Modified coronally advanced flap for multiple anterior gingival recessions: Case report

BACKGROUND: The frontal envelope coronally advanced flap (CAF), designed for multiple adjacent gingival recessions (MAGR) of the anterior maxilla, involves tunneling of the midline papilla. However, when treating frontal and lateral MAGR in a single session, the tunneled midline papilla can act as a fixed point, which may limit coronal advancement or lead to mucosal folds in the gingival margin. METHODS: This case report introduces a modification of the CAF technique in which a V-shaped split-thickness surgical papilla is elevated at the midline to enhance flap mobility. Two patients with combined maxillary frontal and bilateral types 1 and 2 (RT1, RT2) MAGR ranging from 2-6 mm were treated using this approach. RESULTS: Postoperative healing was uneventful for both cases. In Case 1, complete and stable root coverage with excellent tissue integration and color match was observed at 18 months. In Case 2 (RT2 MAGR), near-complete root coverage was achieved at 6 months. CONCLUSION: Within the limitations of this case report, the modified CAF appears to be an effective approach for managing MAGR extending beyond the incisors and involving both maxillary quadrants. Clinicians may consider this modification when enhanced coronal flap mobility is required to treat extensive frontal and lateral MAGR in a single session. KEY POINTS: In the traditional frontal envelope coronally advanced flap, the tunneled midline papilla may act as a fixed point, which may restrict coronal advancement or lead to mucosal fold formation in the gingival margin. This case presents a modified design that enhances coronal flap mobility and achieves optimal root coverage in cases of extensive frontal and lateral maxillary anterior gingival recessions (MAGR). The success of this approach relies on midline papilla anatomy and precise incision placement, both of which support adequate flap stability, enhancing the predictability of root coverage outcomes. PLAIN LANGUAGE SUMMARY: Gum recession occurs when the gum margin moves downward, exposing part of the tooth root. When several neighboring teeth in the upper front region are affected, treatment can be particularly challenging because of the esthetic demands in this visible area. A commonly used surgical method, known as the coronally advanced flap (CAF), repositions the gum tissue to cover the exposed roots. However, in its traditional form, the tissue between the two front teeth is not lifted but tunneled, which can limit tissue movement and occasionally cause small folds along the gum line. This report describes a refined version of the CAF technique in which a small, V-shaped flap is gently lifted between the front teeth to improve tissue mobility and adaptation. Two patients were treated using this approach, both achieving favorable healing, stable root coverage, and a natural appearance that blended well with surrounding tissues. This modification may help clinicians manage wider areas of gum recession in the upper front region while maintaining esthetic harmony.