Staged Regenerative-Phenotype Modification Therapy for Multiple RT3 Gingival Recessions in Periodontally Compromised Anterior Mandibular Teeth: A Case Report

This case report details the successful treatment of multiple recession type (RT) 3 gingival reces-sions in periodontally compromised mandibular anterior teeth with limited keratinized tissue. A 35-year-old man with stage III, grade C periodontitis underwent a two-stage intervention. Initially, a modification of the connective tissue graft (m-CTG) wall technique was used as part of phenotype modification therapy. The CTG acted as a protective 'wall,' securing space for periodontal regener-ation and thereby enhancing root coverage, soft tissue thickness, and keratinized mucosal width. Recombinant human fibroblast growth factor-2 and carbonate apatite promoted periodontal regen-eration. This procedure successfully facilitated periodontal regeneration, resulting in the transition from RT3 to RT2 gingival recession and achieving adequate keratinized mucosal width. Eighteen months later, the second surgery used a tunneled coronally advanced flap (TCAF) for root coverage. TCAF involved combining a coronally advanced flap and tunnel technique by elevating the trapezoi-dal surgical papilla and using a deepithelialized CTG inserted beneath the tunneled flap. Root con-ditioning with ethylenediaminetetraacetic acid and enamel matrix derivative gel application were performed. Consequently, the mean clinical attachment level gain was 5.3 mm, mean root coverage was 4.5 mm in height, and the gingival phenotype at the treated sites had improved at the 12-month follow-up. This staged approach addresses the challenges of treating RT3 gingival recession with promising outcomes.