Received: 8 August 2022 Accepted: 29 December 2022

DOI: 10.1002/cap.10233

C A S E S T U DY

Papilla reconstruction for an iatrogenic RT3 gingival defect

using a tuberosity soft tissue graft: A case report

Gerardo Chacón1 Muhammad H. A. Saleh2 Christina Fleming3 Nelson Leon1

Hom-Lay Wang2

1
Private Practice, Medellin, Colombia
2
Abstract
Department of Periodontics and Oral Medicine,
University of Michigan School of Dentistry, Ann Background: Orthognathic surgery is a reliable and safe method to improve
Arbor, Michigan, USA maxillo-mandibular malformations. However, it is a complex procedure that can
3
Department of Periodontics, University of affect deeper structures and the terminal blood supply of specific areas, thereby
Louisville, Louisville, Kentucky, USA affecting the results. Occasionally, despite careful digital planning and diagnosis,
esthetic complications may occur, such as scarring or mucogingival alterations,
Correspondence including localized aseptic necrosis with associated recessions. In more severe
Hom-Lay Wang, Department of Periodontics and
Oral Medicine, University of Michigan School of cases, larger fragments of necrosis may be involved.
Dentistry, 1011 North University Avenue, Ann Methods and Results: The aim of this case report was to present a case, including
Arbor, MI 48109-1078, USA. diagnosis, treatment plan, periodontal plastic surgical technique, and follow-
Email: homlay@umich.edu
up for a recession type 3 (RT3) defect. This RT3 gingival defect was associated
with necrotic crestal bone exposure in the anterior esthetic area resulting from
a complication after orthognathic surgery.
Conclusions: Partial reconstruction of the interdental papilla can be possi-
ble through consideration of the defect characteristics, use of microsurgical
principles, and utilization of a suitable connective tissue grafting technique.

KEYWORDS
complications, gingival recession, orthognathic surgery, root coverage

Key points
Why is this case new information?
∙ To the authors’ knowledge, there is very limited clinical and scientific evi-
dence regarding the management of esthetic complications associated with
ischemic necrosis resulting from orthognathic surgeries. This case study iden-
tified the management of papillary reconstructions of these mucogingival
defects.
What are the keys to the successful management of this case?
∙ For an ideal case management, adequate plaque and infection control and
timely notice of the defect appearance are critical. Additionally, proper sur-
gical soft tissue management of the affected papillae and surrounding
area is required. Finally, the type of connective tissue graft to be used, its

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© 2023 The Authors. Clinical Advances in Periodontics published by Wiley Periodicals LLC on behalf of American Academy of Periodontology.

Clin Adv Periodontics. 2023;13:163–167. wileyonlinelibrary.com/journal/cap 163

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164 CHACÓN ET AL.

management and fixation, and proper postoperative protocols are needed for
case success.
What are the primary limitations to success in this case?
∙ Despite the limitations of this study, the authors consider that the treatment of
mucogingival complications related to orthognathic surgeries is possible, using
microsurgical concepts and connective tissue grafts to reconstruct papillae.

INTRODUCTION Surgical case management

Orthognathic surgery is a reliable tool for the management A healthy, nonsmoker, 24-year-old female presented to
of maxillo-mandibular deformities through the three- the author’s private practice in Medellin, Colombia. The
dimensional displacement of maxillofacial segments.1 patient’s chief complaint was an esthetic concern follow-
There are few reports detailing complications after these ing a Le Fort I surgery that was performed 3 months earlier.
procedures. One retrospective study reported a general Le Fort segmentation was secured with fixation plates and
complication rate of 27%, including dental devitalization, micro screws. At the time of presentation, the interdental
removal of fixation plates, palatal fistulas, and periodontal area of teeth # 8–9 had evidence of ischemia associated
complications.2 In this last aspect, Kramer reported an with the localized recession and deep probing, with evi-
incidence rate of 0.8% for ischemic complications with dent necrosis of the bone crest (Figures 1–3). The patient
associated gingival recessions.3 These complications were did consent to the proposed treatment orally.
directly related to the location of the incision, indicating A coronally advanced flap (CAF) was designed to include
that a more marginally placed incision shows a greater ten- the defect and two adjacent teeth mesial and distal to
dency for postoperative recession.4,5 Additionally, Carrol the defect. Split-thickness incisions were made to the base
et al. reported that the least damaging incisions are made of the papilla, followed by full-thickness flap reflection
between the central incisors, while the most damaging are to the mucogingival junction. For coronal advancement
between the canines and premolars.6
Vascular compromise can be due to poor incision design,
tissue abrasions, osteotomies, maxillary segment displace-
ment, or improper segment fixation—all of which affect
oral tissues through dental devitalization, recessions, and
necrosis of bone fragments.2,6,7 Additionally, the charac-
teristics of hygiene, cigarette smoking status, pre-existing
systemic and/or periodontal diseases, and patient phe-
notype should be considered prior to the orthognathic
surgery. Specifically, patients with a compromised peri-
F I G U R E 1 Initial defect presentation. Loss of the papilla with
odontal complex or thin phenotype are more suscepti- significant recession, soft tissue cleft, and aseptic necrosis of bone crest
ble to later complications. Given the presurgical condi- related to #21-22.
tions, even with proper planning and surgical execution,
the localized prognosis of the treatment is at risk for
complications related to the insufficient blood supply to
the area.

MATERIALS AND METHODS

Clinical presentation

The following case report presents ischemic necrosis of the

bone crest with a deep recession and loss of the papilla
associated with a thin phenotype after segmentation by
orthognathic surgery with subsequent gingival recession
type 3 (RT3) in the central incisor area. This case also F I G U R E 2 Lateral view of the defect. Compromised buccal papilla
presents the use of periodontal plastic surgery techniques with a vertical soft tissue cleft and intact palatal papilla. Bone crest
for the correction of the mucogingival defect. exposed. Class III recession related to #21-22.
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CLINICAL ADVANCES IN PERIODONTICS 165

F I G U R E 3 Deep probing inside the defect showing the significant

compromise in the area, thin phenotype, and scarce blood supply.

FIGURE 5 Removal of the aseptic, necrotic bone crest.

F I G U R E 4 Flap design: papillary split-thickness flap, then full

thickness in the defect area (for access and mechanical treatment) from
the papilla base to the inner mucogingival junction (to advance the flap).
Microsurgical blade (no. 004, MJK Instruments, NSW, Australia) for
removal of the necrotic bone crest avoiding more damage that could
jeopardize blood supply.
FIGURE 6 Mechanical treatment and smoothing of roots #21-22.

of the flap, split-thickness incisions were made beyond

the mucogingival junction as described by Zucchelli and
Sanctis8 (Figure 4). The area of the vertical tissue cleft asso-
ciated with the defect was de-epithelialized to improve
blood flow and adaptation of the tissue with the graft.
Subsequently, the necrotic bone was removed from the
base (Figures 5 and 6). The exposed root surfaces were
polished (Figure 7), and a thin diamond bur was used to
de-epithelialize the palatal papilla to guarantee flap adapta-
tion. A connective tissue graft was taken from the maxillary
tuberosity and sutured using 7-0 polyglycolic acid sutures*
around the defect (Figure 8). Finally, the flap was coronally
advanced and closed (Figure 9). Postoperative instructions
were given to the patient, including the use of a saline

F I G U R E 7 De-epithelialization of the palatal papilla to guarantee

*
VICRYL, Ethicon, Johnson & Johnson, Bridgewater, NJ, USA. adequate adaptation of the buccal flap and blood supply for CTG.
 21630097, 2023, 3, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10233, Wiley Online Library on [23/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
166 CHACÓN ET AL.

FIGURE 10 Advanced healing, 9-month follow-up.

F I G U R E 8 CTG, from tuberosity, placed over the defect area.

Adapted and fixed using 7-0 polyglycolic acid sutures*. Of notice: The
well-shaped tissue and direction to guarantee adequate blood supply
and directed healing.

FIGURE 11 Frontal picture and final presentation, 18 months

post-op.

F I G U R E 9 Advancement and closure sutures for the flap using 7-0

polyglycolic acid sutures*.
F I G U R E 1 2 Final presentation, 18 months post-op. Of notice: Papilla
solution rinse three times a day, amoxicillin 500 mg every reconstruction, improved thickness, covered recessions regarding #21-22.
8 h for 1 week, and ibuprofen 600 mg every 8 h for 5 days. No concerns present in the area. Beautiful evolution and healing over
time after good adaptation of the CTG and maturation of the creeping
attachment.

RESULTS
the stomatological complex. Proper treatment planning of
Suture removal was performed 1 week after surgery and timely postsurgical evaluation is one of the most important
no new adverse events were reported by the patient. aspects of these cases. This allows the clinician to quickly
Clinically, there was an optimal adaptation of the connec- detect complications, determine causation, and execute a
tive tissue graft (CTG) with the primary intention healing treatment plan. Regarding complications, gingival reces-
of the CAF. From initial healing to final evaluation 18 sions have been reported between 0.5 and 3.0 mm and
months postoperatively, there was complete resolution of are more commonly associated with mandibular anterior
the esthetic defect, improved tissue volume, and a high teeth.9 Furthermore, there is a correlation between bone
degree of patient satisfaction. The probing depth of the and tissue thickness, amount of surgical displacement, and
bone crest and soft tissue cleft was also adequately cor- resulting tissue compromise due to larger decreases in
rected (Figure 10). Follow-up beyond 18 months showed blood flow to the area.10,11 If diminished blood flow persists,
continued improvement and the patient was absolutely complications can be seen up to 90 days post-surgery.12
satisfied with the results (Figures 11 and 12). Ischemic necrosis after Le Fort I surgeries has scarce
reports in the literature, occurring in < 1% of cases.3 Possi-
ble sequelae include periodontal defects, loss of pulp vital-
DISCUSSION ity, loss of dentition, or necrosis of the segmented areas.13
There is no pre-established treatment protocol for these
Orthognathic surgery consists of a multifaceted therapeu- lesions, although strict plaque control, palliative antibi-
tic approach to create maxilla-mandibular harmonization of otic therapy, and bone grafting have been suggested to
 21630097, 2023, 3, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10233, Wiley Online Library on [23/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CLINICAL ADVANCES IN PERIODONTICS 167

correct these defects. Ideally, reconstructive surgery should 2. Ho MW, Boyle MA, Cooper JC, Dodd MD, Richardson D. Surgical com-
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5. Kreisler M, Gockel R, Schmidt I, Kuhl S, d’Hoedt B. Clinical evaluation
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10. Shah R, Sowmya NK, Mehta DS. Prevalence of gingival biotype and its
1. Meticulous planning prior to orthognathic surgery, in
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tions in high-risk areas. 11. Saleh MHA, Couso-Queiruga E, Ravida A, et al. Impact of the periodon-
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14. Wei Y, Xu T, Zhao L, Hu W, Chung KH. Ridge preservation in max-
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GC, CF, and NL. Drafting of the manuscript: GC, MS, and
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CONFLIC T OF INTEREST Periodontol. 2015;86:S8-S51.
The authors declare that they have no conflict of inter-
est with this study. The authors do not have any financial
interests, either directly or indirectly, in the products or
information listed in the paper. How to cite this article: Chacón G, Saleh MHA,
Fleming C, Leon N, Wang HL. Papilla reconstruction
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