Inverted Periosteal Flap: An Alternative to the Buccal Advancement Flap for Tension-Free, Watertight Closure

The buccal advancement flap has been universally used in oral and maxillofacial surgery for closure of alveolar ridge incisions. It involves scoring of the buccal periosteum to enhance flap mobility and then stretching the buccal tissues medially (palatally or lingually) to obtain tension-free, watertight closure of a wound. Its applications have included, but have not been limited to, alveolar ridge augmentation procedures and closure of oral–antral communications. However, the buccal advancement flap technique has several major disadvantages. First, because the buccal flap is advanced crestally and medially, this technique invariably results in a significant reduction in vestibular depth. This can cause patients discomfort, such that they have described a sensation that their buccal mucosa has been sutured to their alveolar mucosa. In addition to being uncomfortable, this vestibular shortening can adversely affect patients' options for future prosthetic rehabilitation. Second, because the buccal flap is advanced medially, the mucogingival junction will be obliged to follow; therefore, the width of the keratinized tissue on the buccal aspect of the alveolus will be diminished. Third, if the buccal flap has been advanced a large distance, even with aggressive periosteal scoring and release, true tension-free closure can be very difficult to achieve, increasing the risk of wound dehiscence. The inverted periosteal flap is a new technique for flap design and closure that has several advantages over the buccal advancement flap. In my experience, the inverted periosteal flap will preserve the vestibular depth, maintain the keratinized gingival dimensions, and provide true tension-free closure. Thus, this flap could be ideal for any oral and maxillofacial surgical procedure in which tension-free, watertight closure is desired.