Tunneled Coronally Advanced Flap with Dual-Site Connective Tissue Grafts for Adjacent RT2 and RT3 Recessions with Isolated Papillary Deficiency: Two Case Reports

Gingival recessions characterized by interproximal clinical attachment loss, as seen in recession types 2 and 3 (RT2 and RT3), present a clinical challenge for achieving complete root coverage. This report presents a microsurgical approach for treating adjacent RT2/RT3 defects with isolated papillary deficiency. The technique involves the use of a tunneled coronally advanced flap (TCAF) to enhance tissue mobility and create an interdental tunnel underneath the deficient papilla. A papillary connective tissue graft (CTG) is contoured to fit the interdental architecture and inserted into the interdental tunnel to 'tent up' the deficient papilla. A facial CTG is placed and stabilized on the facial surface to support the papillary CTG and to obtain root coverage. Clinical outcomes at the 12-month follow-up of cases treated with this approach demonstrated significant improvements in interproximal clinical attachment levels, tissue thickness, and root coverage. The mean root coverage reached 97.6%, with complete root coverage achieved in 94.4% of sites. These findings suggest that combining the TCAF with dual-site CTGs may represent an effective alternative approach for managing complex adjacent gingival recessions with isolated papillary deficiencies.