Full Flap or Flapless: Which Will Give Optimum Esthetics?

Dr. B You do not give any details as to the existing ridge conditions: Is the ridge flat? Has there been some papilla preservation temporization done? How much of the maxillary incisors is evident when the patient smiles? If you have excellent surgical skills and a great cosmetically oriented lab, and follow the proper principles of placement in the esthetic zone, you can have a good long term outcome. If you have not done many of these, I would suggest modifying your treatment plan to implants in the 7 and 9 positions and a nice 3 unit bridge with #8 as a pontic. Three adjacent implants in the maxillary centrals and lateral positions require great attention to detail in biologic and prosthetic principles for a good long term outcome. Hope this helps, and good luck! Carlos Boudet, DDS

I am sorry, I did not address your original question. I would use a surgical flap definitely. It would give you the option to see the available bone, deficiencies, and the ability to do any augmentation required such as bone grafts or subepithelial connective tissue grafts for improving biotype, papilla formation, etc... Carlos Boudet, DDS

I would take a perio probe on the buccal and feel for dehisences(of course the patient will be numb Ha!)I would also look at the biotype of the tissue. Thin biotype will cause be an esthetic chalenge if yu flap. The other problem is that flappless is nice but you have to be able to remove the toooth without fx the bone. flappless takes longer to do and it is hard to visulaize the integrity of the bone. I think if you are asking this question you may try at first to go flappless but if you are having difficulty flap. With a full flap you know what you are drilling into. I will tell you if you do flappless sound the osteotomy with a probe to make sure you are not perforating to the buccal. Good Luck Oh Yeh! Hi Carlos!

It looks like you have good advice on the surgical side...just wanted to reiterate the option of implants in #7, & 9 position and #8 as a pontic. I think that you will have a bit more control in shaping the soft tissue to give a papilla like appearance, the pontic portion can be modified to aid in shaping the soft tissue.

Dear Dr. B: It is very important the assessment of the soft tissue morphology on the edentulous site. A flat tissue will make it extremely difficult to develop papillae that it is going to greatly improve esthetics. More complicated if there are three implants together. I have treated similar situations with two implants and a carfully developed ovate pontic site, as well as the emergence profile at the implant sites allowed me fantastic cosmetic results. I highly recommend the fabrication of a diagnostic wax-up that shows the exact mesial-distal and facial-lingual contour of the teeth as well as an ideal incisal position. Fabricate a scan guide and have a CTscan done prior to surgery. The resulting DICOM file should be processed into a Simplant format. The beauty of this is that you will have a 3D view of the surgical site for a more accurate assessment of the implant site selection and case planning. After that is done, then locate the emergence axis and place implants, verify position and paralellism of the implants and adjacent teeth. Evaluate for possible fenestrations of cortical plates, determine bone density, order the surgical guide. I believe this is one of the most accurate ways to plan and execute the case. Flapless or full thickness flap? For flapless, a minimally invasive technique,lack of visibility makes it more difficult. You need an adequate zone of keratinized tissue, carefully selected platform position and depth, enough thickness of bone facially (there may be a need for bone leveling and or bone graft). I think the use of computer assisted surgical guide helps to reduce the difficulty. With the full thickness flap you have a complete visualization of the field but it does not guarantee you an esthetic success. In addition it is more invasive and the post-op is longer and may be less comfortable for the patient.

Dr Marco's commets are good In maxilla I prefer to use only initial drill & then use osteotomes tapping to create osteotomy site. Its saves bone & also condenses it . Ofcourse if CT Scan & 3D evaluation is not available or possible then raising the flap is always better. shyam

The protocol I described above is valid for both maxilla and mandible.

I would strongly suggest an open procedure. Even in the aesthetic zone the incisions can be distalized {and should be}away from the implant site.I am always prepared to possibly graft in these cases despite preop planning with models ,stents, ct etc .I would agree to look at the option of two implants as it gives a bit of leeway in positioning and allows for better tissue modification with the temp prosthesis as and when needed.Remember the same basic rules apply with regard to depth, bucco-lingual position, keratinized tissue, papillae etc.If you have not done many Iwould suggest a two stage protocol. Good Luck

You may have to develop the site with am osterplasty and gingivoplasty prior to implant placement. Try not to place the implant to labial or you will have loss of the labial plate. Also fixate asap by bonding to the adjacient teeth, which should be nonmobile.

With regard to Dr Hughes comments. All teeth are mobile (unless ankylosed) so implants, especially newly placed and healing ones, should never be fixed to teeth.

Mike Heads, No you took it wrong. Implants should not be anchored to teeth with pathologic mobility. When placing immediate implants or any implant, the adjacent teeth should now have said mobility. Thus, you will place way too much load on the implant. It's elementary!

Dear Dr.B. FIRST OF ALL you should evaluate the patient, but exept in perfect cases w/c is rare, try to make a flap in esthetic cases not only to be able to check the soft and hard tissues, but also to increase the volume of bone labially to avoid future bone loss and to boost the soft tissue if needed. check the ff. CT to know the height and width of the available bone. IS IT A HEALED RIDGE OR FRESH SOCKET ? gingival biotype ,high or low lip line ,age ,the patient desire, the need to augment the bone or soft tissue , and YOUR ABILITY TO MAKE IT. In easy cases it is easier to place 2 implants and a pontic in between,use a surgical stent to guide, and many things more.... HOPE IT HELPS A BIT, good luck.