The restorative procedures in the maxillary arch were carried out over the course of two separate visits. Under local anesthesia, a gingival cord was inserted to isolate the field of restoration. The MRC of each lesion was marked with an oil-based pen. The radicular part contained within the MRC was not prepared and the superficial dentin of the coronal part above the MRC was removed gently with diamond burs set at high speed under abundant cooling. Mild enameloplasty and cervical finishing line formation were also performed in order to minimize over-contouring of the restoration, which may lead to plaque entrapment, tissue inflammation, and tissue contraction during the early healing phase. After the cavity was prepared, adhesive procedures were performed (Figures 2 and 3). After selective enamel etching (Figures 2b and 3a), a two-step self-etch adhesive system (Clearfil SE Bond, Kuraray Medical Inc., Kurashiki, Japan) was used according to the manufacturer's instructions (Figure 3b). A micro-hybrid resin composite (Filtek Z-250, 3M ESPE, St. Paul, MN, USA) was used as the filling material. The composite was progressively layered with straight and curved composite applicators (Satin Steel XTS Composite Instrument TNCIGFT #3 and 4, Hu-Friedy, Chicago, IL, USA) and microbrushes were also used to increase the adaptation of these composite increments. The cervical line of the final restoration was located approximately 1 mm apical to the MRC because the original CEJ is usually located 1 - 2 mm apical to the gingival margin (Figures 2c and 3c).12 This allows a smoother emergence profile and can prevent the exposure of the root surface, which may contribute to the persistence of hypersensitivity.9 All of the over-contoured areas were removed using diamond fine and extra-fine burs to prevent plaque accumulation.13 For gingival reattachment on the restored surface, the surface of resin composite should be made of a stable, smooth, and convex substrate. Therefore, the finest finishing and polishing procedures must completed before mucogingival therapy.14 The polishing procedures were implemented twice in order to ensure the smoothest possible surface: immediately and after a week.

After the use of a fine silicon point (Venus Supra, Hanau, Germany), a series of Sof-lex Discs (3M ESPE) were used to improve the esthetic quality of the restoration and to achieve the highest level of smoothness possible (Figures 2d and 3d). Finally, Biscover LV (Bisco Inc., Schaumburg, IL, USA) was applied after the acid etching to seal the composite restorations.

The surgical procedure was carried out after the resin composite filling by a periodontist. The maxillary left side was treated using the envelope technique, employing a coronally advanced flap without any vertical releasing incisions. This surgical technique enables the simultaneous treatment of multiple adjacent recessions (Figures 4a and 4b).15 Beveled oblique incisions in the interproximal areas were outlined under local anesthesia and a split-thickness flap was raised to the base of the papillae, followed by a full-thickness elevation. The flap was then released above the mucogingival junction by a split-thickness elevation again. Root surface preparation was also performed using hand and ultrasonic instrumentation. The residual interproximal papillae were carefully de-epithelized to provide a good recipient bed for flap attachment (Figure 4c). In order to allow tension-free stabilization of the flap, a double horizontal mattress suture was performed buccally across the entire flap extension with a sling suture (Figure 4d). In the maxillary right side, a modification of the coronally advanced flap was used. Since the right lateral incisor showed a normal gingival level, two independent coronally advanced flaps were performed separately on both sides of the right lateral incisor (Figure 5). Postoperative management included an anti-inflammatory medication and 0.2% chlorhexidine mouthwash twice a day until the sutures were removed and brushing could be resumed. The sutures were removed approximately 10 days later. The patient was seen for follow-up four weeks, eight weeks, and six months later (Figures 6 and 7). Complete coverage of the recession defects was achieved, and the patient complained of no hypersensitivity. At the six month follow-up, excellent esthetic results were observed, with the physiological integration of the restorative material and the new gingival architecture (Figure 8).