Tracing the evolution of root coverage: Clinical milestones leading to a minimally invasive era

Over the past several decades, periodontal plastic surgery has undergone a remarkable transformation, particularly in the field of root coverage procedures. This review traces the historical evolution of surgical techniques, from the early use of pedicle flaps and free gingival grafts (FGGs) to the development of bilaminar approaches incorporating subepithelial connective tissue grafts (SCTGs). Each stage of innovation has contributed to improved predictability and enhanced esthetic outcomes, while also aiming to reduce patient morbidity. The introduction and continuous evolution of the coronally advanced flap (CAF) marked a significant advancement, progressively improving the consistency and predictability of complete root coverage. Later developments, such as tunneling techniques (TUNs), emphasized minimally invasive flap preparation, preservation of vascular supply, and improved esthetics. These principles were ultimately combined in approaches such as the tunneled coronally advanced flap (TCAF), a versatile technique that merges the strengths of both CAF and TUN, with the focus on the specific features of the site and its local anatomy. This review also highlights how clinical insights, surgical refinements, and biologic understanding have shaped modern flap designs, graft handling, and treatment planning. With the growing demand for esthetic outcomes and individualized care, future directions in root coverage surgery are expected to include further refinement of flap designs, integration of injectable biologics and biomaterials, and the implementation of patient- and site-specific protocols. By revisiting the historical foundations and innovations that have defined root coverage surgery, this review underscores the importance of technique selection and customization in achieving optimal clinical outcomes. PLAIN LANGUAGE SUMMARY: Over the years, gum surgery for covering gingival recessions has improved significantly. This review looks at how techniques have evolved-from early methods to more advanced ones using a connective tissue graft obtained from the roof of the mouth. These innovations have made results more reliable, more natural-looking, and easier on patients. A major step forward was the so-called "coronally advanced flap (CAF)," which improved how well and consistently roots could be covered. Later, "tunneling techniques (TUNs)" were introduced to be less invasive and to better preserve blood supply. Eventually, these ideas were combined in a newer approach called the "tunneled coronally advanced flap (TCAF)," which adapts to the specific shape and needs of each treatment site. This review highlights the key modifications and innovations proposed over the years that have shaped the development of various surgical approaches for root coverage.