Flapless or Flap Protocol?

When placing dental implants, a flap is traditionally elevated to better visualize the implant recipient site. When a limited amount of bone is available, a flap elevation reduces the risk of bone fenestrations or perforations [1]. The concept of flapless implant surgery has been introduced for the patients with sufficient keratinized gingival tissue and bone volume in the implant recipient site.

In a flapless procedure, a dental implant is installed through the mucosal tissues without reflecting a flap. The alleged reasons to choose the flapless technique are to minimize the possibility of postoperative peri-implant tissue loss and to overcome the challenge of soft tissue management during or after surgery [2]. Other alleged advantages of the flapless implant surgery include less traumatic surgery, decreased operative time, rapid postsurgical healing, fewer postoperative complications and increased patient comfort [3], [4].

But which approach achieves better long-term clinical results? A recent study, investigated this issue, by measuring marginal bone changes and peri-implant conditions 8.5 years after placement of one-piece implants with an anodically oxidized surface (AOS) using a flapless or flap protocol.[5]

The conclusion:

Similar mean levels of probing pocket depth (PPD) were found in flap and flapless groups (mean [SD] = 2.4 [0.3] and 2.2 [0.4] mm, respectively [P = .18]), as well as similar rates of presence of bleeding on probing (22.8% vs 17.9%, respectively). Papilla levels increased during the first year after implant loading. However, there was little additional change between 1.5 and 8.5 years. A total of eight fractured porcelain crowns and three crown loosenings were reported. One-piece implants with an AOS showed high survival rates and stable marginal bone and periimplant soft tissue levels regardless of whether a flapless or flap protocol was used.[5]

In your practical experience have you see a difference in clinical outcomes between a flapless or flap protocol?

1. Ozan O, Turkyilmaz I, Yilmaz B (2007) A preliminary report of patients treated with early loaded implants using computerized tomography-guided surgical stents: flapless versus conventional flapped surgery. J Oral Rehabil 34: 835“840. [PubMed]

2. Rocci A, Martignoni M, Gottlow J (2003) Immediate loading in the maxilla using flapless surgery, implants placed in predetermined positions, and prefabricated provisional restorations: a retrospective 3-year clinical study. Clin Implant Dent Relat Res 5(Suppl ()) 29“36. [PubMed]

3. Arisan V, Karabuda CZ, Ozdemir T (2010) Implant surgery using bone- and mucosa-supported stereolithographic guides in totally edentulous jaws: surgical and post-operative outcomes of computer-aided vs. standard techniques. Clin Oral Implants Res 21: 980“988. [PubMed]

4. Sunitha RV, Sapthagiri E (2013) Flapless implant surgery: a 2-year follow-up study of 40 implants. Oral Surg Oral Med Oral Pathol Oral Radiol 116: e237“e243. [PubMed]

5. Survival Rates and Bone and Soft Tissue Level Changes Around One-Piece Dental Implants Placed with a Flapless or Flap Protocol: 8.5-Year Results.., Int J Periodontics Restorative Dent. 2017 May/Jun; Froum SJ et al.