This case report describes possible etiology, treatment, and 2-year outcome of a complicated case of gingival recession in the mandibular anterior dentition. Deep, cleftlike Miller Class I and II recessions at both mandibular canines and all incisors were treated using subperiosteal connective tissue grafts and coronally repositioned flaps. During surgery it was noted that the facial aspcts of the roots had lost bone near the apex. After surgery, profound alterations of gingival dimension occurred. Mean gingival thickness increased from 0.87 ± 0.20 mm to 2.58 ± 0.65 mm, and width of keratinized tissue increased from 1.34 ± 0.79 mm to 4.80 ± 0.97 mm. Periodontal probing depths increased from 1.06 ± 0.33 mm to 2.74 ± 0.81 mm, and depthof the recessions was reduced by 56% ± 5%. Gingival thickness and periodontal probing depth remained stable over the 2 years of observation. Gingival width decreased and the mucogingival border moved a mean 2.5 mm coronally. Creeping attachment resulted in a 74% ± 24% coverage of recession after 2 years and a gain in clinical attachment of 1.79 ± 1.56 mm. The present observa tions point to long-lasting, continuous alterations in the mucogingival region following periodontal surgery in a case of cleftlike Class II recessio