Flapless implant surgery: an experimental study

Factors and clinical outcomes for standard and mini-implants retaining mandibular overdentures: A systematic review and meta-analysis

STATEMENT OF PROBLEM

Standard-diameter dental implants are not always applicable because of anatomic limitations of the residual ridge. Thus, mini-implants have been increasingly used and offer an alternative. However, data regarding prosthetic complications, maintenance factors, and clinical outcomes are limited.

PURPOSE

The purpose of this systematic review and meta-analysis was to compare prosthetic complications and maintenance events and clinical outcomes in residual ridges rehabilitated with mandibular implant overdentures (IODs) by using standard implants or mini-implants.

MATERIAL AND METHODS

Nine electronic databases were searched. Quantitative analyses to measure the risk ratio (RR) and standardized mean difference (SMD) were applied. Those methods were used to assess prosthetic complications and maintenance events (abutment adjustments, replacement of retentive element, occlusal adjustment, and overdenture fracture) and clinical outcomes related to postoperative pain, probing depth (PD), plaque index (PI), marginal bone loss (MBL), and implant survival rate.

RESULTS

Altogether, 7 publications were selected. Mini-implants presented reduced abutment adjustments (RR 0.23 [0.07, 0.73], P=.01), replacement of retentive element (RR 0.41 [0.31, 0.54], P<.001), occlusal adjustment (RR 0.53 [0.31, 0.91], P=.02), and overdenture fracture (RR 0.46 [0.23, 0.94], P=.03) compared with standard implants. Additionally, mini-implants presented lower values for PI at 6 months (SMD -0.27 [-0.47, -0.08], P=.006) and 12 months (SMD -0.25 [-0.46, -0.05], P=.01). No additional tangible differences were noted.

CONCLUSIONS

Mini-implants might be an alternative choice based on the number of prosthetic complications and maintenance events. This was also confirmed by the comparable clinical data between standard implants and mini-implants.

Flap versus Flapless Immediate Implants with Bone Augmentation: A Novel Study

Background

This study aimed to equate implants placed using a traditional flap elevation technique with implants placed using a flapless process regarding bone healing and success in clinical conditions.

Materials and Methods

Sixty subjects were included in this research work. The participants were randomly divided into two groups. Patients in group A underwent implant placement with the flap elevation technique. Similarly, group B patients underwent implant placement without flap reflection. Parameters such as plaque index, wound healing index, crestal bone loss, and radiograph were considered to estimate the effectiveness of the two techniques.

Results

Plaque indexes were improved in both groups. The modified gingival index also improved in all the phases of healing. The flapless method showed a better crestal bone.

Conclusion

It can be concluded that this study showed that with the right augmentation techniques, implants could be successfully performed immediate extraction sockets, both with and without elevation of the mucoperiosteal flap.

Healing of Peri-Implant Tissue following Flapless Implant Surgery

Background

Flapless surgery for implant placement has been gaining popularity among implant surgeons. it has numerous advantages, including preservation of circulation, decreased surgical time; improved patient comfort; and accelerated recuperation.

Materials and Methods

As a part of the study to evaluate crestal bone loss changes after placement of implant using the flapless technique, we placed twenty endosseous implants. Access was achieved to the crestal bone using a tissue punch. Clinical and radiographic analyses were performed second and fourth months after placement of the implant. Postoperative pain was measured by the visual analog scale at the 4th, 8th, and 24th hour.

Results

The findings of the present study demonstrate that the average crestal bone loss around the implant at 4 months using the flapless technique was 0.19 mm. No implants failed to osseointegrate, and no implants exhibited bone loss greater than 0.5 mm in the first four months. This present study shows significantly less postoperative pain in the flapless technique of implant placement.

Conclusion

The flapless approach is a predictable procedure when patient selection and surgical technique are appropriate.

Comparative Assessment of Crestal Bone Loss by Flapless and Flap Technique for Implant Placement: A Prospective Study

BACKGROUND

The use of flapless surgery for placing dental implants is extremely popular due to better radiological tools and the availability of software that help in the planning of dental implants.

OBJECTIVE

The present study was done to assess crestal bone loss by using flapless and flap techniques for placing implants.

METHODS

A total of 50 subjects who satisfied the inclusion criteria were selected for this study. Selected patients were then divided equally into two study groups i.e., those who are and those who are not undergoing flap surgery. Statistical analysis was done using the Mann-Whitney U test.

RESULTS

Statistically considerable P values were obtained. Bone loss was lesser with the flapless technique.

CONCLUSION

Flapless implant placement demonstrated less crestal bone loss compared to flap surgery.

Tissue-Level Laser-Lok Implants Placed with a Flapless Technique: A 4-Year Clinical Study

BACKGROUND

The present study aims to analyze the use of Laser-Lok microtextured neck implants placed with a transmucosal surgical approach. The marginal bone level (MBL) and periodontal parameters were evaluated in a cohort prospective 4-year clinical study.

METHODS

A total of 41 implants were placed in 36 healthy consecutive patients (16 males, 20 females, mean age 60 ± 9 years). Tapered tissue level implants, characterized by a 2.0 mm laser-microtextured neck, were used with a flapless approach. Customized abutments and provisional resin crowns were positioned. Definitive metal-ceramic crowns were cemented approximately 4 months after insertion. Periapical radiographs were taken after 1, 3, 6, 12, 36 and 48 months from implant placement to evaluate MBL. Gingival thickness (thin/thick), plaque score (PS) and bleeding on probing (BoP) were evaluated.

RESULTS

After 48 months, all implants were safe from complications. No complications, peri-implantitis, early implant failures or mucositis occurred. The survival rate was 100%. Mean MBL during the follow-up was -0.15 ± 0.18 at T1, -0.29 ± 0.29 at T3, -0.45 ± 0.37 at T6, -0.53 ± 0.45 at T12, -1.06 ± 1.13 at T 36 and -1.10 ± 0.89 at T 48. Implants placed 2-3 months after tooth extraction revealed lower MBL variation when compared to those placed immediately (in fresh extraction sockets) or in completely healed ridges (delayed group). Narrower diameter implants (3.8 mm) showed significantly higher MBL variation when compared to 4.6 diameter implants. Multilevel analysis at T48 revealed that among all the evaluated variables, implant diameter was the factor mostly associated with MBL modifications (p = 0.027).

CONCLUSION

This 4-year clinical study supports the use of Laser-Lok implants placed at tissue level with a flapless approach. A limited bone loss during the 48-month follow-up was observed. Periodontal parameters were stable with no sign of inflammation or soft tissue alteration. The use of Laser-Lok implants with transmucosal surgery represents a suitable technique with a minimally invasive approach.

An In-Vivo comparative study of the soft tissue response and esthetics of the titanium implant with titanium collar by flapless and conventional flap technique

Background:

These days, patients want quick results for tooth replacement and esthetic results. However, there is no direct correlation between the achievement of osseointegration and the outcome of successful treatment always. It is vital to sustaining peri-implant soft tissue health for extensive tenure success of the implant.

Aim:

The purpose of this trial was to determine, estimate, and compare the soft tissue retort and esthetics of the titanium implants with titanium collar at periodic intervals by flapless and conventional flap technique before and after prosthesis placement.

Results:

The difference in soft tissue indices namely, gingival index, plaque index, and the modified sulcular bleeding index was insignificant between the two implants placed by flapless and open flap technique 2. There was a significant difference amid the probing depths of the two implants after 3 months of prosthesis positioning where the implant placed by flapless technique showed lesser values as compared to the implant placed by the open flap technique 3. The esthetics of the soft tissues surrounding the titanium implant with titanium collar, when compared, presented a significant difference between the two techniques of implant placement.

Conclusion:

In conclusion, in recent advancements in dentistry, the flapless technique is becoming prominent because of procedure of minimally invasive surgery in implantology. There are advantages of early re-epithelialization and less inflammation around the soft tissue of the implant in the flapless procedure, provided that the prospective for the establishment of a fully functioning along with aesthetically desirable peri-implant soft tissue collar. The flapless technique accomplishes high degrees of gratification by the patients by shortening the surgery time and minimum invasion to both bone and soft tissue.

Comparative evaluation of crestal bone level by flapless and flap techniques for implant placement: Systematic review and meta-analysis

Aim

:To compare the crestal bone level of flapless technique of dental implant placement with the flap technique.

Setting and Design

This Systematic review and Meta-analysis was conducted according to the Preferred Reporting Items For Systematic Review and Meta-Analyses (PRISMA) Guidelines and registered with PROSPERO.

Materials and Methods

Electronic search of Medline and Google scholar databases for articles from 2010 till March 2020 was performed. Studies comparing the crestal bone level with both the techniques were included. After the collection of data, the risk of bias was assessed for each study.

Statistical Analysis Used

Meta-analysis was executed using RevMan 5 software version 5.3.

Results

23 studies were included. Statistically significant difference in crestal bone level was found between flapless and flap surgery with mean difference of -0.14 (flapless placement versus flap surgery; 95% CI: -0.24 to -0.03; P = 0.01FNx01). The difference in crestal bone level between the 2 groups was not statistically significant with a mean difference of -0.05(Guided flapless placement versus flap surgery; 95% CI: -0.10 to 0.00; P=0.06). Meta-analysis of the freehand flapless surgery with flap surgery generated a mean difference of -0.20 which was found to be statistically significant (Freehand flapless placement versus flap surgery; 95% CI: -0.37 to -0.03; P=0.02FNx01).

Conclusions

Flapless placement of implant can positively influence crestal bone loss in comparison with conventional flap technique.

Comparison of general and aesthetic effects between flapless and flap techniques in dental implantation: a meta-analysis of randomized controlled trials

Background

Information about the aesthetic effects of flapless in implant surgeries is scant. Differences of the survival rate (SR) and crestal bone loss (CBL) between the two techniques were also controversial. Thus, this review was aimed to compare the general and aesthetic effects of flapless and flap approaches in implant surgeries.

Materials and methods

Following the principals of PRISMA, literature databases were searched for the eligible randomized controlled trials (RCTs) comparing the clinical performances of flap and flapless techniques. After that, relevant data of selected studies were pooled and analyzed to compare SR, bleeding on probing (BOP), probing depth (PD), visual analogue scale (VAS), papillae presentation index (PPI), keratinized mucosa (KM) width and CBL between the two techniques.

Results

Fourteen RCTs were included. No significant difference was found in SR (RR = − 0.01, 95% confidence interval (CI) (− 0.05, 0.04)), BOP (OR = 0.40, 95% CI (0.15, 1.02)), KM width (WMD = − 0.42, 95% CI (− 1.02, 0.17)) between two groups. Subgroup analysis revealed that the difference of CBL was insignificant in two groups (WMD = − 0.13, 95% CI (− 0.63, 0.38)). However, flap techniques would lead more peri-implant PD (WMD = − 0.37, 95% CI (− 0.51, − 0.23)). Subgroup analysis also indicated lower VAS scores in flapless group after 1 day (WMD = − 1.66, 95% CI (− 2.16, − 1.16)) but comparable pain experience after 3 days (WMD = − 0.59, 95% CI (− 1.33, 0.16)). Mean difference of PPI (WMD = 0.32, 95% CI (0.28, 0.35)) between the two groups was significant.

Conclusions

The flapless procedure showed a superiority in preserving gingival papillae, reducing postoperative pain and peri-implant PD compared to the flap procedure, while exhibiting comparable effects on SR, BOP, KW width changes and CBL. Flapless technique is more recommended at the ideal soft and hard tissue implanting sites.

Evaluation of Bone Regeneration around Implants with and Without Flap Elevation

Background:

The aim of this study is to clinically evaluate and compare the clinical success and the relative bone healing of the implants which are placed using a flapless procedure and compare it to those placed by the conventional flap technique.

Materials and Methods:

This study was conducted with ten patients that were randomly divided into two groups. Group A included patients with immediately placed implants after extraction with flap elevation. Group B included patients with immediately placed implants after extraction without any flap elevation. The clinical parameters recorded were Plaque index, Modified Gingival Index, Early Wound Healing Index, Buser's criteria, Distance between implant shoulder and the crestal bone (DIB), and Radiographic Examination in a standardized manner to evaluate changes for the DIB values.

Results:

There was an improvement in Plaque Score from baseline to 1 month and baseline to abutment placement (6 months), which was statistically significant, but the plaque score from 3 months to abutment placement (6 months) was statistically nonsignificant in both the group. There was an increase in modified gingival score from baseline to 3 months, baseline to abutment placement (6 months), and 3 months to abutment placement (6 months), which was statistically significant in both the groups. The DIB scores in Group A recorded at baseline to 6 months were 2.80 ± 0.57 and 1.90 ± 0.42, respectively, showing a mean difference of −0.90 and P = 0.001 in comparison. Whereas, the DIB scores in Group B at baseline to 6 months were 3.20 ± 0.57 and 2.50 ± 0.50, respectively, showing a mean difference of −0.70 and P = 0.001 in comparison. The DIC scores in Group A at baseline to 6 months were 1.60 ± 0.54 and 0.00 ± 0.00, respectively, showing a mean difference of −1.60 and P = 0.003 in comparison, Whereas the DIC scores in Group B at baseline to 6 months were 1.40 ± 0.54 and 0.00 ± 0.00, respectively, showing a mean difference of −1.40 and P = 0.005 in comparison.

Conclusion:

Implants placed in fresh extraction sockets with and without mucoperiosteal flap elevation can be successfully done with augmentation procedures. Short-term survival rates and clinical outcomes of both groups were similar and appeared to be predictable treatment modalities.

Comparison between flapless and open-flap implant placement: a systematic review and meta-analysis

No consensus has been reached regarding the influence of the flapless and open-flap surgical techniques on the placement of dental implants. This systematic review compared the effects of flapless implant placement and implant placement with elevation of the mucoperiosteal flap in terms of marginal bone loss, implant survival rate and complications rates. This review followed PRISMA guidelines and was registered in PROSPERO with the registration number CRD42017071475. Two independent reviewers performed a comprehensive search of the PubMed/MEDLINE, Scopus, and Cochrane Library databases for studies published until December 2017. The search identified 559 references. After a detailed review, 24 studies were assessed for eligibility. A total of 1025 patients who had received a total of 1873 dental implants were included. There were no significant differences between the flapless and open-flap surgical techniques in terms of implant survival rates (P=0.34; risk ratio (RR): 1.36; confidence interval (CI): 0.72-2.56), marginal bone loss (P=0.23; MD: -0.20; CI: -0.52-0.13), or complication rates (P=0.67; RR: 1.10; CI: 0.70-1.73). The current meta-analysis showed that the implant survival rate, marginal bone levels, and complications of flapless surgery were similar to those of open-flap surgery over a mean follow-up period of 21.62 months.

Guided implant surgery risks and their prevention

Ideal implant placement may reduce surgical complications, such as nerve injury and lingual cortical plate perforation, and minimize the likelihood of functional and prosthetic compromises. Guided implant surgery (GIS) has been used as the means to achieve ideal implant placement. GIS refers to the process of digital planning, custom-guide fabrication, and implant placement using the custom guide and an implant system-specific guided surgery kit. GIS includes numerous additional steps beyond the initial prosthetic diagnosis, treatment planning, and fabrication of surgical guide. Substantial errors can occur at each of these individual steps and can accumulate, significantly impacting the final accuracy of the process with potentially disastrous deviations from proper implant placement. Pertinent overall strategies to reduce or eliminate these risks can be summarized as follows: complete understanding of the possible risks is fundamental; knowledge of the systems and tools used is essential; consistent verification of both diagnostic and surgical procedures after each step is crucial; proper training and surgical experience are critical. This review article summarizes information on the accuracy and efficacy of GIS, provides insight on the potential risks and problems associated with each procedural step, and offers clinically relevant recommendations to minimize or eliminate these risks.

Clinical Evaluation of Placement of Implant by Flapless Technique Over Conventional Flap Technique

Aim

The aim of this study was to compare the clinical advantages of flapless implant surgery over conventional flap technique of implant placement by assessing the marginal bone loss in 1 month, 2 months and 3 months postoperatively, pain assessment, number of analgesics taken by the patients postoperatively and the postoperative swelling between two groups.

Materials and Methods

This study was conducted at Department of Oral and Maxillofacial Surgery, Rajas Dental College and Hospital, Tirunelveli. The patients were assigned randomly to one of the two groups—flap (ten patients) or flapless (ten patients). Digital IOPARs were taken postoperatively. The parameters assessed were marginal bone loss (interproximal bone height), pain assessment by a 10-cm visual analog scale, swelling assessment by modification of tape measuring method by Gabka and Matsumara and the number of analgesics tablets taken every postoperative day from the day of surgery to 6 days after surgery.

Results and Statistics

Descriptive statistics was done by calculating measures of central tendency (mean) and measures of dispersion (standard deviation) for all the parameters. Inferential statistics were done by unpaired Student’s t test to compare the mean difference between the two groups. The results of this study showed that the mean difference in the bone loss for baseline to the third month for the flap group was 0.34 ± 0.05 and for the flapless group was 0.03 ± 0.004 (p = 0.000***). Pain assessment by visual analog scale was statistically significant in all the 5 postoperative days indicating a better patient compliance in the flapless group and there was no statistical difference in the level of swelling between these two groups.

Conclusion

Within the limitations of this study, it can be concluded that flapless implant surgery results in lesser loss of marginal bone and also results in better patient comfort; however, proper patient selection and technique is essential for a successful flapless implant surgery.

Effect of 2 Different Drilling Speeds on the Osseointegration of Implants Placed With Flapless Guided Surgery: A Study in Rabbits

OBJECTIVE

The aim of this study was to evaluate the influence of the drilling speed on bone healing and the osseointegration of implants placed with a guided flapless surgical technique in rabbit tibias.

METHODS

For the evaluation of bone healing, a total of 30 perforations (defects) were made in both tibias of 15 rabbits using 2 different drilling speeds (1500 rpm-control group; 50 rpm-test group). The regeneration of bone tissue in the surgical sites was evaluated at 0, 7, and 14 days. For the evaluation of implant osseointegration, another 15 rabbits underwent drilling in both tibias for implant placement. Thirty implants (3.75 × 10 mm) were placed to evaluate osseointegration at 4, 8, and 12 weeks after surgery.

RESULTS

Both groups showed a progressive healing of the defect, which involved the complete closure of the perforation. The osseointegration occurred in all groups with no statistically significant differences in the assessment of the osseointegration between the groups.

CONCLUSION

In the experimental models used, the drilling speed does not prejudice the pattern of bone healing and osseointegration of implants placed with guided flapless surgery.

Clinical parameters of implants placed in healed sites using flapped and flapless techniques: A systematic review

BACKGROUND

Dental implant placement using flapless surgery is a minimally invasive technique that improves blood supply compared with flapped surgery. However, the flapless technique does not provide access to allow bone regeneration.

OBJECTIVE

The aim of this systematic review was to evaluate the clinical parameters following implant surgery in healed sites, using two procedures: flapped vs. flapless surgery.

MATERIALS AND METHODS

A detailed electronic search was carried out in the PubMed/Medline, Embase and Cochrane Library databases. The focused question was, "How do flapped and flapless surgical techniques affect the clinical parameters of dental implants placed in healed sites?". All the studies included with a prospective controlled design were considered separately, depending on whether they had been conducted on animals or humans. The following data were recorded in all the included studies: number of implants, failures, location (maxilla, mandible), type of rehabilitation (partial or single), follow-up and flap design. The variables selected for comparison in the animal studies were the following: flap design, gingival index, mucosal height, recession and probing pocket depth. In humans studies the variables were as follows: flap design, plaque index, gingival index, recession, probing pocket depth, papilla index and keratinized gingiva.

RESULTS

Ten studies were included, six were experimental studies and four were clinical studies. Studies in animals showed better results using the flapless technique in the parameters analyzed. There is no consensus in the clinical parameters analyzed in human studies, but there is a trend to better results using flapless approach.

CONCLUSION

The animal studies included in the present review show that implants placed in healed sites with a flapless approach have better clinical parameters than the flapped procedure in a short-term follow-up. In human studies, there is no consensus about which technique offer better results in terms of clinical parameters. Therefore, more research in humans is required in order to overcome the limitations and contrast these results.

Crestal Bone Loss under Delayed Loading of Full Thickness Versus Flapless Surgically Placed Dental Implants in Controlled Type 2 Diabetic Patients: A Parallel Group Randomized Clinical Trial

PURPOSE

To compare crestal bone loss around dental implants using a delayed loading protocol. Bone loss was compared in patients following conventional full thickness flap and flapless surgery in controlled type 2 diabetic patients.

MATERIALS AND METHODS

Eighty-eight type 2 diabetic patients satisfying predetermined inclusion and exclusion criteria were selected for this single center, parallel group study after obtaining institutional review board approval and informed consent. These patients were randomly divided into two groups. Group I consisted of patients undergoing full thickness flap surgery for implant placement, and group II consisted of patients undergoing flapless surgery for implant placement. The mean age, duration of diabetes, glycosylated hemoglobin levels, and male-to-female ratio in both groups were matched and compared statistically. Dental implants were placed followed by delayed loading (4 months) in both groups. Crestal bone loss was assessed with intraoral periapical radiographs with the help of computer software (DBSWIN viewer). Actual implant length acted as the radiographic index, and implant-abutment junctions were used as a reference point for all measurements. Mesial and distal bone levels at baseline, 6, and 12 months post implant placement of the two groups were determined. Mesial and distal crestal bone loss from baseline to 6 and 12 months were calculated and compared with Tukey test using SPSS v15.0 statistical analysis software.

RESULTS

Tukey test revealed similar (not statistically different) mean mesial crestal bone loss between the two groups after 6 months (0.47 ± 0.08 mm vs. 0.36 ± 0.13 mm, p = 0.576) and after 12 months (1.56 ± 0.25 mm vs. 1.50 ± 0.22 mm, p = 0.891). The mean distal bone loss resulting between the two groups was not statistically different at 6 months (0.44 ± 0.08 mm vs. 0.35 ± 0.12 mm, p = 0.687) and at 12 months (1.57 ± 0.23 mm vs. 1.61 ± 0.22 mm, p = 0.947).

CONCLUSIONS

The results of this clinical randomized control trial indicated that in controlled type 2 diabetic patients, levels of crestal bone loss around dental implants placed following conventional full thickness flap surgery was comparable to crestal bone loss around dental implants placed with the flapless surgical technique. More clinical studies are required regarding controlled type 2 diabetics with larger sample sizes, for long time periods to obtain more predictable results.

Flap Designs for Implant-Related Surgical Procedures: A Review

PURPOSE

The objective of this study was to compare the reliability and results of 2 flap techniques, flapless (FL) and full-thickness (FT) flap, during implant placement.

MATERIALS AND METHODS

Online and hand searches of the literature published were conducted to identify studies examining different flap techniques on clinical and histological outcomes. The search terms used, alone or in combination, were "flapless," "full-thickness flap," "crestal bone resorption," "gingival blood circulation," and "biological width."

RESULTS

Fifty studies were selected for comparison and to address the points highlighted in this study. Fourteen articles and 1 book were not directly related to flap design but were included for understanding the process of soft tissue healing. Five articles discussed the principles of oral surgery and flap design.

CONCLUSION

This review revealed that the FL technique might be more appropriate in immediate implant loading cases. This specific technique results in shallower biological width, reduced inflammation, less morbidity with guided implant placement, and better esthetics in comparison with the FT technique. The implant survival rates are not significantly different between the 2 flap techniques. With respect to crestal bone resorption in FL and FT, it is inconclusive, depending on the study type (human or animal).

Minimally invasive flapless vs. flapped approach for single implant placement: a 2-year randomized controlled clinical trial

PURPOSE

The purpose of this 2-year randomized controlled clinical trial was to assess the differences in implant survival rates, soft tissue preservation, patient centered outcome and crestal bone changes applying the minimally invasive (MI) flapless approach for single implant placement compared to flapped implant surgery (FS).

MATERIALS AND METHODS

Subjects eligible for this study were randomly assigned into two groups: MI or FS. Items of evaluation were the following: implant installation position, soft tissue healing, post-surgical pain, soft tissue outcome, marginal bone loss (MBL), and implant survival rate.

RESULTS

Forty subjects (14 women and 26 men, 20 in MI group and 20 in FS group with a mean of 39 ± 13.2 years old) were included in the study. None of the implants demonstrated dehiscence or loss during the follow-up. Subjects in MI group showed significantly lower post-surgical pain and significantly less wound healing index scores at 1-week follow-up. The width of keratinized mucosa decreased from a mean of 4.2 ± 1.6 mm pre-surgically to 3.7 ± 1.1 mm at crown delivery but remained stable at 2-year follow-up in MI group. At every appointment in the study, no statistical significant difference of PD and MBL was found between the two groups.

CONCLUSION

Compared with FS, single implants placed applying the MI technique in selected subjects showed advantages in improving patient comfort and decreasing post-implant placement soft tissue reaction. Meanwhile, implants with MI approach have the same level of MBL and high success rates as FS procedure at 2-year follow-up. The deduction of keratinized mucosa is very limited and the width of KM remained stable with MI approach at 2-year follow-up.

Flapless Versus Traditional Dental Implant Surgery: Long-Term Evaluation of Crestal Bone Resorption

PURPOSE

The literature reports that flapless compared with traditional implant surgery can be associated with several advantages, including the maintenance of peri-implant hard tissues. This study investigated vertical bone resorption during long-term follow-up after implant placement with flapless versus traditional surgery.

MATERIAL AND METHODS

In this prospective, randomized controlled clinical trial, 40 patients underwent implant placement at the Maxillofacial Department Surgery of the Istituto Stomatologico Italiano Hospital in Milan, Italy. Patients were randomly assigned to the control or experimental group. The control group had implants placed with open flap surgery (traditional surgery), whereas the experimental group had implants placed with flapless surgery. The distance between the first implant thread and the marginal crestal bone level was measured at the basal, loading, and long-term control points. The basal recording was performed just after implant placement. The loading measurement was recorded at the time of implant loading, after 2 months of healing for the lower jaw and after 3 months of healing for the upper jaw, and the long-term control record was registered 36 months after implant placement. Statistical analysis was performed using mean values and standard deviations based on bone resorption in the 2 groups. To detect statistical differences, the Student t test was applied. Differences were considered significant if P values were less than .05.

RESULTS

The control group (open flap surgery) was comprised of 19 patients, and the experimental group (flapless surgery) was comprised of 21 patients. No statistical differences were found in peri-implant bone resorption between the 2 groups at the basal, implant loading, and 3-year control recordings.

CONCLUSION

According to this study, the approach to implant surgery does not seem to influence peri-implant bone resorption in humans, at least for the period measured in this study.

The Effect of Flapless and Full-thickness Flap Techniques on Implant Stability During the Healing Period

Purpose : When soft tissue flaps are reflected for implant placement, the blood supply from the periosteum to the bone is disrupted. The aim of this study was to compare the effects of the flapless (FL) and full-thickness flap (FT) techniques on implant stability. Methods : Nine patients received 22 implants. The implants were placed using the FL technique on the contralateral side of the jaw; the FT technique was used as the control technique. Resonance frequency analysis (RFA) was performed at the time of implant placement and at 6 and 12 weeks after implant placement. RFA values were compared between the FL and FT groups and between time intervals in the same group. Results : The median (interquartile range [IQR]) RFA values at the time of implant placement were 75.00 (15.00) for the FL technique and 75.00 (9.00) for the FT technique. At 6 weeks, the median (IQR) values were 79 (3.30) for the FL technique and 80 (12.70) for the FT technique. At 12 weeks, the median (IQR) values were 82.3 (3.30) for the FL technique and 82.6 (8.00) for the FT technique. There were no significant differences between the 2 techniques at the time of implant placement, after 6 weeks or after 12 weeks, with p values of 0.994, 0.789, and 0.959, respectively. There were significant differences between the RFA values at the time of implant placement and after 6 weeks for the FL technique (p=0.028) but not for the FT technique (p=0.091). There were also significant differences between the RFA values at 6 weeks and the RFA values at 12 weeks for the FL technique (p=0.007) and for the FT technique (p=0.003). Conclusion : Periosteum preservation during the FL procedure will speed up bone remodeling and result in early secondary implant stability as well as early loading.

Submerged flapless technique vs. conventional flap approach for implant placement: experimental domestic pig study with 12-month follow-up

OBJECTIVES

The aim of our study was to compare osseointegration and peri-implant crestal bone resorption in submerged flapless and conventional flap surgery over a 12-month follow-up.

MATERIALS AND METHODS

The study used five domestic pigs. Implants were inserted 9 weeks after tooth extraction. Each animal received six implants in the mandible, following a split-mouth design: one side was treated using a flapless technique using mini-incisions, while a flap was raised on the other. The animals were sacrificed at 2 weeks, 1, 3, 6 and 12 months after implant placement. Radiographic images were taken to analyze crestal bone loss, and samples were extracted for histopathological and bone-to-implant contact (BIC) analyses.

RESULTS

Significantly, greater crestal bone loss (P = 0.005) was obtained in the flap group compared with the flapless group. The flapless group presented significantly higher percentages of BIC (P < 0.05) at 3, 6 and 12 months compared with the conventional flap group.

CONCLUSIONS

Within the limitations of this experimental animal study, it may be concluded that the type of surgery (flap or flapless) affects peri-implant bone preservation and osseointegration of regular platform implants. Flapless surgery is associated with peri-implant crestal bone preservation. Flapless surgery in combination with submerged implants allows higher osseointegration values.

Flapless implant surgery: A review of the literature and 3 case reports

Since the 1970s, modern Implantology is based on a concept of surgery with flap elevation. Gradually, several clinical trials demonstrated that a mid-crestal incision gives similar success rates compared to those obtained using the classical protocol. However, over the past decade in medicine it has been established the concept of minimally invasive surgery, consisting in taking advantage of advancements experienced in diagnostic techniques and specific surgical instruments, to perform surgical procedures infringing as less damage as possible to the patient The present work aims to produce a thorough review of the literature published on the field of Implantology with flapless surgery, to determine the current scientific evidence of the technique, along with illustrating the results with different clinical cases. After presenting the clinical cases, and the review of literature, we can say that flapless surgeries should be restricted to well-selected cases in which a proper clinical and radiological planning has been made. Patients treated with anticoagulant drugs or medically compromised equally can get benefitted by this minimal invasion technique. Key words:Flapless, minimally invasive surgery, dental implant.

Flapless implant placement: a case report

Full-thickness periosteal flap elevation for implant placement is often accompanied by potential marginal bone loss and/or soft tissue recession around the implant due to compromised blood supply to underlying bone. To preserve the blood supply to underlying bone, implants can be placed with a flapless surgical procedure. This procedure also provides numerous other benefits, such as decreased trauma, short recovery time, less pain, reduced rate of infection, and improved patient compliance. This report presents a case of flapless implant placement in the mandibular posterior region that achieved optimum results and caused minimal discomfort to the patient. The advantages and limitations of this procedure are also discussed.

The effect of guided flapless implant procedure on heat generation from implant drilling

The objective of this study was to evaluate the heat generation in vitro during the flapless drilling procedure using surgical drill guides. Ten resin models with bilateral edentulous tooth spaces in the first and second molars in the mandible were used in this study. On one side of the mandible, drilling was performed with a flapless approach using a surgical drill guide. On the other side of the mandible, drilling was performed with a flap approach. The temperature changes were measured during final drilling by thermocouples. The mean maximum temperatures during drilling with guided flapless procedures were 29.5 °C and 32.6 °C at the depths of 3 and 6 mm, respectively, whereas for flap procedures they were 29.4 °C and 31.3 °C. There was no statistically significant difference between the groups. These findings suggest that drilling with external irrigation in an up-and-down pumping motion may not lead to a significant increase the bone temperature during a flapless procedure using surgical drill guides.

What is the effect of initial implant position on the crestal bone level in flap and flapless technique during healing period?

Purpose

The level of the implant above the marginal bone and flap design have an effect on the bone resorption during the healing period. The aim of this study is to detect the relationship between the level of the implant at the implant placement and the bone level at the healing period in the mesial and distal side of implants placed with flapless (FL) and full-thickness flap (FT) methods.

Methods

Twenty-two nonsubmerged implants were placed with the FL and FT technique. Periapical radiographs were taken of the patient at implant placement, and at 6 and 12 weeks. By using computer software, bone level measurements were taken from the shoulder of the healing cap to the first bone implant contact in the mesial and distal side of the implant surface.

Results

At 6 weeks, the correlation between the crestal bone level at the implant placement and crestal bone level of the FT mesially was significant (Pearson correlation coefficient=0.675, P<0.023). At 12 weeks, in the FT mesially, the correlation was nonsignificant (Spearman correlation coefficient=0.297, P<0.346). At 6 weeks in the FT distally, the correlation was nonsignificant (Pearson correlation coefficient=0.512, P<0.107). At 12 weeks in the FT distally, the correlation was significant (Spearman correlation coefficient=0.730, P<0.011). At 6 weeks in the FL mesially, the correlation was nonsignificant (Spearman correlation coefficient=0.083, P<0.809). At 12 weeks in the FL mesially, the correlation was nonsignificant (Spearman correlation coefficient=0.062, P<0.856). At 6 weeks in the FL distally, the correlation was nonsignificant (Spearman correlation coefficient=0.197, P<0.562). At 12 weeks in the FL distally, the correlation was significant (Pearson correlation coefficient=0.692, P<0.018).

Conclusions

A larger sample size is recommended to verify the conclusions in this preliminary study. The bone level during the healing period in the FT was more positively correlated with the implant level at implant placement than in the FL.

Flapless Dental Implant Surgery for Patients on Oral Anticoagulants—The “WarLess Procedure”: A Report of 2 Cases

Patients with prosthetic heart valves are maintained on lifelong oral anticoagulant therapy. The optimal anticoagulant management of such patients during surgical dental procedures has been debated for a long time. Compared with conventional dental implant placement, a minimally invasive flapless approach has the potential to reduce bleeding and minimize surgical time, postoperative pain, soft tissue inflammation, and crestal bone. The purpose of these case reports is to show the clinical predictability of dental implant placement using a minimally invasive flapless approach without reducing the dosage of anticoagulants for patients on lifelong anticoagulant therapy. In this study, a 45-year-old woman and a 58-year-old man who had undergone cardiac surgery and were currently under a full therapeutic level of anticoagulation therapy (warfarin) were treated with flapless dental implant surgery without reducing their anticoagulant dosage. Postoperative clinical and radiographic assessment showed no abnormality, minimal signs of inflammation, and excellent healing. The combination of minimally invasive flapless dental implant surgery with no interruption in the normal dose of the anticoagulant medications could be an improved method for placing dental implants in patients on long-term anticoagulant therapy.

Clinical, radiographic, microbiological, and immunological outcomes of flapped vs. flapless dental implants: a prospective randomized controlled clinical trial

OBJECTIVES

The objective of this study was to compare the placement of flapped vs. flapless dental implants utilizing clinical, radiographic, microbiological, and immunological parameters.

MATERIAL AND METHODS

A total of 20 patients received 30 dental implants following a one-stage protocol. The patients were randomly assigned into two study groups: control group with 15 flapped implants and test group with 15 flapless implants. Follow-up examinations were carried out after 1, 2, 6, and 12 weeks. Clinical recordings, sulcular fluid sampling, microbiological analysis, and digital subtraction radiography were utilized to compare the two surgical approaches.

RESULTS

Peri-implant sulcus depth was significantly greater in flapped implants at both 6 and 12 postsurgical weeks (P < 0.001). Flapped implants showed crestal bone loss (0.29 ± 0.06 mm), whereas no bone resorption was detected around flapless implants. Matrix metalloproteinase-8 values were higher to a statistically significant level in the control group at 1 (P = 0.003) and 6 weeks (P = 0.007) after placement. In the test group, the presence of Porphyromonas gingivalis was significantly higher at the 2nd postoperative week (P = 0.005), whereas the counts of Tannerella forsythia were significantly elevated at the 1st (P = 0.005), 2nd (P = 0.001), and 12th (P = 0.002) postoperative weeks, possibly indicating an earlier formation and maturation of the peri-implant sulcus. Patients reported more pain after flapped implant placement.

CONCLUSIONS

Flapless implant placement yielded improved clinical, radiographic, and immunological outcomes compared with flapped implantation. In addition, patients seem to better withstand flapless implant placement.

A 1-year prospective clinical study of soft tissue conditions and marginal bone changes around dental implants after flapless implant surgery

BACKGROUND

Despite several reports on the clinical outcomes of flapless implant surgery, limited information exists regarding the clinical conditions after flapless implant surgery.

OBJECTIVE

The objective of this study was to evaluate the soft tissue conditions and marginal bone changes around dental implants 1 year after flapless implant surgery.

STUDY DESIGN

For the study, 432 implants were placed in 241 patients by using a flapless 1-stage procedure. In these patients, peri-implant soft tissue conditions and radiographic marginal bone changes were evaluated 1 year after surgery.

RESULTS

None of the implants were lost during follow-up, giving a success rate of 100%. The mean probing depth was 2.1 mm (SD 0.7), and the average bleeding on probing index was 0.1 (SD 0.3). The average gingival index score was 0.1 (SD 0.3), and the mean marginal bone loss was 0.3 mm (SD 0.4 mm; range 0.0-1.1 mm). Ten implants exhibited bone loss of >1.0 mm, whereas 125 implants experienced no bone loss at all.

CONCLUSION

The results of this study demonstrate that flapless implant surgery is a predictable procedure. In addition, it is advantageous for preserving crestal bone and mucosal health surrounding dental implants.

Minimally invasive flapless implant placement: follow-up results from a multicenter study

BACKGROUND

The placement of implants using a minimally invasive flapless approach has the potential to reduce operative bleeding and postoperative discomfort and minimize crestal bone loss. This article presents follow-up data on a prospective clinical study of implants placed using a flapless procedure.

METHODS

The original study reported on 57 patients (33 female patients with an age range of 24 to 86 years; 24 male patients with an age range of 27 to 81 years) recruited from three clinical centers (Tucson, Arizona; Gothenburg, Sweden; and Tel Aviv, Israel) who received 79 implants. After an average of 3 years and 8 months, the patients were contacted and invited to return to their respective clinics for reexamination. Thirty-seven patients with 52 implants returned for a follow-up examination; the remaining 20 patients (27 implants) were not available for reexamination and were considered study drop-outs.

RESULTS

The cumulative survival rate at the 3- to 4-year follow-up examination remains at 98.7%, reflecting the loss of one implant. The mean probing depth at abutment connection was 2.2 mm, as reported in the initial study (examination 2 at approximately 2 years postplacement); it was 2.4 mm at the 3- to 4-year second follow-up examination. This change was not clinically or statistically significant. Bleeding score changes also were not significant between the two intervals. The average crestal bone level was -0.7 mm at examination 2 and -0.8 mm at examination 3, a change that approached significance (P <0.06).

CONCLUSIONS

Minimally invasive flapless surgery offers patients the possibility of high implant predictability with clinically insignificant crestal bone loss for up to 4 years. Proper diagnosis and treatment planning are key factors in achieving predictable outcomes.