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.

A prospective analysis of physical examination findings in the diagnosis of facial fractures: Determining predictive value.

BACKGROUND: There are >150,000 patient visits per year to emergency rooms for facial trauma. The reliability of a computed tomography (CT) scan has made it the primary modality for diagnosing facial skeletal injury, with the physical examination playing more a cursory role. Knowing the predictive value of physical findings in facial skeletal injuries may enable more appropriate use of imaging and health care resources. OBJECTIVE: A blinded prospective study was undertaken to assess the predictive value of physical examination findings in detecting maxillofacial fracture in trauma patients, and in determining whether a patient will require surgical intervention. METHODS: Over a four-month period, the authors' team examined patients admitted with facial trauma to the emergency department of their hospital. The evaluating physician completed a standardized physical examination evaluation form indicating the physical findings. Corresponding CT scans and surgical records were then reviewed, and the results recorded by a plastic surgeon who was blinded to the results of the physical examination. RESULTS: A total of 57 patients met the inclusion criteria; there were 44 male and 13 female patients. The sensitivity, specificity, positive predictive value and negative predictive value of grouped physical examination findings were determined in major areas. In further analysis, specific examination findings with n≥9 (15%) were also reported. CONCLUSIONS: The data demonstrated a high negative predictive value of at least 90% for orbital floor, zygomatic, mandibular and nasal bone fractures compared with CT scan. Furthermore, none of the patients who did not have a physical examination finding for a particular facial fracture required surgery for that fracture. Thus, the instrument performed well at ruling out fractures in these areas when there were none. Ultimately, these results may help reduce unnecessary radiation and costly imaging in patients with facial trauma without facial fractures.

HISTORIQUE: Plus de 150 000 patients se rendent à la salle d'urgence chaque année à cause d'un traumatisme facial. En raison de sa fiabilité, la tomodensitométrie est la modalité primaire pour diagnostiquer les lésions squelettiques de la face, tandis que l'examen physique joue un rôle plus superficiel. Le fait de connaître la valeur prédictive des observations physiques en cas de lésions squelettiques de la face pourrait favoriser une utilisation plus appropriée de l'imagerie et des effectifs en matière de santé. OBJECTIF: Les chercheurs ont réalisé une étude prospective à l'aveugle afin d'évaluer la valeur prédictive de l'examen physique pour déceler une fracture maxillo-faciale chez les patients traumatisés et pour déterminer si le patient devra subir une intervention chirurgicale. MÉTHODOLOGIE: Sur une période de quatre mois, l'équipe des auteurs a examiné les patients admis à l'urgence de leur hôpital à cause d'un traumatisme facial. Le médecin a rempli un formulaire d'évaluation de l'examen physique standardisé pour consigner ses observations physiques. Les tomodensitométries correspondantes et les dossiers chirurgicaux ont ensuite été examinés, et un plasticien a consigné les résultats sans connaître ceux de l'examen physique. RÉSULTATS: Au total, 57 patients respectaient les critères d'inclusion, soit 44 hommes et 13 femmes. Les chercheurs ont déterminé la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative des observations groupées des examens physiques dans les principaux secteurs. À l'analyse plus approfondie, ils ont également signalé les observations tirées de de l'examen physique, où n≥9 (15 %). CONCLUSIONS: Les données ont démontré une valeur prédictive négative élevée d'au moins 90 % pour les fractures du plancher orbital, des zygomatiques, des mandibules et du nez par rapport à la tomodensitométrie. De plus, aucun des patients qui n'avait pas de fracture faciale selon l'examen physique n'a dû être opéré en raison d'une telle fracture. Ainsi, l'instrument donnait des bons résultats pour écarter ce type de fractures lorsqu'il n'y en avait pas. Au bout du compte, ces résultats peuvent contribuer à réduire des radiations inutiles et une imagerie coûteuse chez les patients ayant un traumatisme facial sans fractures.