Buccal periosteal inversion (BUPI) for defect closure and keratinized gingiva width preservation after tooth extraction - technique modification

Abstract

Introduction: Several techniques and methods have been proposed to cover alveolar bone after tooth extraction when soft tissue is lacking. Some authors recommend soft tissue flap techniques, and others advocate different types of materials for socket covering. In this article, the authors use a modified buccal inversion technique for adequate coverage of the alveolar ridge to ensure its preservation and to minimize soft tissue shrinkage and loss of keratinized gingiva after tooth extraction. This local mucogingival-periosteal plastic procedure was named by the authors the "Buccal Periosteal Inversion technique" or simply BUPI.

Materials and methods: After extraction of a fractured, endodontically compromised lower right first molar, the BUPI technique was performed to cover the alveolus. After reflecting the two-sided full-thickness flap, the periosteum was split in the cranial direction. The inverted periosteum is used to provide tension-free defect closure of the postextractional defect. Detailed technique implementation and patient postoperative healing are presented here in detail.

Results: Postoperative evaluation at six weeks was presented with photos showing adequate surgical site healing, no signs of infection or dehiscence, and no crestal shift of the keratinized gingiva.

Conclusion: The buccal periosteal inversion (BUPI) technique is a modified technique that allows full socket coverage, avoiding a keratinized gingiva shift in the crestal direction using only the periosteum as a cover material. By inverting the buccal ridge periosteum alone from its normal position, the osteoclastic effect on the buccal bony wall will be eliminated, and this procedure abolishes the need for additional alveolar coverage materials.

Keywords: Alveolar protection; Buccal ridge preservation; Periosteal inversion; Periosteum; Periosteum inversion.

Fig. 1

Schematic representation of the technique. 1a. Socket after tooth extraction. 2b. Horizontal incision of the periosteum will become the base of the periosteal flap. An elevation of a full thickness flap has already been performed. 3c. Preparation of the periosteum was performed with its detachment from the subjacent submucosa in the marginal direction. The inversion of the periosteal flap is performed. 4d. Closure of the alveolar ridge defect with the inverted periosteum to the lingual marginal gingiva. Red = marginally keratinized gingiva, yellow = soft gingiva, green = the periosteum inner layer, and blue = the periosteum outer (fibrous) layer.

Fig. 2

The periosteal portion of the flap. 2a. The periosteal flap being released and elevated to show its extension. 2b. Inversion of the periosteum out of the buccally elevated flap. Note the periosteal attachment to the marginal gingiva.

Fig. 3

Closure of the alveolus defect. 3a. The inverted periosteum was gently manipulated to cover the grafted alveolus and sutured with 5–0 mononylon material. 3b. Final suturing of the periosteal flap with its inner layer exposed and the vertical border of the releasing incision is sutured back to its precise initial position.

Fig. 4

Postoperative healing. 4a. Initial healing process depicted after one week. 4b. Healing process on the fourteenth day after extraction. 4c. Healing six weeks after the BUPI technique.