• Users Online: 900
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
REVIEW
Year : 2021  |  Volume : 21  |  Issue : 4  |  Page : 328-338

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


Department of Prosthodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India

Date of Submission10-May-2021
Date of Decision08-Sep-2021
Date of Acceptance01-Oct-2021
Date of Web Publication09-Nov-2021

Correspondence Address:
Krishankumar Lahoti
Department of Prosthodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jips.jips_208_21

Rights and Permissions
  Abstract 


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 = 0.01*). 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=0.02*).
Conclusions: Flapless placement of implant can positively influence crestal bone loss in comparison with conventional flap technique.

Keywords: Crestal bone level, dental implant, flapless, guided flapless


How to cite this article:
Lahoti K, Dandekar S, Gade J, Agrawal M. Comparative evaluation of crestal bone level by flapless and flap techniques for implant placement: Systematic review and meta-analysis. J Indian Prosthodont Soc 2021;21:328-38

How to cite this URL:
Lahoti K, Dandekar S, Gade J, Agrawal M. Comparative evaluation of crestal bone level by flapless and flap techniques for implant placement: Systematic review and meta-analysis. J Indian Prosthodont Soc [serial online] 2021 [cited 2021 Dec 7];21:328-38. Available from: https://www.j-ips.org/text.asp?2021/21/4/328/330178




  Introduction Top


Dental implants facilitate mastication, phonation, and esthetics and are one of the most common treatment modalities used for the rehabilitation of missing teeth. To provide support for the dental prosthesis, implants form a direct connection with the surrounding bone known as “osseointegration.”[1] Enhancing patient comfort and predictability of treatment with precise presurgical treatment planning have been the goals of evolving implant dentistry.[2]

Branemark has advocated flap elevation technique for implant placement since the 1970s. The protocol by Branemark placed the incision line and sutures away from the implant location, reducing the risk of infection at the surgical site location.[3],[4] The current advancements and incorporation of new technologies have led to an approach wherein the implants can be placed with minimal incision either freehand or with the assistance of surgical guide. Sustained efforts to incorporate this minimally invasive flapless technique have been made in the field of implantology. Although the scientific evidence to prove the accuracy is still not considered adequate, many researchers advocate this approach based on their assessment of the literature.[5],[6],[7] Chrcanovic et al. in 2014[5] in their systematic review stated that flapless approach significantly influenced the implant survival rate compared to conventional surgery. Lin et al.[6] and Lemos et al.[7] could not establish a significant difference in the survival rate or crestal bone loss between the two techniques. Although freehand implant placement is not considered as accurate as guided flapless surgery as reported by Nickenig et al. in 2010,[8] a review by Voulgarakis et al. in 2014[9] suggested that the surgical guides did not significantly influence the outcome.

No real conclusion has been reached to date which would clearly state the benefit of one approach over the other. This systematic review was thereby designed to compile the literature and compare the flapless and flap techniques in terms of crestal bone level.


  Materials And Methods Top


This systematic review was designed and performed in accordance with PRISMA guidelines laid down in 2015.[10] A specifically formulated protocol was registered with PROSPERO (CRD42020162689) before the start of the review.

Study question

“How is the crestal bone level by flapless technique compared to flap technique for dental implant placement?” which fulfills the PICOS framework [Table 1].
Table 1: PICOS framework

Click here to view


Search strategy

Electronic search of MEDLINE and Google Scholar from 2010 to March 2020 was performed. Subject AND Adjective combinations were used:

Subject: Dental implant OR dental implant placement AND Adjective: flapless technique OR flapless placement OR open flap OR flap elevation OR flapless surgery OR Keywords – combinations of the following keywords: “crestal bone level;” “dental implant;” “surgery;” “flap;” and “flapless;” “Flapless versus Flap surgery;” and “crestal bone loss.” Furthermore, a manual search was conducted based on the references of selected studies.

Inclusion criteria

  1. Studies on patients requiring rehabilitation with dental implant
  2. Studies which had data regarding the crestal bone level of both the intervention and comparison groups
  3. Prospective clinical studies
  4. Full-text access of article
  5. Primary language of article: English.


Exclusion criteria

Duplicate studies, In vitro studies, case reports, opinions, letters, and reviews.

Data collection

After the studies were scanned for information, relevant data were tabulated which comprised authors of the study, study year, technique of placement, crestal bone changes, and other outcome measures. Any disagreements were resolved by discussion. The data were compiled to perform meta-analysis.

Risk of bias for individual studies

Bias assessment for randomized studies was done based on the fulfillment of criteria of sequence generation, blinding, allocation concealment, and addressed outcome measures. For nonrandomized studies, the Newcastle–Ottawa scale was used.

Statistical analysis

Crestal bone level was the primary outcome measure, which was treated as a continuous data variable. Aggregate analysis using a fixed-effects model and a random-effects model was carried out. Heterogeneity was tested. Forest plot was generated showing standardized mean difference as the effect measure. Funnel plot was drawn to check for publication bias. The analysis was performed by using Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.


  Results Top


Study selection

Four thousand four hundred and forty-three records were obtained by the selection process [Figure 1]. After removing duplicate records, 2343 were held back. Fifty-seven records were reached after 2286 were scanned according to eligibility criteria. Thirty-four articles were removed after full-text reading for reasons mentioned in [Table 2]. In the end, only 23 articles were retained for meta-analysis.
Figure 1: PRISMA flow diagram for study selection process

Click here to view
Table 2: List of excluded studies

Click here to view


Description of included studies

This review consisted of 23 studies listed in [Table 3]. Total data from 948 patients rehabilitated with 1407 implants were included. Of the 23 studies, 3 studies had a follow-up time of up to 3 months.[43],[56],[58] Six had a long follow-up of 3 years or more.[42],[46],[47],[48],[51] In 8 studies, flapless surgery was done with the help of computed tomography (CT)-guided or surgical stent,[56],[46],[47],[48],[54],[59],[61] while the remaining 15 were performed by the freehand approach. Some studies used a submerged protocol,[41],[44],[53],[56] whereas others used a nonsubmerged protocol,[40],[43],[45],[49],[51],[52],[57],[58],[60] and two studies involved both the protocols.[46],[55] Loading time of the implants was also mentioned in the studies. In five studies, implants were loaded immediately or early for both the groups.[43],[50],[59],[60],[61] Fourteen studies applied a delayed loading protocol,[40],[41],[42],[44],[45],[47],[48],[49],[51],[52],[53],[54],[55],[57] whereas two studies[46],[54] involved both protocols of loading, and in two studies, the implants were not loaded.[56],[58]
Table 3: Description of studies

Click here to view


Among the 23 studies, 694 implants were placed by flapless technique and 713 implants were placed by flap technique. Implant survival ranged from 87.2% to 100% for flapless implant placement and 93.3% to 100% for flap technique. 100% survival was found in 10 studies.[42],[45],[47],[49],[53],[55],[56],[57],[58],[59] Significant results indicating less crestal bone loss with flapless technique were reported by studies.[42],[44],[49],[51],[57],[58]

Risk of bias assessment of the studies

The Newcastle–Ottawa scale, as shown in [Table 4]a, showed that all the studies had low bias considering the number of stars. For randomized studies, if studies did not fulfill two or more of the four criteria, the risk of bias was considered high. Among the ten randomized studies, five were low risk,[41],[45],[57],[60],[61] two were judged to be at moderate risk,[46],[47] and the remaining three were at high risk of bias [Table 4]b.[41],[44],[48]
Table 4:

Click here to view


Meta-analysis of the studies

Twenty-three studies were included with 1407 implants placed in 948 patients. On account of the heterogeneity (Tau2 = 0.04, Chi-square = 126.96, df = 21, P < 0.00001; I2 = 83%), a random-effects model was used. Meta-analysis revealed statistically significant difference in crestal bone level with MD of −0.14 (flapless placement vs. flap surgery; 95% confidence interval [CI]: −0.24–−0.03; P = 0.01*), indicating the positive effect of flapless technique on the outcome measure in comparison with flap technique, as shown in [Figure 2].
Figure 2: Forest plot of meta-analysis results comparing crestal bone level of flapless and flap surgery groups

Click here to view


For subgroup analysis, meta-analysis of eight studies was performed. Low heterogeneity (Chi-square = 7.77, df = 7, P = 0.35; I2 = 10%) led to the fixed-effects model. The results indicated that the difference in crestal bone level between these guided flapless and flap technique groups was not statistically significant with a mean difference of −0.05 (guided flapless placement vs. flap surgery; 95% CI: −0.10–0.00; P = 0.06) [Figure 3]. Subgroup analysis of the freehand flapless surgery with flap surgery generated a random-effects model due to the high heterogeneity (Tau2 = 0.07, Chi-square = 110.60, df = 13, P < 0.00001; I2 = 88%) with MD of −0.20, which was found to be statistically significant (freehand flapless placement vs. flap surgery; 95% CI: −0.37–−0.03; P = 0.02*) [Figure 4].
Figure 3: Forest plot of meta-analysis results comparing crestal bone level of guided flapless and flap surgeries

Click here to view
Figure 4: Forest plot of meta-analysis results comparing crestal bone level of freehand flapless and flap surgery groups

Click here to view


Publication bias

Funnel plot indicated the absence of publication bias, as shown in [Figure 5], [Figure 6], [Figure 7].
Figure 5: Funnel plot for studies reporting outcome of crestal bone levels of freehand flapless and flap surgeries

Click here to view
Figure 6: Funnel plot for studies reporting outcome of crestal bone levels of guided flapless and flap surgeries

Click here to view
Figure 7: Funnel plot for studies reporting outcome of crestal bone levels of freehand flapless and flap surgeries

Click here to view



  Discussion Top


Implant placement with flap reflection is a traditional well-accepted approach, while flapless placement has been an experimental evolving technique which still requires a backup of substantial evidence. It is much of a controversy with versatile opinions, and no specific conclusion has still been reached. Thus, this review was aimed to compare the available literature to reach a more specific conclusion with evidentiary support from meta-analysis.

Narrowing the inclusion criteria to only randomized trials could have enhanced the homogeneity, but it was noticed that it could exclude several studies with significant data.

The latest meta-analysis concerning the outcome was published in 2020 by Cai et al.[25] They included only six studies with high heterogeneity (I2 = 78%) in the meta-analysis and failed to state a statistical difference in long-term crestal bone loss. Results of the analysis performed by Cai et al.[25] should be interpreted with caution because of the limited number of studies included. Furthermore, they included only the long-term studies which excluded all the literature published after 2017.

In this meta-analysis, 23 studies were included. The result showed that the flapless placement significantly reduced the crestal bone loss with the mean difference of −0.14. This reduced bone loss could be explained by intact periosteum and blood supply which is a known advantage of flapless technique.[62] In flap technique, the branches of supraperiosteal vessels get compromised, affecting the blood supply.[63] Kim et al. in 2009[64] in their study on dogs stated that flapless implant placement presented a much richer vascularization. Al Juboori et al.[58] and Kim et al.[64] attributed lesser bone with flapless technique to the excellent defense to bacterial invasion because of the intact bloody supply. Jeong et al. in 2007[65] showed that sites with flapless technique had a greater bone–implant contact and less bone loss. Similar findings of reduced bone loss with flapless technique were noted by You et al.,[66] Mazzocco et al.,[37] Kumar et al.,[41] Shamsan et al.,[44] Maier,[49] and Sunitha and Sapthagiri.[55] The flapless technique ensures a favorable healing environment for the soft-tissue architecture as well as hard-tissue volume with reduced time for stable remodeling.[67]

Studies[50],[61] with the view that flapless surgery leads to more crestal bone loss than conventional flap failed to prove a significant difference. One of the reasons for more bone loss associated with flapless technique could be because of the contamination of the surgical site with the epithelial and connective tissue cells from the oral mucosa.[68]

Interestingly, several studies[45],[48],[51],[53],[56],[59] and reviews[5],[20] showed comparable outcome with both the surgical techniques. The flapless surgery can thus be considered as an acceptable treatment option based on the evidence obtained from the literature. The use of CT scans, advanced planning software, surgical guides, and dynamic navigation systems can help to improve the predictability and precision.

Subgroup analysis comparing the guided flapless approach with the conventional surgery did not yield a significant result. This could be attributed to the limited data available and the variability of the guided approach used. Furthermore, there remain concerns with the deviations in the inclination and positioning of implants by flapless surgery from the ideally planned position, which could affect the outcome.[5]

Comparison of the freehand flapless placement with conventional surgery showed a significant difference, indicating that flapless surgery can affect the crestal bone loss even without the use of a guided approach.

Based on the results of this study, the choice of surgical technique significantly affects crestal bone level which is in agreement with a previous systematic review by Zhuang et al. in 2018.[23] However, the studies included have high heterogeneity, and the authors in cases of doubt have opted for direct visualization of the surgical field. Presurgical planning is a must to reduce the possible complications. The fear of such complications should not stop the clinicians to acknowledge the benefits that the flapless technique can provide. With the upcoming digital trends in implantology, flapless surgeries have the capacity to evolve with a greater safety margin.

The results of this review should be interpreted with caution because of its limitations. Confounding factors may have affected the outcomes. Further, less emphasis was given on local or systemic condition of patients. Furthermore, heterogeneity of the included studies was high. Double-blinded randomized controlled trials with broader pool of patients to determine the effect of flapless implant surgery on patient outcome variables are required to reach definitive conclusions.


  Conclusions Top


  1. Flapless technique of dental implant placement has significantly less crestal bone loss compared to the flap technique. Therefore, flapless implant surgery can be considered as a promising alternative to conventional flap
  2. The use of a guided or freehand approach of flapless surgery both showed less crestal bone loss compared to flap surgery; however, significant results could not be obtained.


Acknowledgment

The authors acknowledge Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, and all the concerned authorities for the opportunity to work on this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100.  Back to cited text no. 1
    
2.
Lindeboom JA, van Wijk AJ. A comparison of two implant techniques on patient-based outcome measures: A report of flapless vs. conventional flapped implant placement. Clin Oral Implants Res 2010;21:366-70.  Back to cited text no. 2
    
3.
Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25.  Back to cited text no. 3
    
4.
Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1-132.  Back to cited text no. 4
    
5.
Chrcanovic BR, Albrektsson T, Wennerberg A. Flapless versus conventional flapped dental implant surgery: A meta-analysis. PLoS One 2014;9:e100624.  Back to cited text no. 5
    
6.
Lin GH, Chan HL, Bashutski JD, Oh TJ, Wang HL. The effect of flapless surgery on implant survival and marginal bone level: A systematic review and meta-analysis. J Periodontol 2014;85:e91-103.  Back to cited text no. 6
    
7.
Lemos CA, Verri FR, Cruz RS, Gomes JM, Dos Santos DM, Goiato MC, et al. Comparison between flapless and open-flap implant placement: A systematic review and meta-analysis. Int J Oral Maxillofac Surg 2020;49:1220-31.  Back to cited text no. 7
    
8.
Nickenig HJ, Wichmann M, Schlegel KA, Nkenke E, Eitner S. Radiographic evaluation of marginal bone levels during healing period, adjacent to parallel-screw cylinder implants inserted in the posterior zone of the jaws, placed with flapless surgery. Clin Oral Implants Res 2010;21:1386-93.  Back to cited text no. 8
    
9.
Voulgarakis A, Strub JR, Att W. Outcomes of implants placed with three different flapless surgical procedures: A systematic review. Int J Oral Maxillofac Surg 2014;43:476-86.  Back to cited text no. 9
    
10.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol 2009;62:1006-12.  Back to cited text no. 10
    
11.
Nikzad S, Azari A. Custom-made radiographic template, computed tomography, and computer-assisted flapless surgery for treatment planning in partial edentulous patients: A prospective 12-month study. J Oral Maxillofac Surg 2010;68:1353-9.  Back to cited text no. 11
    
12.
Jeong SM, Choi BH, Kim J, Xuan F, Lee DH, Mo DY, et al. A 1-year prospective clinical study of soft tissue conditions and marginal bone changes around dental implants after flapless implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:41-6.  Back to cited text no. 12
    
13.
Lee DH, Choi BH, Jeong SM, Xuan F, Kim HR. Effects of flapless implant surgery on soft tissue profiles: A prospective clinical study. Clin Implant Dent Relat Res 2011;13:324-9.  Back to cited text no. 13
    
14.
Tee YL. Minimally invasive surgical placements of nonsubmerged dental implants: A case series report, evaluation of the surgical technique and complications. J Oral Implantol 2011;37:579-87.  Back to cited text no. 14
    
15.
Kareem JJ, Al Garrawi HA, Badeia R. A clinical assessment of peri-implant marginal bone loss and soft tissue status in dental implant placed by flapless implant surgery. Mustansiria Dent J 2012;9:70-82.  Back to cited text no. 15
    
16.
Oliver R. Flapless dental implant surgery may improve hard and soft tissue outcomes. J Evid Based Dent Pract 2012;12:87-8.  Back to cited text no. 16
    
17.
Komiyama A, Hultin M, Näsström K, Benchimol D, Klinge B. Soft tissue conditions and marginal bone changes around immediately loaded implants inserted in edentate jaws following computer guided treatment planning and flapless surgery: A ≥1-year clinical follow-up study. Clin Implant Dent Relat Res 2012;14:157-69.  Back to cited text no. 17
    
18.
Altinci P, Can G, Gunes O, Ozturk C, Eren H. Stability and marginal bone level changes of SLActive titanium-zirconium implants placed with flapless surgery: A prospective pilot study. Clin Implant Dent Relat Res 2016;18:1193-9.  Back to cited text no. 18
    
19.
Jesch P, Jesch W, Bruckmoser E, Krebs M, Kladek T, Seemann R. An up to 17-year follow-up retrospective analysis of a minimally invasive, flapless approach: 18 945 implants in 7783 patients. Clin Implant Dent Relat Res 2018;20:393-402.  Back to cited text no. 19
    
20.
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. 20
    
21.
Romero-Ruiz MM, Mosquera-Perez R, Gutierrez-Perez JL, Torres-Lagares D. Flapless implant surgery: A review of the literature and 3 case reports. J Clin Exp Dent 2015;7:e146-52.  Back to cited text no. 21
    
22.
Llamas-Monteagudo O, Girbés-Ballester P, Viña-Almunia J, Peñarrocha-Oltra D, Peñarrocha-Diago M. Clinical parameters of implants placed in healed sites using flapped and flapless techniques: A systematic review. Med Oral Patol Oral Cir Bucal 2017;22:e572-81.  Back to cited text no. 22
    
23.
Zhuang J, Zhao D, Wu Y, Xu C. Evaluation of outcomes of dental implants inserted by flapless or flapped procedure: A meta-analysis. Implant Dent 2018;27:588-98.  Back to cited text no. 23
    
24.
Yadav MK, Verma UP, Parikh H, Dixit M. Minimally invasive transgingival implant therapy: A literature review. Natl J Maxillofac Surg 2018;9:117-22.  Back to cited text no. 24
[PUBMED]  [Full text]  
25.
Cai H, Liang X, Sun DY, Chen JY. Long-term clinical performance of flapless implant surgery compared to the conventional approach with flap elevation: A systematic review and meta-analysis. World J Clin Cases 2020;8:1087-103.  Back to cited text no. 25
    
26.
Arisan V, Karabuda CZ, Ozdemir T. 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 2010;21:980-8.  Back to cited text no. 26
    
27.
Berdougo M, Fortin T, Blanchet E, Isidori M, Bosson JL, Chrcanovic BR, et al. Flapless implant surgery using an image-guided system. A 1- to 4-year retrospective multicenter comparative clinical study. PLoS One 2010;9:980-8.  Back to cited text no. 27
    
28.
Bashutski JD, Wang HL, Rudek I, Moreno I, Koticha T, Oh TJ. Effect of flapless surgery on single-tooth implants in the esthetic zone: A randomized clinical trial. J Periodontol 2013;84:1747-54.  Back to cited text no. 28
    
29.
Meizi E, Meir M, Laster Z. New-design dental implants: A 1-year prospective clinical study of 344 consecutively placed implants comparing immediate loading versus delayed loading and flapless versus full-thickness flap. Int J Oral Maxillofac Implants 2014;29:e14-21.  Back to cited text no. 29
    
30.
Yadav R, Agrawal KK, Rao J, Anwar M, Alvi HA, Singh K, et al. 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. J Prosthodont 2018;27:611-7.  Back to cited text no. 30
    
31.
Gupta R, Luthra RP, Kukreja S. To compare and evaluate the difference in crestal bone loss after implant placement by conventional flap and flapless technique followed by early loading of implants : An in vivo study. Int J Appl Dent Sci 2018;4:213-8.  Back to cited text no. 31
    
32.
Rousseau P, Stoupel J, Lee CT, Glick J, Sanz-Miralles E, Chiuzan C, et al. The clinical and radiographic outcome of implants placed in the posterior maxilla with a guided flapless approach and immediately restored with a provisional rehabilitation: A randomized clinical trial. Clin Oral Implants Res 2010;21:1171-9.  Back to cited text no. 32
    
33.
De Bruyn H, Atashkadeh M, Cosyn J, van de Velde T. Clinical outcome and bone preservation of single TiUnite™ implants installed with flapless or flap surgery. Clin Implant Dent Relat Res 2011;13:175-83.  Back to cited text no. 33
    
34.
Nguyen M, Doan N, Du Z, Reher P, Xiao Y. A measure of clinical outcomes in dental implant surgery flapless surgery versus flap technique in posterior maxilla of post menopause women. IFMBE Proc 2015;46:133-4.  Back to cited text no. 34
    
35.
Yue Q, Hu XL, Lin Y. Study on clinical effectiveness between flap and flapless immediate implant placement in maxillary esthetic zone. Chin J Pr Stomatol 2015;8:410-4.  Back to cited text no. 35
    
36.
Stoupel J, Lee CT, Glick J, Sanz-Miralles E, Chiuzan C, Papapanou PN. Immediate implant placement and provisionalization in the aesthetic zone using a flapless or a flap-involving approach: A randomized controlled trial. J Clin Periodontol 2016;43:1171-9.  Back to cited text no. 36
    
37.
Mazzocco F, Jimenez D, Barallat L, Paniz G, Del Fabbro M, Nart J. Bone volume changes after immediate implant placement with or without flap elevation. Clin Oral Implants Res 2017;28:495-501.  Back to cited text no. 37
    
38.
Danza M, Carinci F. Flapless surgery and immediately loaded implants: A retrospective comparison between implantation with and without computer-assisted planned surgical stent. Stomatologija 2010;12:35-41.  Back to cited text no. 38
    
39.
Kaur T, Kumar S, Jain S, Aggarwal R, Choudhary S, Reddy NK. A radiographic evaluation of peri-implant bone level in immediate and conventionally loaded implants using flap and flapless techniques. J Contemp Dent Pract 2019;20:707-15.  Back to cited text no. 39
    
40.
Anumala D, Haritha M, Sailaja S, Prasuna E, Sravanthi G, Ravindra N. Effect of flap and flapless implant surgical techniques on soft and hard tissue profile in single-stage dental implants. J Orofac Sci 2019;9:22-7.  Back to cited text no. 40
    
41.
Kumar D, Sivaram G, Shivakumar B, Kumar T. Comparative evaluation of soft and hard tissue changes following endosseous implant placement using flap and flapless techniques in the posterior edentulous areas of the mandible – A randomized controlled trial. Oral Maxillofac Surg 2018;22:215-23.  Back to cited text no. 41
    
42.
Naeini EN, Dierens M, Atashkadeh M, De Bruyn H. Long-term clinical outcome of single implants inserted flaplessly or conventionally. Clin Implant Dent Relat Res 2018;20:829-37.  Back to cited text no. 42
    
43.
Singla N, Kumar S, Jain S, Choudhary S, Dandiwal N, Nandalur KR. Crestal bone changes around immediately loaded single-piece implants using flap and flapless technique: A radiographic study. J Contemp Dent Pract 2018;19:949-54.  Back to cited text no. 43
    
44.
Shamsan YA, Eldibany RM, El Halawani GN, Rania A. Flapless versus conventional flap approach for dental implant placement in the maxillary esthetic zone. Alexandria Dent J 2018;43:80-5.  Back to cited text no. 44
    
45.
Wang F, Huang W, Zhang Z, Wang H, Monje A, Wu Y. Minimally invasive flapless vs. flapped approach for single implant placement: A 2-year randomized controlled clinical trial. Clin Oral Implants Res 2017;28:757-64.  Back to cited text no. 45
    
46.
Bömicke W, Gabbert O, Koob A, Krisam J, Peter R. Comparison of immediately loaded flaplessplaced one-piece implants and flapped-placed conventionally loaded two-piece implants, both fitted with all-ceramic single crowns, in the posterior mandible: 3-year results from a randomised controlled pilot trial. Int J Oral Implant 2017;10:179-95.  Back to cited text no. 46
    
47.
Froum SJ, Khouly I. 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;37:327-37.  Back to cited text no. 47
    
48.
Pisoni L, Ordesi P, Siervo P, Bianchi AE, Persia M, Siervo S. Flapless versus traditional dental implant surgery: Long-term evaluation of crestal bone resorption. J Oral Maxillofac Surg 2016;74:1354-9.  Back to cited text no. 48
    
49.
Maier FM. Initial crestal bone loss after implant placement with flapped or flapless surgery – A prospective cohort study. Int J Oral Maxillofac Implants 2016;31:876-83.  Back to cited text no. 49
    
50.
Maló P, de Araújo Nobre M, Lopes A. Three-year outcome of fixed partial rehabilitations supported by implants inserted with flap or flapless surgical techniques. J Prosthodont 2016;25:357-63.  Back to cited text no. 50
    
51.
Prati C, Zamparini F, Scialabba VS, Gatto MR, Piattelli A, Montebugnoli L, et al. A 3-year prospective cohort study on 132 calcium phosphate-blasted implants: Flap vs. flapless technique. Int J Oral Maxillofac Implants 2016;31:413-23.  Back to cited text no. 51
    
52.
Samad A, Haider A, Shihab O. Comparison between flapless and flap dental implant surgery: A clinical and radiographic study. Zanco J Med Sci 2016;20:1267-71.  Back to cited text no. 52
    
53.
Kanwar K, Madan R, Kanwar S, Singh GP. Comparative evaluation of peri-implant vertical crestal bone changes following implant placement with 'flapless 'and 'with-flap' techniques – In vivo study. Asian J Oral Health Allied Sci 2016;6:3-8.  Back to cited text no. 53
    
54.
Marcelis K, Vercruyssen M, Naert I, Teugh- els W, Quirynen M. Model-based guided implant insertion for solitary tooth replace-ment: a pilot study. Clin Oral Implants Res 2012;23:999-1003.  Back to cited text no. 54
    
55.
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:e237-43.  Back to cited text no. 55
    
56.
Katsoulis J, Avrampou M, Spycher C, Stipic M, Enkling N, Mericske-Stern R. Comparison of implant stability by means of resonance frequency analysis for flapless and conventionally inserted implants. Clin Implant Dent Relat Res 2012;14:915-23.  Back to cited text no. 56
    
57.
Tsoukaki M, Kalpidis CD, Sakellari D, Tsalikis L, Mikrogiorgis G, Konstantinidis A. Clinical, radiographic, microbiological, and immunological outcomes of flapped vs. flapless dental implants: A prospective randomized controlled clinical trial. Clin Oral Implants Res 2013;24:969-76.  Back to cited text no. 57
    
58.
Al-Juboori MJ, Ab Rahman S, Hassan A, Bin Ismail IH, Tawfiq OF. What is the effect of initial implant position on the crestal bone level in flap and flapless technique during healing period? J Periodontal Implant Sci 2013;43:153-9.  Back to cited text no. 58
    
59.
Froum SJ, Cho SC, Elian N, Romanos G, Jalbout Z, Natour M, et al. Survival rate of one-piece dental implants placed with a flapless or flap protocol – A randomized, controlled study: 12-month results. Int J Periodontics Restorative Dent 2011;31:591-601.  Back to cited text no. 59
    
60.
Cannizzaro G, Felice P, Leone M, Checchi V, Esposito M. Flapless versus open flap implant surgery in partially edentulous patients subjected to immediate loading: 1-year results from a split-mouth randomised controlled trial. Eur J Oral Implantol 2011;4:177-88.  Back to cited text no. 60
    
61.
Van de Velde T, Sennerby L, De Bruyn H. The clinical and radiographic outcome of implants placed in the posterior maxilla with a guided flapless approach and immediately restored with a provisional rehabilitation: A randomized clinical trial. Clin Oral Implants Res 2010;21:1223-33.  Back to cited text no. 61
    
62.
Campelo LD, Camara JR. Flapless implant surgery: A 10-year clinical retrospective analysis. Int J Oral Maxillofac Implants 2002;17:271-6.  Back to cited text no. 62
    
63.
Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: A review of the recent literature. Int J Oral Maxillofac Implants 2004;19 Suppl:30-42.  Back to cited text no. 63
    
64.
Kim JI, Choi BH, Li J, Xuan F, Jeong SM. Blood vessels of the peri-implant mucosa: A comparison between flap and flapless procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:508-12.  Back to cited text no. 64
    
65.
Jeong SM, Choi BH, Li J, Kim HS, Ko CY, Jung JH, et al. Flapless implant surgery: An experimental study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:24-8.  Back to cited text no. 65
    
66.
You TM, Choi BH, Li J, Xuan F, Jeong SM, Jang SO. Morphogenesis of the peri-implant mucosa: A comparison between flap and flapless procedures in the canine mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:66-70.  Back to cited text no. 66
    
67.
Sclar AG. Guidelines for flapless surgery. J Oral Maxillofac Surg 2007;65:20-32.  Back to cited text no. 67
    
68.
Berdougo M, Fortin T, Blanchet E, Isidori M, Bosson JL. Flapless implant surgery using an image-guided system. A 1- to 4-year retrospective multicenter comparative clinical study. Clin Implant Dent Relat Res 2010;12:142-52.  Back to cited text no. 68
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials And Me...
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed411    
    Printed12    
    Emailed0    
    PDF Downloaded122    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]