Combining the tunneled coronally advanced flap (TCAF) with internal frenectomy–vestibular incision subperiosteal tunnel access (IF‐VISTA) for the treatment of mandibular anterior gingival recessions: A technique report

Abstract Introduction Gingival recession (GR) defects in the mandibular anterior region represent a particularly challenging scenario in periodontal plastic surgery, owing to a thin soft tissue phenotype, minimal keratinized tissue, limited vestibular depth, and the frequent presence of a prominent labial frenum. While significant advances have been made in root coverage procedures for the anterior mandible, simultaneously addressing these coexisting anatomical factors in a single, minimally invasive procedure remains a clinical challenge. Methods This technique report describes the combined application of the tunneled coronally advanced flap (TCAF) with the internal frenectomy–vestibular incision subperiosteal tunnel access (IF‐VISTA) and connective tissue graft for the treatment of multiple mandibular anterior GRs in two systemically and periodontally healthy, non‐smoking patients. The TCAF framework guided site‐specific papilla management, while the IF‐VISTA provided internal frenectomy, vestibular deepening, and expanded subperiosteal access through a single minimally invasive incision. Results Healing was uneventful, with limited postoperative morbidity. At 10–12 months, complete root coverage was observed at most treated sites in the two cases, accompanied by an increase in soft tissue phenotype, papilla fill, and resolution of dentinal hypersensitivity. Conclusions The TCAF + IF‐VISTA combination addresses, within a single procedure, the multiple anatomical factors most commonly compromising outcomes in the mandibular anterior region, including mandibular midline frenum pull, limited vestibular depth, and restricted surgical access. The synergy between the two approaches facilitates tension‐free flap advancement, precise graft insertion, simultaneous frenulum elimination, and preservation of papillary integrity. Prospective controlled studies are needed to validate the long‐term outcomes and reproducibility of this technique. Key points The combination of tunneled coronally advanced flap (TCAF) with the internal frenectomy–vestibular incision subperiosteal tunnel access (IF‐VISTA) allows clinicians to address, in a single surgical procedure, the multiple anatomical factors most commonly associated with mandibular anterior gingival recessions, including limited vestibular depth, high mandibular midline frenum insertion, and restricted surgical access. The internal frenectomy component of IF‐VISTA eliminates the mandibular midline frenum attachment through a closed, scarless approach, avoiding the morbidity associated with conventional open frenectomy while simultaneously enhancing coronal flap mobility and tension‐free tissue advancement. The TCAF decision‐making framework allows site‐specific adaptation of the flap design—selectively incising or tunneling each papilla based on its morphology and the local anatomy—making this combined approach flexible and adaptable to varying clinical presentations in the mandibular anterior region. Plain language summary Gum recession occurs when the gum tissue pulls away from the teeth, exposing the root surface, and can cause sensitivity, esthetic concerns, and long‐term damage to the tooth and surrounding tissues. In the lower front teeth, treating gum recession is particularly difficult because the gum tissue in this area is naturally thin, there is limited space between the gum and the lip, and a small band of tissue called the frenum is often attached too high and pulls on the gum, making it harder to achieve stable results. This report describes a surgical approach that combines two existing techniques into a single minimally invasive procedure: one technique guides how the gum tissue is managed around each tooth individually, while the other removes the frenum from the inside without leaving visible scars. A small piece of tissue taken from the roof of the mouth is also used to reinforce and thicken the gum. In two patients treated with this approach, most teeth showed complete gum coverage and improved tissue thickness at 10 to 12 months after surgery, with minimal discomfort during recovery. Future studies with larger patient groups are needed to confirm these promising results.