The challenge of RT2 recessions in the anterior mandibular zone

The management of gingival recessions in the anterior mandibular region is complex due to specific anatomical limitations that often compromise the predictability of conventional root coverage techniques. This clinical case report specifically addresses this issue by documenting the treatment of an isolated and deep Cairo type 2 (RT2) gingival recession on tooth 31, associated with a severe deficiency of keratinized mucosa in a 46-year-old patient with no systemic history.

Objective and hypotheses of the combined surgical approach

The primary objective of this study was to evaluate the clinical outcome of a therapeutic strategy combining a laterally positioned flap (LPF) with a connective tissue graft (CTG). The authors test here the efficacy of a bilaminar technique in an anatomically unfavorable environment. The hypothesis is based on the ability of this combination to increase gingival thickness and provide satisfactory root coverage, while ensuring long-term tissue stability. The study aims to demonstrate that the association of LPF and CTG represents a predictable alternative for RT2 recessions, offering both aesthetic and functional benefits after a one-year follow-up.

Study design and patient profile

This case report documents the management of a deep isolated gingival recession in an anatomically complex area. The study subject is a single 46-year-old female patient, systemically healthy, presenting with a Cairo RT2 type gingival recession at tooth 31 (mandibular central incisor). This lesion was associated with a marked deficiency of keratinized mucosa.

Experimental protocol and surgical steps

The therapeutic approach combined two periodontal plastic surgery techniques: the connective tissue graft (CTG) and the laterally positioned flap (LPF). The protocol was carried out as follows:

• Initial phase: Performance of non-surgical periodontal therapy prior to the intervention.
• Harvesting: Collection of a connective tissue graft from the palate.
• Site preparation: Creation of a partial-thickness flap at the recipient site.
• Stabilization: Fixation of the connective tissue graft onto the exposed root surface.
• Coverage: Lateral displacement of the flap to cover the graft and the root.

Monitoring and analysis criteria

Soft tissue stability and coverage effectiveness were evaluated during standardized follow-up visits at 7, 14, and 30 days postoperatively, as well as long-term, one year after the procedure. The main parameters analyzed included the increase in gingival thickness, the percentage of root coverage achieved, and the overall aesthetic outcome.

Clinical results and long-term follow-up

The postoperative follow-up of this 46-year-old patient, treated for an RT2 recession on tooth 31, reveals a favorable evolution of the periodontal tissues. Clinical observations were documented over a one-year period, confirming the viability of the combination of connective tissue graft (CTG) and laterally positioned flap (LPF) in this anatomically complex area.

Follow-up period	Major clinical observations
7 to 30 days	Uncomplicated initial healing phase; stabilization of the partial flap.
1 year	Significant increase in gingival thickness and stability of periodontal tissues.

The main quantitative and qualitative results of the study include:

• Root coverage: The treatment achieved coverage qualified as satisfactory by the authors. However, in accordance with the initial RT2 class diagnosis (involving interproximal attachment loss), complete root coverage was not achieved.
• Tissue thickness: A notable increase in gingival thickness was observed, transforming the initially thin phenotype into a more robust tissue, capable of withstanding mechanical stresses.
• Aesthetics and function: The patient reported a perceived aesthetic improvement, validated by a harmonious chromatic and textural integration of the palatal graft at the recipient site.
• Stability: The results show an absence of recession recurrence or loss of keratinized mucosa height at the 12-month follow-up.

Although p-values are not applicable to this single case report, the long-term stability in the anterior mandibular region — an area known for its anatomical limitations and delicate management — highlights the efficacy of this combined approach for the management of deep isolated recessions.

Analysis of the results: a response to mandibular challenges

This clinical case illustrates the benefits of a combined Laterally Positioned Flap (LPF) and Connective Tissue Graft (CTG) approach to treat a deep RT2 recession on incisor 31. In the anterior mandibular zone, local anatomy often limits the predictability of coronally advanced flaps. The use of a partial-thickness flap positioned laterally allowed for the provision of keratinized tissue where it was lacking. At 12 months, the stability of the soft tissues and the notable increase in gingival thickness validate this strategy for strengthening the marginal periodontium in an anatomically complex sector.

Clinical limits and nuances

The main drawback of this procedure remains the lack of complete root coverage. This result is predictable in RT2 configurations, where interproximal attachment loss constitutes a biological barrier to total coverage, unlike RT1 classes. Furthermore, this study reports a single case (n=1) in a healthy 46-year-old female patient; the results must therefore be interpreted with the caution inherent to case reports, although the literature (Bosco et al., 2021) corroborates the effectiveness of bilaminar techniques for isolated mandibular recessions.

Implications for the practice

In the practice, the LPF + CTG approach proves relevant when the practitioner faces a deep isolated recession with sufficient adjacent donor attached gingiva. Rather than striving for total coverage, which is sometimes illusory in the presence of interproximal bone loss, priority must be given to increasing the gingival phenotype. The tissue stability achieved here at one year demonstrates that this technique is a predictable alternative for ensuring the long-term sustainability of the periodontal environment and improving the aesthetics perceived by the patient.

Summary of results

This clinical case report on an RT2-type recession (tooth 31) in a 46-year-old female patient demonstrates that the combination of a connective tissue graft (CTG) and a laterally positioned flap (LPF) achieves significant gingival thickening and stable root coverage at 1 year. Although total root coverage was not achieved, the approach ensured aesthetic and functional stability in a mandibular sector with strong anatomical constraints.

In concrete terms, for the practitioner:

• Optimize narrow mandibular areas: Use the LPF + CTG combo for isolated recessions where apical keratinized gingiva is insufficient; the lateral flap provides the necessary keratinized tissue while the graft secures the biotype.
• Manage expectations for RT2 type: In the presence of interproximal attachment loss, prioritize thickness gain and long-term stability rather than 100% root coverage, which is often anatomically impossible.
• Select the adjacent site rigorously: The success of this technique depends on the presence of healthy and sufficient keratinized tissue on the collateral tooth to allow flap displacement without creating a new defect.

Treating gingival recession in the antero-mandibular sector is a challenge that every periodontologist dreads. Between the narrowness of the keratinized mucosa, the depth of the vestibule, and muscular tensions, the predictability of conventional techniques is often put to the test. This case report explores a surgical alternative for a deep Cairo RT2 type recession on incisor 31.

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