The patient complained of poor esthetic due to 2 rt1 recession on right and left upper central incisors.
After an accurate analysis both recessions showed more than 2 mm of residual keratinized tissue, medium phenotype, no root convexity or rotation, no root concavity, no interproximal periodontal attachment loss. In this way a coronally advanced flap was planned, without connective tissue graft, palatal harvesting or biomaterials.
Fig.1
After local anesthesia a T-CAF (Tunneled Formally Advanced Flap) was designed.
This flap design allows to avoid interproximal papilla elevation, preserving blood supply in a crucial aspect of the surgical area and avoiding papilla’s shrinkage; in distal area two rectangular surgical papillae were designed, measuring rec depth and reporting this measurement from the tip of papillae to an apical direction; surgical papilla has conventionally a 3 mm mesial distal width, and from there 2 vertical releasing incision were designed and extended just 1 mm after mucogingival junction.
Fig.2
Tunnel between the two recession was performed trough central papilla; this step was performed with 15 c blade and microperiosteal elevators, reducing the surgical trauma.
Fig.3
Flap was elevated split thickness in correspondence of surgical papillae, full thickness from recession to mucogingival junction to preserve all the thickness and quality of keratinized tissue apically to recessions, and again split thickness again to separate muscles from periosteum and mucosa.
Fig.4
Flap can be considered tension free when it can reach final position passively.
Fig.5
After root planning, epithelium from anatomical papillae was removed, to create a vascular bed for surgical papillae.
Fig.6
Flap was advanced and sutured 1 mm coronally to CEJ, and stabilized with isolated suture on vertical releasing incision and with sling sutures in correspondence of papillae.
Fig.7
Follow up at 8 months shows soft tissue margin stability; recessions were completely covered, color match is extremely natural.
Absence of scar tissue, mucogingival line alignment and natural look match with high patient’s satisfaction; bevel on vertical releasing incision masks tissue scar and deformities, and the possibility to avoid soft tissue graft increase natural look of the final outcome, decreasing patient’s post operative pain.
Conclusions
These techniques allow us to achieve aesthetic and natural results. A careful study of the case and observation of certain tissue aspects such as thickness, quantity of residual keratinized tissue, and tooth anatomy allows us to avoid graft harvesting from palpalate, reducing the patient’s post-operative pain; one of the crucial aspects to avoid a graft and obtain complete coverage is the absence of loss of interdental periodontal attachment, exactly as in this case; in these conditions (RT1) root coverage and an excellent final aesthetic result are extremely predictable.the possibility of tunneling the interproximal papilla without elevating it reduces the risk of its contraction in the post-surgical phase, reducing the risk of unesthetic results.
Bibliography
- J Clin Periodontol. 2007 Mar;34(3):262-8. Coronally advanced flap: a modified surgical approach for isolated recession-type defects: three-year results. de Sanctis M. , Zucchelli G.
- J Clin Periodontol 2011 Jul;38(7):661-6. doi: 10.1111/j.1600-051X.2011.01732.x. Epub 2011 Apr 20. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study Francesco Cairo Michele Nieri, Sandro Cincinelli, Jana Mervelt, Umberto Pagliaro.
- The Tunneled Coronally Advanced Flap (TCAF) for Root Coverage Procedures: Rationale, Indications, and a Novel Papilla-Based Decision Tree. Tavelli L, Barootchi S. J Periodontal Res. 2026 Jul 4. doi: 10.1111/jre.70147.
