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Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 11-15

Effect of Flap and Flapless Implant Surgical Techniques on Soft and Hard Tissue Profile in Single-Stage Dental Implants

Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication9-Aug-2019

Correspondence Address:
Dr. Deepa Anumala
Department of Periodontics, CKS Teja Institute of Dental Sciences, Tirupati, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_127_18

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Introduction: Over the past 30 years, flap designs for implant surgery have been modified and atraumatic technique was introduced. It has several potential advantages, including reduction of complications at the patient level. The aim of the present study to compare the soft tissue profile and heights of crestal bone levels around the single-stage implants after single-piece implant placement with two different surgical techniques, that is, open flap procedure and flapless (FL) procedure. Materials and Methods: Thirty participants were randomly selected and categorized into two groups. Group 1 (flap technique) and Group 2 (flapless technique) consisted of 15 participants each. All of these participants underwent evaluation of soft tissue parameters of papillary index, probing pocket depth, sulcus bleeding index, and hard tissue evaluation such as crestal bone levels by radiovisiography at 0, 3, and 6 months. Results: All clinical parameters improved in FL technique when compared with the flap technique. Conclusion: The results concluded that the FL implant surgery results in lesser loss of interproximal bone and also results in better soft tissue changes when compared with the flap technique. However, controlled, further studies are needed to confirm this possibility.

Keywords: Crestal bone loss, flap; flapless; modified sulcus bleeding, papillary index, pocket probing depth

How to cite this article:
Anumala D, Haritha M, Sailaja S, Prasuna E, Sravanthi G, Reddy NR. Effect of Flap and Flapless Implant Surgical Techniques on Soft and Hard Tissue Profile in Single-Stage Dental Implants. J Orofac Sci 2019;11:11-5

How to cite this URL:
Anumala D, Haritha M, Sailaja S, Prasuna E, Sravanthi G, Reddy NR. Effect of Flap and Flapless Implant Surgical Techniques on Soft and Hard Tissue Profile in Single-Stage Dental Implants. J Orofac Sci [serial online] 2019 [cited 2023 Jun 9];11:11-5. Available from:

  Introduction Top

Implant dentistry has undergone drastic changes in the last few decades. The principles, hypothesis, and method of treatment have changed considerably. In recent times, the treatment of edentulism using implant therapy has undergone an array of changes to its various phases. Included among these are the use of single-stage implant placement with a flapless (FL) surgical approach.[1]

Dental implants generally present with multiple therapeutic possibilities, a high predictability of success, and are considered to be a reliable approach to replace missing teeth regardless of any disease or injury of the stomatognathic system. Simply put, an implant is said to be successful if it is osseointegrated well with the host bone and is able to sustain occlusal stress during function.[2]

Traditionally, access for implant placement has been by a flap approach. In the late 1970s, Branemark established the use of extensive surgical flaps to visualize the surgical field during implant surgery. According to this protocol, an incision in the mucosa or the mucobuccal fold was made and then a flap was reflected to expose the underlying bone. The implants were then placed and the flaps repositioned with sutures. However, flap elevation is always associated with some degree of morbidity and discomfort, and it also requires suturing to close the surgical wound. In the early 1970s, studies demonstrated a correlation between flap elevation and gingival recession, as well as bone resorption, around natural teeth. Furthermore, there have been reports of postsurgical tissue loss from flap elevation, implying that the use of flap surgery for implant placement may negatively influence the esthetic outcomes of the implant.[3]

The FL technique is one of the latest minimally invasive surgical methods of implant placement without the need to raise a mucoperiosteal flap. This procedure has many advantages for the patient as well as for the surgeon; these include a shorter surgical treatment time, minimal bleeding, and less postoperative discomfort for the patient. Another concern regarding the FL technique is the presumption that some amount of epithelial tissue could be carried to the osteotomy site; such a situation is highly undesirable because it might affect the complete osseointegration onto the implant surface.[4]

The two-stage technique in dental implantology, due to raising a full-thickness periosteal flap, results in the possibility of marginal bone loss and soft tissue recession, whereas the FL technique has the potential to minimize crestal bone loss and soft tissue inflammation. Avoiding the creation of a mucoperiosteal flap results in less postoperative patient discomfort and a reduced chance of scar tissue formation. Leaving the periosteum intact on the buccal and lingual aspects of the ridge maintains a better blood supply to the site, reducing the likelihood of resorption. In a single-stage technique, the coronal portion of the implant protrudes through the soft tissue so a second surgical exposure is not necessary as in the two-stage surgical treatment.[4]

The choice of surgical procedure, according to the literature, depends upon its success rate, simplicity, and the experience of the operator, whereas for the patient, comfort is an important criterion. Limited controlled data are available to evaluate the crestal bone height (CBH) after FL implant surgery. In addition, most crestal bone loss occurs in the early phase after implant placement.[2] The purpose of this study is to evaluate and compare the changes in the CBH and marginal soft tissues around single-stage dental implants placed with the “flapless” and the “flap” techniques, for a period of 6 months.

  Materials and Methods Top

Participants who had been diagnosed as partially edentulous were selected from the outpatient section of our department. Detailed medical and dental records were obtained. It was made clear to the patients that their participation was voluntarily, and after obtaining their written consent, they were invited to participate in the study. All eligible participants were thoroughly informed of the nature, potential risks, and benefits of the study. Ethical approval for this study (Ethical Committee Ref. no.: 167/IEC-CKS/Lr/17) was provided by the Ethical Committee IEC of CKS, Tirupati, on November 14, 2017. Patients were selected using the following inclusion criteria: age range from 25 to 50 years, good oral hygiene, partially edentulous, normal-to-thick flat gingival biotype, adequate bone height, and adequate bone width, whereas patients with systemic diseases, smoking, bruxism, presence of active infection, loss of labial crest, pregnancy, and HIV infection were excluded from the study.

Preoperative evaluation of the patient

Thirty patients were selected based on their hematological investigations, diagnostic casts, case history, bone mapping, and radiographs.

Implant selection

Single-stage, single-piece threaded titanium root-form endosseous implants (varying from 8 to 13 mm in length and 3.6 to 5 mm in diameter) were selected based on the available dimensions. Implants (Adin dental implants, ADIN Dental Implant Systems Ltd, Alon Tavor, Afula, Israel) were carefully placed in the prepared sites using the routine protocol with all surgical precautions to avoid implant complications.

Presurgical procedure

Selection of patients was followed by full-mouth scaling, root planning, and oral hygiene instructions. Informed consent was obtained after explaining the proposed nature of the study. A single dose of antibiotic (amoxicillin [500 mg] + clavulanate potassium [125 mg]) was given 1 h before surgery.

Surgical procedure

The surgical field was prepared, isolated, and the area was anesthetized using 2% xylocaine hydrochloride with epinephrine (1:2,00,000). At the implant recipient site of the flap (F) group, a midcrestal incision was made and a sulcular incision was made on the mesial aspects of the adjacent teeth with a Bard-Parker blade no. 15; then a full-thickness flap was elevated. Initial entry was gained with a round bur. The pilot drill was then used to the required depth. A digital radiovisiography was taken to verify the length and angulation of the prepared osteotomy with the pilot drill in place. Incremental drilling was done using drill sizes starting from 2.5 mm. A recommended drill speed of 800 rpm was selected for all drills. The depth gauge was used intermittently to ensure the required depth. The preparation was done carefully progressing over 1 mm every 5 s under copious saline irrigation. The site was then prepared to the required diameter to receive the appropriate implant. The implants were then placed into the osteotomy site and the flaps were approximated and sutured using interrupted sutures (3-0 nonresorbable-braided black-threaded silk). For the FL group, there was no flap elevation. A round tissue punch was used to remove the soft tissue or to drill directly through the soft tissues and the bone. The site preparation was completed similar to the flap group and the implants were placed. Suturing was not required for this group.

Postsurgical procedure

The patients were prescribed amoxicillin (500 mg, three times daily for 5 days) and diclofenac potassium (5 days). The patients were recalled after 14 days for suture removal and oral hygiene was reinforced. The patients were checked at regular intervals. The final metal-ceramic crowns were made 3 months after the surgery.

Clinical and radiographic assessment

The soft and hard tissue changes were evaluated at baseline, and 3 and 6 months after implant placement. Radiovisiography was obtained using a paralleling technique for the measurement of the bone level on the mesial and distal surfaces of the implant.

Statistical analysis

All the recorded clinical and radiographic parameters were entered in the standard pro forma drawn for this study and were subjected to statistical analysis. All of the data were analyzed using a software program (SPSS version 11.5, SPSS Inc., Chicago, IL, USA). A sample size of 15 was taken, and it was found to be adequate to achieve more than 80% power at a level of significance of 0.1. Testing for the validity of normality assumption using standardized range statistics was carried out and it was found that the assumption was valid.

  Results Top

During the interval of 6 months, no implant was lost in either groups and all clinical parameters improved in the FL technique when compared with the flap technique. The mesial papillary index (PI) increased in both the groups (1.000 ± 0.655 to 2.733 ± 0.458 for group 1, and 1.400 ± 0.632 to 2.933 ± 0.258 for group 2); similarly, the distal mean PI also increased from baseline to 6 months for both group 1 and group 2 (0.867 ± 0.743 to 2.433 ± 0.604 for group 1, and 1.000 ± 0.655 to 2.533 ± 0.64 for group 2). When this was compared between the two groups, there was no statistical signification. The modified sulcus bleeding index decreased significantly from baseline to 6 months in the FL technique when compared with the F technique (3.00 to 1.400 ± 0.50 for F, and 2.20 to 0.86 for FL) and it was statistically significant (P < 0.05) at different periods. The mean probing pocket depth (PPD) was 4.96 to 1.09 for the flap group and 2.86 to 0.90 for the FL group. When comparing the two surgical techniques, there was a statistical significance (P < 0.05). Crestal bone loss decreased from baseline to 6 months mesially (0.394 ± 0542 to −0.087 ± 0.802) for the FL technique and increased (0.405 ± 1.248 to 0.733 ± 1.97) for the flap technique. On the distal side, it decreased (0.394 ± 0.542 to 0.080 ± 0762) for the FL technique and also decreased (0.845 ± 0.984 to −0.253 ± 1.975) with the flap technique. When comparing the two groups, the FL method showed decreased bone loss when compared with the flap method and it was not statistically significant (P > 0.05) [Table 1] and [Table 2].
Table 1 Wilcoxon signed rank test to compare mesial papilla, distal papilla, and modified sulcus bleeding index at different point of time

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Table 2 Paired t test for probing and marginal bone level Groups 1 and 2

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  Discussion Top

Over the past 30 years, flap designs for implant surgery have been modified and an atraumatic techni­que was introduced. The atraumatic technique causes less crestal bone resorption that could influence the final aesthetic results. This is because it has several potential advantages, including reduction of complications at the patient level, that is, swelling and pain, reduction of intraoperative bleeding, reduction of surgical time, preservation of soft and hard tissues, and maintenance of blood supply. Therefore, FL implant therapy can be used to preserve the soft tissue profile and increase patient comfort and satisfaction.[2]

Two-stage procedures require a waiting time and a second abutment surgery. A one-piece design with no separate abutment screw for the implant was used in the present study. The advantage of this design is its increased strength, elimination of the risk of the abutment screw loosening, and reduced crestal bone loss due to the nonexistence of a microgap between the abutment and implant.[5]

The aim of the present study was to evaluate and compare the changes in the soft tissues and CBH around single-stage implants placed with “flap” and “flapless” techniques, for a period of 6 months.

In the present study, it was shown that the mesial mean PI increased from baseline to 6 months for both groups 1 and 2; similarly, the distal mean PI also increased from baseline to 6 months for both the groups. The mean PI was higher for the FL technique than the flap technique up to the 6-month interval. The results of the current study showed that the papilla presence index (PPI) increased up to 6 months for both the groups, with no significant difference between the two groups (P > 0.05). These results are in accordance with Oh et al.[6] and Sunitha and Sapthagiri.[7] Oh et al.[6] evaluated clinical parameters including PPI, PPD, modified bleeding index in the flap versus flapless techniques. The results showed that the PPI increased from baseline to 2 months (1.5 to 2.3) and continued increasing up to 6 months (2.16), both mesially and distally. They concluded that the FL implant provides better soft tissue results than the flap surgery; however, there was no significant differences.

The modified sulcus bleeding index was recorded using the index described by Albrektsson et al.[8] The mean modified bleeding index was higher for the flap technique than the FL technique from baseline to 6 months, and it was statistically significant (P < 0.05) at different periods. The present study results agreed with the earlier studies conducted by Rajpal et al.[9] and Ravindran et al.[10]

According to the study by Rajpal et al.,[9] the mean bleeding on probing between the two groups decreased significantly (P < 0.05) from 1 to 6 months, and there was a subsequent decrease (0.125 to −0.100) observed. Another study by Ravindran et al.[10] compared the bleeding index in single-stage implants, placed with the FL technique. The bleeding on probing decreased from baseline to 6 months (0.38 to 0.25).

The PPD of the present study showed a significant decrease from baseline to 6 months in both the groups (P < 0.05). When comparing the two surgical techniques, there was a statistically significant difference from baseline to 6 months. The present results agree with the studies by Atassi[11] and Dereka et al.[12] In the study by Atassi et al., the PPD showed a slight increase of up to 3 months (1.4 to 1.6) and then it decreased (1.6 to 1.2) up to 9 months (P > 0.05); this indicates that the implant mucosa was kept in a healthy condition.[11] According to the study by Dereka et al., which compared the PPD in single-stage implants at 4 and 12 weeks,[12] there was a reduction in mean PPD overtime (2.55 to 2.44) and the P value was >0.05.

The assessment of marginal bone levels and periimplant soft tissues has become an integral part of the evaluation of the implant patient and is usually a significant indicator of implant health. The present study showed that the mean change in the mesial marginal bone level from baseline to 6 months in the FL technique was lower than in the flap technique but there was no statistical significance in both the groups (P > 0.005). Similarly, on the distal side, the bone mean changed from baseline to 6 months for the FL technique, which was lower than the flap technique (P > 0.005). This shows that the loss of bone during the 6-month period on the mesial and distal side of the implant placed with the FL method was lower when compared to those placed using the flap method.

These results were in accordance with the previous research by Sunitha and Sapthagiri.[7] In their results, the mean bone loss was greater for the flap group when compared with the flapless group (P > 0.005).[4] Shibu et al. found that FL implant surgery has improved crestal bone levels and osseointegration compared with the conventional technique.[13] A study by Abdul-Saheb et al.[14] concluded that the FL implant placement ensures less bone level reduction when compared with the flap technique.[14]

The findings of the present study demonstrate that the mean bone loss was less after FL implant surgery and that no implants failed to osseointegrate. The lower rate of crestal bone loss in the present study may be due to our use of a tissue punch that was narrower than the implant itself. Another explanation for the high success rate may be that when flaps are not reflected, the periosteum is preserved, which may help to optimize the healing of the periimplant tissue. Therefore, the FL technique can be considered as a better treatment approach for the placement of implants.

Limitations of the study

The main limitation of this study was the short observational period. The second limitation was the small number of samples. The third limitation was the difficulty in standardizing the selection of the participants. To obtain more accurate findings when comparing the parameters in the study, the variables need to be standardized. Future long-term studies with a higher sample size and a better standardization procedure for patient selection are recommended.

  Conclusion Top

Our results concluded that FL implant surgery results in a lower loss of interproximal bone and also results in better soft tissue changes when compared with the flap technique. However, further studies with more control are needed to confirm this possibility.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Andreasi Bassi M, Andrisani C, Lico S, Silvestre F, Gargari M, Arcuri C. Increasing volume of vestibular soft tissues in flapless implant surgery through a modified connective punch technique: a controlled clinical trial. Oral Implantol (Rome) 2016;9:143-50.  Back to cited text no. 1
Vohra F, Al-Kheraif AA, Almas K, Javed F. Comparison of crestal bone loss around dental implants placed in healed sites using flapped and flapless techniques: a systematic review. J Periodontol 2015;86:185-91.  Back to cited text no. 2
Wadhwa B, Jain V, Bhutia O, Bhalla AS, Pruthi G. Flapless versus open flap techniques of implant placement: a 15-month follow-up study. Indian J Dent Res 2015;26:372-7.  Back to cited text no. 3
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Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants 2009;24:118-25.  Back to cited text no. 4
Mantena SR, Sivagami G, Gottumukkala SN. Evaluation of crestal bone loss and stability of immediate functional loading versus immediate non-functional loading of single-mandibular posterior implants: a pilot randomized controlled clinical trial. Dent Res J (Isfahan) 2014;11:585-91.  Back to cited text no. 5
Oh TJ, Shotwell JL, Billy EJ, Wang HL. Effect of flapless implant surgery on soft tissue profile: a randomized controlled clinical trial. J Periodontol 2006;77:874-82.  Back to cited text no. 6
Sunitha RV, Sapthagiri E. Flapless implant surgery: a 2-year follow-up study of 40 implants. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:237-43.  Back to cited text no. 7
Albrektsson T, Buser D, Sennerby L. Crestal bone loss and oral implants. Clin Implant Dent Relat Res 2012;14:783–91.  Back to cited text no. 8
Rajpal J, Gupta KK, Tandon P, Srivastava A, Chandra C. Assessment of hard and soft tissue changes around implants: a clinico-radiographic in vivo study. J Dent Implant 2014;4:126-34.  Back to cited text no. 9
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Ravindran DM, Sudhakar U, Ramakrishnan T, Ambalavanan N. The efficacy of flapless implant surgery on soft-tissue profile comparing immediate loading implants to delayed loading implants: a comparative clinical study. J Indian Soc Periodontol 2010;14:245-51.  Back to cited text no. 10
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Atassi F. Periimplant probing: positives and negatives. Implant Dent 2002;11:356-62.  Back to cited text no. 11
Dereka X, Mardas N, Chin S, Petrie A, Donos N. A systematic review on the association between genetic predisposition and dental implant biological complications. Clin Oral Implants Res 2012;23:775-88.  Back to cited text no. 12
Shibu J, Vinaya B. An insight into flapless implant placement technique. J Indian Prosthodont Soc 2008;8:140-3.  Back to cited text no. 13
Abdul-Saheb A, Abdul-Saheb R, Fatihallah A. Comparison between flapped and flapless implant techniques by measuring crestal bone level: a prospective radiographical trial. Iraqi Dent J 2015;37:51-5.  Back to cited text no. 14


  [Table 1], [Table 2]

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