials
Independent variable Estimate Standard error t value p-value
Qualitative analysis of other comparisons
Various graft substitutes were explored in other studies. For
instance, Patra et al. [30] compared PRF + CM with CM
alone, showing increased cRC (67% vs. 53.95%) and better
KGW, CAL, and recession width in the CM + PRF group.
Similarly, Jain et al. [29] compared PRF to CM, reveal-
ing significantly higher mRC for PRF (77.5% vs. 61.67%,
p = 0.04). Another study assessed buccal fat pad graft ver-
sus PRF, showing significantly higher mRC for PRF (82%
vs. 51.25%) at 6 months. Notably, all these studies focused
on Miller’s class I and/or II (RT I) defects. Lastly, Fig. 4d
presents a network visualization of available direct and indi-
rect evidence comparing different materials with the VISTA
technique.

Complete root coverage (cRC) % Meta‑regression results

Intercept 26.868 49.667 0.541 0.617
BL GR depth − 31.145 8.748 − 3.560 0.023 Mean root coverage
BL KGW 43.842 8.535 5.137 0.006
Mean root coverage (mm) The meta-regression analysis revealed no significant asso-
Intercept 0.40826 0.42405 0.963 0.3639 ciation between baseline GR depth and mRC outcome
BL GR depth 0.11785 0.13553 0.870 0.4099 (estimate, 0.11785; SE = 0.13553; t = 0.87; p = 0.4099). In
BL KGW 0.46407 0.16416 2.827 0.0225 contrast, the baseline KGW yielded a significant positive
Abbreviations: BL baseline, GR gingival recession, KGW keratinized association with the mRC (estimate, 0.46407; SE = 0.16416;
gingiva width t = 2.827; p = 0.0225) (Table 2 and Fig. 5a and b).

Fig. 5  Mixed-models, multivariate, meta-regression analysis graphs. gingiva width and d baseline recession depth on complete root cover-
a Impact of baseline keratinized gingiva width and b baseline reces- age percentage
sion depth on mean root coverage. Influecne of c baseline keratinized

13
7184
Complete root coverage
The coefficient for baseline GR depth was estimated to
be − 31.145 (SE = 8.748). This negative coefficient suggests
that an increase in baseline recession depth was significantly
associated with a decrease in cRC (p = 0.023). On the other
hand, the coefficient for baseline KGW was estimated to be
43.842 (SE = 8.535). This positive coefficient suggests that
an increase in baseline KGW was associated with a signifi-
cant (p = 0.006) increase in cRC (Table 2 and Fig. 5c and d).
Notably, these findings were adjusted for variations in
graft materials among the included studies. The analy-
sis accounted for study-level dependencies with random
effects using study IDs, and a weighted model was applied
to accommodate varying sample sizes across trials.
Certainty of the evidence (GRADE)
The GRADE approach applied to mRC (VISTA vs. TUN),
KGW gain (CTG vs. PRF), and CAL gain (CTG vs. PRF)
yielded moderate, low, and very low evidence levels. These
downgrades were mainly due to significant bias risks and
small sample sizes. Comprehensive results are presented in
Appendix N.
Discussion
Numerous systematic reviews and meta-analyses have
assessed various techniques for treating GR defects [3, 13,
14]. Yet, no study has specifically appraised VISTA’s effi-
cacy. Thus, this study aimed to systematically evaluate treat-
ing multiple adjacent GR defects with VISTA through meta-
analysis. Since its 2011 introduction, the VISTA technique
has gained attention, as evidenced by exponential growth of
clinical trials. This research allowed a comparative assess-
ment to compare VISTA with TUN and analyzed different
graft materials. Our search identified 50 + VISTA studies,
beyond the scope of this study, including orthodontic and
periodontal applications [32–34].
VISTA proved notably effective for multiple GR treat-
ment, with demonstrated mRC of 88.15 ± 20.79 and cRC %
of 67.85 ± 21.72.
These promising results can be attributed to the distinct
characteristics of the VISTA surgical protocol. The VISTA
technique involves a remote incision within the vestibule,
allowing for a greater degree of flap mobilization to reduce
flap tension. Importantly, this approach avoids compromis-
ing the vasculature in the marginal gingiva, distinguishing
VISTA from the direct marginal and papillary incisions
utilized in CAF, as well as the intra-sulcular incisions in
TUN, which have a higher potential to induce vascular com-
promise. Furthermore, the utilization of coronally anchored
13
Clinical Oral Investigations (2023) 27:7171–7187
sutures in the VISTA method contributes to sustaining gin-
gival margins in a slightly over-corrected position and effec-
tively curbing flap mobility during the healing phase. These
distinctive attributes of the VISTA technique effectively
address the challenges associated with other flap techniques,
such as TUN, all the while adhering to the principles of
minimally invasive periodontal plastic surgery. This aspect
is particularly pivotal in the context of this study’s multiple
GRs, where the passive repositioning of the flap and precise
coronal suturing play a pivotal role in achieving successful
outcomes.
The current analysis exposed a significantly higher mRC
using VISTA compared to TUN (SMD = 0.55, p < 0.01), fur-
ther reinforcing VISTA’s surgical superiority. It is important
to note that the GRADE approach categorized the evidence
certainty for this outcome as “moderate,” given that only two
out of the four included articles met the low bias risk cri-
teria. A recent meta-analysis on the efficacy of TUN found
mRC of 89.16% ± 12.38% [3], which is comparable to the
mRC of VISTA found in the present study. However, the
cRC of VISTA observed in our study (67.85%) was signifi-
cantly higher than that of TUN (57.5%).
Our available evidence facilitated a meta-analysis com-
paring VISTA outcomes using CTG and PRF as graft mate-
rials. VISTA’s emphasis on minimal invasiveness [10] has
prompted the majority of RCTs on VISTA to explore graft
substitutes. Our results showed no significant mRC differ-
ence between PRF and CTG when utilized in conjunction
with VISTA (MD = 0 mm, p = 0.98). However, the meta-
analysis favored CTG for KGW and CAL gain (though
GRADE indicated low and very low certainty). Overall,
findings suggest PRF can substitute CTG for root cover-
age, especially when patient comfort is paramount and
acceptable KTW exists. Recent systematic reviews (Man-
cini et al. 2021) [2] compared mRC with PRF vs. CTG in
CAF, revealing CAF + PRF outperformed CAF alone but
not CAF + CTG.
The meta-regression analysis in this study examined the
associations between specific factors and the root coverage
outcomes, while accounting for the influence of graft mate-
rials, study-level dependencies, and varying sample sizes
across different trials.
Our analysis found that initial GRs depth at base-
line was not significantly associated with mRC (esti-
mate = 0.11785, SE = 0.13553, p = 0.4). However, baseline
KGW showed a significant positive association with mRC
(estimate = 0.46407, SE = 0.16416, p = 0.0225), indicating
that an increase in baseline KGW is associated with higher
mRC outcomes. Concerning cRC, the analysis revealed
interesting findings. The coefficient for baseline GR depth
was estimated to be − 31.145 (SE = 8.748, p = 0.023), indi-
cating a significant negative association with cRC. This sug-
gests that an increase in baseline GR depth is associated with
Clinical Oral Investigations (2023) 27:7171–7187
a decrease in cRC. Conversely, the coefficient for baseline
KGW was estimated to be 43.842 (SE = 8.535), indicating a
significant positive association with cRC (p = 0.006). This
means that an increase in baseline KGW is associated with
an increase in cRC.
The analysis in the present report took into account
the influence of different graft materials used across the
included studies. This ensures that the observed associations
are independent of the specific graft material employed.
Additionally, the analysis accounted for potential study-
level dependencies by incorporating random effects based
on study ID. Lastly, a weighted model was constructed to
address the variability in sample sizes across different trials,
considering each study’s contribution. Overall, the result of
this multivariate regression indicated that baseline KGW
was positively correlated with root coverage achieved with
VISTA. This may be explained by various reasons such as
facilitating rigid suture placement, which is one of the key
features in the VISTA approach. The results of the present
study on cRC were consistent with other studies such as
Tavelli et al. [3] meta-analysis on efficacy of TUN as they
reported a reduced likelihood of achieving cRC in recessions
deeper than 2.5 mm [35]. As indicated in Fig. 5, the results
of our study showed approximately 70% cRC in GRs deeper
than 2.5 mm. Additionally, a cutoff point of 5.5 mm of base-
line GR depth has been reported to achieve cRC [36]. How-
ever, caution is warranted when interpreting these results,
as the overall data on this matter is limited, and the analyses
have certain limitations.
As with any study, it is important to acknowledge the
limitations of the present study. Due to limited data, despite
adjusting the statistical model for the location of GRs (ante-
rior/posterior, maxilla/mandible), the possible influence of
this factor on mRC could not be thoroughly investigated.
Nevertheless, a previous analysis by our group [37] showed
a negative correlation between posterior location and the
achievement of root coverage. Moreover, it can be inferred
from the results of the GRADE approach that the sample
size included in the meta-analytic model was limited. We
aimed to perform the highest quality data analysis by only
including RCTs, which might account for this limitation.
Additionally, the trials comparing CAF with VISTA or using
CM or ADM were limited, preventing us from conducting a
network meta-analysis instead. Nevertheless, as a reference
for future research, the network graph depicting the avail-
able evidence on VISTA with various graft materials is pre-
sented herein. Moreover, in recent years, gingival phenotype
has gained significance as the most important predictor of
therapeutic stability. Currently, very little data are available
on this outcome. To draw more definitive conclusions and
extend the findings of the present study on the efficacy of
VISTA, further research and evidence are required. Globally,
we are aware of dozens of RCTs that are currently underway
7185
which should allow a more thorough assessment of the effi-
cacy of VISTA, as well as general factors that influence
therapeutic outcomes of GR.
Clinical implications and recommendation for future
research
• Treatment of multiple GRs with VISTA yielded higher
mRC than TUN, especially with ADM.
• In VISTA therapies, PRF showed similar root coverage
outcomes to CTG. PRF can be an alternative to CTG
when sufficient KG is present, prioritizing patient com-
fort.
• For increasing KGW, CTG offers superior outcomes and
is recommended.
• Awareness of negative link between baseline GR depth
and positive correlation of baseline KGW with cRC
achievement is crucial.
• Future research needed: CAF vs. VISTA, PDGF inclu-
sion, larger sample sizes.
• Evaluate various periodontal plastic surgeries for gin-
gival phenotype modification in future studies. Patient-
reported outcomes are vital in planned clinical investiga-
tions.
Conclusions
Within its limitations, the present meta-analysis revealed
superior outcomes of VISTA compared to tunneling, par-
ticularly when ADM or CTG is used. VISTA in conjunction
with CTG and PRF demonstrates comparable root coverage
outcomes, while CAL and keratinized tissue gain favor CTG.
The baseline recession depth negatively impacts, while base-
line keratinized gingival width positively influences the out-
comes. For the mean root coverage, only higher baseline
keratinized gingiva is associated with improved outcomes.
Supplementary information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00784-0​ 23-0​ 5383-7.
Author contribution H. S: Conceptualization, search strategy, statisti-
cal analysis, manuscript writing, F.SJ: search strategy, data collection,
manuscript writing, F. S: conceptualization, critical review, manuscript
writing, H–L. W: conceptualization, critical review, final approval,
H. HZ: Conceptualization, manuscript writing, critical review, final
approval.
Data availability The collected and analyzed data in this study will
be provided upon reasonable request from the corresponding or first
author.
Declarations
Competing interests H.H. Zadeh holds patent for VISTA instruments
and discloses financial interest in REGENimmune and iKON Biomedi-
13
7186
cal companies, which hold the patents and are involved in manufactur-
ing of the instruments. Other authors declare no conflict of interest
pertinent to this research article.
Ethics approval and consent to participate Not applicable.
Conflict of interest H.H. Zadeh holds patent for VISTA instruments
and discloses financial interest in REGENimmune and iKON Biomed-
ical companies, which hold the patents and are involved in manufactur-
ing of the instruments.
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