Aims: Upper gingival squamous cell carcinoma (UGSCC) remains challenging because posterior tumor extension often compromises local control and salvage for recurrence is limited. We evaluated whether anatomically tailored surgical approaches designed to improve surgical exposure could improve oncologic outcomes. Methodology: Thirty-two patients with surgically treated UGSCC were retrospectively reviewed and divided into a conventional approach group (n=11) and a modified approach group (n=21). Median age was 72 and 75 years, respectively. The modified group included more stage IV disease (15 vs 6), while nodal status was broadly comparable. Overall survival (OS), recurrence-free survival (RFS), local control (LC), and recurrence patterns were compared. Results: Despite including more advanced disease, the modified approach group showed improved oncologic control. Five-year OS was comparable between groups (80.0% vs 79.1%), while 5-year RFS improved from 36.4% to 49.0%. Most notably, 5-year LC improved from 45.5% to 80.0%. Recurrence pattern analysis suggested improved control of challenging posterior disease with the modified approaches, although posterior recurrence remained observed. Given the limited salvageability of such recurrence, improved initial local control appears clinically meaningful. Conclusion: Anatomically tailored surgical approaches substantially improved local control in UGSCC, despite treatment of more advanced disease. Optimizing surgical exposure according to tumor extension may represent an important strategy for improving disease control in this challenging malignancy.